TWIN BLOCK AND ITS

MODIFICATIONS

1
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 normal function
have a distal component of force that is unfavorable to normal
forward mandibular development. The inclined planes formed by
the cusps of the upper and lower teeth represent a servo-
mechanism that locks the mandible in a distally occluding
functional position.

2
They 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 win Block appliances are simple bite blocks that
are designed for full-time wear

3
PROPRIOCEPTIVE STIMULUS TO GROWTH:
The inclined plane mechanism plays an important part in
determining the cuspal relationship of the teeth as they
erupt into occlusion. A functional equilibrium is
established under neurological control in response to
repetitive tactile stimulus. Occlusal forces transmitted
through the dentition provide a constant proprioceptive
stimulus to influence the rate of growth and the trabecular
structure of the supporting bone.

4
Malocclusion is frequently associated with discrepancies
in arch relationships due to underlying skeletal and soft-
tissue factors, resulting in unfavourable cuspal guidance
and poor occlusal function. The proprioceptive sensory
feedback mechanism controls muscular activity and
provides a functional stimulus for the full expression of
mandibular bone growth.

5
The unfavourable cuspal contacts of distal occlusion
represent an obstruction to normal forward mandibular
translation in function, and as such do not encourage the
mandible to achieve its optimum genetic growth potential.
Functional appliance therapy aims to improve the
functional relationship of the dentofacial structures by
eliminating unfavourable developmental factors and
improving the muscle environment that envelops the
developing occlusion. By altering the position of the teeth
and the developing structures, a new functional behavior
pattern is established that can support a new position of
equilibrium.

6
OBJECTIVES OF FUNCTIONAL TREATMENT:
In a natural dentition a functional equilibrium is established
under neurological control in response to repetitive tactile
stimuli as the teeth come into occlusion. A favourable
equilibrium of muscle forces between tongue, lips and cheek
is essential for normal development of dental arches in
correct relationship.

Any persistent deviation from normal function is associated

with malocclusion. Discrepancies in the dental arches due to
underlying skeletal or soft tissue factors
Result in unfavourable cuspal guidance and poor occlusal
function.

7
The purpose of functional therapy is to change the functional
environment of the dentition to promote normal function.
Functional appliances are designed to control the forces applied
to the dentition by the surrounding soft tissues and muscles that
control the position and the movement of the mandible.

The natural occlusal forces acting on a mandible in distal

occlusion do not favour mandibular development to the patient's
full potential of growth. The mandible is locked in a distal
position by an unfavorable or distal driving occlusion.
Conversely, in a Class III malocclusion the maxilla is locked in
a distal relationship by unfavourable occlusal forces. Altered
occlusal function in this type of malocclusion has the effect of
restricting maxillary development and advancing the mandible

8
A new functional behavior pattern is established to
support a new position of equilibrium by eliminating
unfavourable environmental factors in a developing
malocclusion.
Functional therapy aims to unlock the malocclusion
and stimulate growth by applying favourable forces
that enhance skeletal development.

9
LIMITATIONS OF FUNCTIONAL APPLIANCE DESIGN:
All the functional appliances that have evolved from the monobloc
share the limitation that the upper and lower components are joined
together. As a result, the patient cannot eat, speak or function
normally with the appliance in the mouth. It is also impossible to
wear a one-piece functional appliance full time if it is attached to
the teeth in both jaws.

The early functional appliances were designed for night-time wear,

which limited the response to treatment. It was also important to
select patients who had a favourable growth pattern in, order to
improve the prognosis for correction, and to eliminate the
uncertainty associated with night-time functional appliances. There
is better potential for rapid mandibular growth when the patient has
a favourable horizontal growth pattern than when the facial growth
vector is more vertical.

10
11
BITE REGBISTRATION IN FUNCTIONAL THERAPY:
Bite registration is a crucial factor in the design and construction
of a functional appliance. The construction bite determines the
degree of activation built into the appliance, aiming to reposition
the mandible to improve the jaw relationship. The degree of
activation should stretch the muscles of mastication sufficiently to
provide a positive proprioceptive response.

