TWIN BLOCK

PAVITHRA DEVI .S
1st YR MDS
DEPT. OF ORTHODONTICS &
DENTOFACIAL ORTHOPEDICS
 CONTENT
• Introduction
• History
• Philosophy behind twin block therapy
• Occlusal inclined plane
• Angulation of inclined planes
• Diagnosis and treatment planning
• Indications & Contraindications
• Bite registration
• Appliance design & construction
• Types of twin block
• Stages of treatment
• Treatment of class II div 1 malocclusion deep overbite
• Treatment in mixed dentition
• Combination therapy
• Twin block traction technique
• Treatment of anterior open bite and vertical growth patterns
• Treatment of class II div 2 malocclusion
• Treatment of class III malocclusion
• Management of crowding
• Treatment of facial asymmetry
• Magnetic twin blocks
• Adult treatment
• TMJ pain & Dysfunction syndrome
• Conclusion
 INTRODUCTION

Twin blocks are simple bite blocks with occlusal inclined planes.

They are designed for full time wear

that achieve rapid functional
correction of malocclusion by
transmission of favourable occlusal
forces to occlusal inclined planes
that cover the posterior teeth.
Comprises of separate upper and
lower units which are not joined
together.
HISTORY

 WILLIAM J CLARK was a Scottish orthodontist

 Introduced TWIN BLOCK in the year 1977
 As the saying goes,
“ Necessity is the mother of all inventions.”
 Even the twin block was evolved in response to a
clinical problem.
 DEVELOPMENT OF TWIN BLOCK

 A young patient COLIN GOVE , fell down & completely luxated an upper central incisor.
Fortunately, he kept the tooth and within few hours of accident the tooth was reimplanted
using temporary splint and later on with stabilizing splint.
 After 6 months, the occlusal relation was CLASS II div 1 with
overjet of 9 mm and lip trap. This lip trap was causing mobility
and root resorption.
 Then it was necessary to design an appliance that could be worn
full time to posture the mandible forward. That time due to
unavailability of such appliance simple bite block were
constructed with an inclined plane of 90˚ with incisor edge to edge
with 2mm of vertical separation.
DIFFERENT STAGES OF
TREATMENT
 Fortunately, the young patient successfully made an effort to wear the
appliance and then this technique came into being.
 The first Twin block appliances were fitted on 7 th September 1977 in
the same patient whose age was 8 yrs, 4 months and in a span of 9
months, overjet reduced from 9mm to 4mm.
 PHILOSOPHY BEHIND TWIN BLOCK
THERAPY
 Considerable forces are applied through the muscles of mastication to the teeth
and the underlying bony structures to influence both the internal and external
structure of the basal bone.
 It is this natural mechanism of bone remodelling by occlusal
force vectors that forms the basis of functional correction by
the Twin Block technique.
 OCCLUSAL INCLINED PLANE

 Fundamental functional mechanism of the natural

dentition.

TWIN BLOCK APPLIANCES:

Simple bite blocks
Rapid function correction by transmission of
favourable occlusal forces to inclined planes.
If the mandibular inclined planes are in a
distal relation to that of maxilla then the force
acting on the mandibular teeth will have a
distal force vector leading to a class II growth
tendency.

The occlusal plane acts as a guiding

mechanism causing mandible to be displaced
downward and forward.
ANGULATION OF INCLINED PLANES

Earliest twin blocks were constructed

with inclined planes articulated at 90˚.
Later altered to 45 degrees.
Finally changed to 70˚ which is
widely used now.
 DIAGNOSIS AND TREATMENT
PLANNING

Clinical Examination
Photographs
Study models
Radiographs
VISUAL TREATMENT OBJECTIVE

The test enables us to visualize how the patient’s profile would be

after functional appliance therapy.
An improvement in the profile is considered a positive indication for
the use of an appliance.
 FUNCTIONAL TREATMENT OBJECTIVE

• This method is suitable for use with

visual imaging techniques using
superimposition of cephalometric and
photographic records.
• FTO predicts the facial changes that
result from mandibular advancement.
 INDICATIONS
Uncrowded permanent dentition with class II div 1
Patient should be in growing age for favourable skeletal
change
Class II div 1 in mixed dentition period
Class II div 1 with anterior open bite
Class II div 1 with deep overbite
Class II div 2 malocclusion
Class III malocclusion

Class III Malocclusion

 CONTRAINDICATIONS

Vertical growth
Crowding that may require extractions
Examination of profile
 ADVANTAGES

• Aesthetics & Comfort.

