Twin Block

Moderator: Dr Sujala
Presented by: N. Shweta
1
23/03/2017
Contents:

• Introduction
• Development of Twin block
• Appliance design
• Stages of Treatment
• Appliance Fabrication
• Use of Twin block in various malocclusion
• Twin block in TMJ disorders and sleep apnoea
• Effects of Twin block
• Modifications of Twin block
• Advantages of Twin block

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Introduction

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• Twin Block appliances are simple bite blocks that are designed for full-time
wear.

• They were introduced by William J Clark in 1977

• They achieve rapid functional correction of malocclusion by the transmission

of favourable occlusal forces to occlusal inclined planes that cover the
posterior teeth 4
 Development of Twin block:

• After the evolution of functional appliances therapy, many variations in the

appliances design occurred after original development of MONOBLOCK at
turn of century.

• Early appliances were bulky and cumbersome for the patients and only
suitable for night time wear. Subsequent modifications of design reduced the
bulk of these appliances as clinicians sought to increase the day time wear by
reducing palatal acrylic and replacing acrylic with some wire components.

5
• However all these functional appliances shared the common
disadvantage of being made in one piece to fit the teeth in both the jaws.

• When the upper and lower components were joined together, patient
could not speak, eat or perform other oral functions with appliance in the
mouth. In additions some variations were not esthetic and proved
uncomfortable and full time wear of appliance was not possible.

• By addressing these requirements, Twin Blocks satisfy both the patient

and the operator as one of the most “patient friendly” of all the functional
appliances.

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• Twin Block appliance evolved in response to a clinical problem that
presented when a young patient, the son of a dental colleague, fell and
completely luxated an upper central incisor.

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8
• The first Twin Block appliances were fitted on 7 September 1977, when the
patient was aged 8 years 4 months. The bite blocks proved comfortable to wear
and treatment progressed well as the distal occlusion corrected and the overjet
reduced from 9 mm to 4 mm in 9 months.

• The re-implanted incisor was crowned successfully, and the result is stable at
age 25 years.

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Philosophy behind Twin block

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The Occlusal Inclined Plane:
The occlusal inclined plane is the fundamental
functional mechanism of the natural dentition.

Cuspal inclined planes play an important part in

determining the relationship of the teeth as they
erupt into occlusion

If the mandible occludes in a distal relationship to

the maxilla, the occlusal forces, acting on the
mandibular teeth in a normal function have a
distal component of force that is unfavorable to
normal forward mandibular development.
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• The Twin block achieve rapid functional correction of malocclusion by the
transmission of favourable occlusal forces to occlusal inclined planes that
cover the posterior teeth.

• The forces of occlusion are used as the functional mechanism to correct the
malocclusion

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Appliance Design

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Standard
appliance

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Components:
• Delta clasps/ Adam’s clasp:

Delta clasps were designed by Clark and is similar to Adam's clasp in principle,
but incorporates new features to improve retention, reduce metal fatigue and
minimize the need for adjustment. The retentive loops, may be triangular in
shape (from which the name 'delta' is derived) or alternatively the loops may be
circular both having equal retentive properly

15
Ball end Clasps:
These are employed usually mesial to lower canine and in the upper premolar
or deciduous molar region to gain interdental retention from adjacent teeth.

Labial Bow:
Retracting the upper incisor prematurely limits the scope for functional
correction by 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
completed and a class I buccal segment relationship is achieved

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• Base plate

• Occlusal inclined planes:

 During the evolution of the technique, the angulation of the inclined plane
varied from 90° to 45° to the occlusal plane, before arriving at an angle of 70°
to the occlusal plane.

 An angle of 45° may be used for patients who have more difficulty in
maintaining a forward mandibular posture.

 Angle of 70° to the occlusal plane applies a more horizontal component of

force. It was reasoned that this may encourage more forward mandibular
growth.
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• A new Twin Block tool is available to facilitate construction of the
inclined planes to 45° or 70° angles.

• This was designed by Roger Harman

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Stages of Twin block Treatment

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 Stage 1: Active Phase

• Twin Blocks achieve rapid functional correction of mandibular position from

a skeletally retruded Class II to Class I occlusion using occlusal inclined
planes over the posterior teeth to guide the mandible into correct relationship
with the maxilla.

• In all functional therapy, sagittal correction is achieved before vertical

development of the posterior teeth is complete. The vertical dimension is
controlled first by adjustment of the occlusal bite blocks, followed by use of
upper inclined plane appliance.