At the same time, activation must be within the physiological

range of activity of the muscles of mastication and the
ligamentous attachhments of the temporomandibular joint. Bite
registration should achieve a balance between these factors by
providing the degree of mandibular protrusion required to achieve
the optimum functional stimulus to growth.
12
According to Woodside,
A bite registration used commonly throughout the world
registers the mandible in a position protruded approximately 3.0
mm distal to the most protrusive position that the patient can
achieve, while vertically the bite is registered within the limits
of the patient's freeway space.
.
Beyond this point the medial capsular ligament begins to
displace the disc by pulling the disc medially and distally off the
condyle. This guideline allows us to measure the total
mandibular displacement and relate the amount of activation to
the freedom of movement of the joint for each individual
patient.

13
Bite registration in Twin Block technique:
Bite registration for Twin Blocks originally aimed for a single
activation to an edge-to-edge incisor relationship, with 2 mm
inter incisal clearance for an overjet of up to 10 mm. Allowance
was made for individual variation if the patient had difficulty in
maintaining an edge to edge position on registering the occlusion.
This proved to be successful in correcting the overjet and
reducing the distal occlusion in
the majority of class II cases.

Where the overjet was greater than 10 mm, an initial

advancement of 7 or 8 mm was followed by reactivation of the
appliance after occlusion had corrected to the initial bite
registration. Normally, a single further activation was sufficient
to fully correct the overjet and distal occlusion.
14
The young patient usually has more freedom of movement
while there is generally more restriction in the adult. In Class
II division I malocclusion, young patients commonly
have a protrusive path of 13 mm and will tolerate activation up
to 10 mm.

Beyond this range the muscles and ligaments cannot adapt to

altered function and the patient will tend to posture out of the
appliance.

If the overjet is larger than 10 mm the initial activation should

only partially reduce the overjet. The appliance is then
reactivated during the course of treatment.

15
The George Bite Gauge has a millimeter gauge to
measure the protrusive path of the mandible and to
determine accurately the amount
of activation registered in the construction bite.
The total protrusive movement is calculated by first
measuring the overjet in centric occlusion and then
in the position of maximum protrusion. The
protrusive path of the mandible is the difference
between the two measurements. Functional
activation within normal physiological limits
should not exceed 70% of the protrusive path. By
checking the protrusive path the adjustment may be
related to the patient's physiological movements.

16
The young patient usually has more freedom of movement while
there is generally more restriction in the adult. In Class II
division I malocclusion, young patients commonly
have a protrusive path of 13 mm and will tolerate activation up to
10 mm.

Beyond this range the muscles and ligaments cannot adapt to

altered function and the patient will tend to posture out of the
appliance.

If the overjet is larger than 10 mm the initial activation should

only partially reduce the overjet. The appliance is then
reactivated during the course of treatment.

17
Vertical activation:
The amount of vertical activation is crucial to the success of Twin
Block treatment. The most common fault in Twin Block
construction is to make the blocks too thin, so that the patient can
posture out of the appliance, reducing the effectiveness of the
treatment.

An important principle is that the blocks should be thick enough

to open the bite slightly beyond the free-way space. This is
necessary to ensure that the patient does not posture out of the
appliance when the mandible is in the rest position.

On average the blocks are not less than 5-mm thick in the first
premolar or first deciduous molar region. This thickness is
normally achieved in Class II division I deep bite cases by
registering a 2-mm vertical interincisal clearance.
18
In Class II division 2 malocclusion with excessive overbite it is
sufficient to register an edge-to-edge incisal bite registration
without the additional 2 mm interincisal clearance. This is
normally sufficient in this type of malocclusion to accommodate
blocks of the correct thickness.
In treatment of anterior open bite it is necessary to register with a
greater interincisal clearance to make allowance for the anterior
open bite. The Projet or George bite gauge has thicker versions to
accommodate an interincisal clearance of 4 or 5 mm. At bite
registration a judgement should be made according to the amount
of vertical space between the cusp tips of the first premolars or
deciduous molars to achieve the correct degree of bite opening to
accommodate blocks of atleast 5 mm thickness.

