Vous êtes sur la page 1sur 565

Twin Block

Functional Therapy
Applications in Dentofacial Orthopedics
Twin Block
Functional Therapy
Applications in Dentofacial Orthopedics

Third Edition

Editor
William J Clark BDS DDO DDSc FDSRCS (Eng)
New Horizons in Orthodontics
Member of British Orthodontic Society
American Association of Orthodontists
World Foundation of Orthodontists
International Functional Association
Fife, Scotland, United Kingdom

Foreword
OP Kharbanda

The Health Sciences Publisher


New Delhi | London | Philadelphia | Panama
  Jaypee Brothers Medical Publishers (P) Ltd

Headquarters
Jaypee Brothers Medical Publishers (P) Ltd.
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
E-mail: jaypee@jaypeebrothers.com

Overseas Offices
J.P. Medical Ltd. Jaypee-Highlights Medical Publishers Inc.
83, Victoria Street, London City of Knowledge, Bld. 237, Clayton
SW1H 0HW (UK) Panama City, Panama
Phone: +44-20 3170 8910 Phone: +1 507-301-0496
Fax: +44(0)20 3008 6180 Fax: +1 507-301-0499
E-mail: info@jpmedpub.com E-mail: cservice@jphmedical.com

Jaypee Medical Inc. Jaypee Brothers Medical Publishers (P) Ltd.


The Bourse 17/1-B, Babar Road, Block-B, Shaymali
111 South Independence Mall East Mohammadpur, Dhaka-1207
Suite 835 Bangladesh
Philadelphia, PA 19106, USA Mobile: +08801912003485
Phone: +1 267-519-9789 E-mail: jaypeedhaka@gmail.com
E-mail: jpmed.us@gmail.com

Jaypee Brothers Medical Publishers (P) Ltd.


Bhotahity, Kathmandu, Nepal
Phone: +977-9741283608
E-mail: kathmandu@jaypeebrothers.com

Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com
© 2015, Jaypee Brothers Medical Publishers
The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those
of editor(s) of the book.
All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical,
photo­copying, recording or otherwise, without the prior permission in writing of the publishers.
All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective
owners. The publisher is not associated with any product or vendor mentioned in this book.
Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter
in question. However, readers are advised to check the most current information available on procedures included and check information from
the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse
effects and contra­indications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the
author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.
This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services
are required, the services of a competent medical professional should be sought.
Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have
been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity.

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Third Edition: 2015


ISBN: 978-93-5152-314-7
Printed at
Dedication
This third edition of my book is dedicated in memory of my parents,
Agnes and Andrew Clark. Without their support and dedication
I could not have achieved anything. My father was a coal miner.
He inspired me not to follow in his footstep but to work hard at
school to achieve a good education and, as he said, “a collar and tie job”.
My mother taught us to behave well and to speak well.
Our school motto was “Perseverando”, and it was appropriate to
encourage young aspiring students to use their talent to achieve
their objectives in life. My sister was the first from our
village to attend university, and I followed in her
footsteps when I went to St Andrews University to study dentistry.
It was a great privilege. I am forever grateful
for the start I received from my parents.
Contributors to the Third Edition
Dr. Derek Mahony BDS, MScOrth Dr. Ramesh Sabhlok BDS, MDS
Private Practice Adjunct Professor of Orthodontics
Hardwick, New South Wales, Australia Manipal College of Dental Surgery
University of Manipal
Dr. Dilip Patel MDS (Ortho) Manipal, Karnataka, India
Private Practice Consultant Orthodontist
Rajkot, Gujarat, India Dubai Smile Dental Center
Dubai, United Arab Emirates

Contributors to the Second Edition

Gary G Baker DDM GD Singh DDSc PhD BDS

A Gordon Kluzak DDS LDS (M)RCDC BioModeling Solutions, Inc.


Beaverton, Oregon, USA
Forbes Leishman BDS DDOrth MscO

Mel Taskey BSc DDS MSc


Christine Mills DDS MS
Private Practice
Private Practice
Edmonton, Alberta, Canada
Vancouver, British Columbia, Canada
Foreword
William Clark’s Twin Block Functional Therapy: Applications in Dentofacial Orthopedics, Third Edition, is a significant
work and an improvement over the first two editions.
This book provides a comprehensive insight into dentofacial orthopedics using the Twin Block functional appliance
and its integrated biomechanics with fixed appliance therapy. Its 556 pages have been intelligently structured into
29 chapters. The book has a wealth of information on fundamentals and philosophy, case diagnosis, treatment
approaches, clinical case reports, and research related to functional jaw orthopedics with the Twin Block appliance.
The clinical experience of the inventor of the Twin Block appliance, meticulous records, and long-term follow-up of
the wide variety of cases are perfectly blended with an easy-to-comprehend text that is supported by an excellent
layout and professional-quality line drawings.
Following my first interaction with Dr Clark in 1990, when I visited his clinic in Kirkcaldy, Fife, Scotland, we
introduced his Twin Block appliance at the All India Institute of Medical Sciences in New Delhi. Over the next couple
of years, it took Indian orthodontics by storm. The low-cost, simple-to-fabricate, patient-friendly, effective therapy has
helped innumerable patients to have a balanced face and normal occlusion without extractions.
Some of the features unique to Dr Clark’s book on dentofacial orthopedics are his approach to cephalometric
diagnosis, case selection, and the philosophy of arch development. The book also has chapters devoted to modifications
of the appliance design for open-bite malocclusion, Class II Division 2, non-extraction therapy, integration of Twin
Block with fixed appliance therapy, treatment of facial asymmetry and pain in the temporomandibular joint, as well
as reverse Twin Blocks and Class III malocclusion. A separate chapter on management of vertical growers is a useful
addition.
Interesting chapters include treatment for adults and the role of Twin Block in obstructive sleep apnea and
advances in Twin Blocks, including fixed re-fabricated Twin Block appliances, invisible Twin Blocks, and the “Breath
Easy” Twin Block.
I compliment Dr Clark for producing this textbook on Twin Block therapy in orthodontics, as well as the publishers
for producing a beautifully laid out book. It is certainly useful for postgraduates, practicing clinicians, and those
interested in dentofacial orthopedics.
OP Kharbanda
BDS MDS (Lucknow) M Orth RCS (Edinburgh) M Med (Dundee)
FDSRCS (Edinburgh) Hon FAMS Fellow
Indian Board of Orthodontics, Hon Causa
Professor and Head
Department of Orthodontics and Dentofacial Deformities
Centre for Dental Education and Research
All India Institute of Medical Sciences
New Delhi, India
Preface
Twin Blocks were developed in 1977, and the author has taught the technique for the past 33 years in more than
50 countries. Twin Blocks produce dramatic improvements in facial aesthetics in correction of severe malocclusion.
As a result, Twin Blocks are the most popular functional appliance worldwide.
Twelve years have elapsed since the second edition was published, and many improvements have been made as
the technique continues to evolve. Since the last edition, new research has provided convincing evidence to support
the value of functional orthopedic techniques. Research has now established that Twin Blocks influence the functional
environment of the developing dentition and produce significant improvements in the pattern of facial growth and
dental arch development.
This edition contains important new sections to illustrate improvements and to advance our knowledge of
Twin Block technique and other related aspects of functional therapy:
• Pitfalls in appliance design and management are explained with examples of problem patients and contrain-
dications for functional therapy.
• Fixed Twin Blocks: The author has developed and tested Fixed Twin Blocks for the past 15 years and treatment
records show the evolution of this technique, leading to a final solution with an improved design and protocol to
integrate Fixed Twin Blocks with fixed appliances.
• Fixed functional appliances: A new range of spring-driven Fixed Functional Appliances have been developed
and are illustrated with examples of treated cases.
• Treatment of sleep apnea: Intraoral appliances are used increasingly in the treatment of sleep apnea. A new
chapter with a comprehensive contribution by Dr Derek Mahony outlines the dental approach to this important
subject.
• Breathe Easy Twin Blocks: Invisible Twin Blocks with preformed occlusal blocks present a patient-friendly
approach to the treatment of sleep apnea, with the added advantage of correcting Class II malocclusion.
• TransForce lingual appliances represent a revolution in interceptive treatment and dental arch development.
TransForce appliances are invisible, using a pre-activated nickel-titanium spring mechanism for correction of arch
form in all classes of malocclusion from mixed dentition to adult therapy. Sagittal and Transverse appliances are
designed to correct arch width, resolve anterior crowding and correct dental asymmetry.
• Reverse Twin Blocks: New examples illustrate the scope for functional correction of Class III malocclusion.
This new edition provides “state-of-the-art” instruction in all aspects of functional therapy, including diagnosis,
case selection, appliance design, and clinical management.

William J Clark
Acknowledgments
This book is based on a new approach to functional orthopedics in clinical orthodontic practice. I wish to acknowledge
the cooperation of many excellent patients and their primary role in the development of the Twin Block technique,
not least Colin Gove, the first patient I treated with Twin Blocks in 1977.
My dental technician, James Watt, has made my removable appliances for the past 45 years. He made the first Twin
Blocks, and I should like to acknowledge his invaluable contribution and support in providing the expert technical
help I needed to develop the Twin Block Technique.
It has been interesting and challenging to travel and teach throughout the world, and to all the people who have
offered their support and encouragement I offer my sincere thanks.
Tom Graber was most generous in his support and was always a wise counsel in matters relating to functional
orthopedics. Tom was mainly responsible for changing the title of the American Journal of Orthodontics to include
Dentofacial Orthopedics, recognizing the importance of orthopedics in the future development of the specialty of
orthodontics. He was a pioneer in the cause of functional therapy.
It is always difficult to introduce new techniques, and I wish to acknowledge support from Jim McNamara of the
University of Michigan for his help in the early days when I traveled and taught Twin Blocks abroad. In 1990 Professor
Kharbanda and Professor Singh visited my orthodontic practice in Scotland to attend a course. They introduced Twin
Blocks in India and carried out valuable research on the technique. Academic research is essential for acceptance of
any new technique.
In producing a third edition I am indebted to outstanding contributions from my professional colleagues who
were represented in the second edition. Their valuable contributions are reproduced in this new edition.
Christine Mills developed a new approach to the treatment of anterior open bite and vertical growth in her orthodontic
practice in Vancouver. She investigated growth changes in a scientific study with matched controls from the Burlington
Growth Center in Toronto.
Gordon Kluzak came to Scotland and learned how to integrate techniques for lingual arch development with Twin
Block therapy in his pedodontic practice in Calgary.
Mel Taskey applied Twin Blocks in the treatment of temporomandibular joint therapy.
Gary Baker is the fourth Canadian to offer a significant contribution by developing a new approach to integrate
Twin Blocks with straight wire technique in his dental practice in Vancouver.
David Singh is a researcher with an excellent reputation in the study of facial growth and development using finite
element analysis and similar techniques. We worked in collaboration at the University of Dundee to investigate
mandibular growth changes and to identify significant areas and mechanisms of growth related to Twin Block therapy.
Forbes Leishman attended the first ever Twin Block course in Scotland in 1979 and subsequently emigrated to
New Zealand, where he successfully combined Twin Blocks with fixed appliances in his orthodontic practice in
Auckland, producing remarkable results in nonsurgical treatment of severe Class II malocclusion.
In the third edition we are fortunate to have further outstanding contributions from international experts in
Twin Block therapy.
Derek Mahony is a teacher of outstanding ability in his series of courses, “Full Face Orthodontics.” This covers all
aspects of orthodontics, including functional therapy and a comprehensive approach to treatment of sleep apnea
(www.fullfaceorthodontics.com).
xiv  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
Dilip Patel is expert in the treatment of severe Class II and Class III malocclusion with Twin Blocks as an alternative
to surgical correction. He presents excellent case reports showing his individual approach in his orthodontic practice
in India.
Ramesh Sabhlok is based in Dubai, United Arab Emirates, and presents courses and lectures internationally on a
wide range of techniques in orthodontics, including Twin Blocks. His contribution illustrates the potential of treatment
by the Forsus fixed functional appliance.
In their own individual way, all the contributors are experts on Twin Blocks in their environment of practice or
research. I thank them sincerely for their contributions.
Chapter 23, “New Horizons in Orthodontics,” introduces important new developments in orthodontic technique.
TransForce Lingual Appliances are invisible appliances for arch development using a pre-activated nickel-titanium
spring mechanism for correction of arch form in all classes of malocclusion. TransForce Appliances represent a
revolution in interceptive treatment for correction of arch form in all classes of malocclusion from mixed dentition
to adult therapy. They integrate with fixed appliances and are recommended as an excellent Pre-Aligner technique
to extend the range of malocclusions that can be treated with invisible appliances. I am indebted to Lindsay Brehm
and Ortho Organizers and the engineering skills of Steve Franseen and Steve Huff in the design and development
of TransForce appliances. My thanks are due to Henry Schein Orthodontics for continued support and marketing of
this technique (www.orthoorganizers.com).
After 15 years of clinical testing, case reports demonstrate the effectiveness of Fixed Twin Blocks (see Chapter 24).
A new design and protocol simplifies the fitting and management of Fixed Twin Blocks for integration with fixed
appliances. I acknowledge the support of Carlos Martinez Avilla in Mexico in manufacturing preformed occlusal
blocks to bring this technique to fruition. (Contact orthorg@prodigy.net.mx for further information).
Finally, I would like to thank Joe Rusko, Carol Field, and Tom Gibbons for their help and support in producing
this edition, as well as the production team of Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, India for the
high quality of the illustrations.
Contents
1. The Art of Orthodontics 1
• Dental Chess  1
• Orthodontics and Dental Orthopedics  2
• The Philosophical Divide  2
• The Genetic Paradigm  2
• Treatment Concepts  3
• Orthodontic Force  3
• Orthopedic Force  3
• Dentofacial Orthopedics  4
2. Introduction to Twin Blocks 7
• The Occlusal Inclined Plane  7
• Proprioceptive Stimulus to Growth  7
• Twin Blocks  8
• Development of Twin Blocks  11
• Modification for Treatment of Class II Division 2 Malocclusion  13
• The Twin Block Technique—Stages of Treatment  16
• Retention  18
• Response to Treatment  18
• Case Selection for Simple Treatment  22
3. Form and Function 25
• Development of Functional Technique  25
• Bone Remodeling in Response to Functional Stimuli  26
• Objectives of Functional Treatment   29
• Bite Registration in Functional Therapy   29
• Control of the Vertical Dimension  32
4. Growth Studies in Experimental Animals 35
• Histological Response to Orthodontic and Orthopedic Force  35
• The Occlusal Inclined Plane in Animal Experiments  36
• Functional Regulation of Condylar Cartilage Growth Rate  36
• Central Control of Adaptive Response   38
• Adaptation in Bone Growth in Response to Functional Stimulus  38
• The Influence of Functional Appliance Therapy on Glenoid Fossa Remodeling  38
• A Review of the Paradigm of Genetic Control  39
5. Diagnosis and Treatment Planning 47
• Clinical Examination  47
• Examination of Models  49
xvi  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

• Differential Diagnosis   52
• Treatment Planning in Crowded Dentition   54
• Nonextraction Therapy  55
• Contraindications for Twin Block Therapy  55
6. The Clark Cephalometric Analysis 59
• The Jigsaw Puzzle  59
• Vision, Balance and Posture  60
• Parallelism in Dentofacial Development  61
• A Registration Framework for Cephalometric Analysis  61
• The Facial Rectangle  62
• Balanced Facial Proportions  63
• A Correlative Cephalometric Analysis  64
• Descriptive Terms in Cephalometric Analysis  68
• Facial Changes in Twin Block Treatment  68
7. Appliance Design and Construction 85
• Evolution of Appliance Design  85
• Standard Twin Blocks  86
• Twin Block Construction  86
• The Delta Clasp  88
• Adjustment of the Delta Clasp  89
• The Base Plate  89
• Twin Blocks for Arch Development  90
• Sagittal Development  92
• Treatment of Class III Malocclusion  96
• Screw Advancement Mechanism for Progressive Activation of Twin Blocks  97
• The Bite Guide  98
• Twin Block Tool  99
• Invisible Twin Blocks  100
8. Treatment of Class II Division 1 Malocclusion Deep Overbite 101
• Clinical Management of Twin Blocks  101
• Full-Time Appliance Wear  103
• Management of Deep Overbite  104
• Establishing Vertical Dimension  105
• Soft Tissue Response  105
• Functional Orthopedic Therapy  109
• Reactivation of Twin Blocks  113
• Progressive Activation of Twin Blocks  113
• Summary—Adjustment and Clinical Management  114
• Robin’s Monobloc: The Original Sleep Apnea Appliance!  116
9. Treatment in Mixed Dentition 119
• Appliance Design  119
• Transverse Development  124
Contents  xvii

• Twin Blocks for Arch Development  124


• Occlusoguide Appliance  127
• Two-Phase Treatment in Mixed and Permanent Dentition  128
• Pedodontic Practice  138
10. Combination Therapy 145
• Permanent Dentition  145
• Concurrent Straightwire and the Twin Block Therapy  152
11. The Twin Block Traction Technique 165
• Orthopedic Traction  165
• The Concorde Facebow  165
• Twin Blocks Combined with Orthopedic Traction  167
• Treatment of Maxillary Protrusion  167
• Directional Control of Orthopedic Force  173
12. Treatment of Anterior Open Bite and Vertical Growth Patterns 177
• Pitfalls in Treatment of Anterior Open Bite  179
• Bite Registration  179
• Treatment of Vertical Growth  187
• Intraoral Traction to Close Anterior Open Bite  192
• Vertical Elastic to Correct Anterior Open Bite  192
• Treatment of Anterior Open Bite and Vertical Growth  201
• Response to Treatment of Anterior Open Bite  203
13. Treatment of Class II Division 2 Malocclusion 205
• Twin Block Sagittal Appliance—Appliance Design  206
• The Twin Block Sagittal Appliance  208
• The Central Sagittal Twin Block Followed by Fixed Appliances  216
14. Treatment of Class III Malocclusion 227
• Reverse Twin Blocks  227
• Treatment of Class III Malocclusion with Reverse Twin Blocks  229
• Reverse Twin Blocks: Appliance Design  230
• Reverse Twin Blocks: Management  230
• Early Treatment of Severe Class III Malocclusion with Reverse Twin Blocks  239
• Reverse Pull Facial Mask  239
• Class III Malocclusion with Facial Asymmetry  240
15. Orthodontics, Orthopedics or Surgery? 251
• Case Reports  252
• Discussion  270
• Additional Case Studies  270
16. Management of Crowding 275
• Nonextraction Therapy  275
• Arch Development before Functional Therapy  276
xviii  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

• Combination Fixed/Functional Therapy  276


• Management of Crowding: Nonextraction Therapy  280
• Class II Division 1 Malocclusion with Crowded Canines  291
• Combination Therapy by Twin Blocks and Fixed Appliances  291
• Management of Crowding with an Anterior Open Bite  294
• Treatment of Contracted Archform  298
17. Extraction Therapy 301
• Treatment of Patients with Unfavorable Skeletal and Dental Factors  304
18. Treatment of Facial Asymmetry 311
• Case Report: M Mck Aged 10 Years 4 Months  311
19. Magnetic Twin Blocks 317
• Magnetic Force  317
• Attracting or Repelling Magnets  317
• Magnetic Force in the Correction of Facial Asymmetry  323
20. Adult Treatment 325
• Treatment of a Young Adult  328
21. Temporomandibular Joint Pain and Dysfunction Syndrome 331
• The Importance of Occlusion  331
• Relief of Pain  332
• Case History and Diagnosis  333
• Temporomandibular Joint Therapy  335
• Appliance Design  336
• Clinical Management  336
• Anterior Open Bite Temporomandibular Joint Dysfunction  340
22. Pitfalls and Problems: Contraindications for Functional Therapy 343
• Pitfalls in Design and Management of Twin Blocks  343
• Pitfalls and Problem Patients  344
23. New Horizons in Orthodontics 361
• Arch Development  362
• Appliance Design  363
• Interceptive Treatment of Class II Division 2 Malocclusion  368
• TransForce 2 Sagittal Expander  374
• TransForce Sagittal Arch Development  378
• Transverse Arch Development  382
• TransForce 2 Transverse Expander  383
• TransForce Transverse Arch Development in Mixed Dentition  385
24. Fixed Twin Blocks 395
• Treatment Concepts and Protocol  395
• Development of Fixed Twin Blocks  395
• Evolution of Fixed Twin Blocks Phase 1—2008  396
• Phase 1—Integration with Fixed Appliances  396
Contents  xix

• Individual Fixed Blocks  397


• Phase 2—2010: Eliminates Attachment to Molar Bands  398
• Phase 3—2014: The Ultimate Solution  399
• Fixed Twin Blocks Phase 3—2014  400
• Guidelines for Case Selection  401
• Integrating Orthodontic and Orthopedic Therapy  402
• Arch Development before Mandibular Advancement  408
• Concurrent Arch Development and Fixed Twin Blocks  414
• Integrated Fixed and Functional Therapy  419
• Management of Severe Class II Division 1 Malocclusion  424
• Construction Bite and Indirect Bonding Technique  438
• Laboratory Preparation of Transfer Positioning Trays  439
• Indirect Technique for Bonding Fixed Twin Blocks  440
• Fixed Twin Blocks in Class II Division 2 Malocclusion  446
• Positioning Trays for Class II Division 2 Malocclusion  450
• Fixed Twin Blocks in Severe Dolichofacial Pattern  452
• Transforce Fixed Twin Blocks  457
• Fixed Twin Blocks and Sagittal Arch Development  458
• Combining Fixed Twin Blocks and Fixed Appliances  460
• Fixed Twin Blocks in Post-Pubertal Stage  463
• Retention  469
25. Fixed Functional Appliances 471
• Form and Function  471
• The Herbst Appliance  471
• Examples of Fixed Functional Appliances  475
26. Treatment of Sleep Apnea Using Mandibular Repositioning Appliances 491
• Evolution of Intraoral Appliances  491
• Patient Selection for Intraoral Appliances  493
• Possible Side Effects  493
• Daily Exercise to Stretch the Lateral Pterygoid Muscle  493
• Studies of the Effectiveness of Intraoral Appliances in the Management of Snoring and OSA  494
• Types of Oral Appliances for Treatment of Snoring and OSA  496
• Protrusive Bite Registration  499
• The Phonetic Bite  499
• The Neuromuscular Bite  501
• The Moses Appliance and the Moses Bite  502
• Twin Blocks in Treatment of Sleep Apnea  503
• Twin Blocks Increase the Airway  503
• Twin Blocks in Class II Therapy  504
• Twin Blocks in Treatment of Sleep Apnea  505
• Breathe Easy Twin Blocks  506
• Sleep Apnea and Health  511
xx  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

27. The Flat Earth Concept of Facial Growth 513


• Limitations of Cephalometric Analysis  513
• Relevance of Statistical Evidence  513
• The Flat Earth Concept of Facial Growth  514
• Volumetric Analysis of Facial Growth by Imaging Technology  517
• Morphometric Analysis  519
28. Growth Response to Twin Block Treatment 525
• The Twin Block Traction Technique  526
• Growth Response to Twin Blocks with Traction  526
• Twin Blocks versus Fixed Appliance  529
• Twin Blocks and Matched Normative Growth Data  532
• Twin Blocks FR-2 and Controls  532
• Twin Block Appliance Treatment Effects  532
• Dentoalveolar Changes  533
• Post-Treatment Stability  534
• Interpretation of Growth Changes  535
• Temporomandibular Joint Adaptations Following Two Phase Therapy:
A Magnetic Resonance Imaging Study  538
• Twin Block Therapy Treatment  539
29. Art and Science in Orthodontics 543
• Dental Chess  543
• The Role of Science in Orthodontics  544
• Twin Block Studies  544
• Limitations of Statistical Analysis  545
• Pitfalls in Design and Management of Twin Blocks  546
• Errors in Bite Registration  547
• Control of the Vertical Dimension  549
• Vertical Control of Deep Overbite  550
• Vertical Control of Anterior Open Bite  551
• The Art of Orthodontics  552
• Orthodontics or Orthopedics?  553
• An Allegory  554
• Review of Functional Treatment Objectives  555
• Life before Twin Blocks  555
• Piano Keys  556

Index 557
The Art of Orthodontics  1

Chapter 1

The Art of Orthodontics

INTRODUCTION DENTAL CHESS


Orthodontics presents a philosophical challenge in that Orthodontics may be thought of as the dental equivalent
both art and science are of equal importance. A quotation of chess. The analogy is appropriate in many respects.
of Edward Angle (1907), from the turn of the 20th century, The game is played with 32 ivory pieces that are arranged
is still pertinent today: symmetrically about the midline on a board in two equal
The study of orthodontia is indissolubly connected with and opposing armies.
that of art as related to the human face. The mouth is The opening moves are crucial in determining the
a most potent factor in making or marring the beauty strategy of the game. From the outset, the game is won
and character of the face, and the form and beauty of or lost depending on the strategy of development of the
the mouth largely depend on the occlusal relations of individual pieces.
the teeth. Indeed, these opening moves can determine whether
Our duties as orthodontists force upon us great the game is eventually won or lost. It is a mistake in chess
respon­sibilities, and there is nothing which the student to become obsessed with the individual pieces. Rather,
of orthodontia should be more keenly interested than one must take a broader view and look at the game plan
in art generally, and especially in its relation to the as a whole to maintain a balanced position of the pieces
human face, for each of his efforts, whether he realizes on the board in order to achieve mutual protection and
it or not, makes for beauty or ugliness; for harmony support.
or inharmony; for perfection or deformity of the face. In dental chess, the board is analogous to the facial
Hence it should be one of his life studies. skeleton which is of fundamental importance in support-
Although orthodontics has gained wide recognition ing the individual pieces. As the orthodontic chess game
by the general public, it can be argued that the term progresses and the dental pieces are developed, the board
“orthodontics” is self-limiting and does not describe may become overcrowded, with pieces converging upon
adequately the wider aesthetic and holistic aims of a each other, so that even the most experienced player may
specialty that is as concerned with harmonious facial at times sacrifice pieces only to realize as the game deve­
balance as with a balanced functional occlusion. lops that the gambit was miscalculated.
The true art of the speciality lies in its pursuit of ideals Only after the passage of time, on proceeding to the
in the arrangement and function of the dentition, but end game, can the success of the strategy be evaluated.
never at the expense of damaging facial aesthetics. Beauty Successful treatment is judged in terms of facial balance,
is a precious, indefinable quality that is expressed in aesthetic harmony and functional stability in the end
balanced facial proportions. Facial balance and harmony result. One may conclude that the objectives of treatment
are goals of orthodontic treatment, of equal importance have been achieved only when the final post-treatment
to a balanced functional occlusion. balance of facial and dental harmony is observed.
2  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

ORTHODONTICS AND DENTAL complex that control the response to treatment are of
ORTHOPEDICS special significance. Since the beginning of the 20th
century, the pendulum of scientific opinion has swung
An essential distinction exists between the terms “ortho- back and forth in the evaluation of the “form and
dontics” and “dental orthopedics.” They represent a function” philosophy in relation to the implementation
fundamental variance in approach to the correction of of orthodontic and orthopedic treatment.
dento­ facial abnormalities. By definition, orthodontic At the turn of the last century, a division occurred in
treat­
ment aims to correct the dental irregularity. The the evolution of orthodontic technique that split treat-
alternative term “dental orthopedics” was suggested by ment philosophy into the separate disciplines of fixed
the late Sir Norman Bennett, and although this is a wider and functional appliance therapy.
definition than “orthodontics” it still does not convey the The two schools of thought had a common origin
objective of improving facial development. The broader in the “form and function” philosophy as a basis to
description of “dentofacial orthopedics” conveys the con- establish treatment objectives. The general goal was to
cept that treatment aims to improve not only dental and correct arch-to-arch relationships, as defined by Angle,
orthopedic relationships in the stomatognathic system while at the same time improving the skeletal relation-
but also facial balance. The adoption of a wider defini- ships through the stimulation and guidance of adaptive
tion has the advantage of extending the horizons of the remodeling of bone to support those corrected dental
profession as well as educating the public to appreciate relationships.
the benefits of dentofacial therapy in more comprehen- This philosophical divide in treatment approach can
sive aesthetic terms. be related to geographical factors as well as to differences
A fundamental question that we must address in in socioeconomic development between the USA and
diag­nosis is: “Does this patient require orthodontic treat­ Europe. In his efforts at developing the foundations of
ment or orthopedic treatment, or a combination of both, modern US fixed appliance technique, Angle attempted
and to what degree?" Alternatively, does the patient require to accommodate a full complement of teeth in every case,
dentofacial surgery, or to what extent can orthopedic treat­ irrespective of the degree of crowding or lack of available
ment be considered as an alternative to surgery? underlying bony support. The following generation of
An orthodontic approach aims to correct the dental orthodontists subsequently rejected Angle’s “form and
irregularity and is inappropriate in the treatment of function” philosophy as a basis for fixed appliance
what are essentially skeletal discrepancies. By definition therapy, and discarded the functional concept of growth
orthodontics must either be combined with dentofacial in favor of a concept of genetic control that dismissed the
orthopedics or maxillofacial surgery in the correction of potential of environmental factors to influence growth.
significant skeletal abnormality. One dogmatic philosophy was replaced by another.
If the malocclusion is primarily related to a musculo­ Provided skeletal development is within the range of
skeletal discrepancy we should select an orthopedic normal, fixed appliances are ideally suited to detailing
approach to treatment. It is in the treatment of muscle the occlusion by precise three-dimensional (3D) control
imbalance and skeletal disproportion that functional of tooth movement. Fixed appliances are designed
orthopedic appliances come into their own. Functional specifically to apply the optimum forces to move teeth,
appliances were developed to correct the aberrant muscle but they are less effective in the treatment of major muscle
environment—the jaw-to-jaw relationship—and as a function imbalances or their companion jaw-to-jaw
result restore facial balance by improving function. To skeletal discrepancies.
achieve the best of both worlds it is necessary to combine
the disciplines of fixed and functional appliance therapy. THE GENETIC PARADIGM

THE PHILOSOPHICAL DIVIDE In the development of orthodontic technique the concept


of genetic control of the pattern of maxillofacial develop-
In each succeeding generation the clinical approach to ment was based on serial growth studies that came about
treatment is determined by the background of scien­ as a byproduct of the development of the cephalostat by
tific research. The growth processes of the maxillofacial Broadbent (1948).
The Art of Orthodontics  3