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• In treatment of deep overbite, the bite blocks are trimmed selectively to
encourage eruption of lower posterior teeth to increase the vertical
dimension and level the occlusal plane

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• Conversely, in treatment of anterior open bite and vertical growth
patterns, the posterior bite blocks remain unreduced and intact throughout
treatment. This results in an intrusive effect on the posterior teeth, while
the anterior teeth remain free to erupt, which helps to increase the
overbite and bring the anterior teeth into occlusion

• At the end of the active stage of Twin Block treatment the aim is to
achieve correction to Class I occlusion and control of the vertical
dimension by a three-point occlusal contact with the incisors and molars
in occlusion. At this stage the overjet, overbite and distal occlusion should
be fully corrected

• Average time 6–9 months to achieve full reduction of overjet to a normal

incisor relationship and to correct the distal occlusion.
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 Stage 2: Support Phase:

• The aim of the support phase is to maintain the corrected incisor

relationship until the buccal segment occlusion is fully interdigitated.
To achieve this objective an upper removable appliance is fitted with
an anterior inclined plane with a labial bow to engage the lower
incisors and canines

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• The lower Twin Block appliance is left out at this stage and the
removal of posterior bite blocks allows the posterior teeth to erupt.
Full-time appliance wear is necessary to allow time for internal bony
remodelling to support the corrected occlusion as the buccal
segments settle fully into occlusion

• Average of 3–6 months for molars to erupt into occlusion and for
premolars to erupt after trimming the blocks.

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Bite guide:

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Retention phase:

• Treatment is followed by retention with the upper anterior inclined

plane appliance. Appliance wear is reduced to night time only when the
occlusion is fully established.

• A good buccal segment occlusion is the cornerstone of stability after

correction of arch-to-arch relationships. The appliance-effected
advanced mandibular position will not be stable until the functional
support of a full buccal segment occlusion is well established.

• Duration is 9 months, reducing appliance wear when the position is

stabilized.
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Occlusoguide Appliance:

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 Treatment Timing

Treatment timing for Twin-block therapy

Am J Orthod Dentofacial Orthop 2000;118:159-70

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• This cephalometric study evaluated skeletal and dentoalveolar changes induced by the
Twin-block appliance in 2 groups of subjects with Class II malocclusion treated at
different skeletal maturation stages in order to define the optimal timing for this type of
therapy. Skeletal maturity in individual patients was assessed on the basis of the stages
of cervical vertebrae maturation

• The findings of this short-term cephalometric study indicate that optimal timing for
Twin-block therapy of Class II disharmony is during or slightly after the onset of the
pubertal peak in growth velocity. When compared with treatment performed before the
peak, late Twin-block treatment produces more favourable effects that include:

(1)greater skeletal contribution to molar correction

(2)larger increments in total mandibular length and in ramus height
(3)more posterior direction of condylar growth, leading to enhanced mandibular
lengthening and to reduced forward displacement of the condyle in favour of effective
skeletal changes.
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Appliance Fabrication

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Bite Registration:
• Class II div 1 Malocclusion:

 Exactobite or project bite Gauge is designed to record a protrusive bite for construction
of twin blocks.

 The blue bite gauge registers 2mm vertical clearance between the incisal edges of the
upper and lower incisors, which are appropriate inter incisal clearance for bite
registration in most class II division 1 malocclusions with increased overbite.

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• In growing child, with an overjet of up to 10mm, provided the patient can posture
comfortably forwards, bite may be activated up to edge-to-edge on the incisors with a
2mm inter incisal clearance. Larger overjet require partial correction.

• The clinician can then place the bite gauge in the patient's mouth to register the bite.
Central lines should be coincident when provided no dental asymmetry is present.

• In a vertical dimension a 2mm Inter incisal clearance is equivalent to an

approximately 5-6mm clearance in the 1st premolar region and usually leaves 3mm
clearance distally in the molar region, and ensures that space is available for vertical
development of posterior teeth to reduce the overbite.

• After removing the registration bite from the patient's mouth, wax is chilled in cold
water.
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Vertical Height:

• A simple guidance is used to establish the correct vertical dimension during

the twin block phase of treatment. The inter gingival height is measured
from the gingival margin of the upper incisor to the gingival margin of the
lower incisor when the teeth are in occlusion

• The 'comfort zone' for inter gingival height for adult patients is about 17-
19mm. This is equivalent to combined heights of the upper and lower
incisors minus an overbite within the range of normal. Patients whose inter
gingival height varies significantly from comfort zone are at a greater risk
of developing T.M.D. This applies both to patients with a deep overbite
whose inter gingival height is reduced, and to patients with an anterior open
bite who have an increased inter gingival height.
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Bite Registration in Class III Cases:

The blue exactobite is used to register a construction bite with the teeth
closed to the position of maximum retrusion leaving sufficient clearance
between the posterior teeth for occlusal bite blocks. This is normally
achieved by recording a construction bite with 2mm interincisal clearance in
the fully retruded position.

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Step-wise activation or Re-activation of twin block:

• Addition of acrylic to the

anterior incline of the upper
inclined plane to reactivate
Twin Blocks.

• It is incorrect to reactivate by
addition to the lower Twin
Block.