19
CONTROL OF THE VERTICAL DIMENSION:
Opening the bite:
Where a deep overbite is present it is necessary first to check that
the profile is improved when the patient postures the mandible
downwards and forwards. This confirms that the bite should be
opened by encouraging eruption of the posterior teeth to increase
the vertical dimension of occlusion in the posterior quadrants.

This is achieved by placing an occlusal table between the teeth to

encourage increased development of posterior facial height by
growth of the vertical ramus. At the same time, the occlusion is
freed between the posterior teeth to encourage selective eruption
of posterior teeth to increase the vertical dimension of occlusion
in the posterior quadrants.

20
In functional therapy antero posterior correction is invariably
achieved before vertical development in the buccal segments is
complete. The overjet is reduced and the distal occlusion corrected
before the buccal teeth have completely erupted into occlusion.
The upper and lower incisors come into occlusion before the
posterior teeth erupt.

If a functional appliance is removed for eating, the tongue often

spreads laterally between the teeth and delays eruption. Full-time
appliance wear with Twin Blocks prevents the tongue from
spreading between the teeth and accelerates correction of deep
overbite

21
Closing the bite
Reduced overbite or anterior open bite is often related to a vertical
facial growth pattern. The lower facial height is already increased,
and the vertical dimension must not be encouraged to increase
during treatment. It is necessary to close the anterior vertical
dimension, and treatment should aim to reduce lower facial height
by applying intrusive forces to the opposing posterior teeth.

An acrylic occlusal table is designed into the appliance to

maintain contact on the posterior teeth throughout treatment. This
occlusal contact results in a relative intrusion of the posterior teeth
while the anterior teeth are free to erupt, thereby reducing the
anterior open bite.

22
In the Twin Block technique the intrusive forces which close the
bite are increased by wearing the appliances for eating. In
treatment of reduced overbite it is very important that the opposing
occlusal bite block surfaces are not trimmed. All posterior teeth
must remain in contact with the blocks throughout treatment to
prevent eruption of posterior teeth.

Manipulation of the occlusal table is an important aspect of

functional appliance therapy. By separating the posterior teeth it is
possible to adjust the dimensions of the intermaxillary space
anteroposteriorly and vertically to correct skeletal discrepancies.

23
APPLIANCE DESIGN AND CONSTRUCTION:

EVOLUTION OF APPLIANCE DESIGN:

The earliest Twin Blocks were designed with the following
basic components:
A midline screw to expand the upper arch.
Occlusal bite blocks.
Clasps on upper molars and premolars.
Clasps on lower premolars and incisors.
A labial bow to retract the upper incisors.
Springs to move individual teeth if needed.
Provision for extraoral traction in some cases.

24
 Twin Block appliances are tooth and tissue borne. The
appliances are designed to link teeth together as anchor units to
limit individual tooth movement, and to maximize the
orthopedic response to treatment.

In the lower arch, peripheral clasping combined with occlusal

cover exerts three-dimensional control on anchor teeth, and
limits tipping and displacement of individual teeth.

When indicated, additional clasps may be placed on lower

incisors but, in practice, it is found that clasps mesial to the
lower canines are equally effective in controlling the
lower labial segment.

25
STANDARD TWINBLOCKS:
Standard Twin Blocks are
essentially for treatment of an
uncrowded Class II division I
malocclusion with a good arch
form and an overjet large enough
to allow unrestricted forward
translation of the mandible to
allow full correction of distal
occlusion.

26
27
THE DELTA CLASP:
The delta clasp was designed by
Clark to improve the fixation of
TwinBlocks. The delta clasp is
similar to the Adams clasp in
principle, but incorporates new
features to improve retention,
reduce metal fatigue and
minimise the need for
adjustment.

28
BASE PLATE:

COLD CURE ?
HEAT CURE ?

29
ANGULATION OF THE INCLINED PLANE:

90 Degree ?
45 Degree ?

30
TREATMENT OF CLASS II DIV I MALOCCLUSION
DEEP OVERBITE:
Bite registration:

Projet 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 &
lower incisors, which is an appropriate interincisal clearance for
most Class II division I malocclusions with increased overbite.