These studies formed the basis for an entire philo­ expressed in the permanent dentition. Early diagnosis and
sophical approach to orthodontic treatment, where the interceptive treatment aims to restore normal function
existing skeletal framework was accepted as genetically and thereby enable the permanent teeth to erupt into
predetermined and therefore not subject to environ­ correct occlusal and incisal relationships.
mental factors. The concept of functional therapy is to expand and
In the literature, there is scant evidence of significant develop the upper arch to improve archform and to use
growth changes showing increased mandibular growth as the maxilla as a template against which to reposition the
a result of an orthodontic as opposed to an orthopedic retrusive mandible in a correct relationship to the normal
approach to therapy. Other studies did confirm that aux- maxilla. The functional orthopedic approach addresses
iliary orthopedic forces restricted downward and forward the skeletal problem of a retrusive mandible, and the mal-
maxillary growth. As a result, maxillary dental retraction occlusion is controlled at an earlier stage of development.
became commonly accepted as a reliable method of cor- Class III malocclusion is also identified by early diagno-
recting Class II malocclusion overjet problems. sis and may often respond to an interceptive approach to
However, a strict interpretation of the genetic para- treatment which aims to reduce the skeletal discrepancy
digm is called into question increasingly by current and restore normal function in order to promote normal
research and is no longer the only valid basis for the prac- growth and development.
tice of orthodontics combined with dentofacial ortho­
pedics. The present findings of modern research into ORTHODONTIC FORCE
bone growth represent a philosophical review that once
again recognizes the potential of improving the existing Fixed appliances are designed to apply light orthodontic
growth pattern by altering the muscle environment and/ forces that move individual teeth. Schwarz (1932) defined
or functional environment of the developing dentition in the optimum orthodontic force as 28 g/cm2 of root
an orthopedic approach to treatment. surface. By applying light forces with archwires and elastic
traction, fixed appliances do not specifically stim­ ulate
mandibular growth during treatment.
TREATMENT CONCEPTS
A bracket or “small handle” is attached to individual
A fundamental difference in approach exists between teeth. Pressure is then applied to those teeth by ligating
orthodontic and orthopedic schools of thought in rela- light wires to the brackets. The resulting forces applied
tion to treatment philosophy and the management of through the teeth to the supporting alveolar bone must
malocclusion. remain within the level of physiological tolerance of the
In the evolution of orthodontic technique, multiband periodontal membrane to avoid damage to the individual
fixed appliances were developed for treatment in the per- teeth and/or their sockets of alveolar bone.
manent dentition. It was customary to delay treatment Smith & Storey (1952), investigating optimum force
until the permanent canines and premolars had erupted, levels in the edgewise appliance, found that 150 g was
at a stage when the malocclusion was already fully deve­ the optimum force for moving canines, compared to 300
loped. The concept of treatment was to retract the upper g for molars.
arch using the perimeter of the orthodontically corrected, Allowance must be made, however, for frictional
albeit retruded, lower arch as a template on which to forces within the bracket slots themselves, in the region of
rebuild the occlusion. 125–250 g, which must be overcome to move teeth along
However, the majority of Class II malocclusions pre- archwires.
sent a laterally contracted maxilla that is often related
correctly to the cranial base but is associated with an ORTHOPEDIC FORCE
underdeveloped mandible. The fundamental skeletal
problem is not correctly addressed by an approach which Orthopedic force levels are not confined by the level of
is designed to retract a normal maxilla to match a defi- tolerance in the periodontal membrane but rather by the
cient mandible. much broader tolerance of the orofacial musculature.
A skeletal mandibular deficiency is well-established An orthopedic approach to treatment is not designed to
at an early stage of dental and facial development. The move the teeth, but rather to change the jaw position and
orthopedic approach to treatment endeavors to correct thereby correct the relationship of the mandible to the
the skeletal relationship before the malocclusion is fully maxilla.
4  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
The forces of occlusion applied to opposing teeth in an appliance that effects a protrusive bite when the appli-
mastication are in the range of 400–500 g and these forces ance is placed in the mouth. The mechanics are reversed
are transmitted through the teeth to the supporting bone. to correct a retrusive maxilla, but the principle remains
Occlusal forces form a major proprioceptive stimulus the same.
to growth whereby the internal and external structure Functional appliances are designed to enhance for-
of supporting bone is remodeled to meet the needs of ward mandibular growth in the treatment of distal occlu-
occlusal function. This is effected by reorganization of sion by encouraging a functional displacement of the
the alveolar trabecular system and by periosteal and mandibular condyles downwards and forwards in the
endochondral apposition. glenoid fossae. This is balanced by an upward and
Considering the anteroposterior forces applied when backward pull in the muscles supporting the mandible.
the mandible is displaced forward in the presence of Adaptive remodelling may occur on both articular sur-
a Class II skeletal relationship, the investigations of faces of the temporomandibular joint to improve the
Graf (1961, 1975) and Witt & Komposch (1971) have shown position of the mandible relative to the maxilla.
that for 1 mm of anterior displacement the forces of the In correction of mandibular retrusion the mandible is
stretched retractor muscles amount to approximately held in a protrusive position by occlusal contact on the
100 g. A construction bite of 5–10 mm will therefore functional appliance. In this case a large “handle” is atta­
transmit considerable forces to the dentition through the
ched to as many teeth as possible in both dental arches.
functional receptors.
The object of a functional appliance is not to move the
Orthopedic forces would exceed the level of tolerance
individual teeth, but to displace the lower jaw downwards
of the periodontal tissues if applied to individual teeth.
and forwards and to increase the intermaxillary space
However, these forces are spread evenly in the dental
in the anteroposterior and vertical dimensions. Reposi­
arches by appliances that are not designed to move
tioning the mandible stimulates a positive proprioceptive
individual teeth, but to displace the entire mandible and
response in the muscles of mastication. The purpose is
promote adaptation within the muscles of mastication.
to encourage adaptive skeletal growth by maintaining the
The muscles are the prime movers in growth, and bony
mandible in a corrected forward position for a sufficient
remodeling is related to the functional requirements of
muscle activity. The goal of functional appliances is to period of time to allow adaptive skeletal changes to occur
elicit a proprioceptive response in the stretch receptors of in response to functional stimulus.
the orofacial muscles and ligaments and as a secondary Dentofacial orthopedics, therefore, represents a posi­
response to influence the pattern of bone growth corres­ tive approach to the treatment of craniofacial imbalance
pondingly to support a new functional environment for by addressing the underlying cause of the malocclusion, in
the developing dentition. an effort to maximize the natural potential for corrective
growth.
DENTOFACIAL ORTHOPEDICS
REFERENCES
In contrast to the philosophical change that has accom-
Angle EH, (1907). Treatment of Malocclusion of the Teeth. 7th
panied the evolution of fixed appliance therapy, the form
edition, SS White Dental Manufacturing Co, Philadelphia.
and function concept steadfastly remains the basic con- Broadbent BH, (1931). In Practical Orthodontics. 7th edition,
cept of functional therapy. The functional matrix theory of ed GH Anderson, CV Mosby, St. Louis, p.208.
Moss (1968) supports the premise that function modifies Graf H, (1961). In Tecknik und Handhabung der Functionsregler.
anatomy. By definition, the purpose of dentofacial ortho- ed Frankel R, Berlin.
pedics is to modify the pattern of facial growth and the Graf H, (1975). Occlusal forces during function. In National
Cave Management Symposium Albuquerque, Proceedings
underlying bone structure of the face. The objective is to
of Symposium. Ann Arbor, University of Michigan.
promote harmonious facial growth by changing the func-
Moss ML, (1968). The primacy of functional matrices in profacial
tional muscle environment around the developing denti- growth. Dental Practitioner and Dental Record. 19:65-73.
tion. The principle of functional therapy is to reposition a Schwarz AM, (1932). Tissue changes incidental to orthodontics.
retrusive mandible to a forward position by constructing Australian Orthodontic Journal, 18:331-52.
The Art of Orthodontics  5

Smith R, Storey E, (1952). The importance of forces in orthodon- Sinclair PM, (1991). The clinical application of orthopedic forces:
tics. Australian Dental Journal. 56:291-304. current capabilities and limitations. In Bone Biodynamics
Witt E, Komposch G, (1971). Intermaxillare Kraftwirkung bimax- in Orthodontic and Orthopedic Treatment, Craniofacial
illarer gerate. Gerate Fortschr Kieferorhop. 32:345-52. Growth Series, eds Carlson DS and Goldstein SA, Ann
Arbor, University of Michigan, pp. 351-88.
Witt E, (1966). Investigations into orthodontic forces of different
FURTHER READING appliances. Transactions European Orthodontic Society.
391-408.
Moyers RE, (1988). Force systems and tissue responses in ortho­ Witt E, (1973). Muscular physiological investigations into the
dontics and facial orthopedics. In Handbook of Ortho­ effect of bimaxillary appliances. Transactions European
dontics, Year Book, Chicago. Orthodontic Society. 448-50.
Introduction to Twin Blocks  7

Chapter 2

Introduction to Twin Blocks

THE OCCLUSAL INCLINED PLANE


The occlusal inclined plane is the fundamental func­tio­
nal mechanism of the natural dentition. Cuspal inclined
planes play an important part in determining the rela­
tionship 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 A
force that is unfavorable to normal forward mandibular
development. The inclined planes formed by the cusps of
the upper and lower teeth represent a servomechanism
that locks the mandible in a distally occluding functional
position.
Twin Block appliances are simple bite blocks that
are designed for full-time wear. They achieve rapid func­
B
tional correction of malocclusion by the transmission of
Figs. 2.1A and B: The occlusal inclined plane is the functional
favorable occlusal forces to occlusal inclined planes that mechanism of the natural dentition. Twin Blocks modify the occlusal
cover the posterior teeth. The forces of occlusion are used inclined plane and use the forces of occlusion to correct the maloc-
clusion. The mandible is guided forwards by the occlusal inclined
as the functional mechanism to correct the malocclusion
plane.
(Figs. 2.1A and B).
Malocclusion is frequently associated with discre­
PROPRIOCEPTIVE STIMULUS TO GROWTH pancies in arch relationships due to underlying skeletal
and soft-tissue factors, resulting in unfavorable cuspal
The inclined plane mechanism plays an important part guidance and poor occlusal function. The proprioceptive
in determining the cuspal relationship of the teeth as sensory feedback mechanism controls muscular activity
they erupt into occlusion. A functional equilibrium is and provides a functional stimulus or deterrent to the
established under neurological control in response to full expression of mandibular bone growth. The unfa­
repetitive tactile stimulus. Occlusal forces transmitted vorable cuspal contacts of distal occlusion represent an
through the dentition provide a constant proprioceptive obstruction to normal forward mandibular translation in
stimulus to influence the rate of growth and the trabecular function, and as such do not encourage the mandible to
structure of the supporting bone. achieve its optimum genetic growth potential.
8  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Transverse Maxillary Development pattern is established that can support a new position
of equilibrium.
Transverse maxillary development is restricted as a result
of a distally occluding mandible. In a retrusive mandible
TWIN BLOCKS
the lower dentition does not offer support to the maxillary
arch, therefore the maxillary intercanine width and inter­ The goal in developing the Twin Block approach to treat­
premolar width is reduced accordingly. The constricted ment was to produce a technique that could maximize
width of the maxillary dentition has the effect of locking the growth response to functional mandibular protrusion
the mandible in a distal occlusion and prevents normal by using an appliance system that is simple, comfortable
mandibular development. and aesthetically acceptable to the patient.
Functional appliance therapy aims to improve the Twin Blocks are constructed to a protrusive bite
func­tional relationship of the dentofacial structures by that effectively modifies the occlusal inclined plane by
eliminating unfavorable developmental factors and means of acrylic inclined planes on occlusal bite blocks.
improving the muscle environment that envelops the The purpose is to promote protrusive mandibular func­
developing occlusion. By altering the position of the tion for correction of the skeletal Class II malocclusion
teeth and supporting tissues, a new functional behavior (Figs. 2.2A to F).

A B

C D
Figs. 2.2A to D: (A and B) Upper Twin Block—occlusal and frontal; (C and D) Lower Twin Block—occlusal and rear views.
Introduction to Twin Blocks  9

E F
Figs. 2.2E and F: Twin Blocks.

The occlusal inclined plane acts as a guiding mecha­ Class II division 1 malocclusion. This basic principle still
nism causing the mandible to be displaced downward and applies but over the years many variations in appliance
forward. With the appliances in the mouth, the patient design have extended the scope of the technique to treat
cannot occlude comfortably in the former distal position a wide range of all classes of malocclusion. Appliance
and the mandible is encouraged to adopt a protrusive design has been improved and simplified to make Twin
bite with the inclined planes engaged in occlusion. Blocks more acceptable to the patient without reducing
The unfavorable cuspal contacts of a distal occlusion their efficiency.
are replaced by favorable proprioceptive contacts on the In the treatment of Class II division 2 malocclusion,
inclined planes of the Twin Blocks to correct the maloc­ appliance design is modified by the addition of sagittal
clusion and to free the mandible from its locked distal screws to advance the upper anterior teeth. Control of the
functional position. vertical dimension is achieved by sequentially adjusting
Twin Blocks are designed to be worn 24 hours per
the thickness of the posterior occlusal inclined planes to
day to take full advantage of all functional forces applied
control eruption (Figs. 2.3A to C).
to the dentition, including the forces of mastication.
Treatment of Class III malocclusion is achieved by
Upper and lower bite blocks interlock at a 70° angle
reversing the occlusal inclined planes to apply a forward
when engaged in full closure. This causes a forward
component of force to the upper arch and a downward
mandibular posture to an edge-to-edge position with
and distal force to the mandible in the lower molar
the upper anteriors, provided the patient can comfortably
maintain full occlusion on the appliances in that position. region. The inclined planes are set at 70° to the occlusal
In treatment of Class II malocclusion, the inclined planes plane with bite blocks covering lower molars and upper
are positioned mesial to the upper and lower first molars deciduous molars or premolars, with sagittal screws to
with the upper block covering the upper molars and advance the upper incisors (Figs. 2.4A to C).
second premolars or deciduous molars, and the lower The first principle of appliance design is simplicity.
blocks extending mesially from the second premolar or The patient’s appearance is noticeably improved when
deciduous molar region. Twin Blocks are fitted. Twin Blocks are designed to be
In the early stages of their evolution, Twin Blocks comfortable, aesthetic and efficient. By addressing these
were conceived as simple removable appliances with requirements, Twin Blocks satisfy both the patient and
interlocking occlusal bite blocks designed to posture the the operator as one of the most “patient friendly” of all
mandible forward to achieve functional correction of a the functional appliances.
10  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Treatment of Class II Division 2 Malocclusion

A B C
Figs. 2.3A to C: Correction of Class II division 2 malocclusion by advancing the mandible and proclining the upper incisors with sagittal
screws. Vertical control is important in management of Class II division 2 malocclusion. The bite registration for this type of malocclusion
is edge to edge on the upper and lower incisors. The overbite is reduced by progressive trimming of the upper blocks to allow eruption of
lower molars. At the end of the Twin Block phase the molars are in Class I occlusion and the overbite is fully reduced.

Treatment of Class III Malocclusion

A B C
Figs. 2.4A to C: Reverse Twin Blocks for correction of Class III malocclusion with sagittal screws to advance upper incisors. The upper
block may also incorporate an occlusal screw for progressive activation.
Introduction to Twin Blocks  11

DEVELOPMENT OF TWIN BLOCKS The appliance mechanism was designed to harness the
forces of occlusion to correct the distal occlusion and also
Case Report: CG Aged 7 Years 10 Months to reduce the overjet without applying direct pressure to
It is true that ‘necessity is the mother of invention’. The the upper incisors.
Twin Block appliance evolved in response to a clinical The upper and lower bite blocks engaged mesial to
problem that presented when a young patient, the son the first permanent molars at 90° to the occlusal plane
of a dental colleague, fell and completely luxated an when the mandible postured forward. This positioned
upper central incisor. Fortunately, he kept the tooth, the incisors edge-to-edge with 2 mm vertical separation
to hold the incisors out of occlusion. The patient had to
and presented for treatment within a few hours of the
make a positive effort to posture his mandible forward to
accident. The incisor was reimplanted and a temporary
occlude the bite blocks in a protrusive bite. Fortunately,
splint was constructed to hold the tooth in position
the young patient was successful in doing this consistently
(Figs. 2.5A to L).
to activate the appliance for functional correction. Had
Before the accident the center line was displaced
he not made this effort the technique may have been
to the right and the luxated incisor had a pronounced
stillborn.
distal angulation with a central diastema of 3 mm. When
The first Twin Block appliances were fitted on
the tooth was reimplanted the socket was enlarged to
7 September 1977, when the patient was aged 8 years
reposition the incisor as near as possible to the midline. 4 months. The bite blocks proved comfortable to wear
Complete correction of the midline was not possible, and treatment progressed well as the distal occlusion
recognizing that enlarging the socket too much might corrected and the overjet reduced from 9 mm to 4 mm
reduce the prognosis for reattachment of the tooth. in 9 months.
After 6 months with a stabilizing splint, the tooth had During the course of treatment radiographs confirmed
partially reattached, but there was evidence of severe that the reimplanted incisor had severe root resorption
root resorption and the long-term prognosis for the and an endodontic pin was placed to stabilize this tooth
reimplanted incisor was poor. after 4 months of treatment. This was successful in stabi­
The occlusal relationship was Class II division 1 lizing the incisor.
with an overjet of 9 mm and the lower lip was trapped At a later stage, in the permanent dentition, a simple
lingual to the upper incisors. Adverse lip action on upper fixed appliance was used to complete treatment. It
the reimplanted incisor was causing mobility and root was not possible to correct the centre line fully in replacing
resorption. To prevent the lip from trapping in the overjet the luxated tooth, and the central incisor ankylosed
it was necessary to design an appliance that could be during the process of reattachment. Consequently, a
worn full time to posture the mandible forward. At that slight displacement of the center line had to be accepted.
time no such appliance was available and simple bite The reimplanted incisor was crowned successfully, and
blocks were therefore designed to achieve this objective. the result is stable at age 25 years.
12  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: CG

A B

D E F

G H I

J K L
Figs. 2.5A to L: Treatment: (A and B) Before treatment: 1 was completely luxated and was reimplanted. An endodontic pin was fitted
to stabilize the incisor. This was successful in achieving bony reattachment; (C) Profiles at ages 7 years 10 months (before treatment),
9 years 7 months (after 9 months of treatment) and 24 years; (D and E) Dental views before treatment at age 7 years 10 months;
(F) After 9 months of treatment, the overjet has reduced, and the distal occlusion is corrected; (G and H) The first Twin Blocks were
simple bite blocks occluding in forward posture. The blocks were angled at 90° to the occlusal plane; (I) A simple fixed appliance is used
to improve alignment in permanent dentition. The damaged upper incisor is now ankylosed; (J to L) The occlusion remains stable 5 years
out of retention.
Introduction to Twin Blocks  13

MODIFICATION FOR TREATMENT OF The original Twin Block prototype appliances were
CLASS II DIVISION 2 MALOCCLUSION modified from the standard design for correction of
Case Report: AK Aged 11 Years 1 Month Class II division 1 malocclusion by the addition of springs
lingual to the upper incisors to advance retroclined upper
Two years later, having developed a protocol for Twin
incisors. At the same time the mandible was translated
Block treatment of Class II division 1 malocclusion, atten­
tion was turned to Class II division 2 malocclusion. The forwards to correct the distal occlusion and the appliance
first patient of this type presented a severe malocclu­ was trimmed to encourage eruption of the posterior teeth
sion with an excessive overbite and an interincisal angle to reduce the overbite.
approaching 180° (Figs. 2.6A to I). As an indication of the The Class II division 2 Twin Blocks were worn for
depth of the overbite the intergingival height from the 6 months, at which stage brackets were fitted on the
gingival margin of the upper incisors to the gingival mar­ upper anterior teeth and activated with a sectional arch­
gin of the lower incisors was 7 mm, suggesting that the wire to correct individual tooth alignment. This combina­
upper incisors were impinging on the lower gingivae. The tion fixed/functional appliance treatment continued for
lower archform was good but the mandible was trapped 6 months. Completion of treatment was then effected
in distal occlusion by the retroclined upper incisors. with a simple upper fixed appliance.

Case Report: AK

A B C

D E F

G H I
Figs. 2.6A to I: A patient with a Class II division 2 malocclusion treated with Twin Blocks: (A to C) Excessive overbite and severely retroclined
incisors; (D and E) After 8 months the distal occlusion is corrected and the overbite is reduced; (F) A simple upper fixed appliance to
correct alignment; (G to I) The occlusion is stable 3 years later. A diagrammatic interpretation of the treatment is given on case report AK.
14  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: AK

AK Age 11.1 13.1 16.8


Cranial Base Angle 26 26 26
Facial Axis Angle 32 30 33
F/M Plane Angle 13 15 12
Craniomandibular Angle 39 42 38
Maxillary Plane –3 0 1
Convexity 4 0 2
U/Incisor to Vertical –5 22 17
L/Incisor to Vertical 16 29 26
Interincisal Angle 169 129 137
6 to Pterygoid Vertical 18 20 28
L/Incisor to A/Po –8 0 –1
L/Lip to Aesthetic Plane –4 –6 –6
Introduction to Twin Blocks  15

Angulation of the Inclined Planes this may encourage more forward mandibular growth. If
the patient has any difficulty in posturing forward, it is
During the evolution of the technique, the angulation of preferable to reduce the angulation of the inclined planes
the inclined plane varied from 90° to 45° to the occlusal to 45° to guide the mandible forward and make it easier
plane, before arriving at an angle of 70° to the occlusal for the patient to maintain a forward posture.
plane. An angle of 45° may be used for patients who have
more difficulty in maintaining a forward mandibular Bite Registration
posture.
The Exactobite or Projet Bite Gauge (the name differs in the
The earliest Twin Block appliances were constructed
USA and the UK) is designed to record a protrusive wax in
with bite blocks that articulated at a 90° angle, so that
wax for construction of Twin Blocks (Fig. 2.7). Typically,
the patient had to make a conscious effort to occlude in
in a growing child, an overjet of up to 10 mm can be
a forward position. However, some patients had difficulty
corrected on the initial activation by registering an inci­
maintaining a forward posture and, therefore, would
sal edge-to-edge bite with 2 mm interincisal clearance
revert to retruding the mandible back to its old distal
(Figs. 2.8A and B). This is provided that the patient can
occlusion position, occluding the bite blocks together
comfortably tolerate the mandible being protruded so
on top of each other on their flat occlusal surfaces. This
the upper and lower incisors align vertically edge-to-
was detectable at an early stage of treatment when it
edge. Larger overjets invariably require partial correction,
could be observed that the patient was not posturing
followed by reactivation after the initial partial correction
forwards consistently. A significant posterior open bite
is accomplished.
was caused by biting on the blocks in this fashion. This
complication was experienced in approximately 30% of
the earliest Twin Block cases. It was resolved by altering
the angulation of the bite blocks to 45° to the occlusal
plane in order to guide the mandible forwards. This was
immediately successful in eliminating the problem.
An angle of 45° to the occlusal plane applies an equal
downward and forward component of force to the lower
dentition. The direction of occlusal force on the incli­ned
planes encourages a corresponding downward and for­
ward stimulus to growth. After using a 45° angle on the
blocks for 8 years, the angulation was finally changed to
the steeper angle of 70° to the occlusal plane to apply a
more horizontal component of force. It was reasoned that Fig. 2.7: Projet bite gauge.

A B
Figs. 2.8A and B: The blue bite gauge registers 2 mm vertical clearance between the incisal edges of the upper and lower incisors. This
gener­ally proves to be an appropriate interincisal clearance in bite registration for most Class I division 1 malocclusions with increased
overbite.
16  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Appliance Design—Twin Blocks for dimension. Once this phase is accomplished, the Twin
Correction of Uncrowded Class II Blocks are replaced with an upper Hawley type of appli­
ance with an anterior inclined plane, which is then used
Division 1 Malocclusion
to support the corrected position as the posterior teeth
It is usually necessary to widen the upper arch to accom­ settle fully into occlusion.
modate the lower arch in the corrected protrusive posi­
tion. The upper appliance incorporates a midline screw Stage 1: Active Phase
to expand the upper arch. Twin Blocks achieve rapid functional correction of man­
Delta clasps are placed on upper molars, with addi­ dibular position from a skeletally retruded Class II to
tional ball-ended clasps distal to the canines, or between Class I occlusion using occlusal inclined planes over the
the premolars or deciduous molars. posterior teeth to guide the mandible into correct rela­
The lower appliance is a simple bite block with delta tionship with the maxilla. In all functional therapy, sagit­
clasps on the first premolars and ball clasps mesial to the tal correction is achieved before vertical development of
canines (Figs. 2.9A and B). the posterior teeth is complete. The vertical dimension is
controlled first by adjustment of the occlusal bite blocks,
THE TWIN BLOCK TECHNIQUE— followed by use of the previously mentioned upper
STAGES OF TREATMENT inclined plane appliance.
In treatment of deep overbite, the bite blocks are
Twin Block treatment is described in two stages. Twin trimmed selectively to encourage eruption of lower poste­
Blocks are used in the active phase to correct the antero­ rior teeth to increase the vertical dimension and level
posterior relationship and establish the correct vertical the occlusal plane (Fig. 2.10). Throughout the trimming

B
Figs. 2.9A and B: Twin Blocks for correction of uncrowded class II Fig. 2.10: Sequence of trimming blocks.
division 1.
Introduction to Twin Blocks  17

sequence 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
achieved with the molars in occlusion.
The upper block is trimmed occlusodistally to leave
the lower molars 1–2 mm clear of the occlusion to encou­
rage lower molar eruption and reduce the overbite. By
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
A
the occlusal surface of the upper molars allowing the
lower molars to erupt fully into occlusion.
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.

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 (Figs. 2.11A and B).
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 B
settle fully into occlusion. Figs. 2.11A and B: Support phase—anterior inclined plane.
18  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

RETENTION RESPONSE TO TREATMENT


Treatment is followed by retention with the upper anterior Rapid improvements in facial appearance are seen
inclined plane appliance. Appliance wear is reduced to
consistently even during the first few months of Twin
night time only when the occlusion is fully established.
Block treatment. These changes are characterized by the
A good buccal segment occlusion is the cornerstone of
development of a lip seal and a noticeable improvement
stability after correction of arch-to-arch relationships. The
in facial balance and harmony. Lip exercises are not
appliance-effected advanced mandibular position will
not be stable until the functional support of a full buccal necessary to achieve this change in soft-tissue behavior.
The patient develops a lip seal naturally as a result of
segment occlusion is well established.
eating with the appliances in the mouth. When the
Timetable of Treatment: Average mandible closes in a forward position it is easier to form
Treatment Time an anterior oral seal by closing the lips together than
to support the lips with an anterior tongue thrust. In
• Active phase: average time 6–9 months to achieve full
growing children, the facial muscles adapt very quickly
reduction of overjet to a normal incisor relationship
to an altered pattern of occlusal function. The changes in
and to correct the distal occlusion.
appearance are so significant that the patients themselves
• Support phase: 3–6 months for molars to erupt into
occlusion and for premolars to erupt after trimming frequently comment on the improvement in the early
the blocks. The objective is to support the corrected stages of treatment.
mandibular position after active mandibular trans­ The facial changes are soon accompanied by equivalent
lation while the buccal teeth settle fully into occlusion. dental changes and it is routine to observe correction of
• Retention: 9 months, reducing appliance wear when a full unit distal occlusion within the first 6 months of
the position is stabilized. treatment. The response to treatment is noticeably faster
An average estimate of treatment time is 18 months, compared to alternative functional appliances that must
including retention. be removed for eating.
Introduction to Twin Blocks  19

Case Report: CH Aged 14 Years 1 Month Clinical Management


An example of treatment for a boy with an uncrowded At the first adjustment visit 2 weeks after the appliance is
Class II division 1 malocclusion with good archform and fitted, it is noted that the patient is not always posturing
a full unit distal occlusion (Figs. 2.12A to D). forward, and is sometimes simply biting together on the
flat occlusal surfaces of the blocks. This would tend to
Diagnosis, Skeletal Classification produce a posterior open bite, and it is important to avoid
this complication by detecting this at an early stage in
• Moderate Class II.
treatment. The problem is resolved simply by trimming
• Facial type: moderate brachyfacial (horizontal growth).
the acrylic slightly from the anterior incline of the upper
• Maxilla: mild protrusion.
block until the patient bites comfortably and consistently
• Mandible: mild retrusion.
on the inclined planes of the blocks. This reduces the
• Convexity = 6 mm.
initial forward activation to 7 mm with 2 mm interincisal
clearance. In spite of the slight upper block reduction,
Diagnosis, Dental Classification
this activation reduces the overjet from 12 mm to 4 mm
• Severe Class II division 1. in 5 months.
• Upper incisors: severe protrusion. Nevertheless, as a general principle, if the overjet is
• Lower incisors: normal. greater than 10 mm it is usually necessary to correct the
• Overjet = 12 mm. occlusion in a two-stage forward activation of the Twin
• Overbite = 5 mm (deep). Blocks. After the initial partial correction, the Twin Blocks
• No crowding. are reactivated to produce an upper to lower incisal edge-
to-edge occlusion with 2 mm vertical clearance by adding
Treatment Plan cold cure acrylic to the anterior aspect of the upper
inclined plane. This second activation by means of the
Functional correction to Class I occlusion by means of
longer upper block completes the mandibular correction
a combination of maxillary retraction and mandibular
to Class I occlusion. The blocks are trimmed occlusally
advancement, with reduction of overjet and overbite.
as before to reduce the overbite and encourage vertical
development.
Bite Registration
The initial bite registration with the blue Exactobite Duration of Treatment
aims to correct the overjet to edge-to-edge with a 2 mm
• Active phase: 8 months with Twin Blocks.
interincisal clearance.
• Support phase and retention: 6 months.
Lower third molars were potentially impacted and
Appliances on completion of treatment all four second molars
Twin Blocks for correction of uncrowded Class II division 1 were extracted to accommodate third molars, which
malocclusion. subsequently erupted in good position.
20  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: CH

B C D
Figs. 2.12A to D: Treatment: (A) Profiles at ages 14 years 1 month (before treatment), 14 years 6 months (after 5 months of treatment)
and 19 years 7 months; (B) Occlusion before treatment at age 14 years 1 month; (C) Occlusal change after 5 months of treatment, at
age 14 years 6 months; (D) Occlusion at age 19 years 7 months. A diagrammatic interpretation of the treatment is given case report CH.
Introduction to Twin Blocks  21

Case Report: CH

CH Age 14.1 15.2 19.7


Cranial Base Angle 26 26 25
Facial Axis Angle 26 27 26
F/M Plane Angle 25 25 23
Craniomandibular Angle 51 51 48
Maxillary Plane –1 –3 –3
Convexity 6 4 4
U/Incisor to Vertical 38 26 27
L/Incisor to Vertical 31 30 30
Interincisal Angle 111 124 123
6 to Pterygoid Vertical 14 14 16
L/Incisor to A/Po 0 1 1
L/Lip to Aesthetic Plane –7 –8 –10
22  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

CASE SELECTION FOR Case Report: JMcL Aged 12 Years


SIMPLE TREATMENT A girl with a Class II division 1 malocclusion and mild
In starting to use any new technique it is important to crowding in the upper labial segment due to narrowing
select suitable cases from which to learn the fundamentals of the upper arch (Figs. 2.13A to G).
of treatment without complications. This is especially
important when the practitioner is not experienced in Diagnosis, Skeletal Classification
functional therapy. Case selection for initial clinical use • Moderate Class II.
of Twin Block should, therefore, display the following • Facial type: mesognathic.
criteria: • Maxilla: slight protrusion, contracted laterally.
• Angle’s Class II division 1 malocclusion with good • Mandible: normal.
archform. It is easier to learn the management of the
• Convexity = 6 mm.
technique first by treating uncrowded cases before
progressing to crowded dentitions. Diagnosis, Dental Classification
• A lower arch that is uncrowded or decrowded and
aligned. • Severe Class II division 1.
• An upper arch that is aligned or can be easily aligned. • Upper incisors: mild protrusion.
• An overjet of 10–12 mm and a deep overbite. • Lower incisors: normal.
• A full unit distal occlusion in the buccal segments. • Overjet = 9 mm.
• On examination of the models in occlusion with the • Overbite incomplete due to tongue thrust.
lower model advanced to correct the increased overjet,
the distal occlusion is also corrected and it can be Treatment Plan
seen that a potentially good occlusion of the buccal Slight functional protrusion of the mandible to reduce
teeth will result. A good buccal segment occlusion is skeletal and dental Class II relationships.
the cornerstone of stability after correction of Class II
arch relationships. Appliances
• On clinical examination the profile should be notice­
ably improved when the patient advances the mandibl • Twin Blocks with labial bow to align the upper incisors.
voluntarily to correct the overjet. This factor is fun­ • Anterior guide plane to support the corrected occlu­
damental in case selection for functional appliance sion and retain.
therapy, and is a clinical indication that the Class II
arch relationship is skeletal in origin. Bite Registration
To achieve a favorable skeletal change during treat­ The construction bite is registered with a blue Exactobite
ment, the patient should be growing actively. A more edge-to-edge with 2 mm vertical interincisal clearance.
rapid growth response may be observed when treatment
coincides with the pubertal growth spurt. Conversely, the Clinical Management
response to treatment is slower if the patient is growing
Progress in this case proved to be slow because the
more slowly. Although the rate of growth will influence
patient did not always posture forward. After 7 months
progress, it is not necessary to plan treatment to coincide
the thickness of the blocks was increased slightly to dis­
with the pubertal growth spurt, as the Twin Block system
courage the patient from dropping out of contact with the
is effective in mixed dentition, transitional dentition and
inclined planes. This appliance adjustment was effective
permanent dentition.
in completing the remaining skeletal correction and the
In experienced hands, Twin Blocks are very effective
overjet was fully reduced after 4 more months.
in the treatment of complex malocclusions that are due to
a combination of dental and skeletal factors. Twin Blocks
Duration of Treatment
integrate more easily with fixed appliances than any other
functional appliance in a combined approach to ortho­ • Active phase: 11 months with Twin Blocks.
pedic and orthodontic treatment. • Support phase and retention: 5 months.
Introduction to Twin Blocks  23

Case Report: JMcL

B C D

E F G
Figs. 2.13A to G: Treatment: (A) Profiles before treatment at age 12 years and 1 year out of retention at age 14 years 7 months;
(B to D) Occlusion before treatment; (E to G): Occlusion 1 year out of retention. A diagrammatic interpretation of the treatment is given
case report JMcL.
24  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: JMcL

JMcL Age 12.0 15.2


Cranial Base Angle 31 31
Facial Axis Angle 27 28
F/M Plane Angle 24 23
Craniomandibular Angle 55 54
Maxillary Plane 0 1
Convexity 6 5
U/Incisor to Vertical 33 28
L/Incisor to Vertical 27 25
Interincisal Angle 120 127
6 to Pterygoid Vertical 15 18
L/Incisor to A/Po –1 1
L/Lip to Aesthetic Plane 0 –3
Form and Function  25