• Function – there is less interference.
• Patient compliance – can be fixed to teeth temporarily or
permanently.
• Full functional correction of occlusal relationship can be achieved in
most cases.
 OTHER ADVANTAGES….

• Facial appearance
• Speech is not drastically affected
• Facial asymmetry can be treated
• High efficiency
• Integration with fixed appliances
• Treatment of temporomandibular dysfunction
 DISADVANTAGES

• Mandibular incisor proclination.

• An increase in the vertical facial dimension is seen.
• Clockwise rotation of the maxillary plane.
• Limited increase in mandibular growth.
• Relapse
 BITE REGISTRATION

Activation aims to achieve :

 Reduction of overjet
 Correction of distal occlusion
 Midline correction.

Upto 10 mm overjet: edge to edge incisor relationship

Overjet greater than 10 mm : Initial advancement of 7mm or 8mm
followed by reactivation of the appliance after occlusion had corrected to
initial bite registration.
 BITE REGISTRATION PROCEDURE
The amount of sagittal advancement of the mandible is planned.
A horse –shoe shaped wax block is prepared for insertion
between the upper and lower teeth.
The patient is made to sit in an upright and non- strained position.
The mandible is guided to the desired sagittal position.
The pt is asked to practice placement of the mandible at the
desired sagittal position a few times before registration of the
bite.
The pt should be instructed to occlude with the midlines coincident.
The wax block is placed over the occlusal surface of the lower cast and is gently
pressed so as to form the indentations of the lower buccal teeth.
The wax block is now placed on the lower jaw & it is asked to bite at the desired
sagittal position.
It is the removed and placed on the models & checked.
If found all right, the excess wax is trimmed off.
 EXACTO BITE/PROJET BITE

 Interocclusal record for accurate control.

 Various amount of sagittal activation can br done by selecting the
appropriate groove to engage the maxillary incisors in registering the
protrusive
 GEORGE BITE GAUGE

 It has a millimetre gauge to measure protrusive path of mandible

 Total protrusive movement is calculated by first measuring the overjet in
centric occlusion and then in position of maximum protrusion
 Bite forks comes in two sizes: 2mm & 5mm
 VERTICAL ACTIVATION

 An important principle is that the blocks should be thick enough to

open the bite slightly beyond freeway space
 On average bite blocks are not less than 5mm thick in the first
premolar or first deciduous molar region
 In treatment of anterior open bite it is necessary to register bite with a
greater interincisal clearance
 CONTROL OF VERTICAL DIMENSION

 Mechanism of control of vertical dimension differs in fixed and functional

therapy
 Fixed mechanics: Teeth remain in occlusion during course of treatment and
the effect is limited to intrusion or extrusion of individual teeth to increase or
decrease overbite and level of occlusal plane.
 Functional appliances: Influence development in antero posterior and
vertical dimensions simultaneously, control of vertical dimension is achieved by
covering teeth in opposing arches & controlling the intermaxillary space.
 OPENING THE BITE
In deep overbite cases check if profile improves when mandible is postured
downwards & forwards
This confirms that bite should be opened by encouraging eruption of posterior
teeth to increase vertical dimension of occlusion
At the same time occlusion is freed between posterior teeth to encourage
selective eruption of posterior teeth to increase vertical dimension of occlusion
in posterior region
 CLOSING THE BITE