The incisal portion of the bite gauge has three incisal grooves on
one side that are designed to be positioned on the incisal edge of
the upper incisor and a single groove on the opposing side that
engages the incisal edge of the lower incisor. The appropriate
groove is selected depending on the ease with the patient can
posture the mandible forwards. 31
Fitting Twin Blocks:
Patient motivation is an important aspect of all removable
appliance therapy. It is often helpful to the patient if the clinician
demonstrates Twin Blocks on models to confirm that it is a simple
appliance system and is easy to wear, with no visible anterior
wires.

Simply biting the blocks together guides the lower jaw forwards to
correct the bite. The appliance system is easily understood even by
young patients, who can see that biting the blocks together
corrects the jaw position. It is important to motivate the patient
before treatment.

The patient is shown how to insert the Twin Blocks with the help
of a mirror, pointing out the immediate improvement in facial
appearance when the Twin Block is fitted and explaining that the
appliances will produce this change in a few months, provided
32
they are worn full time.
TEMPORARY FIXATION OF TWIN BLOCKS:
The most crucial time to establish good cooperation with the
patient is in the first few days after fitting the Twin Blocks, when
he or she is learning to adjust to the new appliance.

Twin Blocks have the unique advantage compared to other

functional appliances in that they can be fixed to the teeth. Such
temporary fixation guarantees full time wear, 24hoursperday,and
excellent cooperation is established at the start of treatment.

The teeth should first be fissure sealed and treated with topical
fluoride as a preventive measure prior to fixation.

SEQUENTIAL TRIMMING:
This is done to encourage eruption of the posterior teeth and
reduce the overbite 33
34
The intergingival height is a useful guideline to
check progress and to establish the correct vertical
dimension during treatment.
To keep track of progress in opening or closing the
bite, this measurement should be noted on the
record card at every visit.
The intergingival height varies according to the
patient's age and and the height of the incisor
crowns. It is small in a young patient whose
incisors have recently erupted, and larger in an
older patient with gingival recession. In the
younger patient a range of 15-17mm is normal.

35
SOFT TISSUE RESPONSE:
Rapid changes occur in the craniofacial musculature in
response to the altered muscle function that results from
treatment of malocclusion by a full-time functional
appliance. As a result of altered muscle balance, significant
changes in facial appearance are seen within 2 or 3 weeks of
starting treatment with Twin Blocks. The rapid
improvement
in muscle balance is very consistent and is observed on
photographs as a more relaxed posture within minutes,
hours or days of starting treatment.

36
 TheTwinBlock appliance positions the mandible downwards
and forwards, increasing the intermaxillary space. As a result it is
difficult to form an anterior oral seal by contact between the
tongue and the lower lip, and patients adopt a natural lip seal
without instruction.
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.
The patient adopts a lip seal when the overjet is eliminated in
the most natural way possible, by eating and drinking with the
appliance in the mouth. This encourages a good lip seal as a
functional necessity to prevent food and liquid escaping from the
mouth. A good lip seal is always achieved by normal function with
Twin Blocks, without the need for lip exercises.

37
STAGES OF TREATMENT:

Twin Block treatment is described in two stages. Twin

Blocks are used in the active phase to correct the
anteroposterior relationship and establish the correct vertical
dimension. Once this phase is accomplished, the Twin
Blocks are replaced with an upper Hawley type of appliance
with an anterior inclined plane, which is then used to support
the corrected position as the posterior teeth settle fully into
occlusion.

38
Stage1: 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.

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. 39
The upper block is trimmed occlusodistally to leave the lower
molars 1-2 mm clear of the occlusion to encourage lower molar
eruption and reduce the overbite fully maintaining a minimal
clearance between the upper bite block and the lower molars the
tongue is prevented from spreading laterally between the teeth.

This allows the molars to erupt more quickly. At each subsequent

visit the upper bite
block is reduced progressively to clear the occlusion with the
lower molars to allow these teeth to erupt, until finally all the
acrylic has been removed over the occlusal surface of the upper
molars allowing the lower molars to erupt fully into occlusion.

It is important not to reduce the leading edge of the inclined

plane, so that adequate functional occlusal support is given until a
three point occlusal contact is established with the molars in
occlusion.
40
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.

41
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 anterior inclined plane to
engage the lower incisors and canines.