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Screw Advancement Mechanism for Progressive Advancement of Twin Blocks

• A recent modification has been described (Carmichael, Banks, & Chadwick, 1999) to
enable controlled progressive advancement of the Twin Block. The activating
mechanism uses a conical screw installed in a housing incorporated in the upper
block. A laboratory kit includes components for installation and alignment and is
supported by a chairside kit with cylindrical co-polymer spacers of different sizes for
progressive advancement

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Indications:

• Stepwise advancement may be used to facilitate reactivation in the treatment

of large overjet

• Unilateral activation may be used to correct asymmetrical mandibular

development

• Patients with vertical growth patterns tend to have weak musculature and are
not able to tolerate large mandibular advancements. In such cases gradual
mandibular advancement may be more effective

• Phased activation is recommended in adult treatment, where the muscles

and ligaments are less responsive to a sudden large displacement of the
mandible 37
• Smaller adjustments are possible to improve patient tolerance

• More gradual advancement may be more physiological, at cellular level, and

may produce an improved mandibular response

• In TMJ disorders

• An occlusal screw from Forestadent has a 6 mm range of action for

progressive activation of Reverse Twin Blocks

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• Once the bite is taken it is transferred on to the set of patients models.
• This is then mounted on to a fixator.
• Individual wire components are then fabricated
• Wax up is done
• Appliance is acrylized, trimmed and polished and is checked for fit

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Post Insertion Instructions:

• At first the appliance will feel large in the mouth, but within a few days it
will be very comfortable and easy to wear.

• Twin Blocks cause much less interference to speech than a one-piece

functional appliance. For the first few days speech will be affected, but
will steadily improve and should return to normal within a week.

• When the patient has learned to insert and remove the appliance,
instruction is given on operating the expansion screw, one quarter turn
per week

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• As with any new appliance it is normal to expect a little initial discomfort.
But it is important to encourage the patient to persevere and keep the
appliance in the mouth at all times except for hygiene purposes.

• The patient may be advised to remove the appliance for eating for the first
few days. Then it is important to learn to eat with the appliance in the
mouth. The force of biting on the appliance corrects the jaw position, and
learning to eat with the appliance in is important to accelerate treatment.

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Clinical response to treatment

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• The placement of the appliance results in an immediate change in the
neuromuscular proprioceptive response.

• Within a few days of fitting twin block, the position of muscle balance is
altered so greatly that the patient experiences pain when retracting the
mandible. This is described as the pterygoid response (McNamara 1980), or
formation of a tension zone distal to condyle (Harvold and Woodside).

• When the mandible is retracted, the condyle compresses the connective

tissue and blood vessels that have proliferated in the tension zone behind the
condyle

• The pterygoid response is a clinical sign of full time wear

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Use of Twin Block in Various Malocclusion

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Class II division 1 with Deep bite
• In the treatment of deep overbite, it is important to encourage vertical
development of the lower molars from the start of treatment, by trimming the
upper bite block occlusodistally to allow the lower molars to erupt.

• The upper bite block is progressively trimmed at each visit over several
months, leaving only a small vertical clearance of 1 or 2 mm over the lower
molars to allow them to erupt into occlusion. The clearance between the upper
appliance and the lower molars is checked by inserting a probe (or explorer)
between the posterior teeth to establish that the lower molars are free to erupt.

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• At each subsequent visit for appliance adjustment the occlusion is cleared by
sequentially trimming the upper block occlusodistally to allow further
eruption of the lower molars, again checking that the clearance is correct.

• This sequence of adjustment does not allow the tongue to spread laterally
between the teeth to prevent eruption of lower molars, and results in a more
rapid development of the vertical dimension. The molars will erupt into
occlusion normally within 6–9 months

• The leading edge of the inclined plane on the upper bite block remains intact,
leaving a triangular wedge in contact with the lower bite block.

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• The final adjustment at the end of the Twin Block stage aims to reduce the
lateral open bite by trimming the upper occlusal surface of the lower bite
block over the premolars by 2 mm.

• Relieved of occlusal contact, the lower premolars erupt, carrying the lower
appliance up into occlusion. The occlusal height of the upper premolars is
maintained by interdental clasps that effectively prevent their eruption. The
lateral open bite in the premolar region now reduces and the occlusal plane
begins to level.

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Class II division 2 Malocclusion:

• The construction bite in Class II division 2

malocclusion is registered with the incisors in
edge-to-edge occlusion.

• When the overbite is excessive, the clearance

between the posterior teeth is correspondingly
increased.

• These patients require more vertical development,

so that the occlusal bite blocks tend to be thicker
in the premolar region to allow clearance of the
upper and lower incisors.
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Sagittal Development

• In the treatment of Class II division 2 malocclusion, sagittal arch development

is necessary to increase arch length and to advance retroclined incisors.
• The design of the upper Twin Block is modified by the addition of two sagittal
screws set in the palate for anteroposterior arch development. The screws
expand the arch by advancing the upper incisors and at the same time, drive
the upper buccal segments distally and buccally along the line of the arch

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Combined Transverse and Sagittal Development

Many patients with malocclusion present arch forms that are restricted in both
transverse and anteroposterior dimensions. The Class II division 2 malocclusion
and variations often require a combination of transverse and anteroposterior arch
development in order to free the mandible from a distal occlusion.

The triple-screw sagittal Twin Block appliance is designed to improve arch form
in anteroposterior and transverse dimensions and simultaneously correct arch
relationships for patients presenting complex problems of arch development.

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Class III Malocclusion:

• Functional correction of Class III malocclusion is

achieved in Twin Block technique by reversing the
angulation of the inclined planes, harnessing occlusal
forces as the functional mechanism to correct arch
relationships by maxillary advancement, while using
the lower arch as the means of anchorage.

