Original Research

Dentoskeletal effects of Twin Block appliance in

patients with Class II malocclusion

Mahamad Irfanulla Khan1, Praveen Kumar Neela2, Nayeem Unnisa3,

Ajit Kumar Jaiswal4, Nadeem Ahmed5, Abhik Purkayastha6

1) Department of Orthodontics & Abstract

Dentofacial Orthopedics, Oxford Background and aim. Class II malocclusions are most commonly seen in
Dental College, Bangalore, India orthodontic practice and in the recent times Twin Block appliance has been the most
2) Department. of Orthodontics &
popular and widely used among removable functional appliances for the correction
Dentofacial Orthopaedics, Kamineni of Class II malocclusion in growing patients. The aim of this retrospective study was
Institute of Dental Sciences, to evaluate the dentoskeletal effects produced by the Twin Block appliance for the
Narketpally, Andhra Pradesh, India correction of Class II division 1 malocclusion with retrognathic mandible.
3) General Dental Practice, Methods. Pre-treatment (T1) and post-treatment (T2) lateral cephalograms of 30
Bangalore, India patients treated with Twin Block appliance (mean age  =  10.8 ± 1.2 years) for the
correction of class II division 1 malocclusion were compared with the 30 untreated
4) Department. of Orthodontics & class II control patients (mean age 11.2 ± 0.8 years) who did not undergo any
Dentofacial Orthopaedics, BJS Dental
treatment during this period. Both the groups were evaluated for the dentoskeletal
College, Ludhiana, Punjab, India
changes using 24 angular and linear cephalometric measurements. The differences
5) General Dental Practice, Max between the pre and post-treatment were calculated using a paired t-test.
Dental Specialties, Bangalore, India Results. The cephalometric analysis revealed that the Twin Block appliance
6) Welcare Dental Clinic, Kalyani-
stimulated mandibular growth and statistically significant differences were found
Nadia, West Bengal, India between the two groups. Twin Block patients showed a statistically very high
significant (p<0.001) increase in mandibular length (6.02 mm) compared with the
control group (0.3 mm). “Headgear effect” on the maxilla, increase in lower anterior
facial height, significant reduction of overjet, overbite and Class I molar relationship
were achieved in the Twin Block group. However, no significant changes appeared
in the control group.
Conclusion. The results of the present study conclude that the Twin Block appliance
is effective in the treatment of Class II malocclusion and this is due to a combination
of skeletal and dentoalveolar changes in both the arches.
Keywords: Twin Block, Class II division 1 malocclusion, functional appliances,
dentoskeletal effect, cephalometry

Introduction orthodontic treatment is to attain optimal

Class II malocclusions are facial esthetics in addition to normal
most commonly seen in orthodontic dental occlusion. This is achievable
DOI: 10.15386/mpr-1989 practice; they may be either skeletal only if the underlying jaw bases are in
or dental, presenting with different harmony with each other.
Manuscript received: 07.12.2020 clinical manifestations. Globally, an Functional appliances have been
Accepted: 07.01.2021 approximate estimation shows over 20% in use from many years; several varieties
prevalence of Class II malocclusion in of removable functional appliances like
Address for correspondence:
[email protected] North America, Europe and North Africa Activator, Bionator, Frankel, and Twin
[1]. In 1981, McNamara study found Block are used for the correction of Class II
This work is licensed under a Creative that 60% of the Class II malocclusion malocclusions [3]. The primary objective
Commons Attribution-NonCommercial- occurred in children having retrognathic of using these functional appliances is to
NoDerivatives 4.0 International License mandible [2]. The goal of the present-day

MEDICINE AND PHARMACY REPORTS Vol. 95 / No. 2 / 2022: 191 - 196 191
Dental Medicine