Reduced overbite or anterior open bite is often related to vertical facial growth
pattern
An acrylic block is designed to maintain the contact on posterior teeth
throughout treatment.
This result in relative intrusion of posterior teeth while the anterior teeth are free
to erupt thereby reducing anterior open bite
 APPLIANCE DESIGN

Base plate
Occlusal bite blocks with inclined plane
Midline screws to expand upper arch
Clasps on upper molar and premolars
Clasps on lower premolars
Inter dental clasps on lower incisors
A labial bow to retract the upper incisors
 TYPES OF TWIN BLOCK

1. Standard Twin Block

2. Sagittal Twin Block
3. Reverse twin block 4. Magnetic twin block
STANDARD TWIN BLOCK

Labial bow
Delta clasps
Ball end clasps
Baseplate
 LABIAL BOW

 It tends to over correct incisor angulation

 Used to upright severaly proclined incisors
 Earlier activation will act as a brake to limit
functional correction by mandibular
advancement
 DELTA CLASP

Delta clasp was designed by William J

Clark ( 1985 )
 Originally retentive loops – Triangular
 Alternatively the loops – Circular (or)

Ovoid
 DELTA CLASP

 Improves retention
 Reduce metal fatigue
 Minimal need for adjustment
 BALL END CLASP

 Routinely placed mesial to lower canines and in the upper

premolar or deciduous molar regions for interdental retention
from adjacent teeth
 Easy to fabricate
 Single gingival interference
 Less gingival irritation
 Indicated for additional retention
 BASE PLATE

 Appliance can be made of heat cure acrylic

or cold cure acrylic
 Cold cure acrylic: convenient and speed are
advantages but compromises strength and
accuracy
 Heat cure acrylic: additional strength and
accuracy
 OCCLUSAL INCLINED PLANE

• During the evolution of the technique.. The angulations used were 45 degree.
• Also results in equal downward & forward force on the mandibular dentition.
• Finally it was changed to 70˚..to apply a more horizontal component of force.
UPPER & LOWER INCLINED PLANE
 POSITION OF INCLINED PLANE

• Angle stressed the importance of the 1st permanent molars and described the
development of key ridge in the first molar region in response to functional
forces applied to the molars.
• Clark tested the response by moving the inclined planes mesial to the first
premolar region. This reduced both the efficiency of the appliance and the
response to mandibular advancement.
 STAGES OF TREATMENT

 Twin block treatment is described in two stages.

Active Phase Support phase

 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 & transverse dimensions.
 FIRST VISIT
 First visit – on fitting twin block appliances:
 The overjet is measured before treatment with the teeth in occlusion and the mandible fully
retruded, this measurement is recorded for future reference
 The lingual flange of the appliance must be relieved slightly lingual to the lower incisors to
avoid gingival irritation as the appliance is driven in by the occlusion during the first few
days.
 The clasps are adjusted to hold the appliances securely in position without impinging on the
gingival margin. If a labial bow is present, it should be out of contact with upper incisors.
 The clinician should check that the patients bites comfortably in a protrusive bite. Selected
cases benefit by bonding appliances for the first 10 to 14 days.
 SECOND VISIT
 Second visit – after 10 days:
 The patient should be wearing the appliances comfortably & eating with them in
position after 10days.The initial discomfort of a new appliance should be
resolved.
 If the patient is failing to posture forward consistently, the clinician should
consider reducing activation by trimming the inclined planes slightly.
 Improve muscle balance becomes evident quickly in the face because the
appliance is worn full time. This improvement should be noted for the patient
and parents as an encouraging sign of early process.
 THIRD & FOURTH VISIT
 Third visit – after 4 weeks:
 At each visit, progress is reviewed by measuring the overjet. At the same time the
occlusion is checked for correction of the buccal segment relationships.
 Positive progress should now be noted in facial muscle balance, this should be
confirmed by a reduction in overjet measured intraorally with the mandible fully
retracted.
 Fourth visit – after 6 weeks:
 A similar pattern of adjustment and checking of occlusion and overjet should occur
after 6 weeks.
 SEQUENCE OF TRIMMING OF BLOCKS

