ORIGINAL ARTICLE

Skeletal and dentoalveolar effects of Twinblock and bionator appliances in the treatment of Class II malocclusion: A comparative study
Ashok Kumar Jena,a Ritu Duggal,b and Hari Parkashc New Delhi, India Introduction: The purpose of this study was to evaluate the skeletal and dentoalveolar effects of the Twin-block and bionator appliances in the treatment of Class II Division 1 malocclusions. Methods: Fifty-ve girls from North India with Class II Division 1 malocclusion and the same physical growth maturation status were selected for the study. The subjects were divided among a Twin-block group (n 25), a bionator group (n 20), and a control group (n 10). Pretreatment and posttreatment lateral cephalometric radiographs of the treatment group subjects, and prefollow-up and postfollow-up radiographs of the control group subjects, were traced manually and subjected to the pitchfork analysis. Results: Statistical software was used for 1-way analysis of variance and multiple comparisons (post-hoc test, Bonferroni). A P value of .05 was considered statistically signicant. Neither the Twin-block nor the bionator appliance signicantly restricted forward growth of the maxilla (P .476). Mandibular growth in the Twin-block subjects was signicantly greater than in controls (P .005). Mandibular growth was comparable in the control and the bionator subjects. Molar correction, overjet reduction, and proclination of the mandibular incisors were signicantly greater (P .000) in the treated subjects compared with the controls. Conclusions: Both the Twin-block and bionator appliances were effective in correcting molar relationships and reducing overjets in Class II Division 1 malocclusion subjects. However, the Twin-block was more efcient than the bionator in the treatment of Class II Division 1 malocclusion. (Am J Orthod Dentofacial Orthop 2006;130:594-602)

lass II malocclusions can manifest in various skeletal and dental congurations.1-5 Most Class II patients have a deciency in the anteroposterior position of the mandible.6 Several treatment options are available for managing Class II problems, and functional appliances have been used for many years in the treatment of Class II Division 1 malocclusions.7-12 Several varieties of functional appliances are currently in use that aim to improve skeletal imbalances. Alteration of maxillary growth, possible improvement in mandibular growth and position, and change in dental and muscular relationships are the expected effects of these functional appliances. It has been claimed that the forward growth of the maxilla can be inhibited,13-15 redirected,16 or unaffected17-19 by functional appliances. The effect of functional apFrom the Division of Orthodontics, Department of Dental Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India. a Senior resident. b Associate professor. c Professor and head. Reprint requests to: Ritu Duggal, Department of Dental Surgery, All India Institute of Medical Sciences, New Delhi, India; e-mail, rituduggal@ rediffmail.com. Submitted, August 2004; revised and accepted, February 2005. 0889-5406/$32.00 Copyright 2006 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2005.02.025

pliances on mandibular growth is controversial. Some authors suggested that mandibular growth can be increased with functional appliance treatment,20-24 but others believe the appliances have no real effect on mandibular length.25,26 However, most researchers agree that the appliances produce retroclination of the maxillary incisors10,27,28 and proclination of the mandibular incisors.29,30 There is no consensus on how the molar correction occurs. Two of the more popular functional appliances used today are the Balters bionator8,31 and Clarks Twinblock.32 Few studies have compared the effects of these appliances. Both are tooth-borne, but the Twin-block is designed for full-time wear to take advantage of all functional forces applied to the dentition, including the forces of mastication. The purpose of the study was to evaluate the skeletal and dentoalveolar effects of the Twin-block and bionator appliances in the correction of Class II Division 1 malocclusions.
MATERIAL AND METHODS

The subjects for this study were selected from the Orthodontic Clinic, Division of Orthodontics, Department of Dental Surgery, All India Institute of Medical Sciences, New Delhi; 55 girls from North India having the same cervical vertebrae maturation index were

