CONTENTS

Introduction
Twin Blocks
Historical Perspective
Appliance design and modifications
 Occlusal inclined plane
Diagnosis and treatment planning
Construction bite
Bite registration
Progressive activation and reactivation
Stages of Treatment

CLINICAL MANAGEMENT:
 CI. II Div. 1 with deep bite
 Mixed dentition
 Combination therapy in permanent dentition
 Twin blocks with extraoral traction
 Reduced overbite and anterior openbite management .
 CI. II Div.2 malocclusion
 Cl. III malocclusion
 Extraction / Non extraction therapy
 Management of facial asymmetry
 Magnetic twin blocks
 Adult treatment
 Twin blocks in TMJ dysfunction
 Fixed twin blocks
Response to twin block treatment
Relevant studies regarding twin blocks
Advantages of twin block technique
Conclusion
INTRODUCTION
The term "Orthodontics" and "Dentofacial Orthopedics" are essentially'
distinct in that they represent a fundamental variation in approach to the
correction of dentofacial abnormalities.

While Orthodontics implies by definition the correction of dental

irregularities, dentofacial orthopedics conveys the much broader concept that
treatment aims to significantly improve facial appearance and skeletal
relationships in addition to correcting irregularities of the teeth.

Functional appliance therapy is that aspect of dentofacial orthopedics

that aims to improve the functional relationship of dentofacial structures by
eliminating unfavourable developmental factors and improving the muscle
environment enveloping the developing dentition.

Functional appliances, by altering the position of the teeth and

supporting tissues, establish a new and more optimal functional behavioural
pattern which leads to adaptive changes in the bone form and helps the
dentofacial complex achieve, its optimal genetic growth potential.

The occlusal inclined plane is the fundamental functional mechanism of

the natural dentition. In normal development, incisal guidance and cuspal
interdigitation play an important role in determining dental relationships and
movements of the mandible. Occlusal forces transmitted through the dentition
influence not only the dentoalveolar structures but also the growth rate and
adaptation of supporting basal bone and the temporomandibular joint.
 Unfavourable cuspal guidance, hence are the underlying aetiological
factors in malocclusion with discrepancies in arch relationship, as they provide
a functional deterrent to the full expression of maxillary and mandibular bone
growth.

For example, if the mandible occludes in a distal relationship to the

maxilla, the occlusal forces acting on the mandibular teeth have a distal
component of force unfavourable to forward mandibular development. If the
occlusal inclined plane can be modified to transmit ideal forces to the
supporting bone, optimal growth and the structure of the bones can be
achieved. This process of bone remodeling by modifying the natural forces of
occlusion forms the basis of functional correction with the twin block
technique.

TWIN BLOCKS
Twin block appliances are simple bite blocks designed for full time
wear that achieve rapid functional correction of malocclusion by the
transmission of favourable occlusal forces to occlusal inclined planes that
cover the posterior teeth.

The goal in developing the twin block technique was to maximize the
growth response to functional mandibular protrusion by using an appliance
that is simple, comfortable and esthetically acceptable to the patient.

HISTORICALRSPECTIVE
The twin block appliance evolved due to a clinical problem that
presented when a young patient fell and luxated an upper central incisor. The
incisor was reimplanted and stabilised with a temporary splint. The patient had
a CI. II Div I malocclusion with lower lip trap and 9 mm overjet. The adverse
lip action was causing mobility and root resorption of the re-implanted incisor,
hence interfering with proper treatment. To prevent the lip from trapping, an
appliance had to be designed to hold the mandible forward full time without
applying direct pressure on to the upper incisors. As no other appliance was
available, simple bite blocks were designed to achieve the above objectives.
This appliance not only prevented the lip trap but also led to the correction of
the CI II malocclusion and a reduction in overjet, both the results remaining
stable. The first twin-block appliance was fitted on Sept, 7, 1977 which
heralded the development of the Twin block technique.

APPLIANCE DESIGN:
Twin blocks were originally conceived as simple removable appliances
with interlocking occlusal bite blocks designed to position the mandible
forward to achieve functional correction of CI. II Div. I malocclusion.
However, many variations in appliance design have been incorporated to
extend the scope of the technique to treat all classes of malocclusion.

Twin blocks are both tooth and tissue borne appliances. The appliance is
designed to link the teeth as anchor units to limit tipping and displacement of
individual teeth and maximize the functional orthopedic response to treatment.

The earliest twin blocks were designed with the following basic
components.

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.

The various components used in constructing a Twin block appliance are:

Labial bow:
In its earlier stages all twin blocks incorporated a labial bow to retract
the upper anteriors. However, it was observed that if the labial bow engaged
the upper incisor during functional correction, it tended to overcorrect incisor
angulations, retracting upper incisors prematurely and limiting the scope of
functional correction with mandibular advancement. This led to the conclusion
that a labial bow is not always required unless it is necessary to upright
severely proclined incisors and even then it must not be activated until full
functional correction is complete and a class I buccal segment relationship is
achieved.

In twin block treatment, a good lip seal is achieved naturally without

additional lip exercises, as the appliance is worn for eating and drinking,
making it necessary to form a good anterior seal to perform these functions.
The lips act like a labial bow and lip pressure is effective in uprighting upper
incisors making a labial bow superfluous. In most cases, the absence of a
labial bow improves esthetics without reducing the effectiveness of the
appliance.