The lower 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 remodelling to support the
corrected occlusion as the buccal segments settle
fully into occlusion.

42
43
Timetable of treatment:
Average treatment time
Active phase : 6-9 months
Support phase: 3-6 months
Retention: 9 months

44
45
 A spinner may be incorporated in an
upper appliance with a midline screw
without interfering with the action of the
midline screw to expand the arch. The
spinner may be mounted on a piece of
steel tubing supported by wires extending
from either side of the midline.

This is a very positive mechanism for

controlling tongue thrust by retraining
the tongue to move up into the palate
rather than thrusting forwards between
the teeth

46
A tongue guard is a more passive obstruction to
discourage the tongue from thrusting forwards against
the lingual surfaces of the upper incisors. It is in the
form of a recurved wire extending from the premolar
region towards the midline and is recurved to its point
of attachment.

In the treatment of reduced overbite it is essential that

no trimming is done on the blocks, and that occlusal
contact of the posterior teeth is maintained on the
blocks throughout treatment.

47
TWIN BLOCKS FOR ARCH DEVELOPMENT:
TRANSVERSE DEVELOPMENT- TWIN BLOCK SCHWARZ APPLIANCE
- UPPER SCHWARZ / LOWER JACKSON
TWIN BLOCK
-TWIN BLOCK CROZAT APPLIANCE

48
TREATMENT FOR CLASS II DIVISION II
MALOCCLUSION:
(TWIN BLOCK SAGITTTAL APPLIANCE)

SAGITTAL DEVELOPMENT

Twin Block sagittal appliance

Sagittal arch development is required when upper or lower incisors
are retroclined with deep overbite. As the name implies, the Twin
Block sagittal appliance is designed primarily for anteroposterior arch
development by positioning two screws which are aligned
anteroposteriorly in the palate.
Some oblique movement is also possible by offsetting the angulation
of the screws to achieve an additional component of buccal
expansion. Normally, the palatal screws are angled to drive the upper
posterior segments distally along the line of the arch.

49
The anteroposterior positioning of the screws
and the location of the cuts determines whether
the appliance acts mainly to move upper
anterior teeth labially or to distalise upper
posterior teeth. The position of the anterior cut
determines how many teeth are included in the
anterior segment. If only the central incisors are
retroclined, a cut distal to the central incisors
will move only these teeth labially or,
alternatively, the lateral incisors may also be
advanced by placing the cut distal to the lateral
incisors. The incisor teeth are then pitted against
the posterior teeth to advance the labial
segment.

50
TRANSVERSE AND SAGITTAL DEVELOPMENT:

Some cases require a combination of transverse and sagittal

development. A three-way screw incorporates two screws in a
single housing and allows independent activation for transverse
and sagittal expansion, although it is fairly bulky in the anterior
part of the palate and therefore interferes with speech.

The three way sagittal appliance achieves this objective with

an additional midline screw, which can be positioned anteriorly,
or posteriorly in the palate. Alternatively, a midline screw may
be combined with lingual wires to advance and align upper and
lower incisors. This design of appliance may be used in both
arches to advance retroclined upper and lower incisors and to
open the bite in treatment of bimaxillary retrusion.
51
TREATMENT FOR CLASS III
MALOCCLUSIONS:
(REVERSE TWIN BLOCKS):

Reversing the angulation of the inclined plane

Combined sagittal and transverse expansion using

three way screw appliance design

The position of the bite blocks is reversed compared

with that of Twin Blocks for treatment of Class II
malocclusion. The occlusal blocks of the upper
appliance are positioned over the deciduous molars to
occlude distally with blocks placed over the lower first
permanent molars. 52
The addition of two sagittal screws in the palate provides a means of
activation to advance the upper incisors, and the reciprocal force on
the inclined planes uses anchorage in the lower arch to drive the
upper arch labially.

Apart from the reverse position of the blocks and inclined planes, the
design of the upper appliance is similar in principle to the sagittal
design used in treatment of Class II division 2 malocclusion and the
same principles apply in relation to positioning the screws.
A contracted maxilla frequently requires three-way expansion. This is
achieved by a three-screw sagittal design or the three-way screw to
combine transverse and sagittal arch development.