Chapter 3

Form and Function

DEVELOPMENT OF in a high proportion of crowded dentitions treated by


FUNCTIONAL TECHNIQUE fixed mechanics. Consequently, nonextraction therapy
fell into disrepute.
In the early part of the 20th century, the “form and
function” philosophy was the fundamental basis for treat­ The Emergence of Extraction Therapy
ment in both fixed and functional schools of therapy. The
By the middle of the 20th century, the orthodontic
objective of treatment was to achieve ideal correction of
philosophical pendulum had swung to the other extreme
dental arch relationships as defined by Angle (1907) and,
as Tweed (1944) and Begg (1954) gained acceptance for
at the same time, improve the skeletal relationship by
the use of extractions for the relief of crowding as an
skeletal adaptation in response to correction of the dental
integral part of orthodontic treatment planning. Hence,
relationship. However, from this common origin, fixed
a mechanical approach to treatment was adopted that
and functional techniques followed a divergent course of
accepted the extraction of first premolars as standard
development. Modern fixed appliance technique derives
procedure in the majority of crowded cases. The lower
largely from the work of Angle, whose philosophy was
labial segment was thought to be in a position of natural
based on the concept that compensatory growth would
muscle balance before treatment, and the basal perimeter
result from expanding the dental arches with multi-
of the lower arch was therefore used as a template to
banded fixed appliances and archwires, and placing the
position the upper dentition.
orthodontically corrected arches in perfect relationship
However, this approach made no allowance for the
to one another. At the same time, a parallel development
potential to change abnormal muscle behavior by func­
was occurring in Europe, where Pierre Robin (1902a, b)
tional therapy.
first described the monobloc as the forerunner of the
modern functional appliance. This was closely followed
Therapeutic Limitations of the
by a parallel development from Viggo Andresen (1910),
who developed the activator. A philosophical division Genetic Paradigm
originated when Angle attempted to accommodate a The therapeutic limitations of a genetic paradigm are
full complement of teeth to the available jaw space in significant in the treatment of Class II malocclusion due
every case, regardless of tooth-to-bone size discrepancy, to mandibular skeletal deficiency. A philosophy that
degree of crowding or the pattern of facial growth. Non- does not accept the possibility of improving mandibular
extraction techniques were used with fixed appliances growth leaves only three options in the treatment of
to move teeth, without significantly influencing the mandibular retrusion, all of which represent a biological
underlying skeletal pattern. This was followed by relapse compromise.
26  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
1. Maxillary retraction—Reduction of forward maxillary remains the basic concept of functional appliance
growth by orthopedic extraoral force has been well treatment. The “functional matrix” concept of Melvin
documented in the literature (Weislander, 1963, 1974, Moss is a contemporary evaluation supporting the
1975; Weislander & Buck, 1974; Graber, 1969). A distal premise that function modifies anatomy.
extraoral force applied to the maxillary molars by a It is commonly postulated that patients will not
Kloehn facebow is accompanied in some cases by neces­sarily achieve their full growth potential if envi­
a downward and backward rotation of the maxillary ronmental factors are unfavorable during develop­ment.
plane, and a secondary downward and backward Malocclusion is frequently associated with unfavo­
rotation of the mandible. There is some evidence that rable occlusal contacts and aberrant muscle behavior,
maxillary expansion to free the occlusion combined which result in a negative proprioceptive stimulus to
with extraoral traction may help to promote mandi­ normal growth and development.
bular growth in cases where the growth pattern is
favorable. However, a distalizing extraoral force is BONE REMODELING IN RESPONSE TO
designed to retract the maxilla to match the position
FUNCTIONAL STIMULI
of a retrusive mandible and does not encourage a
retrusive mandible to achieve its full genetic potential The internal and external structure of bone is contin­
of growth. uously modified throughout life by the process of bony
2. Surgical correction of mandibular position—The alter­ remodeling. The sensory feedback mechanism helps the
native is to correct arch alignment in a presurgical bony remodeling process to address the changing require­
phase of treatment, followed by surgical correction to ments of function in dentofacial development. Occlusal
advance the mandible into correct relationship with forces transmitted by the muscles of mastication through
the maxilla. Finally, a postsurgical phase of orthodon­ the teeth to the underlying bone provide a propriocep­
tic treatment is then needed to detail the occlusion. tive stimulus to influence the external form and internal
This approach has the disadvantages of being lengthy, trabecular structure of the supporting bone.
traumatic, complex and expensive. The long-term Unlike other connective tissue, bone responds to mild
effects on the temporomandibular joints (TMJ) are degrees of pressure and tension by changes of this nature.
unpredictable. It is not a widely viable solution. These changes are achieved by means of resorption of
3. Dentoalveolar compensation—An orthodontic app­ existing bone and deposition of new bone. This may take
roach to treatment offers a simpler compromise that place on the surface of the bone, under the periosteum
aims for dentoalveolar compensation, while accept­ or, in the case of cancellous bone, on the surfaces of the
ing that the result will not be ideal because the skel­ trabeculae.
etal discrepancy is beyond the limits of orthodontic In this respect, bone is more plastic and adaptive than
therapy. any other connective tissue. The internal and external
An orthodontic approach to treatment is most structure of bone is modified by functional requirements
efficient in correcting Class I malocclusion or mild to enable it to withstand the physical demands made upon
skeletal discrepancies. it with the greatest degree of economy of structure. This
It is in correction of malocclusion due to skele­ principle is exemplified in “Wolff’s law of transformation
tal discrepancies that functional appliances come of bone”. The architecture of a bone is such that it can best
into their own. The timing of treatment by functional resist the forces that are brought to bear upon it with the
appliances lends itself to the interception of malocclu­ use of as little tissue as possible.
sion at an earlier stage of development, attempting to During mastication forces are transmitted through the
resolve skeletal and occlusal imbalance by improving teeth to the alveolar bone and to the underlying basal
the functional environment of the developing denti­ bone. Most of these forces are vertical, but some are
tion before the malocclusion can become fully esta­ transverse and anteroposterior. The external surface of
blished in the permanent dentition. the maxilla and mandible is modified precisely by func­
As previously stated, in contrast to the philosophical tion to absorb the forces of occlusion. Well-defined ridges
change that has accompanied the evolution of fixed of bone are specifically designed to absorb and transmit
appliance therapy, the form and function philosophy these force vectors.
Form and Function  27

Mastication is a function that involves the whole face A change in function from suckling to eating solid food
and even part of the cranium. Considerable forces are is related to further changes in the form and function of
applied through the muscles of mastication to the teeth the TMJ to accommodate the corresponding change in
and the underlying bony structures to influence both the masticatory function. When first deciduous molars erupt
internal and external structure of the basal bone. It is this into occlusion, the form of the articular surface of the
natural mechanism of bony remodeling by occlusal force joint is modified by occlusion of the deciduous molars
vectors that forms the basis of functional correction by that now influence lateral guidance of the mandible.
the Twin Block technique. The forces of occlusion that are As deciduous canines and molars erupt, the proprio­
applied during mastication are harnessed as an additional ceptive sensory feedback mechanism is responsible
stimulus to growth. for continuing subtle changes in the form of the TMJ.
Progressive modification of the shape of the joint articular
Development of the surfaces relates to control of mandibular movement as
Temporomandibular Joint the occlusion develops, and the joint adapts to altered
function.
The relationship between form and function is exemplified
Still further modification of the shape of the temporo­
exquisitely in the normal development of the craniofacial mandibular articulation accompanies the transition from
skeleton. As the patient matures, progressive adaptation mixed to permanent dentition as the joint continues its
of the intricate skeletal structures clearly exhibits the adaptive development in response to the proprioceptive
intimate relationship between skeletal form and function. stimulus of a progressively more robust occlusion.
This relationship may be further demonstrated by In the mature adult, the contours of the joint are fully
examination of skulls to trace the stages of development developed and reflect the adaptive influences of the joint
of the TMJ from infancy to adulthood. Ide et al. in their to the demands placed on it by the occlusion during the
Anatomical Atlas of the TMJ, describe the changes with growth years. Occlusal guidance is directly related to
age as follows: condyle movement, and the shape of the joint articular
The size of the fossa increases by 1.2–1.3 times after eruption of surfaces in turn reflects the freedom of movement of the
the deciduous teeth compared to before and it increases again dentition in function. Malocclusion that presents occlusal
at the beginning of eruption of the permanent teeth. The degree
interferences is related to restricted occlusal guidance
of anterior inclination of the eminence changes drastically
when the deciduous teeth erupt. Eventually it becomes steeper
with corresponding modification of the shape and func­
by three times in the permanent dentition than it was before tion of the TMJ.
the eruption of the deciduous teeth. This correlation of form and function is also observed
in the slope of the articular eminence as it relates to the
In the newborn child the mandible moves freely antero­
occlusion. Restricted anterior movement is experienced
posteriorly to develop suction in the primary function of
in the Class II division 2 malocclusion, where the deep
breastfeeding. At this stage of development the condyle
overbite necessitates a steep vertical movement of the
is level with the gum pads, and the articular surface of
mandible to allow the incisors to avoid occlusal interfer­
the TMJ is relatively flat to allow complete freedom of
ence in opening. There is an equivalent steep angulation
movement during suckling. The form and function of the
of the articular eminence in this type of malocclusion
joint in the infant is similar to that of a herbivore, with flat
that is related intimately to severely restricted mandibular
articular surfaces that place no restriction on mandibular
movement in protrusive function.
movement.
Considering the etiology of internal derangement of
When a positive overbite develops as the deciduous
the TMJ, Hawthorn & Flatau (1990) observe:
central incisors erupt, it is then necessary for the mandible
...displacement of the meniscus anteriorly with subsequent
to take avoiding action by moving slightly downwards
reciprocal click in many cases is the result of confinement
when performing a protrusive movement. This change of mandibular movement caused by deep anterior overbite.
in function is immediately reflected in the shape of the Further degeneration or confinement of mandibular movement
articular surface of the TMJ. A small ridge appears that is brought about by developmental changes that may occur in
represents the first sign of an articular eminence when the occlusion during the mixed dentition stage, resulting in a
restrictive functional tooth angle… it is necessary to release
the deciduous incisors erupt into contact. the mandible from a restrictive closing pathway. For long-term
As yet there is no restriction on lateral movement success… it is also necessary to provide stable, bilateral occlusal
in the joint and, at this stage, the child is still suckling. support.
28  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
Most preactivated fixed appliances in present use The many variations in design of functional appliances
are designed for treatment in the permanent dentition. that have been described since the beginning of the 20th
Late treatment of malocclusion allows adverse occlusal century bear witness to their effectiveness in correcting
guidance to influence the form of the developing TMJ. malocclusion and improving facial balance and harmony
The relationship between malocclusion and the devel­ in the developing dentition.
opment of the TMJ supports the case for early intercep­ Significant progress has been made to improve the
tion of malocclusion. Functional therapy, by interceptive design of functional appliances, which were worn only at
treat­ment at an earlier stage of development, attempts to night for the first half of the 20th century. There followed
achieve freedom of movement in occlusal function and a steady process of evolution, whereby the bulk of the
thereby encourage the development of healthy joints. The early monobloc and Andresen activator was reduced by
form and function philosophy is a natural progression of removing acrylic in order to design a series of “daytime
normal development, where functional stimuli operate activators”, culminating in Balters Bionator, which was
through the sensory feedback mechanism to influence aptly described as “the skeleton of the activator”.
bone growth. In the normal sequence of growth and Another avenue of development produced flexible
development, occlusal function is related directly to the functional appliances by substituting wire for acrylic.
functional development of the TMJ. Bimler (1949) and Frankel & Frankel (1989) made excel­
lent scientific contributions to the theory and practice
Evolution of Functional of functional jaw orthopedics using flexible appliances
Appliance Technique adapted for daytime wear.

It was mainly due to socioeconomic reasons that the Limitations of Functional


development of functional appliances occurred almost
exclusively in Europe during the major part of the 20th
Appliance Design
century. All the functional appliances that have evolved from the
In the early 1900s, parallel development began in monobloc share the limitation that the upper and lower
the USA and Europe in fixed and functional techniques, components are joined together. As a result, the patient
respectively. The Atlantic Ocean formed a geographical cannot eat, speak or function normally with the appliance
barrier that restricted the sharing of knowledge and in the mouth. It is also impossible to wear a one-piece
experience in the fixed and functional philosophies. functional appliance full time if it is attached to the teeth
Integration of the two disciplines was further restricted in both jaws, and the interruption to appliance wear can
during the First and Second World Wars, after which be a major disadvantage.
both cultures were committed to treatment systems that The early functional appliances were designed for
reflected their economic state. night-time wear, which limited the response to treatment.
Construction and fitting of fixed appliances by hand It was also important to select patients who had a favora­
was time consuming and expensive. The bands were ble growth pattern in order to improve the prognosis for
formed on the teeth and welded before attaching brackets. correction, and to eliminate the uncertainty associated
This procedure was beyond the economic means and with night-time functional appliances. There is better
social circumstances of most Europeans at this stage. potential for rapid mandibular growth when the patient
The functional concept employs carefully designed has a favorable horizontal growth pattern than when the
removable appliances in an effort to achieve harmoni­ facial growth vector is more vertical.
ous development of the dentofacial structures by elimi­ The muscles are the prime movers that modify
nating unfavorable myofunctional and occlusal factors bone growth to meet the demands of function via the
and improving the functional environment of the devel­ proprioceptive feedback mechanism. When the appli­
oping dentition. By altering the position of the teeth and ance is removed for eating the patient reverts to func­
supporting tissues, a new functional behavior pattern is tioning with the mandible in a retrusive position. The
established to support a new position of equilibrium. strongest functional forces are applied to the dentition
This concept flourished in Europe and formed the basis during mastication, and the proprioceptive functional
of functional therapy for over a century, resulting in the stimulus to growth is lost if the appliance is removed
development of a wide range of appliances. for eating.
Form and Function  29

Comfort and aesthetics are crucial in appliance OBJECTIVES OF FUNCTIONAL TREATMENT


design. It is essential that the patient can speak clearly
with the appliance in place to avoid embarrassment. A In the natural dentition a functional equilibrium is estab­
monobloc type of appliance that is designed to fit the lished under neurological control in response to repetitive
teeth in both jaws simultaneously interferes with speech tactile stimuli as the teeth come into occlusion. A favora­
and limits normal function. These are important factors ble equilibrium of muscle forces between the tongue, lips
that influence patient motivation and compliance, and and cheeks is essential for normal develop­ment of the
are closely related to success in treatment. dental arches in correct relationship.
Any persistent deviation from normal function is asso­
The Schwarz Double Plate ciated with malocclusion. Discrepancies in arch relation­
ships due to underlying skeletal and soft-tissue factors
The Double Plate of Martin Schwarz (1956) attempted to result in unfavorable cuspal guidance and poor occlusal
combine the advantages of the activator and the active function.
plate by constructing separate upper and lower acrylic The purpose of functional therapy is to change the
plates that were designed to occlude with the mandible functional environment of the dentition to promote nor­
in a protrusive position. The Double Plate resembled a mal function. Functional appliances are designed to con­
monobloc or activator constructed in two pieces. trol the forces applied to the dentition by the surroun­ding
The maxillary appliance for correction of Class II soft tissues and by the muscles that control the position
division 1 malocclusion carried lingual flanges that and movement of the mandible. A new functional beha­
extended into the lower dental arch to articulate with vior pattern is established to support a new position of
the lower appliance on an inclined plane, causing a func­ equilibrium by eliminating unfavorable environmental
tional mandibular displacement on closure. There were factors in a developing malocclusion.
two variations in appliance design that incorporated The natural occlusal forces acting on a mandible in
anterior or lateral lingual flanges, respectively, extending distal occlusion do not favor mandibular development
from the upper appliance to occlude in grooves fashioned to the patient’s full potential of growth. The mandible
in the lower appliance. The anterior lingual flange was is locked in a distal position by an unfavorable or distal
used more, and represented an extension of the principle driving occlusion.
of the anterior inclined plane, originally developed by Conversely, in a Class III malocclusion the maxilla
Kingsley (1877). Graber & Neuman (1977) observed that is locked in a distal relationship by unfavorable occlu­sal
in spite of the advantageous features of the double plates, forces. Altered occlusal function in this type of maloc­
they gained limited acceptance, as they were complicated clusion has the effect of restricting maxillary develop­ment
to construct, and other competing appliances were more and advancing the mandible.
comfortable to wear. Functional therapy aims to unlock the malocclusion
A widely recommended variation in design was des­ and stimulate growth by applying favorable forces that
cribed by Muller (1962). The lateral wings were replaced enhance skeletal development. Growth studies on experi­
by heavy gauge wires of 2 mm diameter that extended mental animals support the view that altered occlusal
downward from the upper appliance at an angle of 70° fun­ction produces significant changes in craniofacial
to engage a groove in the lower appliance. growth.
The anterior version of the double plate was later
modified by FG Sanders using heavy wire extensions to BITE REGISTRATION IN
replace the acrylic flanges.
FUNCTIONAL THERAPY
The emergence of functional appliances for full-time
wear, including for eating, is the next logical step in the Bite registration is a crucial factor in the design and con­
evolution of functional jaw orthopedics, thus taking adva­ struction of a functional appliance. The construction bite
ntage of the forces of mastication to provide an addi­tional determines the degree of activation built into the appli­
proprioceptive stimulus to growth by using the forces of ance, aiming to reposition the mandible to improve the
occlusion to correct the malocclusion. jaw relationship. The degree of activation should stretch
30  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
the muscles of mastication sufficiently to provide a posi­ be identified early in treatment as they tended to posture
tive proprioceptive response. At the same time, activation the mandible back and meet the blocks together behind
must be within the physiological range of activity of the the inclined planes. To overcome this problem the acti­
muscles of mastication and the ligamentous attachments vation of the appliance was reduced slightly by trimming
of the TMJ. Bite registration should achieve a balance the inclined planes until the patient occluded comfor­
between these factors by providing the degree of man­ tably and consistently in the forward position.
dibular protrusion required to achieve the optimum func­ This difficulty can be avoided by relating bite regis­
tional stimulus to growth. According to Woodside (1977, tration to the patient’s freedom of movement and by regi­
p. 293), in construction of the activator as des­cribed by stering the protrusive path of the mandible. The George
Andresen (1910): bite gauge has a millimeter gauge to measure the protru­
A bite registration used commonly throughout the world sive path of the mandible and to determine accu­rately the
registers the mandible in a position protruded approximately amount of activation registered in the cons­truction bite.
3.0 mm distal to the most protrusive position that the patient The total protrusive movement is calculated by first
can achieve, while vertically the bite is registered within the measuring the overjet in centric occlusion and then in the
limits of the patient’s freeway space.
position of maximum protrusion. The protrusive path of
In North America, a similar protrusive bite registration the mandible is the difference between the two measure­
is made, except that the vertical activation is 4 mm beyond ments. Functional activation within normal physiological
the rest position. limits should not exceed 70% of the protrusive path
Roccabado (pers. comm.) quantifies normal physio­ (George, pers. comm.) (Figs. 3.1A to C).
logical TMJ movement as 70% of total joint displacement. By checking the protrusive path the adjustment may
Beyond this point, the medial capsular ligament begins to be related to the patient’s physiological movements. The
displace the disc by pulling the disc medially and distally young patient usually has more freedom of move­ment
off the condyle. This guideline allows us to measure the while there is generally more restriction in the adult. In
total mandibular displacement and relate the amount of Class II division 1 malocclusion, young patients com­
activation to the freedom of movement of the joint for monly have a protrusive path of 13 mm and will tolerate
each individual patient. activation up to 10 mm. Beyond this range the muscles
and ligaments cannot adapt to altered function and the
Bite Registration in Twin Block Technique patient will tend to posture out of the appliance. If the
overjet is larger than 10 mm the initial activation should
Bite registration for Twin Blocks originally aimed for a
only partially reduce the overjet. The appliance is then
single activation to an edge-to-edge incisor relationship
reactivated during the course of treatment.
with 2 mm interincisal 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
Vertical Activation
position on registering the occlusion. This proved to be The amount of vertical activation is crucial to the success
successful in correcting the overjet and reducing the of Twin Block treatment. The most common fault in Twin
distal occlusion in the majority of cases. Block construction is to make the blocks too thin, so that
Where the overjet was more than 10 mm, an initial the patient can posture out of the appliance, reducing the
advancement of 7 mm or 8 mm was followed by reacti­ effectiveness of the treatment.
vation of the appliance after occlusion had corrected to An important principle is that the blocks should be
the initial bite registration. Normally, a single further thick enough to open the bite slightly beyond the free-way
activation was sufficient to fully correct the overjet and space. This is necessary to ensure that the patient does
distal occlusion. not posture out of the appliance when the mandible is
In the early stages of using Twin Blocks it was noted in the rest position.
that some patients had difficulty in maintaining the On average the blocks are not less than 5 mm thick
forward posture and occluding correctly on the inclined in the first premolar or first deciduous molar region.
planes. These patients usually had a vertical growth pattern This thickness is normally achieved in Class II division 1
with weak musculature and were unable to maintain the deep bite cases by registering a 2 mm vertical interincisal
forward mandibular posture consistently. They could clearance.
Form and Function  31

A B

Figs. 3.1A to C: (A) 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;
C (B and C) Lateral views to show method of bite registration.

In Class II division 2 malocclusion with excessive this into account, Falke & Frankel (1989) reduced initial
overbite it is sufficient to register an edge-to-edge incisal activation for mandibular advancement to 3 mm, having
bite registration without the additional 2 mm interincisal previously registered an edge-to-edge bite unless the
clearance. This is normally sufficient in this type of malo­ overjet was excessive. The concept of progressive activation
cclusion to accommodate blocks of the correct thickness. for functional correction to achieve the optimum growth
In treatment of anterior open bite it is necessary response has been investigated (De Vincenzo & Winn,
to register bite with a greater interincisal clearance to 1989; Falke & Frankel, 1989) with differing results, and
make allowance for the anterior open bite. The projet or requires further investigation.
George bite gauge has thicker versions to accommodate The latter study used occlusal bite blocks to investigate
an interincisal clearance of 4 mm or 5 mm. At bite regis­ the relative effects of progressive activation compared to
tration a judgement should be made according to the a single large activation. The study concludes that there
amount of vertical space between the cusptips of the is no difference in either orthodontic or orthopedic
first premolars or deciduous molars to achieve the correct variables between progressive 3 mm advancement and
degree of bite opening to accommodate blocks of at least a single advancement averaging 5–6 mm. Continuous
5 mm thickness. advancement by progressive 1 mm activations shows
a diminished but still statistically significant response.
Single or Progressive Activation Progressive activation is found to be time consuming
Petrovic et al. (1981) found in animal experiments that a with no measurable improvement in the response. These
stepwise activation appeared to be the best procedure to findings support the author’s clinical experience that
promote orthopedic lengthening of the mandible. Taking a single large activation is more efficient than smaller
32  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
progressive activations. However, Carmichael, Banks and functional therapy for a posterior open bite to develop as
Chadwick have described a screw advancement mecha­ the overjet reduces. The upper and lower incisors come
nism for progressive activation of Twin Blocks. Stepwise into occlusion before the posterior teeth erupt. Functional
advancement may be beneficial in correction of larger therapy should continue to encourage development in
overjets, or in the treatment of vertical growth patterns, the vertical dimension until the occlusion of the posterior
where smaller adjustments may improve patient tolerance. teeth is established to support the correction of the
overbite and overjet.
CONTROL OF THE If a functional appliance is removed for eating, the ton­
gue often spreads laterally between the teeth and delays
VERTICAL DIMENSION
eruption. Full-time appliance wear with Twin Blocks pre­
The mechanism of control of the vertical dimension diff­ vents the tongue from spreading between the teeth and
ers in fixed and functional therapy. In fixed mechanics, accelerates correction of deep overbite.
the teeth remain in occlusion during the course of treat­
ment, and the effect is limited to intrusion or extrusion Closing the Bite
of individual teeth to increase or decrease overbite and
Reduced overbite or anterior open bite is often related to
level the occlusal plane. The occlusal level is determined
a vertical facial growth pattern. The lower facial height is
by occlusal contact with teeth in the opposing arch.
already increased, and the vertical dimension must not be
Functional appliances have the advantage of influencing
encouraged to increase during treatment. It is necessary
facial height to control the vertical dimension by covering
to close the anterior vertical dimension, and treatment
the teeth with blocks or an occlusal table.
should endeavor to reduce lower facial height by applying
Functional appliances are designed to influence deve­
intrusive forces to the opposing posterior teeth.
lopment in the anteroposterior and vertical dimen­sions
An acrylic occlusal table is designed into the appli­
simultaneously. Control of the vertical dimension is achi­
ance to maintain contact on the posterior teeth through­
eved by covering the teeth in the opposing arches and
out treatment. This occlusal contact results in a relative
controlling the intermaxillary space. The management of
intrusion of the posterior teeth while the anterior teeth
the appliance differs according to whether the bite is to
are free to erupt, thereby reducing the anterior open bite.
be opened or closed during treatment.
In the Twin Block technique the intrusive forces which
close the bite are increased by wearing the appliances for
Opening the Bite eating. In treatment of reduced overbite it is very important
Where a deep overbite is present it is necessary first that the opposing acrylic occlusal bite block surfaces are
to check that the profile is improved when the patient not trimmed. All posterior teeth must remain in contact
postures the mandible downwards and forwards. This with the blocks throughout treatment to prevent eruption
confirms that the bite should be opened by encouraging of posterior teeth (Fig. 3.2).
eruption of the posterior teeth to increase the vertical
dimension of occlusion.
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.
In functional therapy, anteroposterior 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. It is common in Fig. 3.2: Occlusal blocks contact posterior teeth to prevent eruption.
Form and Function  33

Manipulation of the occlusal table is an important Muller GH, (1962). Die Doppelplatte mit O berkeifer-sporn­
aspect of functional appliance therapy. By separating the fuhrung. Fortschr Kieferorthop. 23:245-50.
posterior teeth it is possible to adjust the dimensions of Petrovic AG, Stutzmann JJ, Gasson N, (1981). The final length
of the mandible: is it genetically determined? in Craniofacial
the intermaxillary space anteroposteriorly and vertically Biology, Monograph No. 10, ed DS Carlson Center for Human
to correct skeletal discrepancies. The concept of using Growth & Development, University of Michigan, pp. 105-26.
occlusal inclined planes as a functional mechanism to Robin P, (1902). Demonstration practique sur la construction
correct distal malocclusion is the next logical step in the et la mise en bouche d’un nouvel appareil de redressement,
evolution of functional appliance technique. The mecha­ Revue de stomatology, 9.
nics can be reversed, applying the same principles for Robin P, (1902). Observation surun nouvel appareil de redresse­
ment, Revue de stomatology. 9.
correction of Class III malocclusion.
Schwarz AM, (1956). Lehrgang der Gebissregelung, 2nd edition,
Urban & Schwarzenberg, Vienna.
REFERENCES Tweed CH, (1944). Indications for the extraction of teeth in
orthodontic procedure, American Journal of Orthodontics
Andresen V, (1910). Beitrag zur retention, Z Zahnaerztl Orthop,
and Oral Surgery. 42:22-45.
3:121-5.
Wieslander L, Buck DL, (1974). Physiological recovery after
Angle EH, (1907). Treatment of Malocclusion of the Teeth, 7th
cervical traction therapy, American Journal of Orthodontics.
edition, SS White Dental Manufacturing Co, Philadelphia.
66:294-301.
Begg PR, (1954). Stone age man’s dentition, American Journal
Wieslander L, (1975). Early or late cervical traction therapy
of Orthodontics. 40:298-312.
in Class II malocclusion in the mixed dentition, American
Bimler HP, (1949). Die elastichen Gebissformer, Zahnarzel Welt.
Journal of Orthodontics. 67:432-9.
19:499-505.
Wieslander L, (1974). The effect of force on craniofacial deve­
De Vicenzo JP, Winn MW, (1989). Orthopedic and orthodontic
lopment, American Journal of Orthodontics. 65:531-8.
effects resulting from the use of a functional appliance with
Wieslander L, (1963). The effect of orthodontic treatment on
different amounts of protrusive activation, American Journal
concurrent development of the craniofacial complex, American
of Orthodontics and Dentofacial Orthopedics. 96:181-90.
Journal of Orthodontics, 1963. 49:15-27.
Falke F, Frankel R, (1989). Clinical relevance of step by step
Woodside DG, (1977) ‘The activator’ in Removable Orthodo­
mandibular advancement in the treatment of mandibular
ntic Appliances, eds Graber TM, Neumann B, WB Saunders,
retrusion using the Frankel appliance, American Journal of
Philadelphia.
Orthodontics and Dentofacial Orthopedics. 96:333-41.
Frankel R, Frankel CH, (1989). Orofacial Orthopedics with the
Function Regulator, Basel, Karger. FURTHER READING
Graber, 1962, Dentofacial orthopedics, Current Orthodontic
Concepts and Techniques. Philadelphia, WB Saunders. Broadbent JM, (1987). Crossroads: acceptance or rejection of
Hawthorn R, Flatau A, (1990). Temporomandibular joint anatomy functional Jaw Orthopedics, American Journal of Orthodontics.
in A Colour Atlas of Temporomandibular Joint Surgery, Eds, 92:75-8.
Norman JEDeB, Bramley PE, Wolfe Publishing, London. Carmichael GJ, Banks PA, Chadwick SM, (1999). A modification
Ide Y, Nakazawa K, Hongo J, (1991). Anatomical Atlas of the to enable controlled progressive advancement of the Twin
Temporomandibular Joint, Quintessence Publishing Co, Tokyo. Block Appliance, British Journal of Orthodontics. 26:9-14.
Kingsley NW. (1877). An experiment with artificial palates. George PT, (1992). A new instrument for functional appliance
Dental Cosmos. 19:231. bite registration, Journal of Clinical Orthodontics. 721-3.
Moss ML. (1968). The primacy of functional matrices in profacial N Wolff J, (1892). Das Gesets der Transformation der Knochen,
growth. Dental Practitioner. 19:65-73. Hirschwald, Berlin.
Growth Studies in Experimental Animals  35

Chapter 4
Growth Studies in
Experimental Animals

HISTOLOGICAL RESPONSE TO orthopedic treatment is similar to authors perception of


ORTHODONTIC AND ORTHOPEDIC FORCE orthodontic treatment during the first half of the 20th
century.
During the first half of the 20th century animal research Animal experiments to investigate the biological res­
established the basis for orthodontic tooth movement. ponse to orthodontic and orthopedic techniques provide
Classic histological studies by Sandstedt (1904, 1905), a basis for comparison with clinical experience, when
Oppenheim (1911), Schwarz (1932) and Reitan (1951) authors apply similar techniques in the treatment of
defined the ground rules for orthodontic treatment. Dogs patients. Many researchers have reached similar conclu­
were used as experimental animals to determine the sions regarding the effects of functional mandibular pro-
tissue response to the application of force to individual trusion on the growth of the condyle and bony remod-
teeth, and Reitan made comparative studies in human eling in the glenoid fossa. The findings of current research
subjects. Thus, the role of osteoclasts and osteoblasts into the mechanisms that control bone growth are now
in the remodeling of alveolar bone was described and examined.
optimum force levels determined for efficient movement The results of recent growth studies on experimental
of teeth through alveolar bone. The findings of this animals suggest consistently that skeletal form is adap­
research remain of fundamental importance in clinical table to functional stimulus (Charlier et al., 1969; Moyers
orthodontic practice today and indeed established the et al., 1970; Petrovic et al., 1971; Stockli & Willert, 1971;
ground rules for orthodontic treatment. Elgoyhen et al., 1972; McNamara, 1972).
During the second half of the 20th century as the Experiments have shown that condylar cartilage is
emphasis of research moved from orthodontic to ortho- highly responsive to mechanical stimuli (Stockli & Willert,
pedic treatment, histological examination has revealed 1971) and to hormonal and chemical agents (Petrovic &
the mechanism of bony remodeling in the condyle and, Stutzmann, 1977).
of equal importance, in the glenoid fossa in response Hinton (1981), reviews temporomandibular joint (TMJ)
to the application of orthopedic forces by functional function to clarify past misconceptions. Clinical, experi-
mandibular protrusion. Experiments in mon­ keys and mental and biochemical data strongly suggest that the
rodents used full-time appliances with occlusal inclined TMJ is an articulation to which forces are transmitted
planes to demonstrate the biological response to func- during normal dental function, and one that undergoes
tional mandibular protrusion. Animal research is again adaptive remodeling in response to these forces.
important in providing scientific evidence as the basis to Harvold (1983), commented on research started in the
establish guidelines for orthopedic treatment in a simi- University of California in 1965 to examine the changes
lar pattern to the investigation of orthodontic treatment. that occur in the internal structure of bone in response
The present state of knowledge of the biological response to to functional stimulus.
36  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
The pilot studies demonstrated that an alteration in pressure system, including the soft tissues, adapts to re-establish an
distribution on the maxilla caused rapid resorption of the exis­ efficient masticatory system.
ting trabecular system within 2 months. Another few months
were necessary before the stabilized pressure distribution
was manifested in a new, functionally orientated trabecular FUNCTIONAL REGULATION OF
system. These pilot experiments indicated that only stimuli that CONDYLAR CARTILAGE GROWTH RATE
were relatively uniform for a period of several months could
contribute to the development of a trabecular system. The theory of functional regulation of condylar carti-
lage growth rate is supported by recent evidence from
THE OCCLUSAL INCLINED PLANE IN animal experiments (Stutz & Petrovic, 1979; McNamara,
ANIMAL EXPERIMENTS 1980). Fixed occlusal inclined planes have been used to
alter the distribution of occlusal forces in animal experi-
Moss (1980), investigating the effects of the inclined plane ments investigating the effects of functional mandibu-
in six adult ferrets, concluded: lar displacement on mandibular growth and on adap-
The results of this simple experiment illustrate the profound tive changes in the TMJ (Stutzman & Petrovic, 1979;
effect that a biting force on an inclined plane can have on the
whole of the dental arch, including the condylar head, the mus-
McNamara, 1980). Results have demonstrated improved
cle attachments and teeth remote from the tooth being moved. mandibular growth in experimental animals compared
Even in the adult animal, the whole of the stomatognathic to control animals (Figs. 4.1A to D).