Clasps:
Though the early design of twin blocks incorporated Adam's clasps
(modified arrowhead clasps), Clark introduced the Delta Claps in 1985 to
enhance appliance fixation. It is similar in principle to the modified arrowhead
clasp but includes new features to improve retention, minimize adjustment and
reduce metal fatigue, thereby reducing breakage.

The Adam's clasp is designed to fit individual teeth and incorporates

interdental tags and mesial and distal retentive loops that are directed lingually
into undercuts and joined by a buccal bridge. The slope and position of the
crown heads allows the clasp to open slightly with repeated insertion and
removal. The Adam's clasp therefore requires routine adjustment at every visit
to maintain retention. This increases the risk of metal fatigue and breakage.

The Delta clasp retains the basic shape of the Adams clasps with its
interdental tags, retentive loops, and buccal bridge. However, the 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. Both types of Delta clasps have similar retentive properties.
Depending on the anatomy of the tooth, 2 methods of retention can be used if
the tooth is favourably shaped with good undercuts mesially and distally. The
retention loops are angled to follow the curvature of the tooth into mesial and
distal undercuts. If the tooth is not favourably shaped, the loops are directed
interdentally to gain retention from the interdental undercuts.

Delta clasps are generally constructed from 0.70 to 0.75 SS wire. Their
advantage is that 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.

Clark has evaluated that the breakage rate of Delta clasp (1 %) was
significantly less than that of Adam's Clasp (10%).

Delta clasps are routinely used on upper permanent molars and lower 1 st
premolars. They may also be used on deciduous molars. The apex of the
triangular arrowhead is made more acute for premolars than molars to confirm
to the more slender shape of the tooth.

Other clasps that are routinely used are the C clasps and interdental ball
ended clasps. C clasps are especially useful in the mixed dentition for
peripheral clasping on deciduous molars and canines. They can be used to
improve retention and provide resistance to anteroposterior tipping.

Ball shaped interdental clasps may be placed for increased retention.

They are generally placed on lower anteriors to provide control over lower
anterior segment but clasps mesial to lower canines are equally effective. Ball
shaped clasps are specially useful when removable twin blocks are combined
with fixed appliances and no other clasps can be used.

The Delta clasp can be adjusted in 2 ways

1. By placing pliers on the wire as it emerges from the acrylic. A slight
adjustment extends the retentive loop of the clasp into the gingival or
interdental undercut.
2. By grasping the arrowhead from the buccal aspect and twisting the
retentive loop inwards towards the tooth to adjust into the mesial and
distal undercut.

Base Plate
The base plate and occlusal bite blocks may be made from heat cure or
cold cure acrylic. The main advantage of heat cure acrylic is additional
strength and precision (as blocks are first made in wax) .,Cold cure acrylic has
the advantage of speed and convenience but strength is less Breakage is a
problem in later stages of treatment, when blocks are trimmed for allowing
eruption in deep bite cases and hence a top quality acrylic should be used. The
inclined planes can lose their definition if a soft acrylic is used. Preformed bite
blocks made of good quality heat cure acrylic are being manufactured for
incorporation into cold cure appliances to combine convenience with strength
and accuracy.

Occlusal Inclined planes:

The position and angulation of the occlusal inclined planes are crucial to
efficiency in correcting inter arch relationships. The earliest twin blocks had
bite blocks articulating at a 90 degree angle. This forced the patient to make a
conscious effort to bite in a forward position. 30% of patients failed to bite
forward consistently and tended to bite back to their retruded position. As a
result, posterior open bites developed as the bite blocks occluded on their flat
surfaces and the sagittal correction was hampered.

So, the occlusal inclined plane was developed based on the functional
mechanism of the natural dentition. Initially 45 degree angulation was used
which was immediately successful. However 45 degree angulation leads to an
equal downward and forward stimulus to growth. Taking this into account,
clinicians decided on a 70 degree angulation to increase the horizontal
component of force, reasoning that this may cause more horizontal mandibular
growth. This is generally used by most clinicians now. If the patient has
difficulty posturing forward, the inclined planes may be trimmed to reduce the
angulation as well as the amount of protrusion.

The position of the inclined plane is determined by the lower block. In

deep bite cases, the upper bite block has to be trimmed to allow eruption of the
lower molars. Since, the inclined planes should not be disturbed during
trimming, it is necessary to place them anterior to the lower molar.

The lower inclined plane is placed anterior to the distal marginal ridge
of lower 2nd premolar or deciduous molar to allow the leading edge of upper
inclined plane to be positioned mesial to the lower I st molar and thus not
interfere with its eruption.

The lower inclined plane is angled from the mesial surface of 2nd
premolar or deciduous molar at 70 degree to the occlusal plane.
Buccolingually the lower block covers the occlusal surface of lower premolars
or deciduous molars. It becomes thinner in the lower canine region so as not to
interfere with tongue movements and phonetics. However, the lingual flange
in the canine region should be sufficiently thick to avoid breakage.

The upper inclined plane is angled from the mesial of the upper 2nd
premolar to the mesial of the upper 1st molar. The flat occlusal portion then
passes distally over the remaining upper posterior teeth in a wedge shape,
reducing in thickness as it extends distally.

