Thiruvenkatachari 2010

ONLINE ONLY
Comparison of Twin-block and Dynamax

appliances for the treatment of Class II
malocclusion in adolescents: A randomized
controlled trial
Badri Thiruvenkatachari, Jonathan Sandler, Alison Murray, Tanya Walsh, and Kevin O’Brien
Manchester, Chesterfield, and Derbyshire, United Kingdom
Introduction: The aim of this study was to compare Read the full text online at: www.ajodo.org,
the effectiveness of Twin-block and Dynamax appliances pages 144.e1-144.e9.
for the treatment of Class II Division 1 malocclusion.
Methods: This was a randomized controlled trial EDITOR’S COMMENT
involving 32 boys and 32 girls aged 10 to 14 years with The Dynamax appliance was developed in 2003 for
Class II Division 1 malocclusion. They were randomly al- the treatment of Class II malocclusion. Because of
located to either the Dynamax appliance group or the limited research into its effectiveness, these authors
Twin-block appliance group. Treatment was provided decided to conduct a randomized controlled trial to
by 4 clinicians at 2 centers. Records were taken at the compare the effectiveness of the Dynamax and the
start and the end of the functional phase and after all Twin-block appliances for the treatment of Class II
treatment. In addition, incisal overjet, the number of Division 1 malocclusion. See Figure 4 for a description
appliance breakages, and adverse events or side effects of the flow of patients through the Dynamax treatment
of the treatment were recorded at each patient visit. trial before the project was stopped because of the
Results: The data monitoring committee in an difficulty with continued use of the new appliance.
interim analysis at 18 months after the start of the trial Noted the primary author, ‘‘When the trial was stopped,
found significantly greater overjet reduction in the 17 Twin-block patients and 5 Dynamax patients had
Twin-block group than in the Dynamax group and completed the first functional phase of treatment. Seven
more breakages and adverse events with the Dynamax Twin-block patients and 3 Dynamax patients had drop-
appliance. As a result, treatment with the Dynamax ped out of the trial. In the Dynamax group, the clinicians
appliance was terminated, and those patients decided to transfer 11 patients to Twin-block treatment,
completed treatment with the Twin-block or a fixed because they had too many breakages (3 patients), or
appliance. Regression analysis showed a statistically overjet reduction was either minimal or nonexistent (8
significant difference in the performance over time patients). Seven patients were transferred to fixed
between the Twin-block and Dynamax appliances in appliance treatment. One patient in the Twin-block
terms of reduction in overjet, with the Twin-block group was moved to headgear treatment.’’ The authors
appliance performing significantly better than the explained the patients’ stage of treatment when the trial
Dynamax. The incidence of adverse events was greater was terminated, and, as a result, all 64 patients who
in the Dynamax group (82%) than in the Twin-block started the trial were included in the data analysis.
group (16%), with a statistically significant difference The committee monitoring the outcome of the trial
(P \0.001) between the 2 groups. concluded that there was a significantly greater overjet
Conclusions: The Twin-block appliance was more reduction in the Twin-block group than in the Dynamax
effective than the Dynamax appliance when overjet group and more breakages and adverse events with the
was evaluated and the Dynamax appliance patients Dynamax appliance. Perhaps more interesting to the
reported greater incidence of adverse events with their casual observer is the resourcefulness of these investiga-
appliance than those who were treated with the tors when their well-designed trial went bad, primarily
Twin-block appliance. because of appliance breakage and patient-compliance
issues. Having an orthodontic clinical trial halted before
Am J Orthod Dentofacial Orthop 2010;138:144-5
0889-5406/$36.00
completion certainly adds an interesting twist to the
Copyright Ó 2010 by the American Association of Orthodontists. story.
doi:10.1016/j.ajodo.2010.04.002
144
American Journal of Orthodontics and Dentofacial Orthopedics Thiruvenkatachari et al 145
Volume 138, Number 2
Q&A
Turpin: Did you have any experience with the
Dynamax appliance before this study? If so, did the
breakage problems surprise you?
Thiruvenkatachari: Yes, all clinicians had used the
appliance before this study, and we had a few break-
ages with it. However, what we didn’t expect was the
adverse events with the Dynamax appliance. Eighty-
one percent of the patients in the Dynamax group
came in at least once reporting problems (excluding
breakages), compared with just 17% in the Twin-
block group. This was surprising and a main reason
that we stopped this trial early.
Fig 1. Design of the Dynamax appliance.
Turpin: How did you finally decide to switch patients
from 1 appliance to another before the end of the
18-month trial period?
Thiruvenkatachari: I don’t think the results would
Thiruvenkatachari: Before we started the study, we
be any different in another prospective trial with the
had discussed this with the data monitoring commit-
same appliances. This study was conducted at 2 cen-
tee and determined that we would switch groups if
ters, and 4 clinicians participated. The results were
any patient had either more than 3 breakages with
similar for both centers and all clinicians. If it had
the appliance or no clinical change after 9 months
been a single-center study with 1 clinician, we could
with the appliance. Thus, we followed the protocol.
argue that the results were because of the clinician’s
Turpin: Do you think another prospective trial lack of experience or the patients’ socioeconomic
comparing these functional appliances would yield status. All clinicians involved in the study were
different outcomes? specialist orthodontists.
Fig 4. Flow of patients through the Dynamax treatment trial for treatment of Class II Division 1 patients.

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Comparison of Twin-block and Dynamax

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