53
Management of reverse Twin Blocks:
With the sagittal appliance design, because of the
curvature of the palate it is easier for the patient to operate
the screws from the fitting surface of the appliance. The
screws should be positioned so that both are opened by
turning in the same direction. This is less confusing for a
young patient. The lower appliance is retained with clasps
on the lower molars and additional interdental clasps as
required.
Opening the screws has the reciprocal effect of driving
the upper molars distally and advancing the incisors. Distal
movement of! upper molars is resisted by occlusion of the
lower bite blocks on the reverse inclined planes. Therefore
the net effect of opening the screws is a forward driving
force on the upper dental arch.
54
 The position of the cut for the screws will influence
their action on individual teeth. The cuts may be
positioned distal to the lateral incisors to advance only the
four upper incisors.
Positioning the cuts mesial to the upper molars, would
increase the distalising component of force on the molars,
but distal movement is resisted by occlusion with the
lower bite blocks, and the reciprocal force acts to advance
the entire upper arch mesial to the molars, using the lower
arch as anchorage.

To enhance forward movement of the upper labial

segment, lip pads may be added.

55
THE TWIN BLOCK TRACTION TECHNIQUE:

Indications
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.

56
Concorde facebow:
In the early years using Twin
Blocks, tubes were added to clasps
for extraoral traction on the upper
appliance to be worn at night so as to
reinforce the functional component
for correction of a class II buccal
segment relationship.

A method was developed to

combine extraoral and intermaxillary
traction by adding a labial hook to a
conventional face bow and extending
an elastic back to attach to the lower
appliance in the incisor region. 57
 The Concorde face bow is a new means of applying
intermaxillary extraoral traction to restrict maxillary growth
and, at the same time, to encourage mandibular growth in
combination with functional mandibular protrusion.
A conventional face bow is adapted by soldering a
recurved labial hook to extend forwards to rest outside the
lips as an anchor point to combine intermaxillary and
extraoral traction. Patient comfort and acceptance is similar
to a conventional facebow.
Intermaxillary traction was added to the appliance system
to ensure that if the patient postured out of the appliance
during the night, the intermaxillary traction force would
increase. This ensured that the appliance was effective 24
hours per day.

58
 The labial hook is positioned extraorally, I cm clear of the
lips in the midline. This enables an elastic back to pass
intraorally to attach anteriorly to the lower appliance to apply
intermaxillary traction as a horizontal force vector. This has the
advantage of eliminating the unfavourable upward component of
force in conventional intermaxillary elastic traction, which can
extrude lower molars and cause tipping of the occlusal plane.

When distal extraoral traction is applied to a removable

appliance, the outer bow of the facebow should be adjusted to lie
slightly above the inner bow in order to apply a slight upward
component of force to help retain the upper appliance.

59
 The traction components are worn at night only to
reinforce the action of the occlusal inclined plane. If the
patient fails to posture the mandible to the corrected occlusal
position during the night, the intermaxillary traction force is
automatically increased to compensate and to ensure that
favourable intermaxillary forces are applied continuously.
The aim is to make the appliances active 24 hours per day to
maximise the orthopedic response.

Occasionally (Orton, 1990), high pull traction may be

indicated to intrude the upper posterior teeth in cases with a
severe vertical growth pattern, in an effort to achieve a
forward mandibular rotation by intruding upper molars. The
same objective can be achieved more simply by using vertical
intraoral elastics to intrude the posterior teeth.

60
MAGNETIC TWIN BLOCKS:
The role of magnets in Twin Block therapy is specifically
to accelerate correction of arch relationships. The purpose
of the magnets is to e encourage increased occlusal contact
on the bite blocks to maximise the favourable functional
forces applied to correct the malocclusion.

Two types of rare earth magnets.

SAMARIUM COBALT
NEODYNIUM BORON

61
Both are effective, but neodynium boron delivers a
greater force from a smaller magnet.

Attracting magnets incorporated in occlusal inclined

planes may be effective in maintaining forward
mandibular posture when the patient is asleep.

Patients who have magnets added to Twin Blocks

during treatment report increased occlusal contact by
day and observe also that the blocks are in contact on
waking.