Because the upper arch is wider than the lower, only the lingual cusps of
the upper posterior teeth are covered. This'makes the clasps more flexible and
makes adjustment easy.

The blocks can be aligned to the line of the arch in 2 ways.

1. At right angles to the line of the arch, in the some pattern as the teeth
are aligned.

2. The lower blocks are aligned perpendicular to the midline, with the upper
blocks constructed to match this configuration.

In the second method, the blocks maintain the same alignment relative
to each other even if midline screws are turned to widen the arch form.
Screws:
These can be used for arch development. Normally the upper arch has a
midline screw to enable expansion to accommodate the advancing lower arch.
Lower midline screws can also be used for transverse development of the
lower arch. Screws may also be used for sagittal development especially if
upper incisors are retroclined with deepbite. Two screws are placed aligned
anteroposteriorly in the palate.
The position of the screws and the cut can be varied depending upon
whether the objective is to move anterior teeth labially or posterior teeth
distally.

In placing the screws in the palate, they should be placed in the

horizontal plane and not inclined downwards anteriorly, which would cause
the appliance to ride down the anterior teeth reducing its effectiveness.

Three dimensional screws may be used for combined transverse and

sagittal development.

The lower twin block appliance may also incorporate curved screws in
the canine region to advance the labial segment or straight screws in the 2nd
premolar region to upright and distalize the molars and open premolar spaces.

Standard twin blocks and modifications

They are used for uncomplicated CI. II Div I malocclusion. The upper
appliance has a midline screw and delta clasps on upper first molars.
Additional ball shaped clasps may be placed interdentally distal to the canines
or between the premolars or deciduous molars.
 The lower appliance has delta clasps on the 1st premolars and ball clasps
mesial to the canines.

Twin blocks have the gift of versatility of design. They can be modified
by the addition of screws, springs and bows to move individual teeth. Screws
can be used for independent control of upper and lower arches and for
asymmetrical movement to suit the need for individual patient.

An upper TP A or lower Jackson design can be used as an alternative to

Schwarz Twin blocks (U/L blocks with midline screws) for transverse
development.

The twin block Crozat appliance has minimum palatal and lingual
coverage and is useful for adult treatment.

In addition, twin blocks can be easily modified to suit the individual

malocclusion. Other modifications will be discussed along with discussions
focusing on the management of individual malocclusions.

DIAGNOSIS AND TREATMENT PLANNING:

The essential orthodontic records are a diagnostic report supported by
study models, x-rays and photographs.

Clinical Guidelines
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.

Photographs:
Profile and frontal photographs with the mandible in retrusive and
advanced position, are used to assess the changes that can occur during
treatment.

Study models:
They serve as adjuvants to direct examination in the mouth. Occlusal
changes can be checked by sliding the lower model forward and observing the
articulation of the mandibular dental arch with that of the upper model.

In uncrowded CI II Div. I with 10 mm or more overjet, it can be seen

that good buccal segment occlusion will result from advancing the mandible
and at the same time, laterally expanding the maxilla to match the width of the
mandibular dental arch in the projected advanced position.

If the arches are crowded with irregular teeth, the upper and lower
models will often not fit on advancement of lower model. If the irregularity is
severe, a first phase of arch development with fixed appliances may be
necessary before fitting twin blocks. If the irregularity is less severe, modified
twin blocks with springs, screws or bows may be used to correct the arch form
during the twin block phase.
Radiographs:
OPG is vital to study the dentition and condition of alveolar bone and
periodontium. This may be supported with intra oral films of certain teeth as
required. TMJ X-rays may also be required to assess the joint condition before
treatment. A hand wrist film may be taken to assess the developmental status
of the patient. Finally, lateral cephalograms are necessary to support and
confirm the clinical diagnosis.

CONSTRUCTION BITE

The construction bite determines the degree of activation built into

the appliance, aiming to reposition the mandible to improve jaw
relationship. The degree of activation should stretch the muscles of
mastication sufficiently to provide a positive proprioceptive response. At
the same time, activation must be within the physiologic range of activity
of the muscles of mastication and the ligamentous attachments of the
temporomandibular joint.

In CI II Div I malocclusion, a protrusive bite is registered to reduce the

overjet and distal occlusion by 5 to 10mm on initial activation depending on
the freedom of movement in protrusive function. 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.
So, the total protrusive path of the patient is recorded by measuring the
overjet in the fully retruded position and then in the position of maximal
protrusion. The George bite gauge can be used for this purpose as it has a
sliding jig attached to a millimeter scale.

Forward positioning into a edge to edge relationship is preferred for twin

blocks as this is a most easily reproducible position for the patient. Generally
horizontally growing young patients have a maximal protrusive path of about
13 mm and hence, up to 10mm of forward positioning can be done for these
patients. If overjet is greater than 10mm, initial activation of 7 -8mm is done
followed by reactivation later.

The amount of activation also depends on the effect of forward posture

on the profile of the patient The activation should be such that profile
improvement is optimized.

The amount of activation should not significantly exceed the mandibular

growth potential, otherwise unfavourable dentoalveolar compensation
-protruding lower incisors -might occur. Hence, young patients who are
horizontally growing can withstand a single large activation. On the other
hand, stepwise activation with small increments are preferred in adults or
those who are vertically growing (unfavourable growth pattern).