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chosen.33 Each met the following criteria: (1) Class II Division 1 malocclusion with normal maxilla and retrognathic mandible, (2) stage 3 cervical vertebra maturation index (transition stage), (3) full-cusp Angle Class II molar relationship on either side, (4) mandibular plane angle less than or equal to 25, (5) little or no crowding or spacing in either arch, and (5) overjet of 6 to 10 mm. Girls with a history of orthodontic treatment, an anterior open bite, a severe proclination of the maxillary and mandibular teeth, or a systemic disease affecting growth were not considered for this study. Ten subjects constituted the control group; they received no treatment but were followed until the end of the study. The remaining 45, contstituting the treatment group, were divided into a Twin-block (n 25) and a bionator (n 20) group. The subjects in the treatment group were treated with standard Twin-block or bionator appliances. Single-step mandibular advancement was carried out during wax bite registration. An edge-to-edge incisal relationship with 2 to 3 mm bite opening between the central incisors was maintained for all subjects. The Twin-block and bionator appliances were all made by the same operator (A.K.J.). The Twin-block patients were instructed to wear the appliance 24 hours per day, especially while eating; they could be removed for toothbrushing. The patients in the bionator group were instructed to wear the appliance at least 15 hours per day. All subjects in the treatment group were checked every 4 weeks until the end of active functional appliance therapy. Interocclusal acrylic trimming was performed in all patients to allow unhindered vertical development of the mandibular buccal segments. Activation of the labial bow was avoided during treatment. Appliance use was discontinued when overjet and overbite were reduced to 1 to 2 mm or when the patient either was deemed to have nished active appliance therapy or went on to further appliance therapy. Wearing times varied greatly, depending on the level of patient cooperation and the rate at which the deciduous teeth exfoliated. Lateral cephalometric radiographs with the teeth in occlusion were obtained for all subjects before the start of treatment and at the end of active functional appliance therapy, or at the beginning and end of the observation period. All cephalometric lms were taken with the same machine with the same settings. The pitchfork analysis was used to evaluate skeletal and dentoalveolar changes that contributed to the correction of Class II malocclusions.34 This analysis uses cephalometric superimposition to measure physical movement of the maxillary and mandibular molars and

Fig 1. Pitchfork diagram: Cranial Base, base of cranium; Maxilla, maxillary change in relation to cranial base; Mandible, mandibular change in relation to cranial base; ABCH, anteroposterior change in relationship between maxilla and mandible; Total U6, total maxillary molar movement; Total L6, total mandibular molar movement; Total Molar, ABCH total U6 total L6, change in molar relationship; Total U1, total maxillary incisor movement; Total L1, total mandibular incisor movement; Overjet, ABCH total U1 total L1, change in incisor relationship.

incisors relative to their dental bases, as well as the displacement of the maxilla and mandible relative to the cranial base. Measurements are dened as positive if they contribute to Class II correction and negative if they aggravate the Class II relationship. The magnitude of changes during treatment and the source of the changes eg, skeletal or dentalwere also determined. The algebraic sum of the various components is equal to the change in molar relationship and overjet. The pitchfork diagram summarizes the various components of change (Fig 1). Pretreatment and posttreatment cephalograms were traced for each patient at the same time, as suggested by Johnston.34 All measurements were made 3 times, manually, with an electronic digital caliper, and the means were used for statistical analysis.
Statistical method

A master le was created and the data statistically analyzed on a computer with software (SPSS, Chicago, Ill). A data le was created under dBase and converted into microstat le. The data were subjected to descriptive analysis for mean, range, and standard deviation of all variables. One-way analysis of variance and posthoc test (Bonferroni) for multiple comparisons were used. Probability (P value) of .05 was considered statistically signicant.

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Table I.

Mean ages and duration of study among control, Twin-block, and bionator groups
Control group (n Mean SD 10) Twin-block group (n Mean SD 11.40 12.78 0.90 4.00 25) Bionator group (n Mean SD 11.00 16.18 1.30 2.52 20)

Age at start of treatment (y) Duration of study (mo)

10.97 16.37

0.46 0.94

Table II.