modify or redirect mandibular growth to correct a skeletal of untreated children with Class II malocclusion. All the
discrepancy [4]. records were obtained from 5 different private dental
Multiple evidence-based studies of functional offices based on the following inclusion criteria:
appliances have reported the varying degrees of 1) Skeletal Class II malocclusion (ANB 5° or
dentoskeletal effects in the treatment of Class II greater)
malocclusions [5-9]. In the recent times, Twin Block 2) Mandibular retrognathism
developed by William J. Clark is the most popular and 3) Average or horizontal growth pattern.
widely used removable functional appliances for the 4) Full-cusp Angle Class II molar relationship on
correction of Class II malocclusion in growing patients both sides
due to increased patients acceptance and compliance, 5) Overjet of 6 to10 mm
the separate upper and lower two-piece design of the 6) The age group of 9 to 12 years
appliance allows freedom of speech and mastication 7) All the subjects with same bite recording
[10-15]. Several randomized controlled trials and systematic technique and standard Twin Block appliance design and
reviews have described the role of the Twin Block treatment protocol suggested by Dr Clark.
appliance on skeletal, dental and soft tissue structures in The subjects excluded from the study were
the treatment of Class II malocclusions [16-18]. patients with severe maxillary prognathism, severe
Therefore this study aimed to retrospectively dental crowding (more than 5 mm), history of previous
evaluate the dentoskeletal effects of Twin Block appliance orthodontic treatment.
in patients with Class II division 1 malocclusion. Twin Block Group: consisted of 30 patients (13
boys and 17 girls) with age between 9 to 12 years. The
Methods average age of the patients was 10 years 8 months at
This study was approved by the Institutional the time of the initial film. Control group: 30 untreated
Ethical Committee of Institutional Ethical Committee of Class II subjects (12 boys and 18 girls) who received no
YDC/05-08/03. Two groups of 30 subjects in each were treatment but were followed until the end of the study,
considered for this retrospective cross-sectional study, records were selected based on the similarity of ages with
records of the patients who had been treated with the the Twin Block group. The average age of this sample
Twin Block appliance were compared with the records group was 11 years 2 months.

Figure 1 (left). Cephalometric reference planes: 1) S-N plane; 2) Vertical reference plane (VRP); 3) Horizontal reference plane (HRP).
Figure 2 (right). Dentoskeletal parameters: 1) UI-SN; 2) UI-VRP; 3) UI-HRP; 4) U6-VRP; 5) U6-HRP; 6) IMPA; 7) L1-VRP;
8) L1-HRP; 9) L6-VRP; 10) L6-HRP.
Palatal plane: the plane formed by joining ANS and PNS was used as a Horizontal Reference Plane (HRP) for maxillary teeth;
Mandibular plane: the plane formed by joining Gonion and Menton. (HRP for mandibular teeth); Vertical reference plane (VRP): the
reference plane constructed through sella turcica perpendicular to the palatal plane.

192 MEDICINE AND PHARMACY REPORTS Vol. 95 / No. 2 / 2022: 191 - 196
 Original Research

Cephalometric analysis the mandibular plane and vertical reference plane

In this study, pre-treatment (T1) and post-treatment were used to determine the mandibular teeth movement.
(T2, post appliance removal / equivalent time frame in Statistical analysis
controls) records of 30 patients treated with standard Statistical analyses were performed using
Twin Block appliance design and treatment protocol Statistical Package for the Social Sciences (SPSS)
suggested by Dr Clark and control group (30 patients) software version 22 (SPSS Inc, Chicago, Illinois, USA).
were evaluated before and after functional therapy. The differences between pre and post-treatment were
All the pre-treatment and post-treatment cephalograms calculated using a paired t-test. When data were not
were traced on matte acetate paper, using a 0.03” lead normally distributed, Wilcoxon signed-rank test was used.
pencil by one investigator with verification of anatomic Man-Whitney U test was used to compare the changes
outlines and landmarks by the two more investigators. A between the two groups. The comparison was tested at
single average tracing was made in instances of bilateral 5% level of significance (P-value < 0.05 was considered
structures. The cephalometric landmarks, reference statistically significant).
planes and angular measurements were used as defined by
Alexander Jacobson [19] and Thomas Rakosi [20]. Results
The following Cephalometric reference planes Descriptive information and pre and post-
(Figure 1) and Dentoskeletal parameters were used treatment comparison between Twin Block and control
(Figure 2). groups are shown in table I. Whereas, group differences,
The horizontal movement of the maxillary teeth in the percentage of changes between the two groups are
was measured from VRP, whereas vertical changes presented in table II.
were measured relative to the palatal plane. Similarly,