The vertical activation is determined by 2 factors. Firstly adequate

vertical clearance must be available between upper and lower teeth to
accommodate blocks of sufficient thickness to activate the appliance.
Secondly, the vertical activation must open the bite beyond the freeway space
to ensure that the patient cannot drop the mandible into rest position and
negate the proprioceptive functional response to inclined planes. This is
especially pertinent to ensure that the appliance is active when the patient is
asleep.

Generally, vertical activation is done to achieve 2mm of interincisal

clearance. This normally leads to opening the bite beyond the free way space
and achieving 5-6mm opening in the premolar region and about 2mm in the
molar region.

In CI II Div 2 malocclusion, edge to edge bite may be sufficient to

achieve 6mm of opening in premolar region. While in anterior openbite,
generally incisal clearance of 4-5 mm is required.

Twin blocks may be activated unilaterally to correct postural mandibular

displacement and asymmetries. Adjusting the registration bite such that the
midlines coincide does this.

BITE REGISTRATION:
The centric position is checked and the desired degree of activation
decided. The patient is then trained to bite in the desired position by giving
him a mirror. For accurate control the Exactobite registration device is
recommended. 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. The wax is
softened in a water bath and adapted. The patient is instructed to bite into the
desired position. After the wax has hardened sufficiently, it is removed and
chilled.

Alternatively, bite registration can be done in polysiloxane material.

The patient is instructed to bite forward. composite filling material is placed
between the teeth when the incisors are in correct position. The composite is
light cured to make a template. The template guarantees correct positioning
while the bite is registered. As the patient bites into the template, polysiloxane
is injected between the upper and lower teeth to register the bite.

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

PROGRESSIVE ACTIVATION:
This is indicated in the following conditions:
1. If overjet is greater than 10 mm, initial activation is 7-8 mm. The
second activation brings the incisors in edge to edge relationship.
2. If full correction is not achieved by initial activation.
2. If the direction of growth is vertical, gradual advancement is
preferred to allow adequate time for compensatory mandibular
growth.
3. In adult patients in whom muscles and ligaments are less responsive
to a sudden, large displacement of the mandible.
4. In the treatment of TMJ dysfunction, activation should not be
beyond the level of tolerance of injured tissue.

REACTIVATION
Reactivation of the twin block can be done as a simple chair side
procedure by the addition of cold cure acrylic to extend the anterior incline of
the upper twin block mesially as the clinician inserts the appliance to record a
new protrusive bite before the acrylic is fully set.
 No acrylic should be added to the distal incline of the lower twin block.
This is specially pertinent in deep bite cases as extending the occlusal acrylic
of the lower block distally will prevent eruption of lower 1 st molar.

The patient's growth rate and direction should be taken into account in
determining the timing and amount of reactivation.

Recent modifications of twin blocks incorporate screws on the bite

blocks for progressive reactivation of twin blocks.

STAGES OF TREATMENT
Twin block functional therapy is divided into 3 stages:
1. Active phase
2. Support phase
3. Retention.
Active Phase:
During the active phase, twin blocks are worn full time. The objective is
to correct to the arch relationship in the sagittal, vertical and transverse
dimensions.

Normally, overjet and overbite are corrected within 6 months and the
lower molars erupt into occlusion in 9 months. The average wear time for twin
blocks is 6 to 9 months though sagittal correction may be obtained in 2 to 6
months. At the end of the active phase, there should be a three point contact in
the incisor and molar region and the sagittal relationship should be in a
slightly overcorrected position.
Support Phase:
The objective of the support phase is to retain the corrected incisor
relationship until the buccal segment occlusion is fully established. The lower
twin block is left out at this stage and posterior bite blocks are removed. The
appliance of choice is a steep anterior inclined plane borne on a removable
appliance. The anterior inclined plane, without interfering with occlusion,
should engage the lower incisors and canines which should occlude at the base
point of the upper incisors and canines. For this purpose the inclined plane
should have an angulation of 70-80 degree to the occlusal plane and should
have a thickness of 6 to 8 mm.

If the molars have fully settled, an upper Hawley type of retainer with
clasps on molars can be used to bear the inclined planes. If the molars still
requires some settling, the inclined plane can be borne on a Begg type retainer.
If fixed appliance therapy is to be instituted after the twin block stage, a
simple "clip- over" removable retainer or a fixed anterior bite plane can be
used.

The upper and lower buccal teeth usually settle into occlusion within 4
to 6 months. Full time wear is continued for another 3 to 6 months to allow
time for internal bony remodelling to support the corrected occlusion.

Retention:
A normal period of retention follows treatment after occlusion is fully
established. The same appliance used during the support phase is used, where
in appliance wear is gradually reduced to night time wear.
Support phase and retainers are vital to ensure stability of results achieved
with twin blocks. For stable changes, the total treatment time should not be
less than 15 to 18 months.

Support phase and retention are especially prolonged if twin blocks

have been used for correction in the mixed dentition and final detailing of the
occlusion is to be done in the permanent dentition.

The Rickenator and some night time functional appliances have

occasionally been used to support and maintain the correction achieved with
twin "" blocks. The Occluso-guide is another simple, pre-formed appliance,
resembling, a minipositioner, which is used in the mixed dentition to retain the
incisor and molar relationship by night time wear while maintaining space for
eruption of premolars and canines.