• The position of the bite blocks is reversed compared

to Twin Blocks for Class II treatment. The occlusal
blocks are placed over the upper deciduous molars
and the lower first molars.

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Case Selection:

• The simplest clinical guideline is whether or not the patient can occlude
squarely edge-to-edge on the upper and lower incisors. The ease with
which the patient can achieve this position is an indication of the
prognosis for correction.
• The most favourable cases for correction present a postural Class III
where the incisors can meet comfortably edge-to-edge, but the patient is
forced to move the mandible forward in order to occlude on the posterior
teeth.

• If an edge-to-edge occlusion is achieved only with difficulty the

prognosis for orthodontic correction is poor.
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• To enhance the forward movement of the upper labial
segment, lip pads may be added to support the upper lip
clear of the incisors with an action similar to that of the
Frankel III.
• It is important to attach the lip pads to the anterior segment
of the appliance so that they advance as the screws are
opened, otherwise the pads become compressed against the
gingiva in the labial segment.

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Effects of Reverse Twin block:

• Retroclination of lower incisors.

• Proclination of upper incisors.
• Increase in sella, Nasion, A-point (SNA)
• Decrease in sella, Nasion, B-point (SNB)
• Increase in A-point, Nasion, B-point (ANB)
• Decrease in overbite.

 The study concluded that the appliance was well tolerated, and treatment
time was 75% less than with the FR III (Loh and Kerr, 1985)

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Treatment of anterior open bite and vertical growth pattern:

Maintain occlusal contact to intrude Do not allow second molars to over erupt.
posterior teeth Extend occlusal cover or occlusal rests distally
to second molars

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• Patients with anterior open bite and a vertical growth pattern tend to
have weak musculature and may have difficulty in consistently
maintaining a forward posture to engage the occlusal inclined planes
of the bite blocks.

• They are prone to posture out of the appliance, which reduces the
effectiveness in correcting both sagittal and vertical discrepancies.
These patients may benefit from phased progressive activation to
allow the muscles to adapt more gradually to mandibular
advancement.

• Vertical elastics worn at night to intrude the upper posterior teeth

overcome this problem.
56
Bite Registration:

• It is necessary to accommodate blocks of sufficient thickness between the

posterior teeth to open the bite beyond the free-way space so as to intrude
the posterior teeth. The objective is to make it difficult for the patient to
disengage the blocks.

• The activation must not exceed 70% of the total protrusive path. It is
especially important in vertical growth patterns to ensure that the patient can
maintain comfortably the protrusive position

57
• Appliance design is modified to achieve vertical control and close the
anterior open bite. The lower appliance extends distally to the lower molar
region with clasps on the lower first molars and occlusal rests on the second
molars to prevent their eruption.

• The acrylic may be trimmed slightly to relieve contact with the lingual
surfaces of the upper and lower anterior teeth so that they are free to erupt to
reduce the anterior open bite

• The intrusive effect of the bite blocks is reinforced

by running a vertical elastic between upper and
lower teeth on both sides. Elastics may be attached
directly to the upper and lower appliances or to
brackets or bands with gingival hooks.
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Twin block traction technique:

 In the early stages of development of the Twin Block technique a method was
devised to combine functional therapy with orthopaedic traction. This
approach should be limited to the treatment of severe malocclusion, where
growth is unfavourable for conventional fixed or functional therapy.

 The indications are confined to a minority of cases with growth patterns

where maxillary retraction is the treatment of choice. For example:

• In the 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 mandibular growth cannot assist the correction of a

severe malocclusion 59
The Concorde facebow is a new
means of applying intermaxillary and
extraoral traction to restrict maxillary
growth and, at the same time, to
encourage mandibular growth in
combination with functional
mandibular protrusion.

60
• Additional orthopedic forces may help to
control vertical growth by applying an intrusive
orthopedic force to the upper posterior teeth,
delivering an intrusive force to upper molars
and, at the same time, a protrusive force to the
mandible and the lower dentition.

• Intrusion of the upper posterior teeth allows the

bite to close by a favorable forward rotation of
the mandible, and facilitates correction of
mandibular retrusion in vertical growth
discrepancies.

61
Combination Therapy:

• Combination therapy describes the combined use of functional and

fixed techniques in the management of malocclusion.

• By definition this is a one-phase treatment and should be timed to

coincide with eruption of the permanent teeth. The optimum timing for
this approach is either in late mixed dentition or early permanent
dentition.

62
CONCURRENT STRAIGHTWIRE AND THE TWIN BLOCK THERAPY

• An alternative approach is to initiate treatment with fixed appliances,

correcting arch form and applying torque to correct incisor angulation prior to
fitting Twin Blocks, which are integrated with straight wire technique.

• The dental phase of treatment requires

approximately 8–12 months, at which time
the Twin Block appliances are placed.

• An open palate design is used where

possible to facilitate increased tongue space
and better speech.

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64
TMJ Disorders:
Twin Blocks are most likely to be indicated 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 movement.

Twin Blocks then achieve the following objectives in the first phase of treatment:

• Pain is relieved immediately when Twin Blocks are fitted or, in more difficult
cases, within 4–7 days.