A B

C D
Figs. 4.1A to D: (A and B) Fixed inclined planes produced a Class III dental relationship in monkeys; (C and D) Proliferation of condylar
cartilage in experimental animals demonstrated compared to controls.
Courtesy: JA McNamara Jr.
Growth Studies in Experimental Animals  37

A B
Figs. 4.2A and B: Electromyographic study shows the cycle of change in muscle behavior.
Courtesy: JA McNamara Jr.

A fundamental study of the relationship between activity was reached at a higher level of activity than the
form and function was carried out in animal experi- pretreatment record. This level of activity persisted for
ments at the University of Michigan, and the results were 4 weeks before a further decline in muscle activity over a
summarized by McNamara (1980). The studies evalu- period of 4 weeks to the level recorded before treatment.
ated changes in muscle function and related changes The cycle of changes was completed in a 3-months period
in bone growth in the Rhesus monkey by a comparison (Figs. 4.2A and B).
of experimental and control animals as monitored by These changes are consistent with equilibrium of
electromyogra­phic (EMG), cephalometric and histologi- muscle activity before treatment which is disturbed by
cal studies. McNamara concluded: placement of the appliance. The level of muscle activity
increases accordingly until, after a period of adjustment,
These studies demonstrated the close relationship between the
functional and structural components of the craniofacial region. a new equilibrium is reached at a higher level of activity.
Further adaptation within the muscles over a period of
The findings were based on the use of fixed occlusal time results in a reduction of muscle activity when a new
inclined planes that were designed to cause a forward equilibrium is again established at the same level that
postural displacement of the mandible in all active and existed before treatment.
passive muscle activity. The pattern of muscle behavior A similar experimental study at the University of
during the experimental period showed a cyclical change Toronto came to different conclusions on the effect of
in response to functional mandibular propulsion. Each placement of a functional appliance on muscle activity
animal was used as its own control to register muscle (Sessle et al., 1990). This study used chronically implanted
activity by a series of control records prior to appliance EMG electrodes to identify a statistically significant
placement. This established the level of muscle activity decrease in postural EMG activity of the superior and
before treatment. inferior heads of the lateral pterygoid, and the superfi-
Initial placement of the appliance produced an cial masseter muscles, which persisted for 6 weeks and
increase in the overall activity of the muscles of mastication returned to pretreatment levels during a subsequent 6
as the animal sought to find a new occlusal position. weeks period. Progressive mandibular advancement of
A distinct change in muscle activity occurred within 1.5–2 mm every 10–15 days did not prevent the decrease
1–7 days. This was characterized by a decrease in the in postural EMG activity.
activity of the posterior head of temporalis, an increase The clinical implication of these differing results is that
in activity of the masseter muscle, and most significantly the question of activation of a functional appliance by a
an increase in function of the superior head of the lateral single large mandibular displacement or a progressive
pterygoid muscle. After 3 weeks a new plateau of muscle series of smaller activations is still to be resolved.
38  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
It is not established whether active muscle contraction • Mesial migration of mandibular dentition
or passive muscle tension is the primary stimulus to • Increased mandibular skeletal growth
growth in functional therapy. • Adaptations in other regions.
The study concluded that the Class III dental relation­
CENTRAL CONTROL OF ship could not be explained by adaptations in any single
ADAPTIVE RESPONSE craniofacial structure or region, but was a result of both
pronounced and subtle adaptations throughout the struc-
Neuromuscular and Skeletal Adaptations tures of the craniofacial complex.
In principle, the muscles are the prime movers in pro­
moting skeletal adaptation in response to proprio­cep­ ADAPTATION IN BONE GROWTH IN
tive sensory stimulus. Adaptive skeletal changes in the RESPONSE TO FUNCTIONAL STIMULUS
structure and form of bone are a secondary response to
Research on bone growth at the University of Toronto has
alterations in sensory and muscle function. Essentially,
examined adaptive changes in bone in response to func-
skeletal changes occur to support the alteration in load
tional stimulus. Woodside et al. (1983) hypothesized that
and functional requirements, assuming that the altera­
the movement of bone into new positions within a mus-
tions in occlusal function are within the biological limits
cle system results in rearrangement of the stress distribu-
of tolerance of the organism.
tion and reorganization of shape and internal structure.
McNamara (1980) summarizes the adaptive responses
observed in functional protrusion experiments as follows: To test the hypothesis, clinical and animal experiments
involving the use of posterior occlusal bite blocks, Herbst
The placement of the appliance results in an immediate change
in the stimuli to the receptors in the orofacial region, particularly appliances, and temporal and masseter muscle stimula-
those in the tongue, gingiva, palate, dentition and TMJ region. tion were undertaken. This study concluded:
This alteration in stimuli is transmitted to the central nervous Chronic or continuous alteration in mandibular position within
system that mediates changes in muscle activity. This alteration the neuromuscular environment with the posterior occlusal
in muscle function leads to a forward positioning of the jaw. bite block and the Herbst appliance in a sample of monkeys
These muscular changes are very rapid and can be measured produced extensive condylar remodeling and change in man-
in terms of minutes, hours and days. dibular size.
Structural adaptations are more gradual in nature. Structural
These experiments demonstrate the principle that:
adaptations occur throughout the craniofacial region… As
structural balance is restored during the weeks and months Consistent changes in bone shape and internal structure are
following appliance placement, the need for altered muscle obtained when the alteration in neuro­muscular activity is
activity is lessened, and there is a gradual return to more typical continuous and that changing the muscle activity will affect
muscle patterns. This experimental model provides a clear the bone morphology.
illustration of the relationship between form and function in
the growing individual. THE INFLUENCE OF FUNCTIONAL
McNamara concluded that a rapid neuromuscular APPLIANCE THERAPY ON
response is followed by a more gradual skeletal adapta­
GLENOID FOSSA REMODELING
tion. Structural harmony can be restored by a combination
of mechanisms including dentoalveolar movement or In further experiments Woodside et al. (1987) examined:
condylar growth. The exact nature of the skeletal adap­ “The influence of functional appliance therapy on glenoid
tations depends upon the age of the animal. fossa remodeling,” following a period of progressively
In growing monkeys, increased growth of the mandi­ activated and continuously maintained advancement
bular condyle is shown following functional protrusion. using the Herbst appliance. They concluded:
As a result of mandibular hyperpropulsion, the dental In adult, adolescent and juvenile primates, continuous and
relationship changed in the experimental animals from progressive mandibular protrusion produces exten­sive anterior
normal to Class III occlusion. remodeling of the glenoid fossa. In all experimental animals,
The following factors may all contribute to the deve­ including, most importantly, the mature adult, a large volume
of new bone had formed in the glenoid fossa, especially along
lopment of a Class III molar relationship:
the anterior border of the postglenoid spine. With this bone
• Restriction of maxillary skeletal growth formation, and the resorption along the posterior border of the
• Inhibition of downward and forward migration of postglenoid spine, the glenoid fossa appeared to be remodeling
maxillary dentition anteriorly.
Growth Studies in Experimental Animals  39

A B
Figs. 4.3A and B: The control animal on the left shows a uniform thickness of the condylar cartilage and a normal Glenoid fossa and
articular disc attachment. In the experimental animal there is proliferation of condylar cartilage, especially in the posterior aspect of the condyle
and new bone is deposited on the posterior wall of the glenoid fossa. In addition bone is resorbed on the posterior surface of the post
glenoid spine. The glenoid fossa appears to be remodeling anteriorly.

Expert histopathologists agreed that the newly forming bone Our concept of orthopedically modulable growth in the mam-
had a normal appearance. The new bone formation appeared malian condylar cartilage was confirmed by Stockli & Willert
to be localized in the primary attachment area of the posterior (1971); McNamara et al. (1975); Graber (1975) and Komposh &
fibrous tissue of the articular disk. The deposition of the finger- Hocenjos (1977). Only experiments by Gaumond (1973, 1975)
like woven bone seemed to correspond to the direction of in the rat fail to support the possibility that the mandible can
tension exerted by the stretched fibers of the posterior part of be lengthened by orthopedic forces.
the disk.
The orthodontic community began to accept the idea that it is
This study further concluded that the proliferation of possible to change not only growth direction, but also growth
condylar tissue may be age-or sex-related, and was seen rate (Graber, 1972; Linge, 1977). The idea that the final length
only in the juvenile primate. Proliferation of the posterior of the mandible is “genetically preprogramed” has been the
part of the fibrous articular disk was also described, prevalent concept for the past 50 years, even if not specifically
splinting the condyle eccentrically in the glenoid fossa. substantiated (Brodie, 1941; Ricketts, 1952; Bjork, 1955; Hiniker
The skeletal jaw relationship may be altered by both & Ramfjord, 1964; Harvold, 1968; Joho, 1968). Indeed, this
concept is widely accepted as part of the doctrine underlying
glenoid fossa remodeling and condylar extension in young
fixed appliance ideology.
primates, and thereafter by glenoid fossa relocation.
This result may be related to age, sex and the amount Petrovic et al. (1981) conclude:
of mandibular protrusion. Deposition of new bone on Appropriate orthopedic appliances placing the rat mandible in
the posterior wall of the glenoid fossa is even more sig­ a forward position increase the condylar cartilage growth rate
nificant than thickening of the condylar cartilage, and is and growth amount, i.e. the mandible becomes longer than that
a major factor in the repositioning of the mandible of control animals. …No genetically predetermined length of
(Figs. 4.3A and B). the mandible could be detected in these experiments.
When the appliance was removed after the growth of the animal
A REVIEW OF THE PARADIGM OF was completed, no relapse was observed. When the appliance
GENETIC CONTROL was removed before growth was completed no significant
relapse was detected if a good intercuspation had been achieved
It is never too late to give up your prejudices during the experimental phase; if a good intercuspation had not
by Henry David Thoreau been achieved, the “comparator” of the servosystem imposed
The paradigm of strict genetic control of growth mech- an increased or decreased condylar growth rate until a state of
anisms is reviewed in a paper by Petrovic et al. (1981) intercuspal stability was established.
entitled: “The final length of the mandible: is it genetically Appliances used in the child and aimed to produce effects
predetermined?”: similar to those produced in the rat should be appropriate.
40  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

A Comparison of Twin Block Response with to mandibular protrusion. It is extremely rare for such a
Animal Experiments response to be observed with functional appliances that
are not worn full time.
The clinical response observed after fitting Twin Blocks is The initial response to functional mandibular protru­
closely analogous to the changes observed and reported sion is, therefore, a change in the muscles of mastica-
in animal experiments using fixed inclined planes. tion to establish a new equilibrium in muscle behavior.
Harvold (1983), confirms from histological study in ani- Volumetric changes behind the condyle result in cellular
mal experiments that rapid adaptive changes occur in the proliferation at this stage. When the altered muscle func-
tissues surrounding the condyle when a full-time func- tion is established the proprioceptive sensory mecha­nism
tional appliance is fitted: initiates compensatory bone remodeling to adapt to the
The placement of appliances results in an immediate change altered function. The muscles are the prime movers in
in the neuromuscular proprioceptive response… the resulting growth, followed by bone remodeling as a secondary
muscular changes are very rapid, and can be measured in terms response to altered muscle function. Muscle function
of minutes, hours and days. Structural alterations are more
must be altered over a sufficient period of time to allow
gradual and are measured in months, whereby the dentoskeletal
structures adapt to restore a functional equilibrium to support adaptive bone remodeling changes to occur to reposition
the altered position of muscle balance. the condyle in the glenoid fossa.
Harvold has demonstrated in animal experiments the
tissue changes that occur as a result of altered occlusal
Muscle Response to the Twin Block
function. When the mandible postures downward and Appliance–An Electromyographic Study
forward a vacuum is not created distal to the condyle. Research on a group of patients treated with Twin Blocks
Above and behind the condyle is an area of intense cell­ in India (Aggarwal et al., 1999) provides important
ular activity described as a “tension zone” that is quickly information on the adaptive changes during treatment.
invaded by proliferating connective tissue and capillary Bilateral EMG activity of elevator muscles of the mandi-
blood vessels, when the mandible functions in a protru- ble (i.e. anterior temporalis and masseter) was monitored
sive position. longitudinally with bipolar surface electrodes to deter-
These changes occur within hours and days, rather mine changes in postural, swallowing and maximum vol-
than weeks and months of the appli­ance being fitted. untary clenching activity during an observation period of
These tissue changes are reflected in the clinical signs 6 months. The muscle activity was measured at the start
after fitting Twin Blocks. The patient experiences adap­ of treatment, within 1 month of Twin Block insertion, at
tation of muscle function immediately on insertion of the end of 3 months, and at the end of 6 months.
the appliances, in response to altered occlusal function. The results revealed a significant increase in postu­
When an occlusal inclined plane is fitted, a rapid initial ral and maximum clenching EMG activity in masseter
conscious adaptation occurs to avoid traumatic occlusal (P < 0.01) and a numerical increase in anterior tempo­
contacts. ralis activity during the 6-months period of treatment.
Within a few days the patient experiences pain behind The increa­sed activity can be attributed to an enhanced
the condyle when the appliance is removed. From the stretch (myotatic) reflex of the elevator muscles, contri­
studies of histological changes in animal experiments, it buting to isometric contractions. The main corrective
may be deduced that retraction of the condyle results in force for Twin Block treatment appears to be provided
compression of connective tissue and blood vessels and through increased active tension in the stretched muscles
that ischemia is the principal cause of pain. and not through passive tension.
A new pattern of muscle behavior is quickly estab- The 3-months registration appears crucial for ana-
lished whereby the patient finds it difficult and later lyzing the neuromuscular changes occurring with func-
impossible to retract the mandible into its former retruded tional appliance treatment, indicating a strong possibility
position. After a few days, it is more comfortable to wear that sagittal repositioning of a retruded mandible in
the appliance than to leave it out. This change in muscle Class II division 1 cases takes place approximately within
activity has been described by McNamara as the “ptery- 3 months of initiating functional appliance treatment. The
goid response” which results from altered activity of the increased EMG activity during posture and maximum
medial head of the lateral pterygoid muscle in response voluntary clenching supports active reflex contractions
Growth Studies in Experimental Animals  41

(motor unit stimulation) to play a dominant role in the Effects of Twin Block Therapy on
neuromuscular changes with Twin Block treatment and Protrusive Muscle Functions
not passive tension due to viscoelasticity of the mus-
cles. The results of this study reaffirm the importance Further research in the University of Adelaide, Australia
of full-time wear for functional appliances to exert their (Chintakanon et al., 2000a, b) combines the study of pro-
maximum therapeutic effect by way of neuromuscular trusive muscle function with magnetic resonance imaging
adaptation. (MRI) to evaluate the functional adaptation of the con-
This study supports the view that repeated contact dyles within the glenoid fossae during Twin Block treat-
between the inclined planes during posture and clen­ ment.
ching leads to uninterrupted stretch on the muscle spin­ “Fatiguing the protrusive muscles did not alter man-
dles and repeated stimulation of the stretch receptors dibular position in the Twin Block group after 6 months
(Figs. 4.4A to D). treatment. The findings suggest a lack of habitual forward

Postural EMG Evaluation Shows no Significant Difference with or without Twin Blocks

B
Figs. 4.4A and B: (A) Representative sections of EMG during postural position of the mandible without Twin Block; (B) Representative
sections of EMG during postural position of the mandible with Twin Block. (A and B, Tracings 1, 2, 3, and 4 represent raw EMGs, and
5, 6, 7, and 8 are integrated EMGs).
42  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Clenching in Contact with the Occlusal Inclined Planes Shows Highly Significant Differences
in Muscle Activity, Representing a Positive Proprioceptive Stimulus in EMG Activity

D
Figs. 4.4C and D: (C) Representative sections of EMG during maximal voluntary clenching without Twin Block; (D) Representative sections
of EMG during maximal voluntary clenching with Twin Block. (C and D Tracings 1, 2, 3, and 4 represent raw EMGs, and 5, 6, 7, and 8 are
integrated EMGs).
Source: Reproduced with permission from American Journal of Orthodontics and Dentofacial Orthopedics Vol. 118:407-408, Mosby, St Louis 1999.

posture.” In other words, none of the children demon- been reported by Ruf & Pancherz (1998, 1999). However,
strated dual bite or “Sunday bite” as a result of treatment their studies did not include control groups for compari-
with Twin Blocks, as confirmed by a protrusive muscle son. Ruf and Pancherz demonstrated an increase in MRI
fatigue test. signal at the posterosuperior border of the condyle and at
the anterior surface of the postglenoid spine of the fossa
A Prospective Study of Twin Block that has not been demonstrated previously. This increase
Appliance Therapy Assessed by in MRI signal was interpreted as being associated with
remodeling, and the effects on the condyle were more
Magnetic Resonance Imaging prominent than on the fossa. The increase in MRI signal
The use of MRI to demonstrate TMJ adaptation during func­ was found only after 6–12 weeks of therapy, but could not
tional appliance therapy (Herbst appliance) has recently be seen at the end of treatment (7 months).
Growth Studies in Experimental Animals  43

In the present study, no increase in the MRI signal was experimental animals, a better understanding is gained
seen. It is possible that the MRI obtained after 6 months of the changes observed clinically in patients. The growth
of treatment may have missed this remodeling process. response in animals has been measured through full-time
Periodic MRI at shorter intervals is needed to clarify this appliances using inclined planes as the functional mech-
phenomenon. anism. It is now possible to conduct equivalent growth
Comparison between controls and Twin Block groups studies for patients with an identical appliance mecha-
suggested that reduction of the condylar axis angle rep- nism using the occlusal inclined plane. Growth studies of
resents a feature of untreated Class II growth patterns, consecutively treated patients against untreated control
whereas axial angle stability with Twin Block therapy may values form a basis for comparison with the results of
suggest alteration of condylar growth direction. Condyles animal growth studies.
that were positioned at the crest of the eminence at the
beginning of treatment had reseated back into the glenoid A Viscoelastic Hypothesis
fossa after 6 months. However, 75% of the condyles were Voudouris and Kuftinec (2000) present a further expla­
more anteriorly positioned in successfully treated Twin nation to account for growth changes in Twin Block and
Block cases. There was no clear evidence of remodeling Herbst treatment, following recent research in Toronto.
of the glenoid fossa at the eminence as a result of Twin They observe that it was previously thought that increased
Block treatment. Twin Block therapy had neither positive activity in the postural masticatory muscles was the key
nor negative effects on disk position. to promoting condyle-glenoid fossa growth. By analyzing
This research underlines the significance of the direc­ results from several studies they postulate a nonmuscular
tion of growth of the condylar axis, which may result in hypothesis as a result of radiating viscoelastic forces on
forward repositioning of the mandible, as an important the condyle and fossa in treatment and long-term reten-
factor in the adjustment of the maxillomandibular rela­ tion. “This premise is based on three specific findings:
tionship in correction of a retrusive mandible. Increasing significant glenoid fossa bone formation occurs during
evidence is emerging to confirm that the condyle is treatment that includes mandibular displacement; gle-
repositioned in the glenoid fossa after 6 months of therapy noid fossa modification is a result of the stretch forces
with a full-time functional mechanism. of the retrodiscal tissues, capsule, and altered flow of
viscous synovium; observations that glenoid fossa bone
SUMMARY formation takes place at a distance from the soft-tissue
attachment. This latter observation is explained by trans-
Over the past 30 years many animal experiments inves­ duction or referral of forces….. The impact of the vis-
tigating the orthopedic effects of functional mandibular coelastic tissues may be highly significant and should
protrusion have come to consistent conclusions. Electro­ be considered along with the standard skeletal, dental,
myographic, cephalometric and histological studies in neuromuscular, and age factors that influence condyle-
animal experiments provide a better understanding of the glenoid fossa growth with orthopedic advancement”.
biological changes that result from orthopedic technique.
Controlled experiments confirm that the mandibles of
REFERENCES
monkeys and rats are responsive to functional stimuli,
and that bone remodeling occurs in the glenoid fossa, and Aggarwal P, Kharband OP, Mathur R, et al. (1999). Muscle
in muscles and ligaments and their attachments at sites response to the Twin-block appliance: an electromyographic
study of the masseter and anterior temporalis muscles,
which are remote from the dentoalveolar areas normally American Journal of Orthodontics and Dentofacial Ortho­
associated with a response to orthodontic treatment. pedics. 116:405-14.
The conclusions drawn from these experiments differ Bjork A, (1955). Facial growth in man studied with the aid of
from traditional views relating to orthodontic treatment, metallic implants, Acta Odontologica Scandinavica. 13:9-34.
and only serve to underline that different mechanical Brodie AG, (1941). On the growth pattern of the human head
from the third month to the eighth year of life, American
systems do not produce an identical biological response.
Journal of Anatomy. 68:209-62.
Animal growth studies are of direct relevance to clini- Charlier JP, Petrovic A, Stutzmann J, (1969). Effects of mandibular
cal practice. As one evaluates the biological and histo- hyperpropulsion on the prechondroblastic zone of the young
logical changes produced by appliance mechanisms in rat condyle, American Journal of Orthodontics. 55:71-4.
44  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
Chintakanon K, Turker KS, Sampson W, et al. (2000). A pros­ McNamara JA, Carlson DS, (1979). Quantitative analysis of
pective study of Twin-block appliance therapy assessed by temporomandibular joint adaptations to protrusive function,
magnetic resonance imaging, American Journal of Ortho­ American Journal of Orthodontics. 76:593-611.
dontics and Dentofacial Orthopedics. 118:494-504. McNamara JA, Connelly TG, McBride MC, et al, 1975 Histological
Chintakanon K, Turker KS, Sampson W, et al. (2000). Effects studies of temporomandiblar joint adaptations. In Control
of Twin-block therapy on protrusive muscle functions, Mechanisms in Craniofacial Growth, ed McNamara JA,
American Journal of Orthodontics and Dentofacial Ortho­ University of Michigan, Ann Arbor, pp. 209-27.
pedics. 118:392-6. McNamara JA, Hinton RJ, Hoffman DL, (1982). Histological
Elgoyhen JC, Moyers RE, McNamara, JA, et al. (1972). Cranio­ analysis of temporomandibular joint adaptation to protru­sive
facial adaptation to protrusive function in juvenile Rhesus function in young adult Rhesus monkeys (Macaca Mulatta),
monkeys, American Journal of Orthodontics. 62:469-80. American Journal of Orthodontics. 82:288-98.
Gaumond G, (1975). Effets d’un sopareil d’hyperpropulsion Moss JP, (1980). The soft tissue environment of teeth and jaws,
fonctionelle sur la croissance mandibulaire de jeunes rats, British Journal of Orthodontics. 7:127-37, 205-16.
L’Orthodontie Française. 46:107-28. Moyers RE, Elgoyhen JC, Riolo ML, (1970). Experimental produc-
Gaumond G, (1973). Les effets d’une force extraorale de traction tion of class III malocclusion in Rhesus monkeys, European
sur la croissance mandibulaire de jeunes rats, L’Orthodontie Orthodontic Society. 46:61.
Française. 44:213-27. Oppenheim A, (1911). Tissue changes, particularly of the bone,
Graber LW, (1975). The alterability of mandibular growth. incident to tooth movement, Eur Orthodont Soc Trans.
In Determinants of Mandibular Form and Growth. Mono­ 303-59.
graph No. 4, Craniofacial Growth Series, eds McNamara JA, Pancherz H, Ruf S, Thomalske-Foubert C, (1999). Mandibular
University of Michigan, Ann Arbor, pp. 229-41. articular disc position changes during Herbst treatment: a
Graber TM, (1972). Orthodontics: Principles and Practice, 3rd prospective longitudinal MRI study, American Journal of
edition, WB. Saunders, Philadelphia. Orthodontics and Dentofacial Orthopedics. 116:207-14.
Harvold EP, (1983) Altering craniofacial growth: force application Petrovic A, Stutzmann J, Lavergne J, (1971). Mechanisms
and neuromuscular -bone interaction. In Clinical Alteration of of craniofacial growth and modus operandi of functional
the Growing Face, Monograph 14, Craniofacial Growth Series, appliances: a cell-level and cybernetic approach to ortho-
University of Michigan, Ann Arbor. dontic decision making. In Cranofacial Growth Theory and
Harvold EP, (1968). The role of function in the etiology and Orthodontic Treatment. Monograph, Cranial Growth Series,
treatment of malocclusion, American Journal of Orthodontics. ed Carlson DS, University of Michigan, Ann Arbor.
54:883. Petrovic A, Stutzmann J, (1977). Further investigations into the
Hiniker JJ, Ramfjord SP, (1964). Anterior displacement of the functioning of the ‘comparator’ of the servosystem (respective
mandible in adult Rhesus monkey, Journal of Dental Research. positions of the upper and lower dental arches) in the control
43:811. of the condylar cartilage growth rate and of the lengthening of
Hinton RH, (1981) Form and function in the temporomandi­ the jaw. In The Biology of Occlusal Development, Monograph
bular joint. In Craniofacial Biology, Monograph 10, Cranio­ No. 6, Craniofacial Growth Series, ed McNamara JA, University
facial Growth Series, ed Carlson DS, University of Michigan, of Michigan: Center for Human Growth & Development, Ann
Ann Arbor. Arbor, pp. 225-91.
Joho JP, (1968). Changes in the form of the mandible in the Petrovic AG, Stutzmann JJ, Gasson N, (1981). The final length
orthopedically treated Macaca virus (an experimental study), of the mandible: is it genetically determined? In Craniofacial
European Orthodontic Society. 44:161-73. Biology, Monograph No. 10, Center for Human Growth &
Komposh G, Hocenjos Cl, (1977). Die Reaktionsfahigkeit des Development, University of Michigan, pp. 105-26.
temporomandibularen Knorpels, Fortschritte der Kieferortho­ Reitan K, (1951). The initial tissue reaction incident to ortho­
pädie. 38:121-32. dontic tooth movement, Acta Odontologica Scandinavica.
Linge L, (1977). Klinishe Relevanz tier experimenteller Unter­ 9:suppl. 6.
suchungen (Korreferat Zum Vortrag Petrovic), Fortschritte der Ricketts RM, (1952). A study of the changes in temporomandi­
Kieferorthopädie. 38:253-60. bular relations associated with the treatment of Class II
McNamara JA, (1980). Functional determinants of cranio­ malocclusion (Angle), American Journal of Orthodontics, 38,
facial size and shape, European Journal of Orthodontics. 918.
1:131-59. Ruf S, Pancherz H, (1999). Long-term TMJ effects of Herbst
McNamara JA, (1972). Neuromuscular and Skeletal Adaptations treatment: a clinical and MRI study, American Journal of
to Altered Function in the Orofacial Region. In Monograph Orthodontics and Dentofacial Orthopedics. 114:375-88.
No. 1, Craniofacial Growth Series, University of Michigan, Ann Ruf S, Pancherz H, (1998). Temporomandibular joint growth
Arbor. adaptation in Herbst treatment: a prospective magnetic reso-
McNamara JA, Bryan FA, (1987). Long-term mandibular adapta- nance imaging and cephalometric roentgenographic study,
tions to protrusive function: an experimental study in Macaca European Journal of Orthodontics. 20:375-88.
Mulatta, American Journal of Orthodontics and Dentofacial Sandstedt C, (1904). Einige Beitrage zur Theorie der Zahnregu­
Orthopedics. 92:98-108. lierung, Nord Tand Tidskr. 5:236.
Growth Studies in Experimental Animals  45

Sandstedt C, (1905). Einige Beitrage zur Theorie der Zahn­ Woodside DG, Metaxas A, Altuna G, (1987). The influence of
regulierung, Nord Tand Tidskr. 6:1. functional appliance therapy on glenoid fossa remodeling,
Schwarz AM, (1932). Tissue changes incidental to orthodon- American Journal of Orthodontics and Dentofacial Ortho­
tic tooth movement, International Journal of Orthodontics. pedics. 92:181-98.
18:331-52.
Sessle BJ, Woodside DG, Bourque P, et al, (1990). Effect of func-
tional appliances on jaw muscle activity, American Journal of FURTHER READING
Orthodontics and Dentofacial Orthopedics. 98:222-30.
Stockli PW, Willert HG, (1971). Tissue reactions in the temporo­ McNamara JA, Bryan FA, (1987). Long-term mandibular adapta-
mandibular joint resulting from the anterior displacement of tions to protrusive function: an experimental study in Macaca
the mandible in the monkey, American Journal of Ortho­ Mulatta, American Journal of Orthodontics and Dentofacial
dontics. 60:142-55. Orthopedics. 92:98-108.
Stutzmann J, Petrovic A, (1979). Intrinsic regulation of con­ McNamara JA, Carlson DS, (1979). Quantitative analysis of
dylar cartilage growth rate, European Journal of Orthodontics. temporomandibular joint adaptations to protrusive function,
1:41-54. American Journal of Orthodontics. 76:593-611.
Voudouris JC, Kuftinec MM, (2000). Improved clinical use of McNamara JA, Hinton RJ, Hoffman DL, (1982). Histological
Twin Block and Herbst as a result of radiating viscoelastic analysis of temporomandibular joint adaptation to protrusive
tissue forces on the condyle and fossa in treatment and function in young adult Rhesus monkeys (Macaca Mulatta),
long-term retention: growth relativity. American Journal of American Journal of Orthodontics. 82:288-98.
Orthodontics and Dentofacial Orthopedics. 117:247-66. Pancherz H, Ruf S, Thomalske-Foubert C, (1999). Mandibular
Woodside DG, Altuna G, Harvold E, et al. (1983). Primate articular disc position changes during Herbst treatment: a
experiments in malocclusion and bone induction, American prospective longitudinal MRI study, American Journal of
Journal of Orthodontics. 83:460-8. Orthodontics and Dentofacial Orthopedics. 116:207-14.
Diagnosis and Treatment Planning  47

Chapter 5

Diagnosis and Treatment Planning

CLINICAL EXAMINATION and are repeated with the mandible advanced to give the
projected optimum improvement in facial appearance.
What You See is What You Get An additional set of photographs of the patient using a
digital camera may be taken on the patient’s first visit and
Clinical examination provides the fundamental guide­
the patient may receive a printed copy. The improvement
line in case selection for functional therapy. A retrusive
observed in the profile when the mandible is postured
mandible can be detected by examining the profile and the
forward with the lips closed shows the potential for func­
facial contours with the teeth in occlusion. The patient is
tional therapy. This improves motivation by allowing the
then instructed to close the incisors in normal relationship
patient to observe the rapid improvement in appearance
by protruding the mandible, with the lips closed lightly
during the first few months of treatment. It must be stated
together. The change in facial appearance is a preview
that the response is dependent on full cooperation during
of the anticipated result of functional treatment. If the
treatment.
profile improves with the mandible advanced, this is a
clear indication that functional mandibular advance­
ment is the treatment of choice. Clinical diagnosis has the Case Records: SW Aged 14 Years 2 Months
advantage of providing an accurate prediction of the three-
dimensional (3D) change in the facial contours as a result
of mandibular advancement, and is more important than
the diagnostic profiles defined by lines and angles drawn
on a cephalometric X-ray. This does not negate or diminish
the value of cephalometric analysis, but adds a 3D view
to support and confirm the diagnosis (Figs. 5.1A to L).
Important clinical guidelines in treatment planning for
Class II division 1 malocclusion are now considered.