Treatment changes for all measurements

Control group (n 10) Twin-block group (n Mean 1.33 3.69 5.02 0.02 0.05 0.07 0.63 0.82 1.45 5.11 1.45 1.27 6.31 SD 1.77 1.53 1.78 0.48 0.75 1.21 0.74 0.77 1.26 1.78 1.33 0.96 1.71 25) Bionator group (n Mean 1.56 2.86 4.42 0.18 0.13 0.31 0.56 0.79 1.35 3.90 0.59 1.50 4.95 SD 1.12 1.18 1.66 0.71 0.74 1.36 0.51 0.56 0.82 1.45 1.67 0.76 2.00 20) P value .476 .000 .004 .215 .003 .025 .039 .068 .016 .000 .000 .000 .000 Intergroup comparison C-TB C-B TB-B NS NS NS * NS NS NS NS NS NS * NS * NS NS * NS NS * NS NS * * NS

Parameters Maxilla ABCH Mandible U6 tip U6 bodily Total U6 L6 tip L6 bodily Total L6 Molar correction Total U1 Total L1 Overjet

Mean 1.98 1.39 3.37 0.32 0.86 1.18 0.04 0.23 0.27 0.48 0.55 0.60 0.24

SD 0.60 0.43 0.57 0.22 0.36 0.53 0.34 0.73 1.06 0.80 0.51 0.24 0.72

95% CI for mean 2.41-1.55 1.08-1.69 3.02-3.83 0.48- 0.16 1.12- 0.60 1.56- 0.80 0.20-0.27 0.29-0.75 0.48-1.02 0.09-1.04 0.92- 0.18 0.77- 0.43 0.28-0.74

95% CI for mean 2.07- 0.60 3.05-4.32 4.66-6.14 0.18-0.21 0.21-0.40 0.43- 0.57 0.32-0.94 0.50-1.14 0.93-1.98 4.63-6.10 0.90-2.00 0.87-1.67 5.74-7.15

95% CI for Mean 2.09- 1.04 2.30-3.42 3.36-5.16 0.51-0.15 0.48-0.21 0.95-0.32 0.28-0.76 0.53-1.05 0.93-1.70 3.18-4.54 0.18-1.37 1.14-1.86 4.04-5.92

NS NS NS *

C, Control group; TB, Twin-block group; B, bionator group; NS, Not signicant. *P .05; P .01; P .001.

RESULTS

The mean age of the subjects at the beginning of the study and the duration of the study are shown in Table I. The results of all measurements in the pitchfork analysis are shown in Table II and Figures 2 to 4. Positive values are those contributing to the correction of the Class II malocclusion, and negative values are those that aggravated the Class II relationship. Skeletal changes are shown in Table II and Figure 5. Mean movements of the maxilla were 1.98, 1.33, and 1.56 mm in the control, Twin-block, and bionator groups, respectively. Both appliances had a restraining effect, but it was greater with the Twinblock than the bionator. However, comparisons of maxillary growth between the subjects in the 3 groups showed no statistically signicant differences (P .476). The mean changes in mandibular position were 5.02 mm in the Twin-block group, 4.42 mm in the bionator group, and 3.37 mm in the control group. The difference between the control and Twin-block groups was large and statistically signicant (P .004). The difference between the control and the bionator groups was minimal and not statistically signicant (P .386). The difference between the Twin-block and bionator