• The muscles are retrained automatically to a healthy pattern. A consistent feature

of Twin Block therapy is the rapid improvement in facial balance. Muscle spasm is
relieved when Twin Blocks are fitted, by changing the pattern of muscle activity to
achieve a new position of equilibrium in muscle balance.
65
• The disk is recaptured by posturing the mandible downwards and forwards to
advance the condyles.

• Rather than act as a passive splint, Twin Blocks are designed to move the
teeth that are causing occlusal imbalance.

• The upper block may be trimmed selectively over the lower first molars only,
using molar bands with vertical elastics to accelerate eruption of the first
molars. To continue to rest the joint, a posterior occlusal stop is maintained
by occlusal contact of the blocks with the second or third molars to support
the vertical dimension

66
Impact of functional mandibular advancement appliances on the temporomandibular
joint - a systematic review; Med Oral Patol Oral Cir Bucal. 2016 Sep 1;21 (5):e565-72.

Background: Although many orthodontists have no doubts about the effectiveness of

functional appliances for mandibular advancement, the impact on the temporomandibular
joint (TMJ) is still in dispute. The objective of this systematic review is to examine the main
effects on the TMJ of using functional appliances, both in healthy patients and in patients
with a pre-existing disorder.

Material and Methods: A systematic review of the literature was conducted in accordance
with the PRISMA guidelines. Only systematic reviews, meta-analyses, randomized clinical
trials (RCTs), case-control studies and cohort studies were included. A detailed language-
independent electronic search was conducted in the Pubmed, Scopus, Cochrane Library and
Embase databases. All studies published between 2000 and 2015 were included.

67
Results: A total of 401 articles were identified. Of these, 159 were duplicates and were
excluded. On reading the title and abstract, 213 articles were excluded because they did not
answer the research question, leaving a total of 29 articles. These articles were read and
assessed. Following critical reading of the full text, eight articles were excluded: seven
because they were considered of low quality and one because it published redundant data. As
a result, 21 articles were included.

Conclusions: After treatment with functional appliances, the condyle was found to be in a
more advanced position, with remodelling of the condyle and adaptation of the morphology
of the glenoid fossa. No significant adverse effects on the TMJ were observed in healthy
patients and the appliances could improve joints that initially presented forward dislocation of
the disk.

68
Twin block in Obstructive Sleep Apnoea

• The use of intraoral appliances in the treatment of obstructive sleep

pathologies dates from a very long time ago. Pierre Robin describes in
1902 the use of a functional appliance called the “monobloc” which
positions the jaw forward, thereby preventing the tongue from falling
backward.

• Guidelines issued by the American Academy of Sleep Medicine

(AASM) and published in the February 2006 edition of “Sleep”, state
that “the use of oral appliances are indicated in patients with mild to
moderate OSA. These patients may have had failed attempts with CPAP”

69
• Recent research supports the view that Twin Blocks increase the pharyngeal
airway

• After treatment with Twin Block appliance, significant changes occurred in

horizontal dimension (anterior displacement) which resulted in significant
increase in width of the upper pharynx.

• Breathe Easy Twin Blocks are separate upper and lower appliances allowing
freedom of movement of the mandible, as an alternative to the range of one
piece appliances which restrict normal function.

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71
Effects of twin block appliance on obstructive sleep apnea in children: a preliminary
study; Sleep Breath, April 2013

The aim of this study was to investigate the effects of twin block (TB) appliance on
children with OSA and mandibular retrognathia.

Methods: A total of 46 children (31 males, 15 females, aged 9.7±1.5 years, BMI:
18.1±1.04 kg/m2) diagnosed with mandibular retrognathia and OSA by polysomnography
(PSG) and with no obesity or adenotonsillar hypertrophy were recruited for the study.
Patients in the treatment group were instructed to wear the twin block oral appliance full
time for an average of 10.8 months. The efficacy of treatment was determined by
monitoring the PSG and cephalometric changes before and after appliance removal. Data
were analyzed using paired t test.

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Results: Results showed an improvement in patient's facial profile after treatment with
the TB appliance. The average AHI index decreased from 14.08±4.25 to 3.39±1.86 (p<
0.01), and the lowest SaO2 increased from 77.78±3.38 to 93.63±2.66 (p<0.01).
Cephalometric measurements showed a significant increase in the superior posterior
airway space, middle airway space, SNB angle and facial convexity which indicate an
enhancement in mandibular growth, and reduction in the soft palate length.

Conclusions: This preliminary study suggests that twin block appliance may improve
the patient's facial profile and OSA symptoms in a group of carefully selected children
presented with both OSA and mandibular retrognathia symptoms

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Effectiveness of Mandibular Advancement Appliances in Treating Obstructive Sleep
Apnea Syndrome: A Systematic Review; Laryngoscope, 126:507–514, 2016

Objectives/Hypothesis: Mandibular advancement devices are an alternative to continuous

positive airway pressure for patients with mild or moderate obstructive sleep apnea/hypopnea
syndrome (OSAHS). The main aim of this review was to assess the effectiveness of different
devices in treating OSAHS, based on polysomnographic measurements such as the apnea/
hypopnea index (AHI) and oxygen saturation, and on changes in the upper airway and
improvements in the most common symptoms: snoring and somnolence. Their adverse effects
were also noted.