In treatment of deep overbite, bite blocks are

trimmed selectively to encourage eruption of lower
posterior teeth to increase vertical dimension and
level the occlusal plane.
In anterior open bite and vertical growth patterns,
posterior bite block remains un reduced and intact
throughout treatment.
In results in intrusive effect of posterior teeth while anteriors are free to
erupts, which helps to increase the overbite and bring the anterior teeth
into occlusion
At the end of the active phase, there should be a three point contact in
the incisor & molar region and the sagittal relationship should be in a
slightly overcorrected position.
Aim is to achieve correction to class 1 occlusion with overjet & overbite
fully corrected.
 SUPPORT PHASE

The objective of the support phase is to retain

the corrected incisor relationship until the
buccal segment occlusion is fully established.
The appliance of choice is an upper
removable appliance with anterior inclined
plane.
Lower twin block appliance is left out at this stage
and removal of posterior bite blocks allows posterior
teeth to erupt.
The upper and lower buccal teeth usually settle into
occlusion within 4 -6 months.
Full time wear is continued for another 3-6 months
to allow time for internal bony remodelling to
support the corrected occlusion.
 RETENTION

Treatment is followed by retention with upper anterior inclined plane

appliance.
Appliance wear is reduced to night time only when occlusion is fully
established.
Good buccal segment occlusion is important to maintain the
correction of arch to arch relationships.
 AVERAGE TREATMENT TIME

Active phase : 6-9 months

Support phase :3-6 months
Retention : 9 months
Average treatment time :18 months
TWIN BLOCK

Pavithra Devi .S
Ist year MDS
Dept. of. Orthodontics &
Dentofacial Orthopedics
 CONTENT
• Treatment of class II div 1 malocclusion deep overbite
• Treatment in mixed dentition
• Combination therapy
• Twin block traction technique
• Treatment of anterior open bite and vertical growth patterns
• Treatment of class II div 2 malocclusion
• Treatment of class III malocclusion
• Management of crowding
• Treatment of facial asymmetry
• Magnetic twin blocks
• Adult treatment
• TMJ pain & Dysfunction syndrome
• Conclusion
TREATMENT OF CLASS II DIV 1 MALOCCLUSION
DEEP BITE

Bite registration:
2mm vertical clearance between incisal edges of upper
and lower incisors
Protrusive bite registered to reduce overjet and distal
occlusion on average by 5 - 10 mm on initial
activation depending on the freedom of movement in
protrusive function.
 INSTRUCTIONS ON FITTING TWIN BLOCKS

Twin blocks to open the bite

Inclined planes must be clear of lower
molars so that they can erupt without
obstruction
Instructions should be given for proper
insertion and removal of appliance
 FULL TIME APPLIANCE WEAR

Temporary fixation of twin blocks:

Unique advantage of twin block
Guarantees full time wear of appliance at the start of treatment
The teeth should be fissure sealed and applied topical fluoride as a
preventive measure prior to fixation
Two alternative methods of fixation of twin blocks:
1) The appliance may be fixed to the teeth by spreading zinc phosphate or zinc oxide
on tooth bearing areas and seating the appliance in place adhering to the teeth.

2) Twin blocks may also be bonded directly on to teeth by applying composite

around clasps. This is useful in mixed dentition when ball end clasps may be
bonded directly to deciduous molars to improve fixation.
 SOFT TISSUE RESPONSE

As a result of altered muscle balance, significant changes in facial

appearance are seen with in 2 or 3 weeks of starting treatment with
Twin Blocks.
 As the appliance is worn full time, even during eating, rapid soft
tissue adaptation occurs to assist the primary functions of mastication
and swallowing that necessitate an effective anterior oral seal.
 REACTIVATION OF TWIN BLOCKS
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. Specially in deep bite cases as extending
the occlusal acrylic of the lower block distally will prevent
eruption of lower 1st molar.
 PROGRESSIVE ACTIVATION OF
TWIN BLOCKS
 If overjet is greater than 10 mm
 In any case where full correction of arch relationships is not
achieved after the initial activation, an additional activation is
necessary.
 In vertical growth pattern
 In adult treatment
 In treatment of TMJ dysfunction
 TREATMENT IN MIXED DENTITION