Photographic Records
A
Facial and dental photographs are an invaluable diagnostic
Fig. 5.1A: Treatment—the profile far left shows a retrusive mandible
aid to establish the objectives of treatment and to monitor at age 14 years 2 months (before treatment). The middle profile is
progress. Photographs are used to predict the change in also taken before treatment with the mandible protruded to bring
facial appearance that will result from treatment. Pro­ the incisors into normal relationship, showing a preview of the anti­
cipated changes from functional treatment. The profile far right at age
file and fullface photographs with the mandible in the 15 years 1 month confirms that the appearance after treatment is
retrusive position show the appearance before treatment, very close to the predicted result.
48  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Facial and Occlusal Changes before and after 11 Months with Twin Blocks

B C

D E F

G H I

J K L
Figs. 5.1B to L: (B and C) Facial appearance at age 14 years 2 months (before treatment) and 15 years 1 month (after treatment);
(D to F) Occlusion before treatment; (G to I) Occlusion after treatment; (J and K) Facial views before treatment showing anticipated change
in appearance with the mandible protruded; (L) Change in appearance after treatment.
Diagnosis and Treatment Planning  49

Orthodontic Records correct archform before the mandible can be advanced


to correct the occlusion. Alternatively, appliance design
Successful orthodontic treatment is dependent on a disci­
may be modified to improve archform during the Twin
plined approach to record taking and diagnosis, as well as
Block phase, if the irregularity is less severe.
careful monitoring of progress in treatment. Inadequate
If retroclined or irregular upper incisors would pre­
records may reflect a poor standard of treatment. In
vent the mandible from advancing into a class I buccal
general the standard of orthodontic care is directly related
segment occlusion (Figs. 5.2B to D), provision must be
to the quality of the orthodontic records.
made to advance the upper incisors with springs or screws
The essentials for orthodontic records are a diagnostic
to accommodate the mandible in correct occlusion. This
report supported by study models, X-rays and photographs
often applies in a Class II malocclusion when an overjet of
to establish the condition of the case before treatment
less than 9 mm is present with a full unit distal occlusion.
and to record progress during treatment.
It is necessary to procline the upper incisors to release
Radiographic examination is necessary to identify and
the mandible forwards. The same restriction applies in
locate all unerupted teeth. This is accomplished routi­
Class II division 2 malocclusion, and appliance design
nely by a panoral X-ray with intraoral films if required for
must be modified accordingly.
individual teeth. Temporomandibular joint X-rays are also
extre­mely important, especially in today’s litigious society,
Case Report GD Aged 14 Years
to establish the condition of the joint before treatment.
Cephalometric analysis of a lateral skull X-ray gives detai­ This boy presented a mild mandibular retrusion with
led information to support clinical diagnosis. convexity of 3 mm related to a full unit distal occlusion.
A single upper central incisor was proclined and the
other incisors were retroclined. When the lower model
EXAMINATION OF MODELS
was advanced, it was not possible to place the molars in
An equally simple guideline helps to predict occlusal Class I occlusion due to interference from the retroclined
changes by checking the occlusion resulting when the incisors. This indicated that springs or screws must be
mandible postures downward and forward to reduce the added to the appliance design to procline these incisors
overjet. This can be observed directly in the mouth, but to align the anterior teeth and release the mandible for­
is best confirmed on study models by sliding the lower ward to correct the distal occlusion. Light inter-maxillary
model forwards and observing the articulation of the elastics were applied for the first week to guide the man­
mandibular dental arch with that of the upper model. dible forward. In view of the patient’s age, as he was past
In an uncrowded Class II division 1 malocclusion with the pubertal growth spurt the clasps had provision to
an overjet of 10 mm or more, it can be seen that a good add extra oral traction to retract the maxillary dentition,
buccal segment occlusion will result from advancing the for dental correction, but this was not required. The
mandible and, at the same time, laterally expanding the occlusion was fully corrected to Class I after 10 months
maxilla to match the width of the mandibular dental arch and an anterior inclined plane was fitted to support the
in the projected advanced position. corrected occlusion. The same appliance continued as a
If the arches are crowded with irregular teeth, the upper night time retainer.
and lower models will often not fit when the lower model Twin Blocks: 10 months
is advanced. Depending on the degree of irregularity, a Support Appliance: 3 months
first phase of arch development may be necessary to Retention: 9 months
50  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Records: GD Aged 14 Years

B C D

E F G

H I J
Figs. 5.2A to J: (A) Treatment—profiles at ages 14 years (before treatment) and 15 years (after treatment); (B to D) Retroclined incisors
must be proclined with springs or screws on the upper Twin Block to release the mandible forward; (E) Light Class II elastics are optional;
(F and G) Anterior inclined plane to support the corrected incisor relationship and to allow the lower premolars and canines to erupt into
occlusion; (H to J) After 12 months the occlusion has settled and the same appliance serves as a retainer.
Diagnosis and Treatment Planning  51

Case Report: GD

GD Age 13.10 15.2


Cranial Base Angle 25 25
Facial Axis Angle 24 26
F/M Plane Angle 22 21
Craniomandibular Angle 47 46
Maxillary Plane 3 3
Convexity 3 0
U/Incisor to Vertical 36 20
L/Incisor to Vertical 32 33
Interincisal Angle 112 127
6 to Pterygoid Vertical 16 16
L/Incisor to A/Po –1 1
L/Lip to Aesthetic Plane –2 –3
52  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

DIFFERENTIAL DIAGNOSIS Begg (1965) was also a student of Angle who later
developed the Light Wire Technique using round wires
Extraction or Nonextraction Therapy in a vertical slot bracket to achieve a one-point contact on
Throughout the 20th century, the pendulum swung back the archwire. The Begg Technique incorporated auxilliary
and forth between extraction and nonextraction therapy. springs to tip and torque the teeth using differential forces
At the beginning of the century, Angle believed uncondi­ to control tooth movements. Begg, based his philosophy
tionally that all 32 teeth should be accommodated in on Stone Age man’s dentition, after studying the attritio­
every case, regardless of the growth pattern or the rela­ nal occlusion observed in a series of aboriginal skulls in
tionship of the size of the teeth to the basal bone. His Australia. Begg reasoned that the amount of interproxi­
philosophy insisted that if the teeth were moved into nor­ mal attrition in the permanent teeth due to aboriginal
mal interdigitation, functional stimulation would result diet was sufficient to accommodate third molars. By
in compensatory basal bone growth to accommodate comparison, modern man has a refined diet which does
the teeth in their corrected position. It was heresy for a not require chewing, therefore interproximal attrition
disciple of Angle even to think about extraction of teeth does not occur which results in a high incidence of late
as a part of orthodontic therapy. crowding due to mesial migration of the dentition prior
As a student of Angle, Tweed practiced nonex­traction to eruption of third molars. Begg was a strong advocate
therapy for 6 years and observed a high percentage of of routine extraction of premolars, and indeed in some
relapse by reappearance of crowding in cases with a tooth/ cases advised the extraction of all first molars in addition
supporting tissue discrepancy. In edgewise mechanics, to the first premolars. The Begg school introduced the
correction of a Class II dental relationship in permanent concept of interdental stripping to help resolve crowding
dentition by intermaxillary traction was accompanied
of mandibular incisors by flattening the interproximal
by forward movement of the lower dentition. He related
contacts in the lower labial segment. Sheridan (1985)
lack of harmony in facial contour to the extent to which
extended this procedure to the buccal segments by air
the denture was displaced mesially into protrusion and
rotor stripping, as an alternative to extraction.
concluded that the orthodontist must find a means of
In developing the “bioprogressive philosophy,” Ricketts
accurately predetermining the anterior limits of stability
et al. (1979) moved away from a dogmatic approach to
of the denture in functional balance.
extraction therapy. Ricketts related treatment planning
Tweed (1966) gained acceptance for premolar extrac­
to facial aesthetics and the pattern of facial growth.
tion therapy and established an entire orthodontic treat­
Relating treatment to facial form gives further guidance
ment philosophy based on the concept that facial balance
in case selection for extraction or nonextraction therapy.
and harmony are dependent on the mandibular incisors
being upright over basal bone. He expressed a mean Brachyfacial or mesofacial growth patterns are more
angulation of the lower incisor to the Frankfort plane of suited to nonextraction techniques for relief of crowding
65°± 5° as a position of balance. than the vertical growing dolichofacial type.
Tweed differentiated facial growth trends into three Studies of the long-term results of treatment were car­
basic types to account for patients who exhibited balanced ried out by the bioprogressive group, assisted by Rocky
growth, vertical growth and horizontal growth patterns. Mountain Data Systems (Ricketts et al., 1979). This resul­
He believed that extractions were mandatory in vertical ted in improved methods of differential diagnosis for the
growth patterns for patients with high ANB angles, anti­ selection of extraction or nonextraction therapy. These
cipating that point B would always drop down and back studies also provided a foundation for computerized
in treatment. He observed that lower incisors often had growth prediction based on average increments of growth.
to be proclined in treating patients with vertical growth Ricketts defined parameters in cephalometric analysis
patterns to compensate for skeletal discrepancies, but to assist more accurate treatment planning related to
as a rule these teeth then remained stable and devoid facial aesthetics.
of rotations after treatment. Conversely, in patients with The position of the lower incisor relative to the anterior
horizontal growth patterns, the mandible grows forward limit of the skeletal base is crucial in facial aesthetics.
faster than the maxilla, resulting in lingual tipping of the The principle of relating lower incisor position to the
lower incisors and development of crowding in the lower skeletal apical base by means of linear measurements was
labial segments. originally described by Downs (1948) and elaborated by
Diagnosis and Treatment Planning  53

Ricketts (1960). The A-Po line joins point A and pogonion, Arch Length Discrepancy
the anterior points on the maxillary and mandibular
Arch length discrepancy defines the amount of crowding
skeletal bases, respectively. This line defines the anterior
present in the dental arch by comparing the space
limit of the skeletal base. The Begg school was the first to
available with the space required to accommodate all
relate lower incisor stability to the position of the lower
the teeth in the arch in correct alignment. The degree of
incisor relative to the A-Po line. Raleigh Williams, in his
crowding is determined by examining the models from
cephalometric appraisal of the Light Wire Technique in the occlusal aspect, starting at the mesial contact point
Begg’s book, observed: of the first permanent molar on one side and estimating
The incisal edge of the lower incisor reaches a final position the amount of crowding at each contact point, passing
very close to the A-Po line, a very critical position if upper
round the arch to the mesial contact point of the first
and lower lip balance is to be achieved. This simple measure­
ment of dental-skeletal relationship has a profound influence
molar on the opposite side. The summation of crowding
on a harmonious soft-tissue balance in the lower third of at each contact point gives the arch length discrepancy
the face. in millimeters. Allowance may also be made for potential
crowding of second or third molars.The same calculation
In dental prosthetics authors follow the principle
in the mixed dentition is referred to as a mixed dentition
of placing the lower incisors upright over the ridge to
analysis and, if space is maintained by holding the position
stabilize a lower denture. Positioning the incisors too far
of the first molars after loss of second deciduous molars,
labially results in an unstable denture and placing them
provision should be made for an additional 4 mm of arch
too far lingually encroaches on tongue space. The same
length during the transition to permanent dentition.
principle applies in the natural dentition.
Lower incisor position is always reflected in the The “Richter Scale”
position of the lower lip and has a significant influence
on the profile and, therefore, on facial aesthetics. Ricketts It is helpful in treatment planning to classify the degree of
recommends positioning the tip of the lower incisor at difficulty of the malocclusion as mild, moderate or severe.
In arch length discrepancy:
+ 1 to + 3 mm relative to the A-Po line for the best aesthetic
• Mild crowding is in the range 1–3 mm
result (Fig. 5.3). This positions the lower incisor over basal
• Moderate crowding is classified as 4–5 mm
bone close to the anterior limit of the skeletal base, and
• Severe crowding is 6 mm or more.
gives a pleasing contour to the lower lip in profile related
This is a sliding scale (the author describes it as the
to the nose and chin.
“Richter scale”) expressing degree of difficulty for dental
correction by nonextraction therapy. The higher the value,
the more difficult it is to resolve crowding permanently
without extractions. Two factors improve the prognosis for
nonextraction therapy in moderate or severely crowded
dentitions:
1. Early treatment by arch development to increase arch
width before permanent premolars and canines erupt.
2. Lingual positioning of the lower dentition relative to
the skeletal base requires a nonextraction approach.
The “Richter scale” can also be applied when the
measure of convexity is used to determine the skeletal
dis­crepancy:
• A skeletal convexity of 1–3 mm is within the range of
normal
• 4–5 mm convexity is a moderate Class II skeletal dis­
crepancy
• 6 mm or more is severe Class II.
The higher the convexity, the more likely that func­
Fig. 5.3: The distance from the tip of lower incisor to the A-Po line. tional orthopedics is indicated to improve the skeletal
For the best aesthetic result the range is + 1 to + 3 mm. relationship.
54  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

TREATMENT PLANNING IN According to the position of the lower incisors before


CROWDED DENTITION treatment, the space required to correct crowding can be
calculated by repositioning the tip of the lower incisors
Ricketts’ parameters for a lower incisor position relative within the range of + 1 to + 3 mm to the A-Po line. The
to the A-Po line serve as a baseline from which to plan limit of labial positioning of the lower incisors is +1 mm
the treatment of crowding. The degree of crowding in in dolichofacial pattern as bony support is limited long
the lower arch is related to the labiolingual position of thin alveolar processes. In brachyfacial growth pattern
the lower incisor as a guide to determine a differential the lower incisors may advance to +3 mm, where there
diagnosis for extraction or nonextraction therapy. is good supporting bone labial and lingual to the inci­
Assessing arch length discrepancy and lower incisor sors. This is a reliable guideline to relate treatment to
position determines whether the lower incisors can be facial aesthetics in extraction and nonextraction therapy
advanced to a stable position relative to the skeletal base (Figs. 5.4A to C).
after treatment. This depends on the degree of protrusion
One other factor should be taken into account. Func­
or retrusion of the lower incisors related to the degree
tional mandibular advancement carries pogonion forward
of crowding in the lower arch. Before moving the lower
and invariably results in a relative forward movement of
incisors it should be established that good bony support
the lower incisors as the A-Po line becomes more upright.
is available to accommodate the proposed movement.
The lower incisor position should therefore be reviewed
If the lower incisors are retroclined and positioned
after functional therapy when the occlusion has settled.
lingual to the A-Po line, arch length can be increased by
advancing the lower incisors. As a guide, proclination of
the lower incisors by 1 mm increases arch length by 2 mm
Lip Contour
(equivalent to a gain of 1 mm on each side). The fullness of the lips provides an additional aesthetic
Conversely, if lower incisors are proclined and posi­ guideline for extraction or nonextraction therapy. The
tioned too far labial to the A-Po line they should be retra­ angulation of the upper lip is a crucial factor in facial aes­
cted to improve facial aesthetics. Each 1 mm of retrac­tion thetics. Ideally the upper lip should be angled between
will reduce total arch length by 2 mm. 20° and 30° to the nasion vertical for the best aesthetic
appearance. If the angle between the upper lip and the

A B C
Figs. 5.4A to C: Diagram of three profiles to show the relationship of lip position to lower incisor position. (A) The profile on the left shows
good facial balance; Nonextraction treatment is preferred to maintain balance. (B) The middle profile shows the lower incisor positioned
significantly forward to the skeletal base (+7 mm to the A-Po line). Extraction therapy is indicated to improve the lip position. (C) The
profile on the right shows the lower incisor positioned significantly lingual to the skeletal base (-5mm to the A-Po line) Extraction therapy is
contraindicated and non extraction therapy should aim to advance to advance the upper and lower labial segments to improve the profile.
Diagnosis and Treatment Planning  55

undersurface of the nose is more than 90°, the patient’s 1987). Reporting on 500 cases where second molars had
appearance in profile is progressively less aesthetic as the been extracted, Wilson (1974) noted that 87% showed
nasolabial angle becomes more obtuse. Labial movement the third molars erupted in an acceptable position.
of the upper incisors is indicated to restore better balance (Richardson & Mills, 1990; Richardson & Burden, 1992)
between the nose and the upper dentoalveolar structures followed the effects of extraction of second molars and
aiming to improve the aesthetic result by advancing the found that extraction of second molars is effective in
upper lip to reduce the nasolabial angle. reducing the incidence of late lower arch crowding and
Extraction of premolars should be avoided at all costs third molar impaction.
if the lips are a thin red line and the lower lip lies well When examining the effect of second molar extrac­
behind the aesthetic line (tangent to the nose and chin). tion in the treatment of lower premolar crowding it
The resulting loss of lip support would cause further dam­ was concluded that up to 4 or 5 mm of lower premo­
age to the facial appearance, and may compromise tem­ lar crowding can be successfully treated by extraction of
poromandibular joint function. lower second molars, with or without the use of simple
When the lip contour is good before treatment it is orthodontic appliances. Early extraction of lower second
important not to destroy good facial balance and premolar molars, before second premolar eruption, seems to create
extractions should be avoided. In an ideal profile the the most favorable conditions for spontaneous premolar
lower lip lies fractionally behind the aesthetic line (2 mm alignment.
in the child and 4 mm in the adult). The characteristic Richardson & Richardson (1993) investigating lower
flattening of the profile that occurs in the late teens third molar development subsequent to second molar
should be taken into account when planning treatment extraction, found that 99% of third molars upright mesio­
for a young patient. A flat profile in a young child will distally, but few became as upright as the second molars
become retrusive as the child grows into adulthood. they replaced. Model analysis showed that 96% of the
When the lips extend beyond the aesthetic line this lower third molars erupted in good and acceptable posi­
reflects a labial position of the lower incisors. Crowding tions.
associated with bimaxillary protrusion is an indication for
extraction of premolars. CONTRAINDICATIONS FOR
TWIN BLOCK THERAPY
NONEXTRACTION THERAPY Careful case selection is the most important aspect of
Nonextraction therapy has become a popular misnomer diagnosis and treatment planning in order to achieve a
because it refers to nonextraction of premolars. Crowding successful outcome. Besides selecting suitable cases by
may still be relieved by extraction of second or third an orthopedic approach, it is equally important to reco­
molars after a period of nonextraction therapy. This app­ gnize features that contraindicate treatment by functional
roach lends itself to early intervention to combine arch mandibular protrusion. Factors that are unfavorable for
development and functional therapy in a first phase of correction by Twin Blocks include cases with vertical
interceptive treatment, followed by an orthodontic phase growth and crowding that may require extractions.
for detailed finishing in the permanent dentition. Although the majority of Class II malocclusions are
suitable for correction by Twin Blocks, there are some exce­
ptions. The same guidelines as those described to define
Extraction of Second Molars indications for treatment can be used to assess contrain­
Extraction of second molars has long been recognized as dications. Examination of the profile is the most impor­
an effective alternative to premolar extraction in gaining tant clinical guideline. If the profile does not improve
arch length in the lower arch without the disadvantage when the mandible is advanced, this is a clear contrain­
of sacrificing lip support and damaging facial aesthetics dication for functional mandibular advancement, and an
(Wilson, 1964, 1966, 1971; Liddle, 1977; Witzig & Spahl, alternative approach should be considered.
56  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: CH Aged 11 Years 4 Months appearance, as confirmed by clinical and cephalometric
examination. This patient was treated by extraction of four
This girl presents in early permanent dentition with a premolars to relieve crowding, followed by fixed applia­
severe skeletal discrepancy and convexity of 10 mm. nces to reduce the protrusion of the dentition, with an
The maxilla is correctly related to the cranial base, while acceptable improvement in the profile (Figs. 5.5A to C).
the mandible is small and severely retrusive. Moderate
crowding is present in the lower arch with mesial
displacement of lower canines with the molars in Class
Case Report: KJ Aged 13 Years
I relationship. The lower incisors are advanced by 3 mm This boy presents another example of a protrusive
relative to the A-Po line, causing the lower lip to be profile, but in this case, a convexity of 11 mm is due to
protrusive. maxillary protrusion. A vertical growth tendency again
A severe vertical growth pattern is confirmed by limits the improvement observed in the profile when the
cephalometric analysis as the facial axis angle is 17º and mandible is advanced as the degree of convexity would
the Frankfort mandibular plane angle is 39°. An upward not be compensated by predicted mandibular growth.
cant of 4º on the maxillary plane further increases the The profile and facial appearance improved following
lower facial height. While it may seem advisable to advance extraction of four premolars and fixed mechanics by the
the retrusive mandible, this would not improve the facial bioprogressive technique (Figs. 5.6A to C).

Case Report: CH

A B C
Figs. 5.5A to C: (A and B) Profile and tracing before treatment; (C) Profile after treatment.

Case Report: KJ

A B C
Figs. 5.6A to C: (A and B) Profile and tracing before treatment; (C) Profile after treatment.
Diagnosis and Treatment Planning  57

Case Report: KI Aged 11 Years 8 Months Case Report: JS Aged 13 Years 7 Months
A Class II Division I malocclusion is associated with In this case, the Class II Division I malocclusion occurs
bimaxillary dental protrusion, in this case, with upper on a Class I skeletal base relationship with both mandi­
and lower labial crowding. The lower incisors are 4 mm ble and maxilla prognathic relative to the cranial base.
ahead of the A-Po line resulting in the protrusive lower The patient presents a severe brachyfacial growth pat­
lip. Maxillary protrusion is also a factor in the protrusive tern with a strong horizontal growth component in the
profile. Differential diagnosis again depends on evalu­ mandible. Cephalometric analysis confirms a mandibular
ating the profile change when the mandible is advanced. plane angle of 10°, while the facial axis angle is 36°. This
Bimaxillary dental protrusion often does not respond well accounts for the prognathic mandible with a well-devel­
to mandibular advancement, as the profile remains pro­ oped chin, clearly contra-indicating further mandibu­lar
trusive. The crowding cannot be resolved by advancing advan­ cement. The maxillary dental protrusion should
incisors which are already proclined. Extraction of pre­ be corrected by an orthodontic approach to treatment
molars was followed by fixed appliances to relieve the (Figs. 5.8A and B).
anterior crowding with a resulting improvement in the
profile (Figs. 5.7A to C).

Case Report: KI

A B C
Figs. 5.7A to C: (A and B) Profile and tracing before treatment; (C) Profile after treatment.

Case Report: JS

Figs. 5.8A and B: Profile and tracing before


A B treatment.
58  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

REFERENCES Ricketts RM, (1979). Bioprogressive Therapy, Rocky Mountain


Orthodontics, Denver.
Begg PR, (1965). Begg Orthodontic Theory and Technique, WB Sheridan JJ, (1985). Air rotor stripping, Journal of Clinical Ortho­
Saunders Company, Philadelphia. dontics. 19:43-59.
Downs WB, (1948). Variations in facial relationship: their signi­
Sheridan JJ, (1987). Air rotor stripping update, Journal of Clinical
ficance in treatment and prognosis, American Journal of
Orthodontics. 21:781-8.
Orthodontics and Oral Surgery. 34:812.
Tweed CH, (1966). Clinical Orthodontics, CV Mosby, Saint Louis.
Liddle DW, (1977). Second molar extraction in orthodon­ tic
Wilson HE, (1964). Extraction of second molars in treatment
treatment, American Journal of Orthodontics. 72:599-616.
Richardson ME, Burden DJ, (1992). Second molar extraction in planning, L’Orthodontie Française. 25:61-7.
the treatment of lower premolar crowding, British Journal of Wilson HE, (1966). The extraction of second molars as a thera­
Orthodontics. 19:299-304. peutic measure, European Orthodontic Society. 141-5.
Richardson ME, Mills K, (1990). Late lower arch crowding. Wilson HE, (1971). Extraction of second molars in orthodontic
The effect of second molar extraction, American Journal of treatment, Orthodontist. 3:1-7.
Orthodontics and Dentofacial Orthopedics. 98:242-6. Wilson HE, (1974). Long-term observation on the extraction of
Richardson ME, Richardson A, (1993). Lower third molar develop­ second molars, European Orthodontic Society. 50:215-21.
ment subsequent to second molar extraction, American Journal Witzig JW, Spahl TJ, (1987). The great second molar debate.
of Orthodontics and Dentofacial Orthopedics. 104:566-74. in The Clinical Management of Basic Maxillofacial Ortho­
Ricketts RM, (1960). A foundation for cephalometric communi­ pedic Appliances, Vol-1 Mechanics, PSG, Massachusetts, pp.
cation, American Journal of Orthodontics. 46:330-57. 155-216.
The Clark Cephalometric Analysis  59

Chapter 6

The Clark Cephalometric Analysis

You who wish to represent by words the form of man and arrive at a clear perception of the diagnostic significance
all aspects of the ways his parts are put together, drop that of each factor in order to resolve the puzzle.
idea. For the more minutely you describe, the more you No existing method of analysis correlates all the lin-
will confuse the mind of the reader and the more you will ear and angular measurements in a common framework.
prevent him from knowledge of that which you describe. There is no specific orientation of reference points in
So it is necessary to draw and describe. space. Current methods of analysis essentially examine
(Leonardo Da Vinci, Notebooks. each piece of the jigsaw puzzle as a separate entity with-
Translation by Robert E Moyers) out attempting to assemble the component parts into a
Source: Handbook of Orthodontics, 4th Edition. Page 247. unified pattern to define the relationship of the pieces.
It is impossible to isolate the component parts of the
cranio­facial skeleton, and the principle of analysis by
THE JIGSAW PUZZLE
fragmentation is of limited value as a means of illustrat-
The jaw bone’s connected to the head bone. (Popular song). ing the pattern of craniofacial growth.
Consider the jigsaw puzzle: the aim is to assemble all An alternative approach is to examine reciprocal rela-
the pieces into a recognizable pattern, but the method of tionships in the pattern of craniofacial development by a
achieving this objective is rather haphazard. We examine correlative method of cephalometric analysis. The logical
the shape and form of each piece of the puzzle as a separate basis for this approach is that the component parts of the
entity. By concentrating our attention on the detail of the craniofacial complex are mutually interdependent so that
individual pieces we may fail to recognize the underlying variation of one component has a reciprocal effect on the
pattern. Only when all the pieces are assembled in a others. If a reliable registration framework is established
unified framework can we clearly understand the puzzle. using horizontal and vertical axes it is then possible to
Current methods of cephalometric analysis resemble a observe reciprocal variations in the pattern of cranio­facial
jigsaw puzzle. growth of the individual, with less dependence on unre-
Cephalometric analysis attempts to define the pattern lated corporate or average values.
of craniofacial growth by examining the angular and A new approach to cephalometric analysis is derived
linear relationships of clearly defined skeletal landmarks from principles expressed in three previous analytical
on cephalograms. Having defined a series of reference methods. These are the Ricketts (1960), McNamara (1984)
points and planes, the most common analytical method and Bimler (1977) analyses. Having used and studied
is to compare a series of unrelated measurements with these analyses the author has adapted features of these
means and standard deviations to evaluate the diagnostic methods to arrive at a system which aims to simplify and
significance of areas of deficient or excessive craniofacial clarify the analytical method for diagnostic purposes.
growth in the etiology of malocclusion. The lack of Since the early cephalometric studies of Broadbent
correlation of measurements makes it more difficult to (1948) and Brodie (1940, 1941, 1946), the teaching of
60  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
cephalometric analysis has been based largely on the regulator. Superimpositions are made at basion with the
concept that the face grows downward and forward Frankfort plane horizontal.
from the base of the skull along the Y-axis or facial axis. The Clark analysis lends itself well to the expression
Structures in the anterior cranial base were selected for of Coben’s interpretation of facial growth by horizontal
superimposition of serial cephalometric tracings to dem- orientation of the head and evaluation of growth changes
onstrate growth changes. from basion. The same method of superimposition has
Assessment of facial growth by superimposition in the been selected to demonstrate facial growth changes with
anterior cranial base is equivalent to judging the growth Twin Block treatment in this book, using basion as a
of a tree by sitting in its branches. This would give the fulcrum point for analysis of growth changes in the facial
impression that the earth grows downward. Only when rectangle, with the Frankfort plane horizontal.
we stand away from the tree do we realize from a new per-
spective that the tree grows upward. This analogy applies VISION, BALANCE AND POSTURE
with equal logic to our concepts of facial growth.
Our perception of the world is based on horizons that are
Coben (1955) has spent 40 years of research on cepha- dependent on a highly developed mechanism of vision,
lometric analysis, with particular reference to growth of balance and posture. To demonstrate this clearly, we
the cranial base. Coben observes that superimposition of need only tilt our head to one side, or forward or back,
tracings in the anterior cranial base has the major disad- to realize that we cannot function comfortably for long in
vantage of ignoring growth at the primary growth site in this posture. While freedom of movement is necessary in
the base of the skull, the spheno-occipital synchon­drosis, function, in more prolonged postural activity it is neces-
which has a fundamental influence on facial growth. The sary that the face is directed approximately to the front in
growth and angulation of the cranial base inevitably a vertical plane to maintain anatomical and physiological
affects the structure of the face. Growth of the head is balance. A limited range of visual acuity ensures that body
observed more accurately by superimposition at basion posture is adapted accurately to our area of attention.
as recommended by Coben. It is no accident that the facial plane lies approxi-
The head is suspended on the vertebral column and mately in the vertical plane. This is a necessary physio­
grows in a radial direction from its fulcrum of attachment. logical feature in humans as an accommodation to an
Basion is the closest point to this fulcrum that can be used upright stature. A similar principle applies in the midsag-
in cephalometric analysis as a base point to establish ittal plane of the head, which approximates to the vertical
growth of the face. Superimposition at basion gives a new plane, and also to the midtransverse plane which passes
perspective on growth of the face, and this represents an through the head and down through the shoulders. These
improved interpretation of our present concepts of facial characteristics ensure that in normal posture the eyes lie
growth. in a horizontal plane, and are directed forward, in the
Coben (1961) retraced the tracings used in the Bolton same direction as the feet, to assist in balance and loco-
growth study (Broadbent, 1937) to show growth changes motion. The weight of the head is evenly balanced on the
from childhood to adulthood. Comparison with Bolton vertebral column with the minimum of muscular effort.
tracings reveals a more regular pattern of facial growth, Vertical and horizontal axes therefore represent an impor-
illustrated by superimposing the tracings at basion with tant adaptation in anatomical and physiological function
the Frankfort plane horizontal. This is a more accurate to allow humans to adopt an erect posture.
method of evaluating growth vectors in facial development.
Coben’s concept of facial growth is that the wedge Facial Architecture
of the face opens by growth upward and forward along In cephalometric analysis, the significance of horizontal
the cranial base, and downward and forward along and vertical reference planes in relation to facial balance,
the mandibular plane. The opening of the facial wedge and the resulting implications in treatment planning,
increases facial height to accommodate growth in height have not yet been fully realized. Visual appreciation of
of the nasal sinuses and to accommodate the successional aesthetic balance is clearly evident in good architectural
teeth from deciduous to permanent dentition. Frankel & design. The architect, who is involved in planning, makes
Frankel (1989) subsequently used Coben’s concept in his constant reference to horizontal and vertical planes in
book to analyze the results of treatment with the function order to achieve structural balance. The same principle
The Clark Cephalometric Analysis  61

applies in the analysis of facial form and the planning of


reconstructive treatment of the face. In many respects, the
orthodontist is a facial architect who can alter the struc-
ture and balance of the face.
Orthodontic and dentofacial orthopedic techniques
have the potential to produce dramatic changes in facial
appearance that may be beneficial or detrimental accord-
ing to the quality of treatment planning. Successful treat-
ment depends on accurate analysis of the facial growth
pattern before treatment, and prediction of the future
growth trend to select the appropriate technique to pro-
duce the best long-term functional and aesthetic result
within the growth potential of the individual patient.

PARALLELISM IN DENTOFACIAL
DEVELOPMENT
A major advantage of a correlative approach using hori­
zontal and vertical axes is the resulting simplification in Fig. 6.1: Tracing to show facial axis, condyle axis and upper incisor
the interpretation of results. The existence of parallelism parallel, indicating balance in facial development.
in dentofacial development transforms a complex subject.
It immediately becomes easier to teach and understand.
Parallelism has been referred to before in cephalometric not correlated. This complicates both the understand-
analysis. Bimler (1957) and others have noted the parallel ing and the teaching of the principles of analysis, which
relationship that often exists between the Frankfort and remain incomprehensible to a large proportion of the
maxillary planes. Similarly, Ricketts (1960) referred to profession.
the parallel development of the facial axis, the condyle To return to the jigsaw puzzle, the best technique in
axis and the upper incisor. Ricketts recommended that
assembling a puzzle is first to establish the outer frame-
the upper incisor should be positioned parallel to the
work, usually a rectangle, by constructing the edges to
facial axis for stability and balance after treatment. These
define the outer limits of the puzzle. This provides a guide
features may be interpreted as indicating harmony in facial
as a basis for examination and definition of structures
development, and are usually evident in aesthetically
within the framework.
pleasing, well-balanced faces (Fig. 6.1).
The fundamental principle of framing an object in
Ricketts expressed the view that growth and develop­
order to define balance and contour is well exempli-
ment followed the fundamental rules of physics, resulting
fied in the world of art. The concept is of equal value in
in the recurrence of the divine proportion in facial deve­
examining facial contours, and as a means of evaluating
lopment. This can be illustrated using a device to measure
the underlying skeletal structures in aesthetic and scien-
the proportions of the face and the facial features. The
tific terms. Essentially, the principles of cartography are
principle of incremental archial growth was described to
applied to cephalometric analysis to study the relation-
account for the natural balance in facial contours. A bal-
ship of the craniofacial structures.
anced relationship of form and function in facial develop-
On a cephalogram the face is represented in simple
ment is expressed in aesthetic harmony.
terms as a wedge-shaped triangle superimposed on a
recta­ngle. In the upright position, the facial features lie
A REGISTRATION FRAMEWORK FOR
approximately in the anterior vertical plane. A rectangle
CEPHALOMETRIC ANALYSIS provides an ideal framework to examine the position and
The jigsaw concept of cephalometric analysis has the dis­ dimensions of the craniofacial structures in cephalometric
advantage that the component parts of the puzzle are analysis.
62  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Fig. 6.2: The Ricketts triangle. Fig. 6.3: The facial rectangle.