Table I. Descriptive information and pre (T1) and post-treatment (T2) comparison between Twin Block and Control groups.
Twin Block (TB) Control (C)
Cehalometric
Parameter Pre treatment (T1) Post treatment (T2) p -value Pre treatment (T1) Post treatment (T2) p-Value
Mean± SD Mean± SD Mean ± SD Mean ± SD
SNA 81.44±3.01 80.75±3.65 0.01 * 82.33±3.0 81.95±3.55 0.106 NS
SNB 74.35±3.16 76.65±3.28 <0.001 74.20±2.50 74.54±2.57 0.111 NS
ANB 6.06±1.36 4.06±2.04 <0.001 6.60±2.0 6.10±2.01 0.16NS
MAX length 89.90±3.90 90.50±4.79 0.160 NS 87.80±3.80 88.50±4.69 0.158 NS
MAND length 107.20±5.17 113.22±4.32 <0.001 109.90±5.09 110.20±5.01 0.178 NS
WITS 4.88±1.52 2.14±1.94 <0.001 4.20±1.29 3.97±1.25 0.15 NS
BETA angle 22.16±3.54 27.00±3.14 <0.001 21.29±1.66 21.69±1.79 0.18 NS
AFH 110.20±5.17 116.22±4.33 <0.001 109.93±5.09 110.18±5.02 0.179 NS
PFH 73.36±3.74 76.30±3.86 <0.001 72.07±4.14 72.36±4.19 0.065 NS
Facial Convexity 9.36±4.97 6.22±6.33 <0.001 9.86±4.01 9.88±4.19 0.081 NS
U1-SN 116.00±6.61 108.74±7.20 <0.001 109.92±8.76 110.00±8.66 0.701 NS
U1-HRP 26.64±2.87 28.22±3.71 0.022* 27.62±2.85 28.14±3.15 0.002 *
U1-VRP 77.16±3.89 74.96±4.63 <0.001 74.97±5.44 74.98±5.62 0.924 NS
U6-HRP 20.60±1.89 20.83±2.02 0.114 NS 20.61±2.04 20.84±2.17 0.115 NS
U6-VRP 40.60±3.76 39.66±3.82 0.037 * 40.12±3.90 40.09±3.85 0.068 NS
L1-NB 7.64±2.18 8.88±2.34 <0.001 7.49±1.99 7.57±2.10 0.566NS
IMPA 101.56±5.75 103.72±6.10 0.037* 99.46±4.71 100.04±4.80 0.059 *
L1-HRP 41.32±2.72 39.90±3.02 0.011 ** 39.76±4.30 39.84±4.29 0.566 NS
L1-VRP 68.20±3.57 71.36±4.00 <0.001 69.36±4.58 69.92±4.57 0.51NS
L6-HRP 28.66±2.11 31.04±2.96 <0.001 30.32±2.88 30.86±2.92 <0.001
L6-VRP 39.04±3.34 43.48±4.09 <0.001 40.80±4.45 41.12±4.41  <0.001
Overjet 9.40±2.13 3.68±1.74 <0.001 8.08±1.30 7.70±1.21 <0.001
Overbite 4.70±1.05 2.68±1.09 <0.001 4.44±0.92 4.18±1.00 0.003 **
Interincisal angle 110.76±7.28 114.60±9.25 0.033* 109.74±6.02 109.88±6.24 0.327 NS
Abbreviations: TB: Twin Block, C: Control, SD: Standard Deviation, AFH: Anterior Facial Height, PFH: Posterior Facial height, U1-
HRP: Upper 1 to Horizontal reference plane, IMPA: Incisal Mandibular plane Angle, U1-VRP: Upper 1 to Vertical reference plane, U6-
VRP: Upper 6 to Vertical reference plane, U6-HRP: Upper 6 to Horizontal reference plane, L1-HRP: Lower 1 to Horizontal Reference
plane, L1-VRP: Lower 1 to Vertical Reference plane, L6-HRP: Lower 6 to Horizontal Reference Plane, L6-VRP: Lower 6 to Vertical
Reference plane, U1-SN: Upper 1 to SN plane, HRP: Horizontal Reference Plane VRP: Vertical Reference Plane.
Notes: p > 0.05 = NS, * p < 0 .05 = Significant, ** p < 0 .01 = Highly Significant, *** p< 0 .001 = Very highly significant.

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Table II. Mean changes between Twin Block vs Control groups.