Study Design: Systematic review.

Methods: Following an exhaustive search in the Medline, Scopus, and Cochrane Library
databases, 22 articles published in the past 10 years met the quality and inclusion criteria.

74
Results: Using mandibular advancement devices during the hours of sleep helps to prevent
snoring and excessive daytime sleepiness, reduce the AHI significantly, and bring about
beneficial changes in the upper airway. Adjustable and custom made mandibular
advancement devices give better results than fixed and prefabricated appliances. Monobloc
devices give rise to more adverse events, although these are generally mild and transient.

Conclusions: Mandibular advancement devices increase the area of the airway. They bring
the soft palate, tongue, and hyoid bone forward and activate the masseter and submental
muscles, preventing closure. All these effects reduce the AHI, increase the oxygen
saturation, and improve the main symptoms of OSAHS.

75
Effects of Twin Block

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Effectiveness of early orthodontic treatment with the Twin-block appliance: A multicentre, randomized,
controlled trial. Part 1: Dental and skeletal effects, Am J Orthod Dentofacial Orthop 2003;124:234-43

• One of the most important morphologic findings of this study was that early intervention
with a Twin-block appliance successfully reduced dental overjet, molar discrepancies, and
severity of malocclusion. This was achieved by a combination of dental and skeletal
change.

• Interestingly, the amounts of overjet and molar change that were attributable to skeletal
change were 27% and 41%, respectively, and this was made up of growth modification of
both the mandible and the maxilla to a similar degree.

• Even though the skeletal change was statistically significant, it amounted to only 1.9 mm,
which might not be considered to be clinically significant or useful.

• As a result, we can conclude that the most important changes resulting from treatment
were dentoalveolar.
77
Effectiveness of early orthodontic treatment with the Twin-block appliance: A multicentre, randomized,
controlled trial. Part 2: Psychosocial effects, Am J Orthod Dentofacial Orthop 2003;124:488-95

• The most important finding of this study was that children who received early orthodontic
treatment with a Twin-block appliance reported higher self-esteem and more positive
childhood experiences than did the controls who received no orthodontic intervention.

• With respect to negative social experiences, our findings suggest that children who
received the Twin block intervention reported significantly fewer negative social
experiences posttreatment

• The results of this study suggest that early orthodontic treatment for Class II Division 1
malocclusion with a Twin-block appliance results in higher self concept scores and fewer
negative social experiences. The patients also reported treatment benefits that might be
related to improved self-esteem.

78
Treatment effects of the twin block appliance: A cephalometric study; Am J Orthod
Dentofacial Orthop 1998;114: 15-24

• The purpose of this investigation was to determine the treatment effects of the Twin Block
appliance and in particular to assess the extent to which the Twin Block appliance stimulates
mandibular growth.

• A consecutively treated sample of 28 patients with skeletal Class II malocclusions was

compared cephalometrically to a control group of untreated individuals with Class II
malocclusions who were matched closely according to sex, age, and facial type. Treatment
involved solely the use of the Twin Block appliance and was undertaken primarily in the
mixed dentition stage.

• The mandibular unit length (measured from condylion to gnathion) increased by 6.5 mm in
the Twin Block group as compared with only a 2.3 mm increase in the control subjects.
Approximately two thirds of the overall mandibular length increase could be attributed to an
increase in ramus height (measured from condylion to gonion). The remaining one third was
the result of an increase in the mandibular body length (measured from gonion to gnathion).
79
• This mandibular growth probably was responsible for the 1.9° increase in angle SNB in the
Twin Block group. By comparison, an increase of only 0.3° in angle SNB was noted in the
control group.

• In addition, some “headgear effect” was observed, with the Twin Block group experiencing
a slight inhibition of forward maxillary growth as evidenced by a 0.9° decrease in angle
SNA during the treatment phase. The “headgear effect” also was observed dentally as a 1.0
mm distalization effect on the upper molars in the Twin Block group. In contrast, a 0.3 mm
forward migration of the upper molars was measured for the control group

• Slight up righting effect (2.5°) was observed for the upper incisors as a result of the Twin
Block treatment. This was despite the fact that no labial bow was attached to any of the
Twin Block appliances used in this study.

• The lower incisors tipped labially 5.2° on average in the Twin Block group as compared
with only a 1.4° labial tipping in the control subjects.
80
• Molar correction or overcorrection was achieved in all 28 patients in
the treatment group.

• Incisor overjet decreased 5.6 mm on average in the treatment group.

Nearly two thirds of this reduction in overjet could be accounted for
by the forward growth of the mandible.

• Further follow-up studies currently are underway to assess the long-

term stability of the Twin Block treatment effects reported in this
study.

81
Posttreatment changes after successful correction of Class II malocclusions with the
Twin Block appliance; Am J Orthod Dentofacial Orthop 2000;118:24-33

• A study to assess the stability of treatment effects of the Twin Block appliance
3 years posttreatment was carried out on a sample of 26 consecutively treated
patients with severe skeletal Class II malocclusions.