groups was also small and not statistically signicant (P .110). The anteroposterior change in the relationship between the maxillary and mandibular base made a mean positive contribution in all 3 groups. The greatest change in apical base (ABCH) occurred in the Twinblock group (3.69 mm), followed by the bionator group (2.86 mm) and the control group (1.39 mm). The ABCH between the control and Twin-block groups was statistically signicant (P .001), compared with the change between the control and bionator groups (P .05). However, the difference in ABCH between the Twin-block and bionator groups was not statistically signicant (P .107). Dental changes are shown in Table II and Figure 6. In the control group, the mean total movement of the maxillary rst molar (U6) was 1.18 mm ( 0.32 mm tipping and 0.86 mm bodily movement). In the Twin-block and bionator groups, the mean total movement of U6 was 0.07 mm (0.02 mm tipping and 0.05 mm bodily movement) and 0.31 mm ( 0.18 mm tipping and 0.13 mm bodily movement), respectively. In the Twin-block group, U6 was moved distally. Forward movement of U6 was less in the bionator group than in control group. The movement of U6 in

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Fig 2. Pitchfork diagram of changes in control group.

Fig 4. Pitchfork diagram of changes in bionator group.

Fig 3. Pitchfork diagram of changes in Twin-block group.

the Twin-block group was signicantly different from the control group (P .05). However, there was no statistically signicant difference between the control and bionator groups (P .198) or between the 2 treatment groups (P .840) for total movement of U6. The mean total movement of the mandibular rst molar (L6) in the control group was 0.27 mm (0.04 mm tipping and 0.23 mm bodily movement). In the Twinblock group, total mesial movement of L6 was 1.45 mm, signicantly (P .05) greater than in the controls. Such movement included 0.63 mm tipping and 0.82 mm bodily movement. Thus, signicant forward movement of L6 was a factor contributing to molar correction in the Twin-block group. In the bionator group, total movement of L6 was 1.35 mm. The net change in

molar position was due to tipping (0.56 mm) and bodily movement (0.79 mm). The mesial movement of L6 in the bionator group also differed signicantly (P .05) from the control group. However, mesial movement of L6 in the treatment groups was comparable, and the difference was not statistically signicant (P 1.000). Molar correction is the algebraic sum of ABCH total U6 total L6. Molar correction was signicantly greater (P .001) in the treatment group than in the control group (Twin-block, 5.11 mm; Bionator, 3.90 mm; control, 0.48 mm). Although mesial movement of L6 contributed to molar correction in the treated subjects, molar correction was mostly due to ABCH. The amount of molar correction in treated subjects was directly related to the amount of ABCH. The change in the maxillary incisors (U1) in the control group was 0.55 mm. This was small compared with the maxillary skeletal change ( 1.98 mm) in the control group, and it is a good example of dentoalveolar compensation. In the Twin-block and bionator groups, U1 retroclined 1.45 and 0.59 mm, respectively, indicating the appliances had restraining effects. The difference in incisor change between the control and Twin-block groups was statistically significant (P .01). However, comparison of U1 change between the treatment groups showed no signicant difference (P .122). In the control group, the mandibular incisors (L1) retroclined 0.60 mm; this was unfavorable for Class II correction. In the treatment group, L1 proclined 1.27 mm in the Twin-block group and 1.50 mm in the bionator group. Such proclination helped the overjet correction. The difference in L1 change between the control and treatment groups was statistically signi-

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Control group Twin-block group Bionator group

Control group Twin-block group Bionator group

7 6 5 4 3 2 1 0 -1

6 5 4 3 2 1 0 -1 -2 -3

Ma x i l l a

A BC H

Ma n d i b l e

-2

Total U6

Total L6

Total Molar

Total U1

Total L1

Overjet

Fig 5. Comparison of skeletal changes among control, Twin-block, and bionator groups.