Twin Block (TB) Control (C)
Cephalometric Parameter TB vs C
% change Mean ±SD % change Mean± SD
SNA 0.60±2.73 0.46±1.00 <0.001
SNB 6.76±1.69 0.51±1.06 <0.001
ANB 33.17±44.69 5.21±20.44 <0.001
Max length 0.66.±4.69 0.47±3.56 0.09
Mand length 5.55±3.19 0.27±0.69 <0.001
WITS 55.18±42.73 6.90±20.44 <0.001
BETA angle 23.57±16.19 2.40±2.96 <0.001
AFH 5.55±3.10 0.24±0.84 <0.001
PFH 4.02±1.69 0.41±1.05 <0.001
Facial Convexity 88.18±186.19 0.39±10.63 <0.001
U1-SN 6.16±5.27 -0.08±0.94 <0.001
U1-HRP 6.42±13.24 1.83±2.76 0.016**
U1-VRP 2.86±2.98 0.00±1.00 <0.001
U6-HRP 4.14±5.20 1.11±3.46 0.014**
U6-VRP -0.50±4.83 -0.05±1.83 0.502NS
L1-NB 18.65±18.88 7.94±6.99 0.003**
IMPA 2.22±4.74 0.58±0.56 0.009**
L1-HRP 2.25±4.91 0.23±1.78 0.034*
L1-VRP 4.67±3.40 0.82±0.81 <0.001
L6-HRP 8.29±6.83 1.79±1.51 <0.001
L6-VRP 11.43±5.85 0.81±1.08 <0.001
Overjet 60.76±15.46 4.60±3.58 <0.001
Overbite 42.96±19.86 6.27±8.74 <0.001
Interincisal angle -3.63±7.60 -0.12±0.64 0.04*
Abbreviations: TB: Twin Block, C: Control, SD: Standard Deviation, AFH: Anterior Facial Height, PFH: Posterior Facial height, U1-
HRP: Upper 1 to Horizontal reference plane, IMPA: Incisal Mandibular plane Angle, U1-VRP: Upper 1 to Vertical reference plane, U6-
VRP: Upper 6 to Vertical reference plane, U6-HRP: Upper 6 to Horizontal reference plane, L1-HRP: Lower 1 to Horizontal Reference
plane, L1-VRP: Lower 1 to Vertical Reference plane, L6-HRP: Lower 6 to Horizontal Reference Plane, L6-VRP: Lower 6 to Vertical
Reference plane, U1-SN: Upper 1 to SN plane, HRP: Horizontal Reference Plane VRP: Vertical Reference Plane.
Notes: p > 0.05 = NS, * p < 0 .05 = Significant, ** p < 0 .01 = Highly Significant, *** p< 0 .001 = Very highly significant.

Cephalometric findings statistically significant. The skeletal vertical cephalometric

A Class I molar relationship, significant reduction of variables showed an increase in the lower anterior facial
overjet and overbite were observed in Twin Block therapy height and posterior facial height in Twin Block group.
patients. Cephalometric findings of the Twin Block group Overall, Twin Block therapy produced a larger effect on the
and the control group are presented in table I. growth of the mandible than with untreated control subjects.
Skeletal effects Dental effects
A statistically significant increase in the mandibular In Twin Block group maxillary incisors were
length (6.02 mm) and SNB angle (2.3°) was observed in the retroclined, extruded, and distally tipped (U1/SN and
Twin Block group compared with the control group 0.3 mm U1-VRP decreased, U1-HRP increased), whereas the
and 0.3° respectively. The Twin Block group experienced mandibular incisors were proclined (2.3°), intruded, and
“Headgear effect” producing slight inhibition of forwarding labially tipped (L1-NB, IMPA increased, and L1-MP
maxillary growth as evidenced by the reduction seen in decreased). Maxillary molar teeth were distalized (1 mm)
angle SNA (-0.7°) as compared with the small increase and extruded (decreased U6-VRP and increased U6-HRP),
seen in angle SNA in the control subjects. contrarily, lower molars were moved mesially (4.5 mm)
The ANB angle demonstrated a significant decrease and extruded (L6-VRP and L6-MP increased) whereas in
when the two groups were compared. (SNA decreased, and control group maxillary molar teeth were distalized (0.3
SNB and Go-Me increased). In Twin-block group the ANB mm), and lower molars were moved mesially (0.5 mm).
angle reduced by 2°, Wits reduced by 2.74 mm and increase Significant decrease in overjet (5.72 mm) and overbite
in Beta angle by 4.8°, but there were only minor changes were observed at the end of treatment in the Twin Block
in the untreated control group and these differences were patients compared with untreated Class II controls.