62
ATTRACTING MAGNETS
The attracting magnetic force pulls the appliances together
and encourages the patient to occlude actively and
consistently in a forward position.

The functional mechanism of Twin Blocks stimulates a

proprioceptive response by repeated contact on the occlusal
inclined planes.

Attracting magnets may accelerate progress by increasing the

frequency and the force of contact on the inclined planes, thus
enhancing the adaptive response to functional correction.

63
REPELLING MAGNETS

Repelling magnets may be used in Twin Blocks with less mechanical

activation built into the occlusal inclined planes. The repelling magnetic
force is intended to apply additional stimulus to forward posture as the
patient closes into occlusion.

Moss & Shaw (1990) reported at the European Orthodontic Congress on

a controlled study of 12 patients with repe!ling magnets placed in occlusal
inclines of Twin Block appliances. The results indicated a 50% increase in
the rate of correction of overjet compared to a similar group of patients
where magnets were not used, although an improved growth response was
not established.

The repelling magnets were intended to induce additional forward

mandibular posture without reactivation of the blocks. A disadvantage of
this method is that the amount of activation is not clear, and reactivation
of the inclined planes would deactivate the magnets.
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MAGNETIC FORCE IN THE CORRECTION OF FACIAL
ASYMMETRY:
Inclined planes with attracting magnets provide an excellent training
mechanism to improve facial balance by controlling muscle action.
Magnetic force may be used to counteract asymmetrical muscle action
in the development of facial asymmetry.

Mandibular displacement responds rapidly to correction with

attracting magnets in the occlusal inclined planes on the working side.
The nonactive side may be activated to a lesser degree to encourage
centre line correction.

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TWIN BLOCKS IN TMJ THERAPY:

The goals of therapy are:

Relieve the pain caused by distal displacement of the-condyle.

Retrain the muscles to a healthy pattern.
Recapture the disc when possible by advancing the displaced
condyle.
Move the teeth that are causing occlusal imbalance and
mandibular misguidance.
Increase the vertical dimension to reduce deep overbite.

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Twin Blocks are most likely to be indicated to
resolve an early click when the condyle is displaced
distal to the disc and the disc is recaptured at an early
stage in the opening movement.

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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 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.

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 The disc 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.

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FIXED TWIN BLOCKS:
Integration with Wilson lingual appliances: (Esthetic appliance
design)
The integration of the Twin Block with Wilson 3D modular appliances
results in a fixed functional appliance system that is adaptable to the
requirements of combined orthopaedic and orthodontic technique.

The Wilson 3D modular system is suitable for early intervention and arch
development. The use of the Wilson 3D lingual tube as a retentive element
on molar bands provides a means of attachment for occlusal Twin Block
components, which may be fixed or fixed/removable, under the direct
control of the operator.

The facility to combine orthopedic and orthodontic components by using a

common retentive element extends the capabilities of both appliance
systems.

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Three distinct phases of treatment can be defined as follows:

First phase: interceptive treatment and arch development by

theWilson modular appliance system.

Second phase: orthopedic treatment by the fixed/functional

Twin Block system.

Third phase: detailed orthodontic correction by bonded fixed

appliances.

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FIXED TWIN BLOCKS - FUNCTIONALCOMPONENTS

The Twin Block transpalatal arch

This component consists of a transpalatal arch with occlusal
inclined planes over the posterior teeth that can be cemented in
place. The inclined planes are secured by occlusal wire tags that
are an extension of the transpalatal wire. The entire assembly is
secured in Wilson lingual tubes on upper molar bands by the
standard Wilson plug-in attachment.

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The Twin Block Hyrax appliance

The Hyrax screw is commonly used with

fixed appliances for rapid maxillary
expansion.

Transverse development can be combined

simultaneously with mandibular
advancement by adding Twin Blocks to a
rapid maxillary expansion appliance.

The lower appliance may be anchored on

lower second deciduous molars and may
incorporate a
lower lingual arch.
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The Twin Block lingual arch
The occlusal inclined plane component in the lower arch is
combined with the Wilson 3D lingual arch, and extends over
the occlusal surfaces of the lower deciduous molars, or
premolars, depending on the stage of development.