Ricketts Triangle: The Facial Wedge position and angulation of cranial, maxillary, mandibular
and dentoalveolar structures. The rectan­gular framework
The Ricketts triangle defines the face in profile as a
wedge-shaped triangle attached to the undersurface of makes it easier to identify areas where growth departs
the cranial base (Fig. 6.2): from normal in the facial pattern. Perhaps the most obvi-
• The base of the triangle extends from basion to nasion ous feature of the analysis is the visual simplification of
and defines the cranial base plane the underlying pattern that results from placing the face
• The facial plane extends from nasion tangent to the in a rectangle. It is easier to recognize the pattern of the
chin at pogonion to define the angulation of the face jigsaw puzzle when the pieces are fitted together in a rec-
in the anterior plane ognizable framework. The same principle lends itself to
• The mandibular plane is the third leg of the triangle three-dimensional (3D) analysis.
defining the angulation of the lower border of the
mandible Horizontal Registration Plane
• The triangle is bisected by the facial axis, extending
from pterygoid to gnathion to define the direction of The facial rectangle is constructed to define the upper,
growth of the chin. lower, anterior and posterior limits of the face. No single
The facial wedge defined by the Ricketts triangle is anatomical plane consistently relates exactly to the true
superimposed on the facial rectangle to provide a good horizontal in every case. Either a skeletal plane or the true
visual representation of the face with the component parts horizontal may be selected to construct the upper registra-
orientated in a common framework. A few key angu­lar tion plane of the facial rectangle (Fig. 6.3).
measurements define the pattern of craniofacial growth For practical purposes in most cases the Frankfort hori-
and the relationship of the cranial, maxillary and man- zontal is suitable, except where porion or orbitale cannot
dibular structures. It is easy to identify correlations that be identified clearly, or when the Frankfort plane diverges
exist within the craniofacial complex by visual reference significantly from the true horizontal. The true horizontal
to the facial rectangle. may be selected as an alternative when the cephalogram
is taken in the natural head position. The selected plane
THE FACIAL RECTANGLE is used as a horizontal baseline to construct the facial
A facial rectangle is formed to frame the face. The for- rectangle. The following description uses the Frankfort
mation of a facial rectangle helps to define the relative plane as the registration plane.
The Clark Cephalometric Analysis  63

Frankfort Plane—Porion to Orbitale


The Frankfort horizontal has the advantage that it can be
located on external examination of the face, and it may be
defined on a photograph. This is increasingly important
as doctors relate analysis of the underlying bony strucures
to the facial contours in computer-imaging technology.
A further significant advantage of the Frankfort plane is
that it has been widely taught and so it is familiar to the
majority of the profession.
Nasion horizontal: A line is drawn through nasion parallel
to the Frankfort plane. This defines the upper limit of the
face and the anterior point of union with the cranium.
Menton horizontal: This is a tangent through menton on
the lower border of the symphysis parallel to the Frankfort
plane. It defines the lower limit of the face.
Nasion vertical: A perpendicular line is drawn to the
Frankfort plane through nasion. This line defines the
anteroposterior relationship of the maxilla and the man- Fig. 6.4: Patient showing a mesognathic pattern with good facial
dible relative to the anterior cranial base. balance.

Basion vertical: A perpendicular through basion defines


the posterior limit of the face. Basion is an important To achieve ideal facial proportions, the integral parts
anatomical point in the midline on the foramen magnum, of the facial structure must be well related in size, shape
marking the anterior point of union between the cervical and position. In well-balanced faces the Frankfort and
column and the base of the skull. maxillary planes are approximately parallel to the upper
Pterygoid vertical: A perpendicular line to the Frankfort maxillary plane and optic plane, and relate closely to the
plane through the pterygoid point. This midfacial per­ true horizontal in the natural head position. This signifies
pendicular line was selected by Ricketts because it is in parallel development of the anterior cranial base and the
a stable area of growth, being close to the point of emer- floor of the nose. Functional balance of the craniofacial
gence of the trigeminal nerve from the base of the skull. and cervical components may be expressed in a favorable
The facial rectangle now defines the upper, lower, equilibrium of muscle forces acting on the underlying
anterior and posterior limits of the face, with the addition skeletal structures to produce a balanced growth res­
of a midfacial vertical line. This construction facilitates ponse to the forces of gravity and posture. By comparison,
measurement of all factors relative to vertical and hori- divergence of the horizontal planes is an expression of
zontal axes. The spatial relationship of the key structures functional imbalance in facial development that can be
in facial development can now be observed and related recognized in cephalometric analysis, and is significant
to common vertical and horizontal axes.
in the etiology and treatment of malocclusion.
The relative angulation of the upper incisor, the facial
BALANCED FACIAL PROPORTIONS axis, the axis of the condyle and the nasal outline are
If the structure of the face is superimposed on a rectan­ easily compared as they are all related to the vertical axis.
gular framework with horizontal and vertical axes, certain A direct comparison of these measurements is useful in
consistent criteria must be fulfilled in order to achieve evaluating the etiology of the malocclusion in structural
the harmonious facial balance that is characteristic of the and positional terms, and is helpful in diagnosis and
classical straight profile. Excellent facial balance results in treatment planning. In a well-balanced face with a good
the face growing correctly into the facial rectangle so that occlusion these structures show approximately parallel
the facial features relate closely to the anterior vertical development. In treatment, one aims to align these
(Fig. 6.4). structures to improve facial balance.
64  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
A unique feature of this method of analysis is the close
correlation of the mean values of key factors involved in
the determination of facial type. The mean values express
balance and harmony in facial proportions, and departure
from the mean is often related to occlusal imbalance of
skeletal origin in the etiology of malocclusion. Significant
deviation from a mean of 27° in key factors may be used
to identify areas where the pattern departs from the norm.
Disproportion in one area is reflected in reciprocal changes
in other areas when we examine facial proportions in the
facial rectangle. When we assemble all the pieces within
a unified framework a pattern in the jigsaw puzzle begins
to emerge.
The means referred to in this chapter are based on
cephalometric values for caucasian faces and should be
modified for different racial and facial groups. Irrespective
of the racial group, the mean values for a cross-section
of the population differs from values representing ideal
facial proportions. Fig. 6.5: Location of points. See text above for key.
In a predominantly caucasian population the mean
values are biased toward mild Class II skeletal pattern,
Soft-Tissue Planes
reflecting the higher proportion of Class II skeletal
patterns compared to a small proportion of Class III • Nasal plane—the outline of the nose from root to tip
skeletal patterns. There is invariably a difference between • Aesthetic plane—the tangent to the nose and chin.
the mean values and the ideal values observed in patients
with excellent facial balance and aesthetics. For key A CORRELATIVE CEPHALOMETRIC
factors this is expressed in the difference between the ANALYSIS
mean and ideal values.
Measurement relative to common vertical and horizontal
Skeletal Planes axes reveals a surprising consistency in the mean angula-
A further construction is now made to define the main tion of key structures in cephalometric analysis. This con-
facial and dental characteristics by defining points firms the structural interdependence between key parts
(Fig. 6.5) and planes: of the craniofacial skeleton that leads to balanced facial
• Cranial base plane—nasion (N) to basion (Ba) development. Clinical deviation in the following factors
• Mandibular base plane—menton (Me) to gonion (Go) is intended to represent a range of normative values.
• Facial plane—nasion to pogonion (P) Deviation beyond these values may be significant relat-
• Facial axis—pterygoid point (Pt) to gnathion (Gn) ing to facial or dental factors
• Condyle axis—center of the condyle to Xi-point
• Maxillary plane—anterior nasal spine (ANS) to Angular Analysis
posterior nasal spine (PNS) Cranial base angle:
• A to Po—A-point to pogonion (P). Cranial base plane to horizontal registration plane.
Norm = 27°; clinical deviation ± 3°; ideal = 29°–30°.
Dental Planes The angulation of the cranial base to the horizontal is
• Functional occlusal plane—distal the intersection of of fundamental importance in determining facial type.
the first molars to the intersection of the first pre­ Mandibular plane angle:
molars Angle of mandibular plane to horizontal.
• The long axis of the upper incisor Norm = 26°; clinical deviation ± 4°.
• The long axis of the lower incisor. A measure of vertical or horizontal growth potential.
The Clark Cephalometric Analysis  65

Craniomandibular angle: Lower incisor angle:


Angle of cranial base plane to mandibular base plane. Lower incisor to anterior vertical.
Norm = 53°; clinical deviation + 5°. Norm = 25°; clinical deviation ± 4°.
A measure of facial height. This is equivalent to 65° to the Frankfort horizontal in
Equals the sum of the cranial base angle and the the Tweed analysis.
mandibular base angle. Interincisal angle:
Facial plane angle: Angle between upper and lower incisal axes.
Angulation of facial plane to nasion vertical. Norm = 128°; clinical deviation = 6°.
Norm = –3°; clinical deviation = 3°.
Determines the degree of mandibular prognathism or Position of Dentition
retrognathism. Position of upper dentition:
Facial axis angle: Distal of upper molar to pterygoid vertical.
Facial axis to pterygoid vertical. Norm = patient’s age + 3 mm.
Norm 27°; clinical deviation ± 3°; ideal = 29–30°. Indicates whether or not to distalize upper molars.
Determines the direction of growth of the chin. Position of lower dentition:
An important indicator for prognosis related to growth Lower incisor to A-Po line.
direction. Norm = +1 mm; clinical deviation + 2 mm.
Condyle axis angle: This is an important indicator of stability of the lower
Condyle axis to pterygoid vertical. incisor position and a key guideline for extraction and
Norm = 27°; clinical deviation ± 4°. non-extraction therapy as it determines the position of
Relate to the facial axis angle for balance in facial the lower incisors relative to the anterior limit of the
development. skeletal base.
Mandibular arc: Functional therapy moves pogonion forward and
Angulation of condyle axis to body of mandible advances the lower incisors relative to the A-Po line. It is
(Xi to Pm). necessary to review the lower incisor position relative to
Norm = 26° at age 8; clinical deviation = 4°. the A-Po line after functional therapy before completing
Increases by 0.5° per year. treatment.
High angles > square mandible/deep bite/prognathic.
Low angles > open bite/retrognathic. Linear Factors
Craniomaxillary angle:
Convexity: A-point to facial plane:
Cranial base plane to maxillary plane.
Mean = 2.5 mm at age 8; decreases by 0.1 mm per
Norm = 27°; clinical deviation = 3°.
year.
Relates the cranial base angle to maxillary deflection.
Increased convexity is Class II skeletal; decrease is
Maxillary deflection:
Class III skeletal.
Angulation of maxillary plane to horizontal. Maxillary position: A-point to nasion vertical:
Norm = 0°; clinical deviation ± 3°. Mean = 0 mm in mixed dentition; mean = +1 mm in
Determines the proportions of upper and lower facial adult.
height. Positive values measure maxillary protrusion.
Negative values measure maxillary retrusion.
Dental Analysis Mandibular position: pogonion to nasion vertical:
The dental relationship may be defined by the following Mean = –10 mm at age 8; decreases by 0.75 mm per
measurements: year.

The Upper and Lower Incisors are Soft-Tissue Analysis


Related to the Anterior Vertical Nasal angle:
Upper incisor angle: Angulation of nose to anterior vertical.
Upper incisor to anterior vertical. In a harmonious face, the nasal plane is nearly parallel
Norm = 25°; clinical deviation ± 7°. to the facial axis.
66  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
Lower lip to E-plane: growth of the chin does not vary significantly during
Distance of lower lip from a line tangent to nose and growth, with or without orthodontic or orthopedic treat­
chin. ment. This angle is therefore an important indicator of
Norm –2 mm at age 8; decreases by 0.2° per year. the prognosis for correction of the profile by functional
Determines the degree of protrusion or retrusion of the mandibular advancement. In mathematical terms the
lips. gradient of the facial axis can be used to express the
number of millimeters of horizontal growth relative to
Key Factors in Diagnosis and vertical growth of the chin. This proportion determines
Treatment Planning whether or not it is possible to improve the profile by
advancing the mandible. In a straight profile which is
The pattern of facial growth is largely determined by the neither prognathic nor retrognathic the ideal facial axis
relative size and growth vectors of the cranial base, the angle is in the region of 29°–30°. In a caucasian population
maxilla and the mandible. Key angular factors express the with a higher proportion of Class II malocclusions
contribution of these components to the growth pattern. (30–35%) and a small proportion of Class III (3%) a
Three key angles can be used to express the basic mean facial axis angle of 27° expresses mild mandibular
pattern of facial growth as determined by the basal retrusion. As the facial axis angle reduces to the mid or
components (see Fig. 6.4): low twenties, or even into the teens, the degree of mandi­
• Cranial base angle bular retrusion increases accordingly, and the growth
• Facial axis angle pattern becomes progressively more vertical and less
• Mandibular plane angle. favorable for functional correction.
The mean values for the cranial base/facial axis/ Different racial and facial types are characterized
mandibular plane angles are: 27/27/26. These angles by different means of the facial axis angle, expressing
express the basic form of the face. different facial patterns. For example, the mean facial
The cranial base angle represents the degree of flexion axis angle for Japanese is 25°, whereas Hispanic is 29°
of the cranial base as measured to the horizontal axis, and Black is 26°.
while the mandibular plane angle measures the flexion Vertical growth results in a downward translation of
of the mandibular base to the horizontal axis. High or the mandible and the profile does not improve, whereas
low cranial or mandibular plane angles have a significant horizontal growth results in a forward mandibular trans-
effect on the facial pattern. lation, with a corresponding improvement in a retrusive
The craniomandibular angle is the sum of the cranial mandible. The facial axis angle may be used to support
base angle and the mandibular plane angle, because they clinical diagnosis in case selection for functional ortho-
are measured to a common horizontal axis. The mean pedic treatment. The facial axis angle is influenced by the
craniomandibular angle is 53°. This angle measures the relative flexion of the cranial and mandibular base planes.
total facial height. A high mandibular plane angle with a low facial axis
A high craniomandibular angle indicates increased angle may indicate a poor prognosis for functional cor-
facial height, with vertical growth and a dolichofacial rection by mandibular advancement. The profile should
growth pattern, which may be associated with anterior be examined carefully before treatment to determine the
open bite. Conversely, a low craniomandibular angle effect of forward mandibular posture. If the profile does
indicates horizontal growth and a brachyfacial growth not significantly improve, the prognosis for functional
pattern with deep overbite and a skeletal closed bite. correction is poor.
Brachyfacial and mesofacial growth patterns are Conversely as the facial axis angle increases into the
favorable for functional correction, whereas dolichofacial thirties the direction of growth becomes more horizon-
patterns are not favorable, as the growth is expressed tal, expressing mandibular prognathism when pogonion
vertically, and increased vertical growth does not improve moves ahead of the nasion vertical.
the facial appearance or the profile. The facial axis angle is therefore a useful indicator of
the pattern of facial growth. It should be viewed together
The Gradient of Growth of the Chin with the cranial base angle and mandibular plane angle
The facial axis angle measures the gradient of growth of to determine the prognosis for functional correction by
the chin relative to the vertical axis. The direction of mandibular advancement.
The Clark Cephalometric Analysis  67

Maxillary Convexity The A-Po line represents the anterior limit of the skel-
etal base, as it joins the most anterior points on the
Convexity is a measure of the anteroposterior skeletal
maxilla and mandible. This line is an important diag-
relationship. The position of the maxilla relative to the
nostic indicator in determining whether or not the
cranial base and the mandible is measured as the dis-
tance from A-point to the facial plane. Thus A-point, lower incisors should be moved labially or lingually
the anterior point on the maxilla, is assessed relative to during treatment. The aim of treatment is to position
nasion and pogonion, the anterior points on the cranial the lower incisors in a stable position over basal bone
base and mandible respectively. The range of normal at the end of treatment. The ideal position for the tip of
convexity is +1 to +3 mm. Increased convexity is an indi- the lower incisors in a caucasian population is +1 to +3
cation of maxillary protrusion or mandibular retrusion. mm ahead of the A-Po line. This position gives the best
The relative position of the maxilla and mandible is con- aesthetic profile by supporting the lower lip. Ricketts
firmed by reference to the nasion vertical. The maxilla described a broad range of acceptability for this factor
is correctly related to the cranial base when A-point lies from –1 to +3 mm.
on the nasion vertical. The maxilla is protrusive when It must be appreciated that where an anteroposterior
A-point is ahead of the vertical, and retrusive when it lies or vertical discrepancy exists in the mandibular posi-
behind the nasion vertical. The position of the mandible tion, a functional mandibular advancement alters the
is assessed by the distance of the chin point (pogonion) relationship of the lower incisors to the A-Po line. As a
to the nasion vertical. general rule the lower incisors are advanced relative to
the A-Po, and an adjustment must be made to allow for
Position of the Upper Dentition this. A second tracing of the mandible may be made and
The position of the upper dentition can be assessed positioned so that the overjet and overbite are corrected
with reference to the first permanent molars or inci- to give an estimated correction of the lower incisor after
sors. According to Ricketts the upper first molar may treatment. Alternatively, a second cephalogram may be
be related to the pterygoid vertical. The norm for the taken to review the position after functional correction
individual is determined as the age of the patient plus (Fig. 6.6).
3 mm, and this applies only until growth is complete.
This measurement helps to determine whether distal-
izing forces should be applied to the molar. The molar
position is usually related to the position of the maxilla
as indicated by A-point relative to the nasion vertical. A
protrusive maxilla will normally be related to a mesially
positioned upper molar, indicating that the molar can be
moved distally. Conversely, a retrusive maxilla is more
likely to be related to a distally positioned molar relative
to the pterygoid vertical. This would contraindicate distal
movement of the molar.
Upper incisor position may be assessed either by
angular or linear measurement. The mean upper incisor
angle to the nasion vertical is 25°. McNamara determines
the position of the tip of the upper incisor relative to the
nasion vertical, with a normal range of +4 to +6 mm.
A combination of all factors relating molar and
incisor position should be viewed with reference to the
position of the maxilla as a primary etiological factor in
determining the position of the upper dentition.

Position of the Lower Dentition


Fig. 6.6: Functional treatment objective predicts the facial change
The position of the lower dentition may be assessed by that will result from mandibular advancement. The lower incisor trans­
relating the tip of the lower incisors to the A-Po line. lates forward relative to the A-Po line.
68  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
The position of the lower incisors influences the out­ Brachyfacial
line of the lower lip in profile. Lingually positioned lower
The face is typically short and square with a reduced man-
incisors behind the A-Po line are normally associated
dibular plane angle and strong musculature. It describes
with a retrusive lip, which may be trapped lingual to the
a horizontal growth pattern (Ricketts, 1960) with a deep
upper incisors, while labially positioned lower incisors
overbite of skeletal origin. A mild brachyfacial tendency is
are related to protrusive lips. In some facial patterns lip
favorable for normal dental development. A strong brach-
protrusion is the norm, and is an expression of bimaxillary
yfacial growth pattern is accompanied by retrusion of the
protrusion, which is often a racial characteristic. The
lips in the profile. Anchorage is good and nonextraction
normal range for lower incisor position relative to the therapy is indicated.
A-Po line in black populations is 4–6 mm, while the norm
for hispanic populations is 3–5 mm. In general, functional Dolichofacial
treatment is less effective in correction of bimaxillary
The face is typically long and narrow with a high mandibular
protrusion, and may be contraindicated, depending on
plane angle and weak musculature. It describes a vertical
the effect of mandibular advancement on the profile.
growth pattern (Ricketts, 1960) with an anterior open bite
tendency. Patients are likely to exhibit nasorespiratory
DESCRIPTIVE TERMS IN problems with incompetent or strained lip musculature.
CEPHALOMETRIC ANALYSIS The alveolar processes are long and thin due to increased
lower facial height. There is frequently dental crowding
Definition of Facial Type associated with narrow archform. Natural anchorage is
poor and these patients present difficulties in treatment.
Mesognathic
Extraction therapy may be indicated for relief of crowding.
A normal relationship of the maxilla and mandible to the
Note: Confusion arose in terminology when Bimler (1977)
cranial base.
used the anthropological terms dolichoprosopic and lep-
toprosopic to relate facial depth to facial height, while
Prognathic
Ricketts combined Latin and Greek roots in his terminol-
Prominence of jaw position relative to the cranial base. ogy. A detailed explanation of the origin of this confusion
is given by Witzig & Spahl (1989).
Retrognathic To avoid further confusion, because of the use of
Retrusion of jaw position relative to the cranial base. Ricketts’ triangle in the Clark analysis, the terminology
Where the relationship of the maxilla and mandible used in this book is as defined by Ricketts.
to the cranial base is not the same, the terms normal,
protrusive and retrusive are used to describe the individual FACIAL CHANGES IN
jaw relationship. TWIN BLOCK TREATMENT
This section illustrates examples of the treatment of
Mesofacial uncrowded Class II division 1 malocclusion in different
Describes a well-balanced face with harmonious muscu- facial types with Twin Blocks to compare the response
lature and a pleasant soft-tissue profile. to treatment.
The Clark Cephalometric Analysis  69

Case Report: KH Aged 9 Years 7 Months guidelines therefore indicate a functional approach to
treatment. Guiding the mandible forward to match the
This girl was treated in early permanent dentition and
slightly protrusive position of the maxilla will improve the
presented a severe Class II division 1 malocclusion with
profile in this case (Figs 6.7A to C).
an overjet of 10 mm and a full unit distal occlusion.
Cephalometric analysis indicates a mild Class II skeletal Twin Blocks: 5 months
pattern with a brachyfacial growth pattern, indicating Support appliance: 3 months
horizontal growth. There is a prognathic tendency in the Treatment time: 8 months, including retention.
maxilla with convexity of 5 mm due to maxillary protru- Treatment is uncomplicated thanks to good archform,
sion. However, clinical examination confirms that the and the response to treatment is rapid due to the strong
profile improves when the mandible is advanced slightly. horizontal skeletal growth pattern. As a general rule the
When the patient postures downward and forward, the profile will continue to straighten as the patient matu­
resulting change in the profile is a preview of the change res when there is a brachyfacial pattern with horizontal
which will be produced by functional therapy. Clinical growth.

Case Report: KH

B C
Figs 6.7A to C: Treatment: (A) Profiles at ages 9 years 7 months (before treatment), 11 years 3 months (after treatment) and 14 years 7
months (out of retention); (B) Occlusion before treatment at 9 years 7 months; (C) Occlusion 3 years out of retention at age 14 years 7 months.
70  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: KH

KH Age 9.5 11.3 14.7


Cranial Base Angle 24 25 26
Facial Axis Angle 30 27 32
F/M Plane Angle 22 24 20
Craniomandibular Angle 46 49 47
Maxillary Plane 3 2 3
Convexity 5 2 1
U/Incisor to Vertical 29 19 22
L/Incisor to Vertical 32 29 26
Interincisal Angle 119 132 132
6 to Pterygoid Vertical 18 15 18
L/Incisor to A/Po −1 1 −1
L/Lip to Aesthetic Plane −2 −3 −5
The Clark Cephalometric Analysis  71

Case Report: ME Aged 13 Years The overjet reduces from 11 mm to 2 mm in 3 months and
the distal occlusion is corrected by the initial activation
This boy presents a severe Class II division 1 malocclusion
of the Twin Blocks (Figs 6.8A to C).
with an overjet of 13 mm and an excessive overbite.
Cephalometric analysis indicates a severe class II skeletal Twin Blocks: 6 months
pattern with 8 mm convexity due to a combination of Support phase: 4 months
maxillary protrusion and mandibular retrusion. The growth Retention: 4 months
pattern is brachyfacial and the upper central incisors are Treatment time: 14 months.
proclined by a trapped lower lip. The favorable growth Final records: 2 years 10 months out of retention at age
pattern again produces a rapid response to treatment. 17 years.

Case Report: ME

B C
Figs. 6.8A to C: Treatment: (A) Profiles at ages 13 years (before treatment) and 17 years (out of retention); (B) Occlusion before treatment;
(C) Occlusion after treatment.
72  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: ME

ME Age 13.0 13.8 17.1


Cranial Base Angle 26 27 27
Facial Axis Angle 27 26 26
F/M Plane Angle 25 26 24
Craniomandibular Angle 51 53 51
Maxillary Plane 0 −3 −2
Convexity 8 6 5
U/Incisor to Vertical 31 22 24
L/Incisor to Vertical 26 36 26
Interincisal Angle 123 122 122
6 to Pterygoid Vertical 24 19 24
L/Incisor to A/Po 0 4 3
L/Lip to Aesthetic Plane 0 0 −3
The Clark Cephalometric Analysis  73

Case Report: PMcL Aged 11 Years 6 Months registration so as to encourage unilateral activation to
improve the asymmetry. A tongue guard and spinner are
This girl has a Class II division 1 malocclusion on a
effective in controlling the tongue thrust (Figs 6.9A to C).
Class I skeletal base relationship with only 2 mm convexity.
An incomplete overbite is associated with a forward Twin Blocks: 7 months
tongue thrust, causing severe proclination of the upper Support phase: 5 months
incisors and an overjet of 11 mm. Slight facial asymmetry Retention: 9 months
is eliminated by correcting the center lines in the bite Total treatment time: 21 months.

Case Report: PMcL

B C
Figs. 6.9A to C: Treatment: (A) Profiles at ages 11 years 6 months (before treatment) and 13 years (after treatment); (B) Occlusion before
treatment; (C) Occlusion after treatment.
74  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: PMcL

PMcL Age 11.6 13.0 17.1


Cranial Base Angle 25 25 24
Facial Axis Angle 30 32 30
F/M Plane Angle 23 21 23
Craniomandibular Angle 48 46 47
Maxillary Plane 3 1 0
Convexity 2 −1 −1
U/Incisor to Vertical 44 31 31
L/Incisor to Vertical 28 28 28
Interincisal Angle 108 121 121
6 to Pterygoid Vertical 18 22 23
L/Incisor to A/Po 2 2 3
L/Lip to Aesthetic Plane −4 −2 −4
The Clark Cephalometric Analysis  75

Case Report: EF Aged 12 Years 9 Months excessive overbite is partially corrected by an initial
activation of 8 mm, before reactivating to edge-to-edge
A girl with good archform and mild crowding in the
to complete the correction (Figs 6.10A to C).
lower arch and impaction of a lower second premolar.
A moderate Class II skeletal base with a convexity of Twin Blocks: 14 months
5 mm is due to mandibular retrusion, with a favorable Support and retention: 12 months
brachyfacial growth pattern. An overjet of 14 mm and Treatment time: 26 months.

Case Report: EF

B C
Figs. 6.10A to C: Treatment: (A) Profiles at ages 12 years 9 months (before treatment) and 15 years (after treatment); (B) Occlusion
before treatment; (C) Occlusion after treatment.
76  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: EF

EF Age 12.3 15.2


Cranial Base Angle 26 26
Facial Axis Angle 28 29
F/M Plane Angle 22 22
Craniomandibular Angle 47 47
Maxillary Plane 1 2
Convexity 5 5
U/Incisor to Vertical 32 19
L/Incisor to Vertical 39 34
Interincisal Angle 109 127
6 to Pterygoid Vertical 18 19
L/Incisor to A/Po 0 2
L/Lip to Aesthetic Plane 0 −1
The Clark Cephalometric Analysis  77

Case Report: WL Aged 10 Years 3 Months


3 mm in 4 months, and the distal occlusion is corrected
This girl presents a severe Class II skeletal pattern with
by the initial activation of the Twin Blocks. Correction is
8 mm convexity, due to severe mandibular retrusion. The
achieved mainly by mandibular advancement with slight
24° facial axis angle indicates a dolichofacial tendency
maxillary retraction.
with vertical growth of the chin, which is less favorable
for correction. As a result the response to treatment Twin Blocks: 11 months
may be slower and the period of treatment is longer Support phase: 6 months
(Figs 6.11A to E). The screw is operated to expand the Retention: 6 months
maxilla for 3 months. The overjet reduces from 9 mm to Treatment time: 23 months.

Case Report: WL

B C

D E
Figs. 6.11A to E: Treatment (A) Profiles at age 10 years 3 months (before treatment) and 11 years 6 months (after treatment); (B and C)
Occlusion before and after treatment; (D and E) Facial appearance and airway improves and the patient is more alert after treatment.
78  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: WL

WL Age 10.3 11.6 16.1


Cranial Base Angle 27 28 28
Facial Axis Angle 24 25 26
F/M Plane Angle 23 24 21
Craniomandibular Angle 50 52 49
Maxillary Plane 3 4 4
Convexity 8 6 5
U/Incisor to Vertical 31 21 14
L/Incisor to Vertical 34 42 36
Interincisal Angle 115 117 140
6 to Pterygoid Vertical 15 15 18
L/Incisor to A/Po 0 1 1
L/Lip to Aesthetic Plane 0 −2 −3
The Clark Cephalometric Analysis  79

Case Report: AF Aged 11 Years fixed appliance to complete treatment. This was followed
by pericision on 1 1 to stabilize their position after
The cephalometric analysis in this case shows dolicofacial
treatment. Extaction of all seconds molars was carried
tendency with mandibular retrusion and a facial axis
out to reduce the risk of recurrent crowding, and to avert
angle of 25°. The convexity is 7 mm and the overjet
potential impaction of third molars (Figs 6.12A to E).
9 mm with an increased but incomplete overbite.
There was mild upper and lower incisor crowding and Twin Blocks: 6 months
distolabial rotation of 1 1 . Brackets were fitted on the Fixed appliance: 3 months
upper six anterior teeth to correct the rotation of incisors Retention: 12 months
during the twin block phase, progressing to simple upper Treatment time: 21 months

Case Report: AF

B C

D E
Figs. 6.12A to E: Treatment: (A) Profiles at ages 11 years (before treatment) and 17 years 5 months (out of retention); (B) Appearance
before treatment; (C) Occlusion before treatment; (D) Appearance 4 years out of retention; (E) Occlusion out of retention.
80  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: AF

AF Age 11.0 14.3 17.5


Cranial Base Angle 23 25 24
Facial Axis Angle 25 29 28
F/M Plane Angle 26 25 27
Craniomandibular Angle 49 50 51
Maxillary Plane 3 4 5
Convexity 7 4 4
U/Incisor to Vertical 27 23 23
L/Incisor to Vertical 37 32 30
Interincisal Angle 116 125 127
6 to Pterygoid Vertical 18 22 20
L/Incisor to A/Po 2 3 2
L/Lip to Aesthetic Plane 3 2 1
The Clark Cephalometric Analysis  81

Case Report: LC Aged 9 Years This patient required a second Twin Block appliance
to reinforce correction to a class I dental relationship.
This girl presents a dolichofacial pattern with a facial axis
Vertical growth is associated with weak musculature and
angle of 22°, indicating severe vertical growth. This face is
is related to a slower response to treatment because the
retrognathic in both the maxilla and mandible, although
corrective functional forces are reduced. (Fig. 6.13).
the mandibular retrusion is more severe. Convexity is
6 mm and the overjet is 14 mm, with excessive overbite. Twin Blocks: 16 months
The response during Twin Block treatment in this case Support and retention: 12 months
was relatively slow due to the vertical growth pattern. Treatment time: 28 months.

Case Report: LC

B C
Figs. 6.13A to C: Treatment: (A) Profiles at ages 9 years (before treatment) and 14 years 11 months (out of retention); (B) Occlusion
before treatment; (C) Occlusion out of retention.
82  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: LC

LC Age 9.0 10.0 15.4


Cranial Base Angle 26 28 28
Facial Axis Angle 22 23 22
F/M Plane Angle 27 27 29
Craniomandibular Angle 53 56 57
Maxillary Plane 1 −1 3
Convexity 6 7 6
U/Incisor to Vertical 32 15 13
L/Incisor to Vertical 30 42 40
Interincisal Angle 118 123 127
6 to Pterygoid Vertical 9 12 17
L/Incisor to A/Po −4 3 3
L/Lip to Aesthetic Plane 3 3 −1
The Clark Cephalometric Analysis  83

However, the author investigated the reliability of


the natural head position in a thesis: New Horizons in
Orthodontics and Dentofacial Orthopaedics—Aspects of
Twin Block Functional Therapy (2010).
This study concluded that natural head position was
not a reliable method of registration to evaluate changes
during functional therapy, as head posture can change as
muscle balance changes when the mandible is advanced.