The principles of treatment are unchanged in mixed dentition, although

the response to treatment may prove to be slower depending on
patients rate of growth
 APPLIANCE DESIGN

 Similar design to permanent dentition

 Delta clasps are used on lower first or second deciduous molars
 Alternatively C clasp may be used for retention on deciduous molars
 Bonding composite on buccal surface of these teeth to get additional undercut
 Grinding retention grooves
 Using synthetic crown contours
 OCCLUSOGUIDE APPLIANCE

 It’s a preformed mini positioner appliance

 It is designed to fit upper and lower teeth and to act as
a functional retainer by engaging the teeth in edge
relationship in a slightly open position with an inter
incisal distance of 3mm
 Comes in different sizes
 Worn 1-2 hours per day and patient is instructed to
actively bite into the appliance
 COMBINATION THERAPY

Combination therapy describes the combined use of functional and

fixed techniques in the management of malocclusion
Optimum timing of treatment is either in late mixed dentition or
early permanent dentition.
In some cases twin blocks may be adapted for simultaneous use with
fixed appliances
CONCURRENT STRAIGHTWIRE AND THE TWIN BLOCK
THERAPY :
 Based on material provided by Dr. GARY BAKER, Canada.
Timing is Everything (Gary Baker & Beverly Ireland)
Twin block technique corrects skeletal discrepancies first, both in the
anteroposterior and vertical dimension followed by alignment of the teeth.
The first phase ( skeletal correction ) may occur in mixed dentition and the
second phase ( dental correction ) may follow when almost all permanent teeth
has erupted.
 TWIN BLOCK TRACTION TECHNIQUE

When the response to functional correction is poor, the addition of

orthopaedic traction force may be considered.
This method was limited to treatment of severe malocclusion, where
growth is unfavourable for conventional fixed or functional therapy.
 INDICATIONS

In treatment of severe maxillary protrusion

To control a vertical growth pattern by the addition of vertical
traction to intrude the upper posterior teeth
In adult treatment where mandible growth cannot assist the
correction of severe malocclusion
THE CONCORDE FACEBOW

 Cousins & Clark in 1965

Concorde facebow apply intermaxillary and
extra oral traction to restrict maxillary growth
and to encourage mandibular growth in
combination with functional mandibular
protrusion
Intermaxillary traction added to ensure
effectiveness of appliance
 TREATMENT OF ANTERIOR OPEN BITE AND
VERTICAL GROWTH PATTERNS

Aetiology of the problem should be diagnosed

Prognosis for correction of anterior open bite
depends on the degree of skeletal and soft tissue
imbalance
Direction of facial growth also affects prognosis
INTRA ORAL TRACTION TO CLOSE
ANTERIOR OPENBITE

 Intraoral elastics may be used to accelerate bite closure

as an efficient alternative to high- pull extraoral traction
 Introduced by Dr. Christine Mills in Vancouver
 The intrusive effect of the bite blocks is reinforced by
running a vertical elastic between upper and lower teeth
on both sides
TREATMENT OF CLASS II DIV 2 MALOCCLUSION

 Retroclined upper incisors are responsible for

holding the mandible in distal position in
angle’s class II div 2 malocclusion
 Correction is done by advancing mandible
forward & downward and encouraging lower
molars to erupt
 Upper incisor are advanced
Bite registration :
 Construction bite is registered with
incisors in edge to edge occlusion
 Vertical development is the primary
factor in correction of class II div 2
malocclusion with minimum
advancement of mandible
 TWIN BLOCK SAGITTAL APPLIANCE