Fig 6. Comparison of dental changes among control, Twin-block, and bionator groups.

cant (P .001). No signicant difference in L1 change was found between the Twin-block and bionator groups (P 1.000). The change in overjet is the total change in incisor relationship; it is the algebraic sum of ABCH total U1 total L1. Overjet corrections were 0.24 mm in the control group, 6.31 mm in the Twin-block group, and 4.95 mm in the bionator group. In the treatment group, more than half of the overjet correction was contributed by ABCH. Intergroup comparison showed a statistically signicant (P .001) difference in overjet correction between the control and treatment groups. In the Twin-block group, overjet correction was also signicantly (P .05) greater than in the bionator group.
DISCUSSION

Our results showed that forward growth of the maxilla was slightly less in the treated patients than in the controls, but the difference was not statistically signicant. When the mandible was postured forward by the functional appliances, a reciprocal force acted distally on the maxilla, redirecting growth.35 Neither appliance effectively restricted forward growth of the maxilla. This agrees with some studies20,26,36-42 but contradicts others.12,32,43,44 Thus, the design of the appliance and the duration of appliance wear were not major factors in the headgear effect of functional appliance therapy. The effect of functional appliance therapy on mandibular growth is a major controversy. Many researchers have claimed that extra mandibular growth occurs with the Twin-block36-39,43,45 and bionator appliances.43,46 In this study, we showed a statistically signicant difference in mandibular growth between the Twinblock and control subjects. We observed 1.65 and 1.05 mm extra mandibular growth in the Twin-block and

bionator groups, respectively, compared with the controls. Toth and McNamara36 found 3.0 mm additional increase in condylion to gnathion length during a standardized 16-month period of Twin-block therapy, Lund and Sandler47 found 2.4 mm extra mandibular growth in a 12-month period, and Mills and McCulloch38 found 4.2 mm more growth. Illing et al43 reported a 3.9 mm increase in mandibular growth with the bionator appliance. These observations agree with the results of investigations with other functional appliances.48-51 On the other hand, some authors claim that the mandible does not experience additional growth with functional appliance therapy.14,18 In our study, mandibular change was greater with the Twin-block appliance than with the bionator. Duration and timing (during function) of appliance wear could be responsible for the difference. A randomized controlled trial by Tulloch et al52 reported small mandibular changes with the bionator. Keeling et al53 made similar conclusions about growth modication with the bionator. However, OBrien et al40 reported more mandibular changes with the bionator than with the Twin-block. The ABCH value represents the maxillomandibular differential, or the movement of the mandible relative to the maxilla. A positive value indicates that the mandible outgrew the maxilla, and a negative value means that the maxilla outgrew the mandible. ABCH was 1.39 mm in the control group, indicating 1.39 mm greater anteroposterior movement of the mandible than the maxilla. Rushforth et al54 found 1.9 mm ABCH in 17.3 months in Class II Division 1 control subjects. In our study, the ABCH in the Twin-block group was 3.69 mm in 12.78 months. The outgrowth of the mandible was signicantly greater in the Twin-block than in the untreated controls. ABCH was also greater in the

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bionator group than in the control group. However, differences in ABCH between the 2 appliances were not signicant. The greater anteroposterior movement of the mandible in the Twin-block group contributed to greater Class II molar correction. Thus, we showed that mandibular growth is more efcient with the Twinblock appliance than with the bionator or other functional appliances.54 Mesial movement of the mandibular molars and distal movement of the maxillary molars or restraint of the maxillary molars as the maxilla moves forward are ideal conditions for the correction of a Class II molar relationship. Dentoalveolar changes with tooth-borne functional appliances have been widely discussed. In our study, the maxillary rst molars moved 1.18 mm forward in the control group; this was considered normal. In the Twin-block subjects, the maxillary rst molars moved slightly to the distal side (0.07 mm) compared with the forward movement of the maxilla ( 1.33 mm). Restraint of the molars by the Twin-block appliance could be responsible for this effect. Tumer and Gultan37 made a similar observation. However, Toth and McNamara36 found 1.5 mm distal molar movement during Twin-block appliance treatment, and Lund and Sandler47 noted 1.6 mm movement. Clark12 also found distalization of the maxillary molars with the Twinblock appliance, and Mills and McCulloch45 concluded that the headgear effect caused relative distalization of the maxillary molars during Twin-block treatment. Forward movement of the maxillary molars was 0.31 mm in the bionator group. Compared with movement of the maxilla ( 1.56 mm), it appeared that the forward movement of U1 was restricted by the bionator. However, we showed that the Twin-block is more efcient than the bionator in preventing forward movement of the maxillary molars. The mean forward movement of the mandibular rst molars was 0.27 mm in the control group. Lund and Sandler47 noted only 0.1 mm mesial movement of the mandibular rst molars in their Twin-block control subjects, and Toth and McNamara36 found 0.5 mm mesial movement during a 16-month study. In our study, the forward movement of the mandibular molars in the Twin-block subjects was 1.45 mm, signicantly greater than in the control group. More forward movement of the mandibular molars in the Twin-block subjects was a factor contributing to the Class II molar correction. In the Twin-block subjects, Mills and McCulloch45 reported more mesial eruption of the mandibular molars, and Lund and Sandler47 noted substantial (2.4 mm) forward movement compared with the controls (0.1 mm). However, in contrast with our study, Toth and McNamara36 found equal forward movement