CLINICAL MANAGEMENT:

(1) ClII Div. I with deep overbite.

Protrusive bite record is taken according to the principles mentioned
before and the appliance fabricated. The upper bite block is trimmed occluso
-distally to allow the lower molar to erupt and reduce the deep bite with
increase in lower facial height.

The occlusion is cleared over the lower molars progressively at each

visit by I to 2 mm only to facilitate eruption. This prevents the tongue from
protruding between the teeth and interfering with eruption. The inclined plane
must be maintained intact during trimming to preserve the active mechanisms
for functional correction.

At the end of the active phase, incisors and molars are in correct
occlusion and deep bite corrected. However the presence of bite blocks leads
to openbite in the premolar region. The lower block is then trimmed slightly to
allow the premolars to erupt with the appliance.

Eruption of lower molars occurs more quickly if separating elastics are

placed in the interdental contacts of teeth at the start of treatment. Active
eruption of lower molars may be encouraged by applying vertical elastics from
the upper appliance to hooks on the lower molars, or with the help of fixed
appliances if they are already in place. This is specially useful in older patients
in whom eruption by natural forces tends to be slower.

(2) Management in mixed dentition-

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

So C clasps may be used on deciduous molars. Retention can be

enhanced by bonding composite on tooth surfaces to create undercuts.
Alternatively C clasps may be bonded directly to the teeth for 7 to 10 days.
The clasps may then be freed .' and the edges of the composite that remains
attached to the teeth rounded off to improve retention.

Retention grooves and depressions may also be ground into the buccal
surfaces of deciduous teeth, and sealant applied to protect the teeth. Synthetic
crown contours, which are preformed plastic pads may be bonded on
deciduous cuspid and molar buccal surfaces to reshape and provide additional
undercuts.

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.

(3) Combination therapy -permanent dentition:

An initial phase of functional correction by twin blocks is generally
followed by final detailing of occlusion with fixed appliances. This
combination of orthopedic and orthodontic therapy generally leads to optimum
treatment results. The versatility of design of twin blocks allows it to be easily
integrated with fixed appliances. 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.

In cases with vertical growth pattern (high mandibular angle) with deep
bite, VTO does not improve as functional protrusion further increases facial
height. In these cases anterior intrusion is done initially with fixed appliance to
reduce the overbite and then twin blocks are used to advance the mandible.
Secondly, as no anterior wires are used in twin blocks, brackets may be fitted
in the anterior segment and the anteriors aligned with a sectional wire during
twin block stage of treatment.

Thirdly, a full lower fixed appliance may be fitted during the support
phase. Alternatively, a lower lingual appliance may be used to allow premolar
eruption while retaining the correct arch form.

Finally, twin blocks may be combined with fully bonded fixed

appliances by 2 approaches. Simple removable twin blocks may be designed
to fit over the fixed appliance, using ball end interdental clasps for retention.
Another option is to design fixed twin blocks for full time wear. This will be
discussed in another section

(4) Twin blocks with extra oral traction.

In most cases, full functional correction can be achieved with twin
blocks without extraoral forces. However, extraoral force with twin blocks can
be indicated in the following conditions.

1. In the treatment of severe maxillary protrusion, high pull, cervical

pull or combination pull headgear may be combined with twin
blocks to restrain maxillary growth and cause maxillary retraction.
The choice of headgear depends on the individual case.
 2. To control a vertical growth pattern. High pull headgear may be
used. This restrains vertical maxillary growth and applies intrusive
force on upper posteriors.
3. In adult treatment where mandibular growth cannot assist the
correction of severe malocclusion.

The Concorde face bow was designed for combined extraoral and
intermaxillary traction. This was made by soldering a labial hook to the
conventional face bow. While restrictive or intrusive influence is applied to
the maxilla, elastics can be given from the labial hook to the ball shaped
interdental clasps or hooks on the anterior part of lower appliance. This
applies a orthopedic traction on the mandible in addition to the functional
protrusion achieved by twin blocks.

The advantage is that 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. Moreover, compared to CI. II elastics, a more
horizontal intermaxillary force is exerted and extrusive mechanics is avoided.

However, twin blocks combined with extraoral force are very powerful
mechanics to retract the maxilla and should be used in extremely selected
cases. 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. Most patients can be treated effectively without
extraoral traction, with twin blocks alone.
 The attachment of face bow can be done on tubes soldered to clasps on
upper posteriors or using modified arrow head clasps with tubes. If fixed
appliances are in place with twin blocks, face bow may be inserted into the
headgear buccal tubes welded on upper molar bands.

(5) Treatment of reduced overbite and anterior open bite.

Patients with dolichofacial growth patterns show a vertical tendency of
growth with increased lower facial height associated with reduced overbite
and anterior openbite. In these patient's careful management is needed to
prevent posterior eruption and try to achieve intrusion of posterior teeth:

a. AIl 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
controIled by placing occlusal rests or extending upper twin block
distaIly over the upper second molars to contact the lower second
molars.
c. Intrusive orthopedic forces can be applied to upper posterior teeth with
extraoral force as described earlier.
d. MiIls introduced an extremely effective modification to intrude
posterior teeth by using vertical elastics (Intra oral traction). These
elastics are applied bilateraIly and pass from upper to lower arch in the
premolar region. They are attached to the twin block appliance or
brackets on opposing teeth. 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. This
method has proven to be extremely effective and is now
being preferred over extra oral force in a majority of cases.
e. Magnetic twin blocks are also being used in anterior openbite problems"
as wiIl be discussed later.
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 labiaJ bow may be
used to retract extremely proclined incisors and reduce the anterior
openbite.