• Witzig in 1987 used it for anteroposterior

development of arch form
• Design of upper twin block is modified by
addition of two sagittal screws set in palate for
anteroposterior development
• It can be used in lower arch too to increase arch
length
 COMBINED TRANSVERSE AND SAGITTAL
DEVELOPMENT
 Triple screw sagittal appliance  Three way screw
 TREATMENT OF CLASS III MALOCCLUSION

Reverse twin blocks:

 The position of bite blocks are reversed compared to twin
blocks for class II treatment
 Designed to encourage maxillary development by action
of reverse occlusal inclined planes cut at 70˚ angle
 Occlusal forces exerted on mandible is directed
downwards & backwards by the reverse inclined planes
 CASE SELECTION

Early treatment is often indicated

Simplest clinical guideline is ability to achieve edge to edge upper
& lower incisors
Prognosis is reduced when degree of skeletal discrepancy is more
An initial rapid maxillary expansion (RME) is indicated in severe
cases in young patients [ McNamara 1993]
 BITE REGISTRATION
 Construction bite recorded with 2mm inter incisal
clearance with fully retruded position
 In brachyfacial class III additional vertical activation
applied to further open bite by giving 4mm inter
incisal clearance
 LIP PADS
 To enhance the forward movement of upper labial segment
 It supports upper lip clear of the incisors
 PETIT FACE MASK FOR MAXILLARY
PROTRACTION
The reverse pull face mask is combined with rapid
maxillary expansion in young patients to treat
class III malocclusion by the application of
orthopaedic forces.
This enhances the action of forces for maxillary
protraction
Increased skeletal response to improve the
maxillary position.
MANAGEMENT OF CROWDING
 Interceptive treatment should be initiated as early as possible in the
mixed dentition
 Compatibility is checked by sliding lower model forward
 In permanent dentition fixed appliance treatment may precede twin
block treatment to correct an irregular arch form
 In less crowded cases fixed appliances may be intergrated with
twin blocks
TREATMENT OF FACIAL ASYMMETRY

 Sagittal twin block is the

appliance of choice for
correction of dental or facial
asymmetry
 MAGNETIC TWIN BLOCKS
 Magnets in twin block accelerate correction of arch relationship
 Magnets often used are
1. Samarium - cobalt
2. Neodymium - boron
 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.
Attracting magnets :
The attracting magnetic force pulls the appliances together and
encourages the patient to occlude actively and consistently in a
forward position
Accelerated correction of distal occlusion
Can be used in correction of facial asymmetry
Repelling magnets :
The repelling magnetic force is intended to apply additional stimulus to
forward posture as the patient closes into occlusion
Used in twin blocks with less magnetic activation built into occlusal
inclined planes
 ADULT TREATMENT

 Twin blocks can be used in treatment of adults if the skeletal

discrepancy is not severe
 In severe skeletal discrepancies, twin blocks are contraindicated and
orthognathic surgery is the treatment of choice in adult patients
TMJ PAIN AND DYSFUNCTION SYNDROME

 No dental condition is more distressing for the patient than

chronic TMJ pain
 An excellent functional occlusion is the cornerstone of treatment
for temporomandibular dysfunction
 TWIN BLOCKS IN TEMPOROMANDIBULAR
JOINT THERAPY
Pain is relieved within 4 -7 days of fitting twin blocks
Facial balance is improved and muscle spasm relieved
The disk is recaptured by posturing the mandible downward & forward to advance the
condyles
Rather than acting as a passive splint twin blocks can move teeth that are causing
occlusal imbalance
The upper block may be trimmed selectively over the lower first molar only, using
molar bands with vertical elastics to accelerate eruption
 CONCLUSION
 In the pursuit of ideals in orthodontics, facial balance and harmony are
of equal importance to ideal and perfect occlusion
 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
 REFERENCES

 Twin block functional therapy by William J Clark – 3 rd Edition

 Dentofacial orthopedics with functional appliance by Thomas M. Graber,
Thomas Rakoshi, Alexandre G. Petrovic – 2nd Edition
 Essentials of orthodontics by Rohan Mascarenhas – 1 st Edition