of the mandibular molars in the Twin-block and control groups. We found 1.35 mm mesial movement of the mandibular rst molars in the bionator subjects; this was relatively less than in the Twin-block group. De Almeida et al46 found 1.4 mm mesial movement of the mandibular molars in a 13-month period of bionator therapy; this agrees with the results of our study. The total molar movement (molar correction) is the sum of the movements of the maxillary and mandibular molars with ABCH. The means that 5.11 and 3.90 mm of molar correction in the Twin-block and bionator groups, respectively, are largely due to the mandible outgrowing the maxilla, rather than to signicant maxillary and mandibular molar movement. Molar correction in the control group was only 0.48 mm. Thus, in untreated subjects, although mandibular growth was greater than maxillary growth on an average, dentoalveolar compensation appeared to have kept the buccal segment relationship fairly static. In this study, 72.2% of the skeletal changes contributed to molar correction in the Twin-block group, whereas 73.3% of the skeletal changes contributed to molar correction in bionator group. In contrast to this study, OBrien et al40 found only a 41% skeletal contribution to molar correction with the Twin-block appliance. Their nding was also similar to that of Tulloch et al.52 In our study, treatment was started during the peak pubertal growth spurt, and this could have caused more skeletal contribution to molar correction by the Twin-block and bionator appliances. Thus, we showed that molar correction by the Twin-block appliance is not only greater but also occurs in a shorter time compared with the bionator. However, dentoalveolar changes contributed to rapid and greater molar correction with the Twin-block appliance. A widely accepted consensus is that the Twin-block and bionator appliances cause retroclination of the maxillary incisors and proclination of the mandibular incisors.36-38,40,43,46 In our study, maxillary incisor movement was 0.55 mm in control group. However, the amount of incisor movement was less compared with movement of the maxilla ( 1.98 mm), indicating good dentoalveolar compensation. In the Twin-block and bionator groups, the maxillary incisors retroclined by 1.45 and 0.59 mm, respectively. This could be due to the so-called headgear effect of the labial bow appliance. However, this effect was disproved by many authors.40,52,53 Toth and McNamara36 concluded that lingual tipping of the maxillary incisors is due to the contact of the lip musculature during Twin-block treatment. This lingual tipping can also be due to the labial wire in both appliances, which might come into contact with the incisors during sleeping, causing them to