• When compared with an untreated control group of children of the same age, it
was found that the skeletal growth characteristics of both groups were similar
in the posttreatment period.

• Most of the positive gain in mandibular size achieved during the active
treatment phase still was present 3 years posttreatment.

• The mandibular body length actually increased slightly more in the

posttreatment phase in the Twin Block group than in the controls 82
• The treatment group experienced some up righting of the lower incisors (1.5°)
and some slight labial proclination of the upper incisors (0.8°) both of which
contributed to a 1.0 mm increase in the overjet. This overjet increase was
statistically significant

• In addition, the Twin Block group experienced less mesial migration of the
lower first molars posttreatment (1.5 mm on average as compared with 2.5
mm in the control group). This difference was statistically significant (P ≤ .01)
and would account for much of the 1.2 mm loss of molar correction that
occurred posttreatment (P ≤ .05) compared with the control group.

• Much of the favourable skeletal change that resulted during the active
treatment with the Twin Block appliance was maintained when the patients
were assessed nearly 3 years later. Further investigations are needed to see if
this trend continues over the long-term. 83
Modifications of Twin Block

84
Fixed Twin Block:

Temporary Fixation of Twin Block:

• The appliances may be fixed to the teeth by spreading cement on the tooth-bearing areas of
the appliance. The appliance is then inserted and secured in place with cement like Zinc
phosphate or zinc oxide cement is suitable for temporary fixation. Alternatively, a small
quantity of glass ionomer cement may be used, taking care to ensure that the appliance can
be freed easily from the teeth.

• Twin Blocks may also be bonded directly to the teeth by applying composite around the
clasps. This is a useful approach in mixed dentition when ball clasps may be bonded
directly to deciduous molars to improve fixation.
85
Permanently fixed Twin blocks

Prototype Fixed Twin Block Design dating from 1990

86
Evolution of fixed Twin blocks: Phase 1

• In 2008, the first design of preformed blocks was based on attachment to

molar bands using a blade attachment inserted in a lingual sheath. The
blocks covered the occlusal and lingual surfaces of the teeth, leaving the
buccal surfaces free for attachment of brackets. It was felt that attachment
to molar bands was necessary to improve stability.

87
Individual Fixed Blocks:

88
Phase 2:

89
Phase 3:

90
Magnetic Twin block:

• The role of magnets in Twin Block therapy is specifically to accelerate

correction of arch relationships.

• Two types of rare earth magnet (samarium-cobalt and neodymium-

boron) have been used to examine the response to attracting magnetic
forces in Twin Block treatment.

• Both are effective, but neodymium-boron delivers a greater force from

a smaller magnet.

• Both Attracting and repelling magnets can be used.

91
Attracting magnets:

• The attracting magnetic force pulls the appliance together and encourages
the patient to occlude actively and consistently in a forward position.
The functional mechanism of the twin block stimulates a proprioceptive
response by repeated contacts on the occlusal inclined plane.

Repelling Magnets:

• The repelling magnetic force is intended to apply additional stimulus

to forward posture as the patient closes into occlusion.

92
• After a short period of investigation it appears
that magnetic Twin Blocks may help to
resolve some of the problems encountered in
the management of difficult cases.

• It is still to be established whether attracting

or repelling magnets are more effective,
although attracting magnets would appear to
have an advantage by increasing contact on
the inclined planes.

• Magnets should be used only where speed of

treatment is an important consideration, or
where the response to nonmagnetic appliances
is limited 93
Aesthetic Twin block:

94
Advantages of Twin block

• Comfort: patients wear Twin Blocks 24 hours per day and can eat comfortably
with the appliances in place.

• Aesthetics: Twin Blocks can be designed with no visible anterior wires without
losing efficiency in correction of arch relationships.

• Function: The occlusal inclined plane is the most natural of all the functional
mechanisms. There is less interference with normal function because the
mandible can move freely in anterior and lateral excursion without being
restricted by a bulky one piece appliance.

95
• Patient compliance: Twin Blocks may be fixed to the teeth temporarily or
permanently to guarantee patient compliance. Removable Twin Blocks can
be fixed in the mouth for the first week or 10 days of treatment to ensure
that the patient adapts fully to wearing them 24 hours per day.

• Facial appearance: Improvements in facial balance are seen progressively

in the first 3 months of treatment.

• Speech: Patients can learn to speak normally with Twin Blocks. In

comparison with other functional appliances, Twin Blocks do not distort
speech by restricting movement of the tongue, lips or mandible.

96
• Clinical management: adjustment and activation is simple

• Arch development: Twin Blocks allow independent control of upper and

lower arch width. Appliance design is easily modified for transverse and
sagittal arch development.

• Mandibular repositioning: full-time appliance wear consistently achieves

rapid mandibular repositioning that remains stable out of retention.

• Vertical control: Twin Blocks achieve excellent control of the vertical

dimension in treatment of deep overbite and anterior open bite. Vertical control
is significantly improved by full-time wear.