194 MEDICINE AND PHARMACY REPORTS Vol. 95 / No. 2 / 2022: 191 - 196
 Original Research

Discussion the increase in mandibular length, restriction of maxillary

Functional appliances are used in the treatment of growth as validated by a reduction in ANB angle, reduction
Class II malocclusions caused by a retrognathic mandible. in Wits value and increase in Beta angle.
To what extent do these appliances bring about a clinically The vertical relationship of the jaws
significant increase in growth still remains questionable, Relative to the control group, the Twin Block
but several clinical studies and systematic reviews reported applied a forward and downward force to the mandible and
that their use brings favorable skeletal and dentoalveolar caused an increase in the lower anterior facial height and
changes. Early correction of maxillary proclination in a posterior facial height, which is similar to previous studies
severe skeletal Class II division 1 malocclusion may be [10,23,25-30].
useful to reduce the risk of trauma to prominent maxillary Dentoalveolar changes
incisors and will improve the facial esthetics during In the Twin-block group, the maxillary first molars
adolescence [21]. moved distally (1 mm). Lund and Sandler [26] noted 1.6
Effects on the maxilla mm distal movement, Toth and McNamara [27] reported
The results of this study revealed a ‘Headgear effect’ 1.5 mm, Mills and McCulloch [28] reported the distalization
on maxilla with the Twin Block group experiencing an of the maxillary molars during Twin Block appliance
inhibition of forwarding maxillary growth as evidenced by treatment. Clark [10] also found distalization of the
a 0.7° decrease in SNA angle as compared with the control maxillary molars with the Twin-block appliance. Previous
subjects (0.3°). The “headgear effect” also was observed studies of Twin-block treatment indicated ‘headgear effect’
dentally as a 1.0 mm distalization effect on the upper on the maxillary posterior teeth. Our study had a similar
molars in the Twin Block group. These results are similar observation , in agreement with previous studies [10,22,29].
to previous studies [10,11,22-25], but contradict others The mandibular molars in the Twin-block subjects
with no statistically significant reduction in SNA angle and showed extrusion (2.38 mm) and mesial movement (4.5
maxillary length [26-30]. mm) significantly greater than in the control group (0.5
Effects on the mandible mm) which is similar to studies by Mills and McCulloch
In the scientific literature, there is a controversy [26], Lund and Sandler [28] and Pattanaik S et al [34].
over the effects of functional appliances on mandibular The effect on mandibular incisors is critical and variable in
growth. Several evidence-based studies have reported different studies. The mandibular incisors showed greater
that functional appliances increase the mandibular length proclination 2.3° and were probably a result of the mesial
in the treatment of Class II malocclusion. A statistically force on the mandibular incisors induced by the protrusion
significant increase in mandibular length was observed of the mandible [9,16]. Lund and Sandler [26] reported 7.9°
in the Twin-block (6.02 mm) compared with the control proclination, Toth and McNamara [27] by 2.8°, Mills and
group (0.3 mm). These findings were similar to previous McCulloch [28] by 3.8°, Trenouth [29] by 1.4°, Khoja et al.
studies by Mills and McCulloch [23] who reported a 6.5 [32] reported a significant increase in mandibular incisor
mm increase in effective mandibular length, Toth and proclination despite capping into the Twin Block appliance.
McNamara [27] reported a 3.0 mm increase in mandibular A significant decrease in overjet (5.72 mm) and
growth. In addition, Giuntini et al. [31], Khoja et al. [32], overbite were observed at the end of treatment in the Twin
Pattanaik et al. [33,] and Ajami et al. [34] reported similar Block group compared with untreated Class II controls.
results of increased mandibular length. This finding is in accordance with studies by Clark [10],
Maxillo-mandibular changes Illing et al. [16], O’Brien et al. [24], Sharma et al. [25],
The sagittal relationship improved in the Twin Block Trenouth [29], Khoja et al. [32] and Ajami et al [34].
group than in the controls, the greater reduction was seen in
Twin-block group (ANB angle reduced by 2o, Wits reduced Conclusions
by 2.7 4mm and increase in Beta angle by 4.8°). Toth and Twin Block appliance stimulated the mandibular
McNamara [27] reported a similar reduction in ANB angle growth and improved facial esthetics in Class II
(1.8°), Sharma et al. [25] reported ANB reduction by 2.9°, malocclusion by a combination of changes in the skeletal
Khoja et al. [32] found ANB angle reduced by 1.82° and as well as dentoalveolar structures.
Ajami et al. [35] indicated a mean reduction in ANB angle “Headgear effect” was observed with the Twin
by 1.76°. This reduction in the ANB angle was primarily Block group experiencing restricted maxillary growth and
due to an increase in SNB angle. This finding is in maxillary molar distalization.
agreement with results reported by Clark [10,11,22], Illing Increase in lower anterior facial height, significant
et al. [16], Lund and Sandler [26], Mills and Mc Culloch. reduction in overjet and overbite and Class I molar
[28] and Trenouth [29]. relationship was achieved at the end of treatment in the Twin
The result of the present study indicates that skeletal Block group, although no significant changes appeared in
discrepancy in sagittal direction is mainly corrected due to the control group.

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