(6) Management of CI /J Div. 2 Malocclusion.

In severe cases" a preliminary phase of fixed appliances therapy may be
needed to align the arches before functional therapy. However" arch
development can be done simultaneously with functional correction using the
sagittal twin block appliance. 2 screws are put in the palate for arch
development in antero posterior direction. They act by 75-80% advancement
of anteriors and 20-25% distalization of posteriors. In cases where transverse
expansion is required a third screw may be put transversely in the midline or
alternatively a 3D expansion screw may be used (central sagittal twin block).

The lower appliance may likewise incorporate screws for transverse and
sagittal development as described before.
(7) Management of Cl III malocclusion.
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.
The occlusal blocks are placed over upper deciduous molars and lower first
molars. The reverse inclined planes are angled at 70 degrees and drive the
upper teeth forward by the forces of occlusion and at the same time, restrict
forward mandibular development.

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. Therefore the
net effect of opening the screws is a forward driving force on the upper arch.
To enhance the forward movement of the upper labial segment, lip pads may
be added to hold the lips clear of the incisors -similar to the lip pads of Frankel
III. If screws have been used, lip pads must be borne on the anterior
component of the appliance so that they also advance with the anterior
segment as the screws are opened.
 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.

(8) Extraction / Non -Extraction therapy

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.

Two factors improve the prognosis for a non-extraction approach in

moderate to severe crowding cases.
1. If premolars and permanent canines have not erupted, arch width can
be increased and space gained by arch development due to early
intervention.
2. If the lower dentition is lingually positioned relative to the skeletal
base, space can be gained by proclining the lower incisors.
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.
 In the mixed dentition, arch development and functional therapy may be
done, to be followed by a finishing phase of orthodontic treatment in the
permanent dentition.

In the permanent dentition, fixed appliance treatment may precede twin

block stage to correct on irregular arch form where the irregularity is moderate
on severe. Alternatively, in less crowded cases fixed appliances may be
integrate with twin blocks from the start of treatment. .

However, extraction therapy is essential in certain cases. In moderate

discrepancy cases with posterior malalignments, 2nd molar extractions can be
done to gain arch length in the lower arch without sacrificing lip support and
damaging facial esthetics.

Premolar extractions and functional therapy are indicated only in a

minority of cases.

a. If the degree of crowding mesial to the 1 st molars is so severe, that

premolar extractions are inevitable but the patient also requires
functional mandibular protrusion. -

b. If patient presents too late to correct crowding with interceptive

treatment and arch development, but also requires functional
mandibular protrusion.

c. Patients with severe bimaxillary protrusion and a functionally

retruded mandible.
 d. Patients with vertical growth pattern and high mandibular plane
angle, generally grow unfavourably during treatment and require
extractions to resolve crowding or proclination and improve the
profile.

Extraction of premolars are generally done after or during twin block therapy.

(9) Treatment of facial asymmetry:

The occlusal inclined plane is the ideal functional mechanism for
unilateral activation and twin blocks are extremely effective in correction of
facial and dental asymmetry. The sagittal twin block is the appliance of choice
for correction of asymmetries as it allows unilateral screw activation to restore
symmetry in the buccal and labial segments. Magnetic twin blocks are also
extremely useful in this situation as will be discussed in the next section.

While correcting facial asymmetry, more activation is built on the side

to which the mandible is displaced while the other side has lesser activation or
an upper bite block only may be present to prevent any activation on that side.

(10) Magnetic twin blocks:

The role of magnets in twin block therapy is specifically to accelerate
correction of arch relationships. Two types of rare earth magnets are used -
samarium cobalt and neodymium boron with the latter delivering greater force
from a smaller magnet. Two types of magnetic forces have been proposed.
(a) Attracting magnets:
This helps in pulling the appliance together and encourages the patient
to occlude actively and consistently in a forward position. This allows greater
activation to be built into the initial construction bite, with the patient being
encouraged to bite in the new position. This increases occlusal contact in both
working and sleeping hours, thus increasing functional stimulus to growth.

They can be used in the following situations:

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 II 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.

(b) Repelling magnets:

These may be used when less activation is built into twin blocks. The
repelling magnetic force applies additional stimulus to forward posturing as
the patient closes into occlusion. They induce additional forward mandibular
posturing without reactivation; however, the degree of activation induced by
magnetic forces is not ascertained. .
 Moss and Shaw (1990) reported that there is a 100% increase in rate of
overjet correction when repelling magnets are used. However, improvements
in growth response could not be established and significant changes were
produced in incision angulations.

A short period of investigation shows that magnetic twin blocks may

help resolve some of the problems in difficult cases. They should be used in
those cases where speed of treatment is an important consideration or where
response to non-magnetic appliances is poor.

Whether attracting or repelling magnets are more effective still has to be

resolved. Both may be applied in different situations. While attracting magnets
may benefit patients who fail to bite into the appliance in correct posture,
repelling magnets may be used in those in whom initial activation has to be
kept small.