REFERENCES
Bimler HP, (1957). A roentgenoscopic method of quantifying
the facial proportions, European Orthodontic Society. 241-53.
Begg PR, (1965) Begg Orthodontic Theory and Technique, WB
Fig. 6.14: Patient positioned in the cephalostat in natural head Saunders Company, WB Saunders Company, Philadelphia.
position. Note the vertically mounted mirror. Clark WJ. New Horizons in Orthodontics & Dentofacial Ortho­
paedics—Aspects of Twin Block Functional Therapy (2010)
Natural Head Position Thesis for the degree of Doctor of Dental Science, University
of Dundee.
It is fully realized that the selection of a single horizontal Downs WB, (1948). Variations in facial relationship: their signi­
skeletal plane for the purpose of head orientation in ficance in treatment and prognosis, American Journal of
Orthodontics and Oral Surgery. 34:812.
the living subject is a compromise, because the vertical
Liddle DW, (1977). Second molar extraction in orthodontic
location of landmarks varies among individuals. This treatment, American Journal of Orthodontics. 72:599-616.
limitation was accepted when the Frankfort horizontal Richardson ME, Burden DJ, (1992). Second molar extraction in
was defined after much debate in Germany (1884) to the treatment of lower premolar crowding, British Journal of
approximate to a standardized head position of the living, Orthodontics.19:299-304.
Richardson ME, Mills K, (1990). Late lower arch crowding.
in order to orient skulls for craniometric research. In
The effect of second molar extraction, American Journal of
orientating the head relative to the true vertical, therefore, Orthodontics and Dentofacial Orthopedics. 98:242-6.
there is good reason to consider alternative skeletal planes Richardson ME, Richardson A, (1993). Lower third molar deve­
for registration, to compensate for individual variation in lopment subsequent to second molar extraction, American
the position of skeletal landmarks. Journal of Orthodontics and Dentofacial Orthopedics. 104:
566-74.
Determination of natural head position in relation to
Ricketts RM, (1960). A foundation for cephalometric communi­
the true vertical is a starting point in the aesthetic exami- cation. American Journal of Orthodontics. 46:330-57.
nation of the facial profile. This method has been used Ricketts RM, (1979). Bioprogressive Therapy, Rocky Mountain
for the purpose of serial cephalometric radiography, as Orthodontics, Denver.
described by other authors in previous studies. The classic Sheridan JJ, (1985). Air rotor stripping, Journal of Clinical Ortho­
dontics. 19:43-59.
natural head position is a reproducible, standardized
Sheridan JJ, (1987). Air rotor stripping update, Journal of Clinical
position of the head, whereby the individual looks at Orthodontics. 21:781-8.
a point in the distance at eye level. The visual axis is Tweed CH, (1966). Clinical Orthodontics, CV Mosby, Saint Louis.
horizontal. Wilson HE, (1964). Extraction of second molars in treatment
This concept cannot always be achieved in a clinical planning, L’Orthodontie Française. 25:61-7.
Wilson HE, (1966). The extraction of second molars as a
setting, and alternatively the patient may be positioned
therapeutic measure, European Orthodontic Society, 141-5.
standing or seated in an upright position opposite a Wilson HE, (1971). Extraction of second molars in orthodontic
vertical mirror, mounted 150 cm in front of the ear treatment, Orthodontist. 3:1-7.
rods, so that the patient can observe his/her eyes in the Wilson HE, (1974). Long-term observation on the extraction of
mirror (Fig. 6.14). The patient is positioned carefully in second molars, European Orthodontic Society. 50:215-21.
Witzig JW, Spahl TJ, (1987). The great second molar debate.
the cephalostat with the head tilted neither forward nor
In The Clinical Management of Basic Maxillofacial Ortho­
backward, and the true vertical is registered as a plumb pedic Appliances, Vol-1 Mechanics, PSG, Massachusetts, pp.
line suspended over the cassette holder in the occipital 155-216.
region. Investigation has established a method error of
2.3° for variability of head posture recorded by auxiliaries FURTHER READING
for head position to the true vertical (Solow & Tallgren, Ricketts RM, Roth RH, Chaconas SJ, et al. Orthodontic diagnosis
1971; Siersbaek-Neilsen & Solow, 1982). and planning. Denver, Rocky Mountain Orthodontics 1982.
Appliance Design and Construction  85

Chapter 7
Appliance Design
and Construction

INTRODUCTION • Springs to move individual teeth and to improve the


archform as required
Comfort and aesthetics are the two most important fac- • Provision for extraoral traction in some cases.
tors in appliance design. It is important to design appli- Twin Block appliances are tooth and tissue borne.
ances that are “patient friendly” to remove any obstacles The appliances are designed to link teeth together as
to compliance and to motivate the patient to cooperate anchor units to limit individual tooth movement, and to
in treatment. maximize the orthopedic response to treatment. In the
Twin Blocks have the advantage of versatility of design. lower arch, peripheral clasping combined with occlusal
They meet a wide range of requirements for correction cover exerts three-dimensional (3D) control on anchor
of different types of malocclusion for patients through- teeth, and limits tipping and displacement of individual
out the age range from childhood to adulthood. Since the teeth. When indicated, additional clasps may be placed
upper and lower appliances are separate components, on lower incisors but, in practice, it is found that clasps
the design can be adapted to resolve problems in both mesial to the lower canines are equally effective in
arches independently. controlling the lower labial segment. An example of an
early design with a labial bow, lower incisor clasps and
The component parts of Twin Block appliances are
provision for extraoral traction, which is no longer used
common to conventional removable appliances with the
to reinforce anchorage, is shown in Figures 7.1A and B.
addition of occlusal inclined planes. Appliance design is
A common modification to appliance design preferred
modified by the addition of screws and springs or bows
by some orthodontists is the addition of incisal capping
to move individual teeth. Arch development can proceed
over the lower incisors. The reasoning is to prevent
simultaneously with correction of arch relationships in proclination of the lower incisors, but this concern is
the horizontal and vertical dimensions. usually unfounded, as growth studies by the author and
other investigators show that although the lower incisors
EVOLUTION OF APPLIANCE DESIGN procline by up to 5° during the Twin Block stage, they
upright during the support stage. After treatment no
The earliest Twin Blocks were designed with the following significant proclination of lower incisors occurs. The
basic components: author used lower incisal capping during the early
• A midline screw to expand the upper arch stages of development of Twin Blocks, and observed
• Occlusal bite blocks decalcification of the tips of the lower incisors in a few
• Clasps on upper molars and premolars cases where the oral hygiene was poor. One important
• Clasps on lower premolars and incisors difference compared to the bionator, for example, is that
• A labial bow to retract the upper incisors the Twin Block is worn for eating. Oral hygiene is therefore
86  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

A B
Figs. 7.1A and B: Example of an early Twin Block with a labial bow, lower incisor clasps and provision for extraoral traction, which is no
longer used to reinforce anchorage.

an important factor during treatment, and because of In Twin Block treatment a good lip seal is achieved
the risk of decalcification the author abandoned incisal naturally without additional lip exercises, as the appliance
capping. is worn for eating and drinking, making it necessary to form
a good anterior seal. The lips act like a labial bow and lip
STANDARD TWIN BLOCKS pressure is effective in uprighting upper incisors, making
a labial bow superfluous. In many cases, the absence of
Standard Twin Blocks are essentially for treatment of an a labial bow improves aesthetics without reducing the
uncrowded Class II division 1 malocclusion with good effectiveness of the appliance (Figs. 7.2A to D).
archform and an overjet large enough to allow unres­ An alternative design that has gained some popularity
tricted forward translation of the mandible to allow full places an acrylic pad labial to the lower incisors as an
correction of distal occlusion. additional means of retention and control. This procedure
has been used in some cases by McNamara and Mills,
Labial Bow whose work is referred to in the text of other chapters. An
illustration of this modified design of the lower appliance
In the early stages of development, the upper Twin Block
is shown in Figures 7.3A and B.
invariably incorporated a labial bow. It was observed
that if the labial bow engaged the upper incisors during
functional correction it tended to overcorrect incisor
TWIN BLOCK CONSTRUCTION
angulation. It was, therefore, routinely adjusted out of The appliance prescription includes all the details required
contact with the upper incisors. Retracting upper incisors for correction of the individual malocclusion, with specific
prematurely limits the scope for functional correction by instructions on appliance design, including springs and
mandibular advancement. This led to the conclusion that screws to correct individual teeth, or seg­mental correction
a labial bow is not always required unless it is necessary by transverse and/or sagittal correction, to improve arch­
to upright severely proclined incisors, and even then it form. A vague request for “Twin Blocks” does not give
must not be activated until full functional correction is sufficient detail for proper construction of the appliance.
complete and a Class I buccal segment relationship is The laboratory requires a good set of impressions and
achieved. If a labial bow is included in the appliance an accurate construction bite to record the activation to
design, and it is activated prematurely to retract upper be built into the appliance. The construction bite should
incisors, this will act as a brake to limit the functional be taken in modeling wax or bite registration paste that
correction by mandibular advancement. In many cases, retains its dimensional stability after it is removed from
the appliance is more effective for functional correction the mouth. Any excess wax extending over the buccal
without a labial bow. surfaces of the teeth should be removed to allow the
Appliance Design and Construction  87

A B

C D
Figs. 7.2A to D: Standard Twin Blocks.

A B
Figs. 7.3A and B: Modified design of the Twin Block lower appliance used by McNamara & Mills.
88  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
models to seat correctly into the construction bite. In 69 and 72 patients treated consecutively in the author’s
the laboratory the models are mounted on an articulator practice with Twin Blocks between 1979 and 1993 (Clark
to register the construction bite before the occlusal bite & Stirrups, pers. comm).
blocks are constructed. A plasterless articulator may be Results indicated that the incidence of breakage of
used, with adjustable screws to position the models in delta clasps was significantly reduced compared with
the correct relationship. appliances retained with the modified arrowhead clasp.
The percentage of breakages was 10% for the modified
THE DELTA CLASP arrowhead (Adams) clasp and 1% for the delta clasp.
According to the area of best retention there are two
The delta clasp was designed by the author to improve the possible methods of construction for the delta clasp. The
fixation of Twin Blocks. The delta clasp is similar to the first is similar to the Adams clasp, with the retentive loop
Adams clasp (Adams, 1970) in principle, but incorporates angled to follow the curvature of the tooth into mesial and
new features to improve retention, reduce metal fatigue distal undercuts. This design is appropriate if the tooth
and minimize the need for adjustment. The retentive is favorably shaped, with good undercuts mesially and
loops were originally triangular in shape (from which the distally.
name “delta” is derived), or alternatively the loops may If the individual teeth are not favorably shaped, the
be circular or ovoid, both types having similar retentive loop of the clasp may be directed interdentally. The loop
properties. is then constructed at right angles to the bridge of the
The delta clasp retains the basic elements of the clasp, so that it passes into the interdental undercut to
Adams clasp, that is, interdental tags, retentive loops and gain retention from adjacent teeth.
a buccal bridge. The crucial difference is that the retentive In the permanent dentition, delta clasps are placed
loops are shaped as a closed triangle, or a circle or ovoid routinely on upper first molars and on lower first
as opposed to an open U-shaped arrowhead as in the premolars. They may also be used on deciduous molars.
Adams clasp. The advantage of the closed loop is that the Additional interdental ball-ended clasps, finger clasps or
clasp does not open with repeated insertion and removal C-shaped clasps may be placed to improve retention and
and, therefore, maintains its shape better and requires provide resistance to anteroposterior tipping.
less adjustment, and is less subject to breakage. A further Ball-ended clasps are routinely employed mesial to
advantage is that the clasp gives excellent retention on lower canines and in the upper premolar or deciduous
lower premolars, and is suitable for use on most posterior molar region to gain interdental retention from adjacent
teeth (Fig. 7.4). teeth. C-clasps are useful in mixed dentition where they
A comparison of the failure rate of the delta and Adams can be used for peripheral clasping on deciduous molars
clasp was made by statistical analysis of two groups of and canines (Fig. 7.5).

Fig. 7.4: The delta clasp. Fig. 7.5: Clasps on deciduous molars and canines.
Appliance Design and Construction  89

ADJUSTMENT OF THE DELTA CLASP additional strength and accuracy. Making the appliances
in wax first allows the blocks to be formed with greater
The delta clasp may be adjusted gingivally into an inter­ precision.
dental undercut by placing pliers on the wire as it emerges Cold cure acrylic has the advantage of speed and
from the acrylic interdentally. Bird beak or 139 pliers convenience, but sacrifices something in strength and
have a short round beak that is placed under the wire accuracy. It is essential to use a top-quality cold cure
and the square beak is placed on top. A slight adjustment acrylic to avoid problems with breakage, especially in
extends the retentive loop of the clasp into the gingival or the later stages of treatment, after trimming the blocks to
interdental undercut. allow eruption in treatment of deep overbite. The inclined
The other method of adjustment is to grasp the planes can lose their definition as a result of wear if a soft
arrowhead from the buccal aspect and twist the retentive acrylic is used.
loop inwards toward the tooth to adjust into a mesial or The disadvantages of cold cure acrylic can be overcome
distal undercut. by using preformed blocks made from a good quality
heat cured acrylic. This has the important advantage of
THE BASE PLATE making construction easier and increasing the accuracy
Appliances may either be made with heat cure or cold of the inclined planes by providing a consistent angle for
cure acrylic. Heat cure acrylic has the advantage of occlusion of the blocks (Figs. 7.6A to C).

A B

C Figs. 7.6A to C: Appliances with preformed heat-cured blocks.


90  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
The author has observed that laboratory construc- Screws may be incorporated in the upper and lower
tion of Twin Block appliances in cold cure acrylic is time Twin Blocks to develop the archform in mixed dentition.
consuming, especially in forming the occlusal bite blocks, This allows independent control of arch width in both
and subsequently in trimming and finishing the appli- arches to improve anterior crowding or correct posterior
ances. This is the most common method of appliance crossbite. An upper transpalatal arch or lower Jackson
construction and there is scope to improve the process design may be used as an alternative to screws for arch
and to simplify this stage in construction of the appli- development (Fig. 7.9).
ances. New Preformed blocks are now available from The Twin Block Crozat appliance (Crozat, 1920) pro-
<orthog@prodigy.net.mx>. These greatly simplify the vides a useful alternative that is suitable for adult treat-
construction of the inclined planes and save laboratory ment with minimum palatal and lingual coverage. This
time in the construction of Twin Blocks. appliance requires careful adjustment to maintain sym-
metry (Fig. 7.10).
The palate-free Twin Block is an excellent alterna-
TWIN BLOCKS FOR ARCH DEVELOPMENT
tive for added comfort and to improve speech. This is
It is important to realize that when crowding or irregularity illustrated in Chapter 10 in the section on “Concurrent
is present in the dental arches provision must be made for Straightwire and Twin Block Therapy”.
this in the appliance design, and the Twin Blocks must be
modified by the addition of springs or screws to correct Occlusal Inclined Planes
the irregularity. The position and angulation of the occlusal inclined
planes is crucial to efficiency in correcting arch relation­
Transverse Development ships. The inclined planes are angled at 70° or 45° depend-
Upper and lower Schwarz appliances (Schwarz & ing on the severity of the distal occlusion. If the patient
Gratzinger, 1966) were commonly used in the past for has a severe distal occlusion or has difficulty in maintain-
transverse development in mixed dentition. It is now ing a forward posture the angulation is reduced to 45°.
possible to combine transverse arch development simul­ The position of the inclined plane is determined by
taneously with sagittal and vertical correction of arch the lower block and is critical in the treatment of deep
relationships by combining Twin Block and Schwarz overbite. It is important that the inclined plane is clear
appliances (Fig. 7.8). of mesial surface contact with the lower molar, which

Fig. 7.7: Occlusal views of Standard Twin Blocks for uncrowded Fig. 7.8: Twin Block Schwarz appliances in mixed dentition.
Class II Division 1.
Appliance Design and Construction  91

Fig. 7.9: Upper Schwarz/Lower Jackson Twin Blocks. Fig. 7.10: Twin Block Crozat appliances.

must be free to erupt unobstructed in order to reduce the midline should be sufficiently thick to give adequate
the overbite. The inclined plane on the lower bite block is strength to avoid breakage.
angled from the mesial surface of the second premolar or The upper inclined plane is angled from the mesial
deciduous molar. The lower block should extend distally surface of the upper second premolar to the mesial
to the buccal cusp of the lower second premolar or surface of the upper first molar. The flat occlusal portion
deciduous molar, stopping short of the distal marginal then passes distally over the remaining upper posterior
ridge. This allows the leading edge of the inclined plane teeth in a wedge shape, reducing in thickness as it extends
on the upper appliance to be positioned mesial to the distally.
lower first molar so as not to obstruct eruption. The Since the upper arch is wider than the lower, it is
position of the inclined plane is especially important only necessary to cover the lingual cusps of the upper
in correction of deep overbite where the upper block is posterior teeth, rather than the full occlusal surface. This
trimmed to allow eruption of lower molars. If the inclined has the advantage of making the clasps more flexible and
plane extends too far distally, subsequent trimming of allows access to the interdental wires of the clasps for
the upper block weakens the upper inclined plane and adjustment.
leads to breakage. In constructing the blocks a decision must be made
Buccolingually the lower block covers the occlusal concerning the angulation of the blocks in relation to the
surfaces of the lower premolars or deciduous molars to line of the arch. There are two alternatives, both of which
occlude with the inclined plane on the upper Twin Block. are effective in practice.
The flat occlusal bite block passes forward over the first First, the blocks may be aligned in each quadrant at
premolar to become thinner buccolingually in the lower right angles to the line of the arch in the same pattern
canine region. The full thickness of the blocks need as the teeth are aligned. Alternatively, the lower blocks
not be maintained in the canine region. Reducing the may be aligned at right angles to the midline bisecting the
bulk in this area is important, as speech is improved arch. The upper blocks would be constructed to match
by allowing the tongue freedom of movement in the this angulation. This second method has the advantage
phonetic area. that the blocks maintain the same angulation relative to
As this can be the most vulnerable part of the each other even if the midline screws are turned to widen
appliance, the lingual flange of the lower appliance in the archform.
92  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
Appliance design has been progressively simplified designed primarily for anteroposterior arch development
over the years and additional designs have been developed by positioning two screws which are aligned anteroposte-
to treat different types of malocclusion. riorly in the palate. Some oblique movement is also pos-
sible by offsetting the angulation of the screws to achieve
The Position of the Inclined Plane an additional component of buccal expansion. Normally,
Angle stressed the importance of the first permanent the palatal screws are angled to drive the upper posterior
molars and described the development of the key ridge segments distally along the line of the arch.
in the first molar region in response to functional forces The anteroposterior positioning of the screws and the
applied to the molars. The permanent molars are designed location of the cuts determines whether the appliance acts
to resist the forces of occlusion and the muscles of mainly to move upper anterior teeth labially or to distalize
mastication apply the optimum forces in this region. It is upper posterior teeth. The position of the anterior cut
logical that the inclined plane should be placed mesial to determines how many teeth are included in the anterior
the upper first molars in order to optimize the functional segment. If only the central incisors are retroclined, a cut
forces to achieve the best response to treatment. distal to the central incisors will move only these teeth
The author tested the response to moving the inclined labially or, alternatively, the lateral incisors may also be
plane mesially to the first premolar region 30 years ago, advanced by placing the cut distal to the lateral incisors.
during the early stages of development of the technique. The incisor teeth are then pitted against the posterior
This change appeared to reduce both the efficiency of teeth to advance the labial segment (Fig. 7.11).
the appliance and the response to mandibular advance- In cases with asymmetrical arch development, if
ment. Mesial movement of the inclined plane is there- more distal movement is required unilaterally the screw
fore not recommended, as reduction in the functional on one side may be activated more than the other. If the
forces applied results in a corresponding reduction in the cut is positioned distal to the canines or premolars the
response to treatment. distalization of posterior teeth increases in proportion to
Mahoney and Witzig (1999) proposed moving the the number of teeth included as anchorage in the anterior
inclined plane forward to coincide with the distal of the segment.
lower canine in order to free the posterior teeth to erupt.
In addition to reducing efficiency, this approach removes
posterior occlusal support, and may result in overloading
of the condyle and lack of occlusal support can damage
the articular disk.
The same article suggests that there is less need for
a support phase, but in the author’s experience, it is
important to realize that insufficient support and retention
following functional correction can lead to relapse. While
recognizing that any improvements in the design of Twin
Blocks are to be encouraged, these proposals are more
likely to reduce the efficiency of the technique, and lack
of support and retention may produce unstable results.

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 Fig. 7.11: Twin Block sagittal appliance.
Appliance Design and Construction  93

In placing the screws in the palate it is important that may be used in both arches to advance retroclined upper
they are set in the horizontal plane, and not inclined and lower incisors and to open the bite in treatment of
downward anteriorly, which would cause the appliance bimaxillary retrusion (Fig. 7.14).
to ride down the anterior teeth, reducing its effectiveness.
The lower Twin Block sagittal appliance applies similar
principles in the lower arch. To advance the lower labial
segment, curved screws are placed in the lower canine
region, or to open premolar spaces, straight screws are
placed in the second premolar region.

Transverse and Sagittal Development


Many 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 (Fig. 7.12). The three-
screw sagittal appliance achieves this objective with
an additional midline screw, which can be positioned
anteriorly or posteriorly in the palate to achieve a similar
objective (Figs. 7.13A and B). Alternatively, a midline
screw may be combined with lingual wires to advance and
align upper and lower incisors. This design of appliance Fig. 7.12: Three-way screw for upper arch development.

A B
Figs. 7.13A and B: (A) Three-screw upper sagittal appliance, with posterior midline screw; (B) Three-screw upper sagittal appliance, with
anterior midline screw.
94  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Fig. 7.14: Twin Blocks to open the bite and advance anterior teeth; Fig. 7.15: Modified anterior inclined plane with palate-free area to
springs advance upper and lower incisors. control tongue thrust.

Twin Blocks to Close Anterior Open Bite


Twin Blocks are designed to close an anterior open bite
by applying an intrusive force to the posterior teeth.
Occlusal contact of the bite blocks on all the posterior
teeth is essential to prevent eruption, which would
open the bite. Similar principles apply in designing both
upper and lower appliances to achieve these objectives
(Fig. 7.15).
The upper appliance must extend distally to cover
all the upper posterior teeth including second molars
to prevent overeruption. Occlusal rests should extend
distally to control second molars if they are about to erupt.
Prevention is better than cure, as failure to control second
molars will increase the open bite and cause treatment
to fail.
The design of the lower appliance is modified for
anterior open bite to prevent eruption of posterior teeth
by placing clasps on lower molars and first premolars or Fig. 7.16: Vertical extraoral traction force to intrude upper posterior
deciduous molars to give good stability to the appliance. teeth. The appliance is relieved lingual to upper and lower incisors
There is no need to add additional clasps in the lower to allow them to erupt.
labial segment. The appliances should be designed to
allow the upper and lower incisors to erupt in order to relieve contact with the incisors. This method has the
reduce the anterior open bite. The acrylic base plate advantage that the lingual flange serves to shield the
may be extended over the cingulum of the upper and incisors from the tongue, thus allowing the incisors to
lower incisors before trimming the acrylic slightly to erupt to reduce the anterior open bite (Fig. 7.16). A labial
Appliance Design and Construction  95

bow may be added to upright proclined upper incisors


and help reduce the anterior open bite. Tongue thrust
may be controlled by the addition of a spinner or tongue
guard. In some cases, both may be indicated (Fig. 7.17).
Provision can be made in the support appliance to control
tongue thrust by using a modified anterior inclined
plane with a palate-free target area for the tongue thrust
(see Fig. 7.15).

Designer Twin Blocks


Attention to detail is important in designing Twin Block
appliances and the design should be selected to suit the
individual patient. Young patients like to be involved
in choosing the color and design of their appliances.
Orthodontic laboratories have the skill and expertise to
individualize appliances to meet many different styles.
Figures 7.18A to C illustrates examples of “Designer
Fig. 7.17: Spinner to control Tongue thrust with clasps on lower molars
and occlusal rests on second molars to control eruption. Molar clasps Twin Blocks”. The range is unlimited, depending on the
with EOT tubes for addition of high pull extra-oral traction if required. imagination of the designer.

A B

Figs. 7.18A to C: Designer Twin Blocks: (A) The flamingo and


the water melon. The upper appliance gives 3-way expansion;
(B) The Hole in One Twin Block and the Zebra. An alternative
design for 3-way expansion in the upper arch; (C) The dinner-suit
appliance for stage 2. These appliances were made by Ortholab,
Melbourne, Australia.
Source: Reproduced with permission from Graham Manley. They
are representative of the high standard of work observed in
C specialist orthodontic laboratories.
96  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

TREATMENT OF CLASS III MALOCCLUSION incisors, and the reciprocal force on the inclined planes
uses anchorage in the lower arch to drive the upper arch
Reverse Twin Blocks labially. Apart from the reverse position of the blocks
The position of the bite blocks is reversed compared and inclined planes, the design of the upper appliance
with that of Twin Blocks for the treatment of Class II is similar in principle to the sagittal design used in the
malocclusion. The occlusal blocks on the upper appliance treatment of Class II division 2 malocclusion and the same
are positioned over the deciduous molars to occlude principles apply in relation to positioning the screws.
distally with blocks placed over the lower first perma­nent A contracted maxilla frequently requires three-way
molars (Figs. 7.19A and B). expansion. This is achieved by a three-screw sagittal
The addition of two sagittal screws in the palate design or the three-way screw to combine transverse and
provides a means of activation to advance the upper sagittal arch development (Figs. 7.20A and B).

A B
Figs. 7.19A and B: (A) Side view of reverse Twin Blocks; (B) Occlusal view of reverse Twin Blocks.
Appliance Design and Construction  97

A B
Figs. 7.20A and B: (A) Reverse Twin Blocks with occlusal screw for progressive activation; (B) The screw has a range of 6 mm activation.
(Developed by Dr Geserick—Available from Forestadent).

A B
Figs. 7.21A and B: Screw advancement mechanism (Carmichael, Banks, & Chadwick, 1999).

SCREW ADVANCEMENT MECHANISM • Stepwise advancement may be used to facilitate


FOR PROGRESSIVE ACTIVATION OF reactivation in the treatment of large overjets
• Unilateral activation may be used to correct asymme­
TWIN BLOCKS
trical mandibular development
A recent modification has been described (Carmichael, • Patients with vertical growth patterns tend to have
Banks, & Chadwick, 1999) to enable controlled pro­ weak musculature and are not able to tolerate large
gressive advancement of the Twin Block. The activating mandibular advancements. In such cases gradual
mechanism uses a conical screw installed in a housing mandibular advancement may be more effective
incorporated in the upper block. A laboratory kit includes • Smaller adjustments are possible to improve patient
components for installation and alignment and is tolerance
supported by a chairside kit with cylindrical co-polymer • More gradual advancement may be more physiological,
spacers of different sizes for progressive advancement at cellular level, and may produce an improved
(Figs. 7.21A and B). In treatment of deep overbite the mandibular response
placement of an occlusal screw does not permit trimming • An occlusal screw from Forestadent has a 6 mm
of the upper block to allow eruption of lower molars. This range of action for progressive activation of Reverse
is a disadvantage. The followings are indications for use: Twin Blocks (Figs. 7.20A and B).
98  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

THE BITE GUIDE Guide, therefore it is necessary for the overjet to be fully
corrected before the Bite Guide is fitted (Figs. 7.22A to F).
Technological developments are playing an increasing The Bite Guide provides an elegant solution to this
role in the evolution of orthodontic and orthopedic tech­ phase of treatment, also when Twin Blocks are to be
niques. The recent development of a lingual attachment, followed by a second phase of fixed appliances. By bonding
the Bite Guide is a significant factor, not only related to bite guides on the lingual of the central incisors, it is no
Twin Block Technique, but also relevant in many clinical longer necessary to fit a removable appliance to support
situations where vertical control of increased overbite is the corrected overjet and overbite until the posterior teeth
an important aspect of treatment. have erupted into occlusion. Correction of the Class II
The specific application in Twin Block treatment relationship may be reinforced by the attachment of
relates to the support phase, when vertical control is Class II inter-maxillary elastics to encourage the lower
necessary during the transition to the support phase in incisors to engage correctly on the Bite Guide until the
order to maintain the corrected overjet and overbite. The posterior teeth have erupted fully, and the posterior
bite guide acts as a fixed retainer to maintain the corrected occlusion has settled into a Class I relationship. It is
vertical dimension after the molars have erupted into possible to invert the lingual attachment to form a Bite
occlusion, and during the transitional period when the Ramp, as a horizontal platform to engage the lower
premolars and canines (or the deciduous teeth in mixed incisors. While this is an effective method of controlling
dentition) are erupting to establish the buccal segment deep overbite by encouraging eruption of the posterior
occlusion. The inclined plane provided by the Bite Guide teeth in treatment of Class I occlusion, the inclined plane
is specifically designed to engage the lower incisors when provided by the Bite Guide is better suited to act as a
the overjet is up to 3 mm. If the overjet is more than 3 mm fixed support mechanism after Twin Block treatment after
the lower incisors would then bite lingual to the Bite correction of a Class II malocclusion.

A B C D

Figs. 7.22A to F: Bite Guide and Bite Ramp appliances.


E F Courtesy: Ortho Organizers.
Appliance Design and Construction  99

TWIN BLOCK TOOL in patients with deep overbite and a brachyfacial growth
pattern. These patients normally can posture forward
A new Twin Block tool is available to facilitate construction comfortably and have good potential for forward man-
of the inclined planes to 45° or 70° angles (Figs. 7.23A to D). dibular growth. A 45° angle is more appropriate to guide
This was designed by Roger Harman and is available the mandible forward for patients with a vertical growth
from: www.realkfo.com. A steeper angle of 70° to the pattern, as these patients may have difficulty in main-
occlusal plane may be used when the patient can pos- taining a forward posture. This is a sign that the activa-
ture the mandible forward freely. It is common to correct tion should be reduced and stepwise activation with an
an overjet of up to 10 mm with a single large activation occlusal screw may be more comfortable.

A B

C D
Figs. 7.23A to D: The Twin Block tool.
100  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

B D
Figs. 7.24A to D: Invisible Esssix Twin Blocks with preformed occlusal blocks are excellent in treatment of sleep apnea. (Available from
orthog@prodigy.net.mx).