The appliance may be used in mixed dentition, when functional

correction can be combined with interceptive treatment for arch
development by the lingual arch. The Omega loop should be
omitted to provide a more rigid attachment.

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Occlusal inclined planes
The occlusal inclined planes are designed to occlude at a
70 angle mesial to the occlusion with the lower molar.
The position of the inclined planes is critical in
establishing vertical molar control in cases with deep
overbite, where it is important to free the lower molar to
erupt to control the vertical dimension.

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The management of fixed Twin Blocks is very similar to the
management of removable Twin Blocks, except that fixed
Twin Blocks are only removable by the operator for
adjustment.

When the appliances are tried in the mouth, it is advisable to

check that the blocks occlude correctly and are shaped
correctly to allow the objectives of treatment to be achieved.
This relates particularly to the patient being able to achieve a
comfortable occlusion in a forward mandibular posture.

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To correct deep overbite the upper bite blocks are
trimmed occluso-distally before fitting the appliance to
allow eruption of lower molars to reduce overbite.

Normally, vertical development of the molars can be

delayed in the mixed dentition stage until the lower arch
has been translated to a forward position.

This allows the first permanent molars to be used as a

means of fixation for the Twin Block lingual arch
component.

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Support phase: fixed anterior inclined plane:
The anterior inclined plane is constructed from two Wilson
3D sectional appliances joined anteriorly by an inclined
plane, which extends far enough around the upper arch to
engage the six lower anterior teeth. For additional strength,
the sectional wires may be replaced by a heavy-gauge
lingual bar attachment soldered to Wilson lingual posts.

This may be combined with a standard Wilson lower

lingual arch to maintain the arch length and arch form in the
lower arch as the buccal segments erupt into occlusion.
In the support stage of treatment a full-bonded fixed
appliance may be fitted to level the occlusal plane and
detail correction in the lower arch

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A MODIFICATION TO PRODUCE CONTROLLED
PROGRESSIVE ADVANCEMENT OF THE TWIN BLOCK
APPLIANCE: JO 1999

This is possible by the incorporation of steel screws with conical

heads into the blocks of the upper appliance to provide the
inclined plane effect.
Advancement is by the addition of polyacetal spacers between the
screw heads and the upper blocks. The system is used to enhance
the clinical flexibility of the appliance and patient acceptance in
cases where the mandibular protrusion is limited initially.

Another possible application is gradual reactivation for class III

cases.

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The advantage of twin block appliance with an
adjustable screw mechanism are as
follows:
1. Accurately measurable advancement.
2. Quickly adjusted at the chairside.
3. Avoids the use of free monomer.
4. Laboratory support unnecessary.
5. Asymmetric advancement facilitated.

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6. Smaller adjustments possible to allow stepwise
advancement and improve patient tolerance.

7. Gradual advancement, particularly appropriate in

Class III Twin block treatments.

8. Reversible if over-advancement is produced.

9. More gradual mandibular advancement may be more

biological and, therefore, produce improved mandibular
response.

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Principle of the Twin Block Advancement
Mechanism
The appliance modification consists of the insertion
of a screw into the mesial face of each block of the
upper appliance. The 3 mm diameter 18/8 M3
stainless steel screws have slotted pan heads which
are machined to a cone shape giving an included
angle of 140 degrees. This means that when
positioned longitudinally in the block the screw
head will always present a 70-degree angle with the
face of the lower block regardless of the rotational
position of the screw.

The screws are available in 12mm and 16 mm

lengths. The longer screws are used for
advancements greater than 5 mm. Advancement is
achieved by adding cylindrical polyacetal co-
polvmer spacers which have been used in 1-, 2-, 3-,
4-, and 5-mm
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lengths.
The twin block is the most frequently used functional
appliance as it has a number of advantages such as

1. It can be used full time.

2. They cause less interference with normal function
3. It is not bulky as a one piece appliance.
4. Speech difficulty is minimal.
5. Wire components are not visible and hence esthetic.
6. Rapid correction of malocclusion due to 24 hour wear.
7. Allow independent control of upper and lower arch
width.
8. Can be combined with fixed appliance therapy.

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