However, magnetic twin blocks cannot be reactivated by addition of

acrylic to the inclined planes as this deactivates the magnets. Screws may be
needed on the bite blocks for progressive activation of magnetic twin blocks.

(11) Adult Treatment:

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. However, significant facial changes can be
produced in mild to moderate discrepancy cases by dentoalveolar
compensation. However, in severe skeletal discrepancies, twin blocks are
contraindicated and orthognathic surgery is the treatment of choice in adult
patients.

(12) Twin blocks in TMJ Therapy:

Twin blocks are most likely to be used to resolve an early click when
the condyle is displaced distal to the disk and the disk is recaptured at an early
stage in the opening movements. Twin blocks then achieve the following
objectives.

1. Pain is relieved within 4 days of fitting twin blocks.

2. Muscles are retrained to a healthy pattern. Facial balance is improved
and muscle spasm relieved.
3. The disk is recaptured by posturing the mandible downward and
forward to advance the condyles.
4. Rather than acting as a passive splint, twin blocks can move teeth
that are causing occlusal imbalance.
5. The upper block may be trimmed selectively over the lower first
molar only, using molar bands with vertical elastics to accelerate
eruption. Occlusal contact is maintained with 2nd and 3rd molars to
support the vertical dimension and rest the joint.

The twin block sagittal appliance is generally used in TMJ derangement

cases. Bite is registered with mandible moved downward and forward to a
comfortable position.
 If pain is not relieved by forward posture and the disk does not appear to
be recaptured, there may be internal derangement or infolding of the disk
which will not respond to twin block therapy.

The twin block Biofinisher attachment is an alternative method to

extrude lower molars by vertical traction. It has an hook for attachment of
elastics that extends into the upper vestibule. It is a removable attachment to
achieve longer elastic span.

(13) Fixed twin b locks

To increase patient compliance, twin blocks may be temporarily or
permanently fixed to the teeth. Temporary fixation of removable blocks is
done by either of the following 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.

This is generally done in the initial stages of twin block therapy for 7 to
10 days to gain patient compliance.

Twin blocks can also be permanently fixed to the teeth. This can be
done by fabricating molar and/or premolar bands and soldering wire elements
on them. The occlusal bite blocks are then fabricated to engage the occlusal
retentive tags and are hence attached to the bands. Then the bands with the
bite blocks can be cemented on to the teeth. An upper TP A and lower lingual
arch can be added for control of the transverse dimension and arch
development.

Clark has designed fixed twin blocks with the help of Wilson 3D
modular attachments to be used as fixed attachments, removable only by the
operator.

Wilson's 3D lingual tube is used as a retentive component on molar

bands and provides a mode of attachment for occlusal twin block elements,
which, in turn, may be fixed or fixed removable under the direct control of the
operator. A TP A or lingual arch can be added.

Transverse development can be combined with mandibular

advancement by adding bite blocks on rapid maxillary expansion appliance.
This is called the Twin block hyrax appliance.

It is recommended to establish correct arch form in both arches before

fitting fixed twin blocks. Moreover, fissure sealant should be applied prior to
cementation as a precaution against occlusal caries.

In the support phase, a fixed inclined plane consisting of two Wilson 3D

sectional appliances joined by an anterior inclined plane can be used.

After functional treatment, orthodontic detailing in done with fixed

appliance.
Though fixed twin blocks ensure patient compliance, their management
is more difficult than removable twin blocks. Their disadvantages are:
 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.

Hence removable twin blocks are preferred for compliant patients.

RESPONSE TO TWIN BLOCK TREATMENT.

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. Even in the adult animals, the whole
stomatognathic system, including the soft tissues, adapt to establish an
efficient masticatory system.

The clinical response observed after fitting twin blocks is closely

analogous to the changes observed in animal experiments using fixed inclined
planes.

Harvold demonstrated in animal experiments that when the mandible is

advanced, a "tension zone" is created above and behind the condyle. This is an
area of intense cellular activity quickly invaded by proliferating connective
tissue and blood capillaries, within a few hours or days.
 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. From
animal studies, it may be deduced that retraction of the condyle results in
compression of connective tissue and blood vessels and the resulting
ischaemia is the principal cause of pain. Hence, 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 is described by McNamara as the "pterygoid
response" due to altered activity of the medial head of lateral pterygoid. This
response is extremely rare with appliances not worn full time.

The initial response to functional mandibular protrusion is hence, a

change in the muscles of mastication to establish a new equilibrium in muscle
behavior. Volumetric changes behind the condyle result in cellular
proliferation at this stage. This occurs in minutes, hours or within a few days
of inserting the appliance. When the altered muscle function is established, the
proprioceptive sensory mechanism initiates compensatory bony remodeling to
adapt to the altered function. Bony remodeling in the dentoalveolar and basal
bone and the condyle and glenoid fossa occur gradually over a few months to
produce structural changes.

The facial muscles adapt quite quickly to altered occlusal function.

Even in the first few months of twin block treatment, facial appearance is
markedly improved by rapid soft tissue adaptation. The facial changes are
soon accompanied by dental changes and it is routine to observe correction of
a full unit distal occlusion within 6 months of treatment.

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.

a. Michigan growth control (Riolo et a11979)

(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

b. Neijmagen series control (Prahl Andersen et aI, 1979)

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.