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retract.55 Toth and McNamara36 found less lingual tipping of the incisors in subjects wearing Twin-block appliances without a labial bow. Trenouth39 found 14.37 lingual tipping of the maxillary incisors with the Twin-block appliance. Lund and Sandler47 achieved signicant maxillary incisor retraction using a maxillary labial bow, in contrast to Mills and McCulloch,45 who did not use a labial bow and found little change in maxillary incisor position. Illing et al43 found greater reduction in the proclination of the maxillary incisors with the Twin-block appliance (9.1) than with the bionator appliance (7.7). Our results also support the results of other authors.12,32,42,44,46 The most prominent dentoalveolar effect in the treated subjects was proclination of the mandibular incisors, which was signicantly greater than in the controls, and was probably a result of the mesial force on the mandibular incisors induced by protrusion of the mandible.36,43,44,56 In our study, the Twin-block and bionator appliances caused 1.27 and 1.50 mm of mandibular incisor proclination. The slightly greater proclination in the bionator group could be because the appliance was worn longer. Illing et al43 also found more mandibular incisor proclination with the bionator (4.0) than the Twin-block (2.0). Toth and McNamara36 found 2.8 of forward tipping and 0.7 mm of forward movement of the mandibular incisors during Twin-block treatment. Lund and Sandler47 reported 7.9 proclination, and Mills and McCulloch45 found 3.8 proclination with the Twin-block. We found an overall 0.60 mm mean movement of the mandibular incisors in the control group. Such uprighting of the mandibular incisors could be due to the restraining effect of the lower lip. The change in overjet is the total change in incisor relationship and is the algebraic sum of the ABCH total U1 total L1. As a result of treatment, overjet decreased signicantly in both appliance groups. The greatest reduction was in the Twin-block group (6.31 mm), followed by the bionator group (4.95 mm) and the control group (0.24 mm). In the treatment group, ABCH was the major factor contributing to overjet correction; other factors were restriction of forward maxillary growth, retroclination of the maxillary incisors, and proclination of the mandibula incisors. In this study, the Twin-block appliance produced more skeletal and dentoalveolar changes than the bionator, thus accounting for more overjet correction. Mills and McCulloch45 and Baccetti et al57 reported that 50% of overjet correction was due to skeletal changes with Twin-block appliance. Recently, in a multicenter, randomized controlled trial, OBrien et al40 reported only 27% skeletal change in overjet correction. However, we

showed 58.47% and 57.77% skeletal contribution for overjet correction with Twin-block and bionator appliance therapy, respectively. Thus, timing of the appliance therapyat the peak of the pubertal growth spurtplayed a crucial role, contributing more skeletal effect for molar and overjet correction in the treatment of Class II Division 1 malocclusions.
CONCLUSIONS

Early orthodontic treatment with the Twin-block and bionator functional appliances appeared to be effective in correcting molar relationships and reducing overjets in children with Class II Division 1 malocclusions. The following conclusions can be drawn from this study. 1. Neither appliance was efcient in restricting forward growth of the maxilla. 2. Both appliances increased mandibular growth, but the Twin-block induced more mandibular growth than the bionator. 3. Both appliances were signicantly effective in restricting forward movement of the maxillary molars. 4. Both appliances resulted in mesial movement of the mandibular molars, with the Twin-block producing slightly more movement than the bionator. 5. Both appliances helped dramatically in molar correction, and the Twin-block corrected the molar relationship more efciently than the bionator. 6. Forward movement of the maxillary incisors was restricted by the appliances. 7. The Twin-block and bionator appliances caused signicant forward movement of the mandibular incisors. 8. Both appliances were effective for overjet reduction in Class II Division 1 malocclusion patients, but the Twin-block appliance was better than the bionator.
REFERENCES 1. Craig CE. The skeletal patterns characteristics of Class I and Class II Division 1 malocclusions in norma lateralis. Angle Orthod 1951;21:44-56. 2. Gilmore WA. Morphology of the adult mandible in Class II Division 1 malocclusion and in excellent occlusion. Angle Orthod 1950;20:137-46. 3. Henry RG. A classication of Class II Division 1 malocclusion. Angle Orthod 1957;27:83-92. 4. Renfroe EW. A study of the facial patterns associated with Class I, Class II, Division 1, and Class II, Division 2 malocclusions. Angle Orthod 1948;18:12-5. 5. Rothstein TL. Facial morphology and growth from 10 to 14 years of age in children presenting Class II, Division 1 malocclusion:

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