• Facial asymmetry: asymmetrical activation corrects facial and dental

asymmetry in the growing child. 97
• Safety: Twin Blocks can be worn during sports activities with the
exception of swimming and violent contact sports, when they may be
removed for safety

• Efficiency: Twin Blocks achieve more rapid correction of malocclusion

compared to one-piece functional appliances because they are worn full
time. This benefits patient in all age groups.

• Age of treatment: Arch relationships can be corrected from early

childhood to adulthood. However, treatment is slower in adults and the
response is less predictable.

• Integration with fixed appliances: Integration with conventional fixed

appliances is simpler than with any other functional appliance.
98
Twin Block appliance with acrylic capping does not have a significant inhibitory effect on
lower incisor proclination; Angle Orthodontist 2016

Objective: To investigate the effect of acrylic capping, treatment duration,

overjet, and lower incisor inclination on the posttreatment tooth position in
patients treated with 2 Twin Block (TB) appliance versions.

Materials and Methods: Cephalograms of 56 patients with Class II

malocclusion treated with a TB appliance with either acrylic capping or ball-
ended clasps on lower incisors were retrospectively collected and traced. Lower
incisor inclination (L1-GoGn, L1-GoMe, L1-MP) was measured at T1 and after
TB appliance removal (T2). Regression analysis was performed to evaluate the
effect on the lower incisor inclination of appliance type, overjet, lower incisor
inclination at T1, and treatment duration after adjusting for baseline
measurements. 99
Results: Appliance design was not a significant predictor for either incisor
inclination measurement (P, .05). Pretreatment lower incisor inclination was
the only factor significantly associated with final tooth inclination. There was
weak evidence that treatment duration excluding L1-MP and overjet might be
associated with inclination of lower incisors at T2.

Conclusions: TB appliance design with acrylic capping on lower incisors

appears not to significantly control incisor proclination. Pre treatment lower
incisor inclination may be significantly associated with tooth inclination after
active TB treatment and should be considered in treatment planning

100
Comparative evaluation of soft tissue changes one year post-treatment in Twin Block
and FORSUS FRD treated patients; Med J Armed Forces India (2015)

• The objective of this study was to compare and evaluate the effects of two
functional treatment modalities, namely, Twin Block (TB) and FORSUS
fatigue resistant device (FORSUS FRD) on facial soft tissues before and at
one-year post-treatment.

• Methods: This was a retrospective cephalometric study involving 10 patients

with skeletal class II abnormalities in each group. The mean age of patients
was 12.5 1.5 and 13.5 1 years and treatment duration 20 2 and 18 2
months, respectively for TB and FORSUS FRD groups, respectively. The
pre-treatment (T0) and one-year post-treatment cephalograms (T1) were
compared for evaluation.
101
• Statistically significant soft tissue changes were observed after TB and
FORSUS FRD appliance therapy, resulting in improvement of facial balance
and aesthetics.

• Both, TB and FORSUS FRD, have similar effects on soft tissues but the effect
of TB on LAFH and that of FORSUS on mentolabial sulcus was more
profound.

• Although TB can be used in most patients requiring functional jaw

orthopaedics, FORSUS can be substituted in uncooperative patients and/or in
patients with normal to mildly increased LAFH.

• The soft tissue changes though indirectly reflect the treatment effect on hard
tissues, the co-relation may not be in direct proportion for TB and FORSUS
FRD appliance. 102
References:

• Twin Block Functional Therapy, William J Clark, 3rd Edition

• Dentofacial orthopaedics with Functional Appliances, Graber,

Petrovic and Rakosi, 2nd Edition

• Comparative evaluation of soft tissue changes one year post-treatment

in Twin Block and FORSUS FRD treated patients; Med J Armed
Forces India (2015)

• Twin Block appliance with acrylic capping does not have a significant
inhibitory effect on lower incisor proclination; Angle Orthodontist
2016
103
• Posttreatment changes after successful correction of Class II malocclusions
with the Twin Block appliance; Am J Orthod Dentofacial Orthop
2000;118:24-33

• Treatment effects of the twin block appliance: A cephalometric study; Am

J Orthod Dentofacial Orthop 1998;114: 15-24

• Effectiveness of early orthodontic treatment with the Twin-block

appliance: A multicentre, randomized, controlled trial. Part 1: Dental and
skeletal effects, Am J Orthod Dentofacial Orthop 2003;124:234-43

• Effectiveness of early orthodontic treatment with the Twin-block

appliance: A multicentre, randomized, controlled trial. Part 2: Psychosocial
effects, Am J Orthod Dentofacial Orthop 2003;124:488-95
104
• Effectiveness of Mandibular Advancement Appliances in Treating
Obstructive Sleep Apnea Syndrome: A Systematic Review; Laryngoscope,
126:507–514, 2016

• Effects of twin block appliance on obstructive sleep apnea in children: a

preliminary study; Sleep Breath, April 2013

• Impact of functional mandibular advancement appliances on the

temporomandibular joint - a systematic review; Med Oral Patol Oral Cir
Bucal. 2016 Sep 1;21 (5):e565-72.

• Treatment timing for Twin-block therapy; Am J Orthod Dentofacial Orthop

2000;118:159-70

105
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