Mandibular growth change in boys:

Mandibular Length:

Length of mandible: Ar -Gn

Duration of treatment 1 year
Mean increase during treatment 5. 16 mm
Mean annual growth of control 2.71mm
Increased annual growth 2.45mm
Mean increase in the mandibular length after treatment during
observation period -2.71 mm/year
This is same as the annual growth rate of controls.

Facial height:
Increase in the facial height during treatment 6.29mm
Mean annual growth of control 2.58 mm
Therefore increase in growth due to treatment 3.71 mm

Mandibular growth change in Girls:

Mandibular length:
Mean increase after 1 year treatment: 6 mm
Mean annual growth of control : 1.83mm
 Therefore increased growth compared to control: 2. 17mm/year
Mean increase in mandibular length during observation period: 1.89 mm/year

Facial height
Increase in facial height during treatment: 4.93 mm
Mean increase in control: 1.16 mm/year
Increased vertical growth compared to control: 3.77 mm.

Therefore during treatment there was an increase in both facial height

and mandibular length compared to control values after treatment. After
treatment the mandible continues to grow at the normal rate of untreated
controls.
The mean age of boys before treatment was 11.9 years while that of
girls was 11.6 years and duration of treatment was 1 year.

OTHER RELEVANT STUDIES REGARDING TWIN BLOCKS:

1. 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 dentoalveolar effects in both
arches contributed to the overjet reduction. No significant increases in
SN- mandibular plane angle occurred during treatment.
2. Lund and Sandler (AJODO 1998 Jan) treated 36 CI II subjects, mean
age 12.4 yeas 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. No statistically significant restraint of
maxillary growth was observed. 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. 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.

3. Stangl (Functional orthodontist -1997, March-April) studied growth

changes on six patients, 4 boys and 2 girls treated with twin block for
approximately I year and concluded that there was a significant increase
in ramus height and mandibular body length.

4. Yamin Lacouture, Woodside, Sektakof and Sessle (AJODO 1997 Nov)

studied the action of Herbst, Frankl and simulated twin blocks on the
activity of masseter, digastric and superior and inferior heads to lateral
pterygoids using chronically inserted EMG electrodes in non human
primates. Contrary to the popular lateral pterygoid muscle hypothesis,
these appliances caused a decrease in the functional EMG activities of
 these 4 muscles. These animals showed a significant skeletal change in
the TMJ- facial area and hence, the action of these appliances through
stimulating the superior head of lateral pterygoid muscle could not be
supported by this study.

5. Iling Morris and Lee (European journal of orthodontics, 1998 Oct and
Dec) investigated the effects of Bionator, Twin blocks and Bass
appliances on hard and soft tissue and compared them with untreated
controls. Both the Bionator and the twin-block appliances demonstrated
a statistically significant increase in mandibular length compared to the
control group, with an anterior movement of pogonion and point B. All
3 appliances showed significant increases in lower facial height. The
twin block group showed least forward movement of point A. Both
bionator and twin blocks showed significant reduction in upper incisor
angulation to maxillary plane. The bionator group showed maximum
proclination of lower anteriors while the Bass appliance groups showed
the least. The Twin block appliance appeared to be the most effective in
producing sagittal and vertical changes.

Maximum soft tissue changes were also shown by the twin block
appliance. Upper lip position remained stable despite the significant
overjet reduction achieved. All appliances showed increase in lower lip
protrusion, lower lip length and soft tissue total and lower facial height.
Transverse soft tissue changes were also highly significant.

All the above studies highlight the effectiveness of the twin block
appliance in achieving rapid functional correction of malocclusion.
ADVANTAGES OF TWIN BLOCKS:
Twin blocks have a number of advantages over other functional
appliances belonging to the monobloc series. As the upper and lower
components are separated, there is freedom of jaw movements in anterior and
lateral excursion. This also allows the operator independent control of the
upper and lower arches. Speech is minimally affected as there is no restriction
to movements of the tongue, lip or mandible.

Twin blocks are designed with minimum visibility of wire and acrylic
components. Absence of lip and cheek pads prevents distortion of facial
appearance. Rather, facial appearance is enhanced on wearing twin blocks.
The appliance is worn full time, especially during eating. Mastication provides
the strongest functional stimulus to growth. On the other hand, monobloc
appliances have to be removed for eating and the patient tends to posture back
the mandible to the original retruded position, which is a deterrent to rapid
functional correction.

Enhanced comfort and esthetics generally leads to excellent patient co-

operation. If required, twin blocks can be easily fixed to the teeth temporarily
or permanently to improve patient compliance.

All these factors lead to rapid correction of malocclusion with the twin
block appliance.

Moreover, this appliance is subject to easy adjustment and reactivation

is a simple chair side procedure.
 Twin blocks enjoy some advantages over fixed functional appliances
like the Herbst or Jasper Jumper. As the Twin blocks are both tooth and tissue
borne, there is more likelihood of skeletal response compared to fixed
functional appliances which are tooth borne and hence have a tendency to
produce more dentoalveolar changes. Moreover, twin blocks are extremely
cost effective.

Lastly twin blocks have the gift versatility of design and can be
modified and intergrated with fixed or extraoral appliances at any stage of
treatment. This allows their application in a wide variety of clinical situations.

CONCLUSIONS.
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.