INVISIBLE TWIN BLOCKS REFERENCES


Invisible Twin Blocks use preformed occlusal blocks Adams CP, (1970). The design and construction of removable
over the posterior teeth on the models enclosed in orthodontic Appliances, 4th edition, John Wright & Sons Ltd,
Bristol.
pressure molded trays to fit over the teeth. This design
Carmichael GJ, Banks PA, Chadwick SM, (1999). A modi­fication
may be used to construct simple appliances in mixed to enable controlled progressive advancement of the Twin
dentition, to be worn full time or part time as a functional Block appliance, British Journal of Orthodontics.26:9-14.
mechanism to advance the mandible (Figs. 7.24A to D). Crozat GB, (1920). Possibilities and use of removable labiolingual
This concept may be used in permanent dentition and spring appliances, International Journal of Oral Surgery.6:1-7.
adapted for adult therapy. This design is excellent for Jackson VH, (1887). Some methods of regulating, Dental Cosmos.
treatment of sleep apnea and may be worn comfortably 29:373-87.
Mahoney DR, Witzig J, (1999). A modification of the Twin
during the day or to prevent accidents when driving.
Block technique for patients with a deep bite, The Functional
These concepts could also be combined with Invi­salign Orthodontics. 16(2):4-10.
to achieve simulta­neous correction of arch relationships Schwarz AM, Gratzinger M, (1966). Removable orthodontic
and alignment of anterior teeth. appliances, WB Saunders, Philadelphia.
Treatment of Class II Division 1 Malocclusion Deep Overbite  101

Chapter 8
Treatment of Class II Division 1
Malocclusion Deep Overbite

CLINICAL MANAGEMENT OF The Exactobite or Projet Bite Gauge is designed to


TWIN BLOCKS record a protrusive bite for construction of Twin Blocks.
The blue bite gauge registers 2 mm vertical clearance
After a century of development of functional techniques between the incisal edges of the upper and lower incisors,
it is surprising that the forces of occlusion have not been which is an appropriate interincisal clearance for bite
used to any significant extent as a functional mechanism registration in most Class II division 1 malocclusions with
to correct malocclusion. Twin Blocks adapt the functional increased overbite.
mechanism of the natural dentition, the occlusal inclined The incisal portion of the bite gauge has three incisal
plane, to harness the forces of occlusion to correct the grooves on one side that are designed to be positioned on
malocclusion. the incisal edge of the upper incisor and a single groove
The Twin Block is a natural progression in the evolu­ on the opposing side that engages the incisal edge of the
tion of functional appliance therapy. It represents a funda­ lower incisor. The appropriate groove in the bite gauge for
mental transition from a one-piece appliance that restricts bite registration is selected depending on the ease with
normal function to twin appliances that promote normal which the patient can posture the mandible forward.
function. In Class II division 1 malocclusion a protrusive bite is
Twin Blocks are designed on aesthetic principles to registered to reduce the overjet and the distal occlusion
free the patient of the restrictions imposed by a one-piece on average by 5–10 mm on initial activation, depending
appliance made to fit the teeth in both jaws. With Twin on the freedom of movement in protrusive function.
Blocks the patient can function quite normally. Eating and The length of the patient’s protrusive path is determined
speaking can be accomplished without overly restricting by recording the overjet in centric occlusion and fully
normal movements of the tongue, lips and mandible. protrusive occlusion. The activation should not exceed
70% of the protrusive path.
This means that the patient eats with the appliances in
In the growing child with an overjet of up to 10 mm,
the mouth and the forces of mastication are harnessed
provided the patient can posture forward comfortably,
to maximize the functional response to treatment.
the bite may be activated edge-to-edge on the incisors
with a 2 mm interincisal clearance. This allows an overjet
Bite Registration of up to 10 mm to be corrected on the first activation,
The procedure of bite registration for construction of without further activation of the Twin Blocks. Larger
Twin Blocks for a Class II division 1 malocclusion with overjets invariably require partial correction, followed by
deep overbite is described in greater detail. reactivation after the initial correction is complete.
102  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
It is best first to rehearse the procedure of bite regis­ home” into the bite gauge to register the correct vertical
tration, with the patient using a mirror. The patient is opening for the occlusion.
instructed to close correctly into the bite gauge before In the vertical dimension a 2 mm interincisal clearance
applying the wax or bite registration paste. When the is equivalent to an approximately 5 or 6 mm clearance
patient understands what is required, softened wax is in the first premolar region. This usually leaves 3 mm
applied to the bite gauge from a hot water bath. The cli­ clearance distally in the molar region, and ensures that
nician then places the bite gauge in the patient’s mouth to space is available for vertical development of posterior
register the bite. After removing the registration bite from teeth to reduce the overbite.
the mouth, the wax is chilled in cold water and should It is very important to open the bite slightly beyond the
now be firm and dimensionally stable. clearance of the freeway space to encourage the patient to
In registering the bite the wax is kept clear of the close into the appliance rather than allow the mandible to
incisors, so that the operator has an unobstructed view drop out of contact into rest position (Fig. 8.2).
of the anterior teeth. This helps the laboratory to position
the models correctly in the squash bite (Figs. 8.1A to C). Instructions on Fitting Twin Blocks
Silicone putty may be used as an alternative to wax to At first the appliance will feel large in the mouth, but
register the bite, but the elasticity of the material can within a few days it will be very comfortable and easy to
make it more difficult to locate the models correctly in wear. Twin Blocks cause much less interference to speech
the construction bite. than a one-piece functional appliance. For the first few
Center lines should be coincident provided no den­ days speech will be affected, but will steadily improve
tal asymmetry is present. To reduce the overjet when the and should return to normal within a week. When the
lower incisors close into the incisal guidance groove on patient has learned to insert and remove the appliance,
the underside of the bite gauge, the bite gauge is posi­ instruction is given on operating the expansion screw,
tioned with the upper incisors occluding in the appro­ one quarter turn per week. The screw should be turned
priate groove. It is essential that the patient bites “fully for the first time after a few days, when the appliances

A B

Figs. 8.1A to C: Projet Bite Gauge construction bite for deep overbite
C with the project.
Treatment of Class II Division 1 Malocclusion Deep Overbite  103

have settled in comfortably. As with any new appliance It is necessary to check the initial activation and con­
it is normal to expect a little initial discomfort. But it firm that the patient closes consistently on the inclined
is important to encourage the patient to persevere and planes with the mandible protruded in its new position.
keep the appliance in the mouth at all times except for The overjet is measured with the mandible fully retruded
hygiene purposes. The patient may be advised to remove and this measurement should be recorded in the patient’s
the appliance for eating for the first few days. Then it notes and checked at every visit to monitor progress.
is important to learn to eat with the appliance in the
mouth. The force of biting on the appliance corrects the FULL-TIME APPLIANCE WEAR
jaw position, and learning to eat with the appliance in is Temporary Fixation of Twin Blocks
important to accelerate treatment. In a few days, patients
The most crucial time to establish good cooperation
should be eating with the Twin Blocks and, within a week,
with the patient is in the first few days after fitting the
should be more comfortable with the appliance in the
Twin Blocks, when he or she is learning to adjust to the
mouth than they are without it.
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, 24 hours per day and excellent cooperation
is established at the start of treatment.
The technique for fixing the appliances in place is
simple. The teeth should first be fissure sealed and treated
with topical fluoride as a preventive measure prior to
fixation. There are two alternative methods of fixation of
Twin Blocks:
1. The appliances may be fixed to the teeth by spreading
cement on the tooth-bearing areas of the appliance
but not on the gingival areas. The appliance is then
inserted and secured in place with cement adhering
to the teeth. 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 (Fig. 8.3).
2. Twin Blocks may also be bonded directly to the teeth
by applying composite around the clasps. This is a use­
ful approach in mixed dentition when ball clasps may
be bonded directly to deciduous molars to improve
fixation.

Fig. 8.2: In this diagram the inclined plane is placed too far distally Fig. 8.3: Twin Blocks cemented in position.
and may break off after trimming the upper block.
104  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
After 10–14 days, when the patient has adapted to the
Twin Block and is wearing it comfortably, the appliance
can be removed by freeing the clasps with a sickle scaler.
Sharp edges of composite can be smoothed over, leaving
some composite attached to the teeth. The altered con­
tour of the deciduous teeth will improve the retention
of the appliance. If cooperation is doubtful at any stage
of treatment, the operator should not hesitate to fix the
appliance in for 10 days to regain control and restore
full-time wear. After 10 days full-time wear the patient is
more comfortable with the appliance in the mouth than
without it.

MANAGEMENT OF DEEP OVERBITE


Overbite reduction is achieved by trimming the occlusal
blocks on the upper appliance, so as to encourage erup­
tion of the lower molars. A progressive sequence of trim­
ming aims to encourage selective eruption of posterior
teeth to increase the vertical dimension. The objective is
to increase lower facial height and improve facial balance
by controlling the vertical dimension (Fig. 8.4). Provided
the correct sequence of trimming is carried out to con­
trol eruption, closure of a posterior open bite is acceler­
ated in Twin Block treatment compared with a one-piece
functional appliance, which is removed for eating, and
allows the tongue to spread between the teeth and pre­
vent eruption of the posterior teeth. Posterior support
is established as the molars erupt into occlusion before
relieving the appliance over the premolars until they also
are free to erupt into occlusion.
Fig. 8.4: Sequence of trimming blocks to reduce overbite. The
The management of deep overbite begins even before
inclined plane is mesial to the lower first molar and it remains intact.
the appliance is fitted–by placing elastic separators in the This reduces the risk of breakage after trimming the upper block.
molar region. When the appliance is fitted, the separators
are removed and the appliance is adjusted to encourage
the molars to erupt. occlusion is cleared by sequentially trimming the upper
In the treatment of deep overbite, it is important to block occlusodistally to allow further eruption of the
encourage vertical development of the lower molars from lower molars, again checking that the clearance is correct.
the start of treatment, by trimming the upper bite block This sequence of adjustment does not allow the
occlusodistally to allow the lower molars to erupt. tongue to spread laterally between the teeth to prevent
The upper bite block is progressively trimmed at each eruption of lower molars, and results in a more rapid
visit over several months, leaving only a small vertical development of the vertical dimension. The molars will
clearance of 1 or 2 mm over the lower molars to allow erupt into occlusion normally within 6–9 months.
them to erupt into occlusion. The clearance between the It is important that the mandible continues to be sup­
upper appliance and the lower molars is checked by ported in a protruded position throughout the sequence
inserting a probe (or explorer) between the posterior of trimming the blocks. The leading edge of the inclined
teeth to establish that the lower molars are free to erupt. plane on the upper bite block remains intact, leaving a
At each subsequent visit for appliance adjustment the triangular wedge in contact with the lower bite block.
Treatment of Class II Division 1 Malocclusion Deep Overbite  105

When the molars have erupted into occlusion, a lateral from the “comfort zone” are at greater risk of developing
open bite is present in the premolar region because the TMJ dysfunction. This applies both to patients with a
lower bite block is still intact. The final adjustment at the deep overbite, whose intergingival height is significantly
end of the Twin Block stage aims to reduce the lateral reduced, and to patients with an anterior open bite who
open bite by trimming the upper occlusal surface of the have an increased intergingival height.
lower bite block over the premolars by 2 mm. To maintain The intergingival height is a useful guideline to check
adequate inclined planes to support the corrected arch progress and to establish the correct vertical dimension
relationships, the lower bite block is shaped into a trian­ during treatment. Measurement of intergingival height
gular wedge distally in contact with the upper block. is made by using a millimeter ruler or dividers with a
Relieved of occlusal contact, the lower premolars vernier scale to measure the distance between the upper
erupt, carrying the lower appliance up into occlusion. The and lower gingival margins. To keep track of progress in
occlusal height of the upper premolars is maintained by opening or closing the bite, this measurement should be
interdental clasps that effectively prevent their eruption. noted on the record card at every visit.
The lateral open bite in the premolar region now reduces In Twin Block treatment the correct intergingival
and the occlusal plane begins to level. height is achieved with great consistency. Overcorrection
of deep overbite is advisable as a precaution against any
tendency to relapse.
ESTABLISHING VERTICAL DIMENSION
The intergingival height varies according to the
The Intergingival Height patient’s age and stage of development, and the height
of the incisor crowns. It is smaller in a young patient
A simple guideline is used to establish the correct vertical whose incisors have recently erupted, and larger in an
dimension during the Twin Block phase of treatment. The older patient with gingival recession.
intergingival height is measured from the gingival margin
of the upper incisor to the gingival margin of the lower
SOFT TISSUE RESPONSE
incisor when the teeth are in occlusion (Fig. 8.5).
This measurement has proved to be beneficial for Rapid changes occur in the craniofacial musculature
temporomandibular joint (TMJ) practitioners who use in response to the altered muscle function that results
the intergingival height to establish the vertical dimension from treatment of malocclusion by a full-time functional
in a restorative approach to rebuild the occlusion in appliance. As a result of altered muscle balance, signifi­
treatment of patients with TMJ dysfunction. cant changes in facial appearance are seen within 2 or
The “comfort zone” for intergingival height for adult 3 weeks of starting treatment with Twin Blocks. The rapid
patients is generally found to be 17–19 mm. This is equi­ improvement in muscle balance is very consistent and
valent to the combined heights of the upper and lower is observed on photographs as a more relaxed posture
incisors minus an overbite within the range of normal. within minutes, hours or days of starting treatment.
Patients whose intergingival height varies significantly The Twin Block appliance positions the mandible
downward and forward, 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
Fig. 8.5: Measuring the intergingival height. Blocks, without the need for lip exercises.
106  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: LJ Aged 10 Years 9 Months clearance to encourage eruption, so that the tongue
cannot spread between the teeth and delay vertical
This is an example of treatment of an uncrowded Class II
development. The leading edge of the inclined plane
division 1 malocclusion with good archform, deep over­
of the upper bite block remains intact to provide con­
bite, a full unit distal occlusion and an 11 mm overjet. The
tact with the lower bite block. This contact is the key
Class II skeletal discrepancy is measured by a convexity
mechanism which provides the functional stimulus to
of 7 mm, due to a combination of maxillary protrusion
growth by occlusion with the inclined plane on the
and mandibular retrusion. The maxilla is narrow, typical
lower appliance.
of a distal occlusion and the patient shows only four To avoid gingival irritation in the initial stages of
upper incisors when she smiles. The upper intercanine adaptation to the appliance, the fitting surface of the
distance is reduced due to lack of support from the lower lower appliance is trimmed slightly in the area of the
labial segment. This is a major etiological factor causing sulcus lingual to the lower incisors and canines. After
the mandible to be locked in distal occlusion. Maxillary 3 months of treatment the overjet is reduced from 10 mm
expansion is required together with functional mandibular to 3 mm. The posterior teeth are still out of occlusion at
advancement in order to unlock the malocclusion. this stage. Over the next 3 months the occlusal surface of
The facial type is mild brachyfacial, and there is nor­ the upper bite block is trimmed in a sequential fashion
mally a good prognosis for correction of this type of mal­ at each visit, still maintaining the leading edge of the
occlusion provided the unfavorable occlusal factors are inclined plane intact. This will eventually result in the
eliminated to allow the mandible to develop forward into removal of all the acrylic covering the upper molars.
a normal relationship with the maxilla. Clinical examina­ This allows the lower molars freedom to erupt fully into
tion confirms that the profile improves when the patient occlusion. The biting surface of the lower Twin Block is
postures the mandible downward and forward to a nor­ then trimmed slightly in the premolar region to allow
mal overjet with the lips closed (Figs. 8.6A to L). eruption of the premolars carrying the lower appliance
vertically with them as they erupt. This will then reduce
Bite Registration the lateral open bite in the premolar region. The open
A construction bite registers an edge-to-edge occlusion bite quickly resolves and after 6 weeks an upper support
with 2 mm interincisal clearance. This results in a vertical appliance is fitted with an anterior inclined plane and the
clearance in the first premolar region of 6 mm. lower Twin Block is left out. The occlusion settles without
further adjustment. Full-time appliance wear continues
Adjustment for 4 months, followed by 4 months of night-time wear
• When the appliance is fitted at the insertion appoint­ to retain the corrected occlusion.
ment, the patient is instructed to turn the midline
screw one quarter turn per week, expanding the upper Duration of Treatment
arch to assist in unlocking the mandible from distal Active phase: 7 months with Twin Blocks
occlusion. Support phase: 4 months full time with an anterior
• Correction of deep overbite is initiated at the start inclined plane
of treatment by trimming the upper bite block clear Retention: 4 months anterior inclined plane at night only
of the lower molars, thereby stimulating molar erup­ Total treatment time: 15 months, including retention
tion. It is important to leave only 1 or 2 mm occlusal Final records: 5 years out of retention.
Treatment of Class II Division 1 Malocclusion Deep Overbite  107

Case Report: LJ

B C D

E F G

H I

J K L
Figs. 8.6A to L: Treatment: (A) Profiles at ages 10 years 9 months (before treatment), 11 years 3 months (after treatment) and 16 years
11 months; (B to D) Occlusion before treatment: a narrow upper arch with a 10 mm overjet and lower incisors biting into the palate;
(E) After 6 months the overjet is corrected and a posterior open bite is present in the early stages of treatment. The upper block is trimmed
to encourage lower molar eruption; (F) After the lower molars have erupted into occlusion, the lower occlusal block is trimmed to allow
the lateral open bite in the premolar region to reduce. The lower occlusal plane now begins to level, while the upper premolar height
is maintained by the upper appliance. After 9 months of treatment the patient is ready to proceed to the support stage; (G) An anterior
inclined plane is fitted to support the corrected incisor relationship. The lower appliance is left out and the lower premolars and canines
are free to erupt into occlusion; (H) Appearance before treatment at age 10 years 9 months; (I) Appearance after treatment; (J to L) The
occlusion 5 years out of retention.
108  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: LJ

LJ Age 10.9 11.2 16.11


Cranial Base Angle 27 26 25
Facial Axis Angle 27 26 30
F/M Plane Angle 26 26 23
Craniomandibular Angle 53 52 48
Maxillary Plane 0 0 2
Convexity 7 6 4
U/Incisor to Vertical 41 19 29
L/Incisor to Vertical 37 36 36
Interincisal Angle 102 125 115
6 to Pterygoid Vertical 16 19 26
L/Incisor to A/Po 2 3 4
L/Lip to Aesthetic Plane −3 −1 −4
Treatment of Class II Division 1 Malocclusion Deep Overbite  109

FUNCTIONAL ORTHOPEDIC THERAPY Conventional fixed appliances with brackets can­not


produce equivalent physiological changes in the treat­
Case Report: PK Aged 11 Years 4 Months ment of patients with severe malocclusions. A func­
tional approach achieves a rapid improvement in the
This young girl presents a disfiguring Class II division 1
facial appearance and can be followed by a simplified
malocclusion with an overjet of 17 mm and an exces­
orthodontic phase of treatment to detail the occlusion
sive overbite. A combination of maxillary protrusion and
(Figs. 8.7A to P).
mandibular retrusion has resulted in a severe distal occlu­
sion, and an equally severe transverse discrepancy with
buccal occlusion of the upper premolars and a traumatic
Treatment Plan
occlusion of the lower incisors in the palate. The maloc­ To retract the maxilla and advance the mandible. The
clusion is further complicated by the congenital absence dental asymmetry would be difficult to eliminate in view
of the second lower premolar on the left side, resulting of the absence of 5. An orthodontic phase of treatment
in displacement of the lower center line to the left. The was planned to complete the treatment.
dramatic facial and dental changes in this case illustrate
the benefits of a functional orthopedic approach to treat­ Appliances
ment compared to a conventional orthodontic approach. • Standard Twin Blocks
Before treatment this patient has the typical listless • Support phase with an anterior inclined plane
appearance of many severe Class II division 1 malocc­ • Fixed appliances to complete the treatment.
lusions. This has been described as “adenoidal facies”
and is evident in the dull appearance of the eyes and Adjustment
poor skin tone. A large overjet with a distal occlusion is
frequently associated with a backward tongue position, The registration bite reduced the overjet from 17 mm to
and a restricted airway. These patients cannot breathe 8 mm on the initial activation. This correction was achieved
properly and, as a result, are subject to allergies, and in 8 weeks, when the inclined planes were reactivated to
upper respiratory problems due to inefficient respiratory an edge-to-edge incisor occlusion by adding cold cure
function. acrylic to the mesial of the upper inclined plane. The
After only 3 months of treatment the patient undergoes normal adjustments were made to reduce the overbite by
a dramatic change in facial appearance, which exceeds trimming the occlusal surface of the upper bite blocks
the parameters of orthodontic treatment in this time scale. to allow eruption of the lower molars. Twin Blocks were
The patient appears more alert and there is a marked effective in quickly reducing the overjet from 17 mm
improvement in the eyes and the complexion. This is a to 2 mm in 6 months. After 7 months of treatment the
fundamental physiological change, extending beyond the lower appliance was left out and an anterior inclined
limited objective of correcting a malocclusion. The upper plane was fitted to retain the position as the remaining
pharyngeal space increased from 5 mm before treatment posterior open bite resolved and the buccal teeth settled
to 20 mm after treatment. Increasing the airway achieves into occlusion. The space was closed with a simple fixed
the crucially important benefit of improving respiratory appliance, and the slight displacement of the center line
function and may influence basal metabolism as a was accepted. This was followed by an orthodontic phase
secondary effect. Increase in the pharyngeal airway is to complete treatment.
a consistent feature of mandibular advancement with a
full-time functional appliance. This is the most significant
Duration of Treatment
functional benefit of advancing the mandible, as opposed Active phase: Twin Blocks for 7 months
to retracting the maxilla in the treatment of Class II Support phase: 6 months full-time wear
malocclusion. Orthodontic phase: 12 months.
110  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: PK

B C D

E F G

H I J
Figs. 8.7A to J: Treatment: (A) Profiles at ages 11 years 4 months (before treatment), 11 years 7 months (3 months after treatment),
12 years 3 months and 18 years 4 months; (B to D) Occlusion before treatment: overjet=17 mm; (E to G) Occlusal change after 11 months:
(H) Facial appearance before treatment at age 11 years 4 months; (I) Facial change after 3 months of treatment, showing marked
physiological improvement; (J) Facial change after 11 months of treatment.
Treatment of Class II Division 1 Malocclusion Deep Overbite  111

K L M

N O P
Figs. 8.7K to P: Treatment: (K and M) Facial appearance at 18 years 4 months; (L) Upper occlusal view after treatment; (N and P)
Occlusion at age 18 years 7 months; (O) Lower occlusal view after treatment, note congenital absence of 5; (N and P) Occlusion at age
18 years 7 months.
112  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: PK

PK Age 11.4 11.8 13.4


Cranial Base Angle 28 28 27
Facial Axis Angle 27 29 28
F/M Plane Angle 24 24 24
Craniomandibular Angle 52 52 51
Maxillary Plane 1 2 0
Convexity 9 5 4
U/Incisor to Vertical 35 27 19
L/Incisor to Vertical 33 24 25
Interincisal Angle 112 129 136
6 to Pterygoid Vertical 21 20 18
L/Incisor to A/Po −4 0 2
L/Lip to Aesthetic Plane −10 −2 −8
Treatment of Class II Division 1 Malocclusion Deep Overbite  113

REACTIVATION OF TWIN BLOCKS It is important that no acrylic is added to the distal


incline of the lower Twin Block, especially in the treat­
As indicated previously, an overjet of up to 10 mm in
ment of deep overbite. Extending occlusal acrylic of the
a patient who is growing well and has free protrusive
lower block distally would prevent eruption of the lower
movement may be corrected without reactivation of the
first molar. It is necessary to leave the lower first molars
Twin Blocks during treatment. If growth is less favorable,
free to erupt so that the overbite is reduced by increasing
or in treatment of larger overjets, or when the protru­
the vertical dimension.
sive path of the mandible is restricted, it is necessary
If the patient’s rate of growth is slow or the direction
to reactivate the inclined planes more gradually in pro­
of growth is vertical rather than horizontal, it is advisable
gressive increments during treatment.
to advance the mandible more gradually over a longer
Reactivation is a simple procedure that is achieved by
period of time to allow compensatory mandibular growth
extending the anterior incline of the upper Twin Block
to occur. This can be taken into account by reactivating
mesially to increase the forward posture. Cold cure acrylic
Twin Blocks progressively to extend the inclined plane of
may be added at the chairside, inserting the appliance to
the upper bite block mesially (Petrovic & Stutzmann, 1977).
record a new protrusive bite before the acrylic is fully set.
After extending the upper block forward the contact
Even in cases with an excessive overjet, a single reacti­
of the upper block on the lower molar should be checked
vation of Twin Blocks is normally sufficient to correct
to make any necessary adjustment to clear the occlusion
most malocclusions (Fig. 8.8).
with the lower molar for correction of deep overbite.

PROGRESSIVE ACTIVATION OF
TWIN BLOCKS
Progressive activation of the inclined planes is indicated
as follows:
• If the overjet is more than 10 mm it is advisable to
step the mandible forward, usually in two stages.
The first activation is in the range of 7–10 mm. The
second activation brings the incisors to an edge-to-
edge occlusion.
• In any case where full correction of arch relationships
is not achieved after the initial activation, an additional
activation is necessary.
• If the direction of growth is vertical rather than hori­
zontal, the mandible may be advanced more gradually
Fig. 8.8: Addition of acrylic to the anterior incline of the upper
inclined plane to reactivate Twin Blocks. It is incorrect to reactivate to allow adequate time for compensatory mandibular
by addition to the lower Twin Block. growth to occur (Figs. 8.9A and B).

A B
Figs. 8.9A and B: Screw advancement mechanism for progressive activation of Twin Blocks in treatment of vertical growth and anterior
open bite is described in Chapters 7 and 12.
114  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
• Phased activation is recommended in adult treatment, to reduce the activation by trimming the inclined planes,
where the muscles and ligaments are less respon­ to reduce the forward mandibular displacement until the
sive to a sudden large displacement of the mandible patient closes comfortably on the appliances. The angu­
(Chapter 20 Adult Treatment). lation of the inclined planes may be reduced to 45° if
• In the treatment of TMJ dysfunction, care must be the patient is failing to posture consistently forward to
exercised so as not to introduce activation that is occlude the blocks correctly.
beyond the level of tolerance of injured tissue. It is This may be an early sign that progress will be slower
best to be conservative and advance the mandible than normal, due to weakness in the patient’s musculature
slowly to a position that is comfortable and will allow reducing the functional response. This response is more
the patient to rest and function without discom­ likely in the patient who has a vertical growth pattern.
fort (Chapter 21 Temporomandibular Joint Pain and Mandibular advancement will then be more gradual,
Dysfunction syndrome). usually requiring incremental activation of the occlusal
inclined planes.
SUMMARY—ADJUSTMENT AND
CLINICAL MANAGEMENT Adjustment Visit–After 4 Weeks
At the first monthly visit positive progress should already
Stage 1—Active Phase
be evident with respect to better facial balance. Photo­
Appliance Fitting graphs demonstrate this very clearly, and may be repeated
at this stage to record progress.
It is first necessary to check that the patient bites com­
Progress can be confirmed also by noting the amount
fortably in a protrusive bite with the inclined planes
occluding correctly. To avoid irritation as the appliance of reduction in overjet, as measured intraorally with the
is driven home by the occlusion during the first few days mandible fully retracted. To monitor progress, the overjet
of wear, it is important to relieve the lower appliance should be measured and noted on the record card at each
slightly over the gingivae lingual to the lower incisors. visit. This allows any lapse in progress or cooperation to be
The clasps are adjusted to hold the appliance securely in detected readily. There should be a steady and consistent
position without impinging on the gingival margin. If a reduction of overjet and correction of distal occlusion. If
labial bow is present, it should be out of contact with the cooperation is suspect it is advisable to fix the appliance
upper incisors. in place in the mouth to exert immediate control and
restore full-time appliance wear.
Initial Adjustment–after 10 Days Apart from monitoring progress, only minor adjust­
The patient should now be wearing the appliances com­ ment is required at this stage. Check that the screw is
fortably and eating with them in position. The initial dis­ operating correctly, and adjust the clasps if necessary to
comfort of a new appliance should have resolved and the improve retention. If the appliance includes a labial bow,
patient should be biting consistently in the protrusive bite. adjust it so as to be out of contact with the upper incisors.
Patient motivation is reinforced by offering encourage­ In the treatment of deep overbite ensure that the lower
ment for their success on becoming accustomed to the molars are not in contact with the upper block. The upper
appliance so quickly, and reassurance on any difficulties. block is trimmed occlusodistally to clear the occlusion,
The patient should now be turning the upper midline using a probe (explorer) to confirm that the lower molars
screw one quarter turn per week. In the treatment of deep do not contact the upper block.
overbite the upper bite block should be trimmed clear of
the lower molars leaving a clearance of 1–2 mm to allow
Routine Adjustment–Time Interval 6 Weeks
these to erupt. A similar pattern of adjustment continues with steady
At this stage, it is important to detect if the patient is correction of distal occlusion and reduction of overjet.
failing to posture forward consistently to occlude correctly The upper arch width is checked at each visit, until the
on the inclined planes. This would indicate that the appli­ expansion is sufficient to accommodate the lower arch in
ance has been activated beyond the level of tolerance of its corrected position and no further turns of the screw
the patient’s musculature. It would then be appropriate are required.
Treatment of Class II Division 1 Malocclusion Deep Overbite  115

Trimming of the upper block continues until all the Retention


occlusal cover is removed from the upper molars to allow
Treatment is followed by a normal period of retention.
the lower molars to erupt completely into occlusion.
As the buccal segments settle in fully, full-time wear
The overjet, overbite and distal occlusion should be
of the support appliance allows time for internal bony
fully corrected by the end of the Twin Block phase. A
remodeling to support the corrected occlusion. A good
slight open bite in the buccal segments should be limited
buccal segment occlusion is the cornerstone of stability
to the premolar region. It is now appropriate to proceed
after correction of arch-to-arch relationships. Appliance
to the support phase.
wear is reduced to night-time only when the occlusion
is fully established.
Stage 2—Support Phase If treatment is carried out in the mixed dentition,
Anteroposterior and vertical control remains equally retention may continue with an anterior inclined plane
important in the support phase to maintain the correc­ to support the occlusion during the transition to the
tion achieved in the active phase. permanent dentition. In early treatment of severe skel­
The purpose of the support phase is to maintain the etal discrepancies a night-time functional appliance of
corrected incisor relationship until the buccal segment the monobloc type may be used as a retainer. This gives
occlusion is fully established. To achieve this objective, additional functional support and may be activated to
an upper removable appliance is fitted with an anterior enhance the orthopedic response to treatment during
inclined plane to engage the lower incisors and canines. the transitional dentition. An excellent alternative is the
The lower appliance is left out at this stage and occlusoguide, which is a preformed appliance resembling
removal of the posterior bite blocks allows the posterior a mini-positioner. It is available in a range of sizes and
teeth to erupt into occlusion. The anterior inclined plane is designed to retain the corrected incisor relationship
extends distally to engage all six lower anterior teeth and with a functional component to retain the correction to
the patient must not be able to occlude lingual to the a Class I occlusion. The management of this appliance is
inclined plane. It must be adequate to retain the incisor described in Chapter 9 on mixed dentition treatment.
relationship effectively, but at the same time should be
neat and unobtrusive so as not to interfere with speech. Advantages of Twin Blocks
Many anterior inclined planes are mistakenly made The Twin Block is the most comfortable, the most aesthetic
too large and bulky which causes discomfort for the and the most efficient of all the functional appliances.
patient, who may then be discouraged from wearing Twin Blocks have many advantages compared to other
such an appliance. There is no necessity for the anterior functional appliances:
inclined plane to extend much beyond the level of the • Comfort—patients wear Twin Blocks 24 hours per day
incisal tips of the upper incisors, provided it also extends and can eat comfortably with the appliances in place.
far enough distally to engage the canines. • Aesthetics—Twin Blocks can be designed with no
The patient must understand the importance of wear­ visible anterior wires without losing efficiency in
ing the support appliance full time to prevent relapse at correction of arch relationships.
this critical stage of treatment. An appliance that is com­ • Function—the occlusal inclined plane is the most
fortable and carefully designed is more readily accepted natural of all the functional mechanisms. There is
by the patient. less interference with normal function because the
Vertical control is essential during the support phase mandible can move freely in anterior and lateral
after reduction of overbite. To maintain the corrected ver­ excursion without being restricted by a bulky one-
tical dimension, a flat occlusal stop of acrylic extends for­ piece appliance.
ward from the inclined plane to engage the lower incisors. • Patient compliance—Twin Blocks may be fixed to the
The occlusal stop is an important addition to maintain teeth temporarily or permanently to guarantee patient
the corrected intergingival height as the posterior teeth compliance. Removable Twin Blocks can be fixed in
erupt into occlusion. The upper and lower buccal teeth the mouth for the first week or 10 days of treatment
should normally settle into occlusion within 2–6 months, to ensure that the patient adapts fully to wearing them
depending on the depth of the overbite. 24 hours per day.
116  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
• Facial appearance—from the moment Twin Blocks correction of arch relationships during the orthopedic
are fitted the appearance is noticeably improved. phase. During the support phase an easy transition
The absence of lip, cheek or tongue pads, as used in can be made to fixed appliances.
some other appliances, places no restriction on nor­ • Treatment of temporomandibular joint dysfunction—
mal function, and does not distort the patient’s facial the Twin Block may at times also be used as an effec­
appearance during treatment. Improvements in facial tive splint in the treatment of patients who present
balance are seen progressively in the first 3 months TMJ dysfunction due to displacement of the condyle
of treatment. distal to the articular disc. Full-time wear allows the
• Speech—patients can learn to speak normally with disk to be recaptured, when disk reduction is pos­
Twin Blocks. In comparison with other functional sible in early stage TMJ problems, and at the same
appliances, Twin Blocks do not distort speech by res­ time sagittal, vertical and transverse arch develop­
tricting movement of the tongue, lips or mandible. ment proceeds to eliminate unfavorable occlusal con­
• Clinical management—adjustment and activation tacts (Chapter 21 Temporomandibular Joint Pain and
is simple. The appliances are robust and not prone Dysfunction syndrome).
to breakage. Chairside time is reduced in achieving
major orthopedic correction. ROBIN’S MONOBLOC: THE ORIGINAL
• Arch development—Twin Blocks allow independent
SLEEP APNEA APPLIANCE!
control of upper and lower arch width. Appliance
design is easily modified for transverse and sagittal Pierre Robin (1902) used the monobloc to treat patients
arch development. with severe mandibular retrusion, in the condition
• Mandibular repositioning—full-time appliance wear now defined as the Pierre Robin syndrome. The ortho­
consistently achieves rapid mandibular repositioning dontic aim of correcting Class II malocclusion was only
that remains stable out of retention. addressed later when Andresen developed the activator.
• Vertical control—Twin Blocks achieve excellent con­ Robin’s monobloc was the original sleep apnea appli­
trol of the vertical dimension in treatment of deep ance (Fig. 8.10). We tend to forget that functional therapy
overbite and anterior open bite. Vertical control is developed, not to correct a dental malocclusion, but to
significantly improved by full-time wear. keep patients alive! Improving the airway delivers holis­
• Facial asymmetry—asymmetrical activation corrects tic benefits that profoundly affect a patient’s health and
facial and dental asymmetry in the growing child. function. Accommodating the tongue in a forward posi­
• Safety—Twin Blocks can be worn during sports activi­ tion by expanding the maxilla and advancing the mandi­
ties with the exception of swimming and violent con­ ble is fundamental in improving the pharyngeal airway.
tact sports, when they may be removed for safety. This remains the basic concept of functional therapy.
• Efficiency—Twin Blocks achieve more rapid correc­
tion of malocclusion compared to one-piece func­
tional 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. In combined techniques,
Twin Blocks can be used to maximize the skeletal
correction while fixed appliances are used to detail
the occlusion. Since Twin Blocks do not need to have
anterior wires, brackets can be placed on the anterior
teeth to correct tooth alignment simultaneously with Fig. 8.10: Robin’s monobloc.
Treatment of Class II Division 1 Malocclusion Deep Overbite  117

Twin Blocks Increase the Airway with an excessive overjet and overbite before treatment
are typical of this effect. Before treatment many patients
Recent research supports the view that Twin Blocks with severe Class II division 1 malocclusions have a
increase the airway [Verma et al. (2012) Vinoth et al. (2013) typical listless appearance, evident in the dull appea­rance
and Temani (2013)]. A recent article, “Cephalometric of the eyes and poor skin tone (Figs. 8.11A to F). After
evalu­ation of hyoid bone position and pharyngeal spaces only 3 months treatment patients undergo a dramatic
following treatment with Twin Block appliances” compared change in facial appearance. They appear more alert
three groups of patients; hypodivergent, normodivergent and there is a marked improvement in the eyes and the
and hyperdivergent. This study concluded that the width complexion. A large overjet with a distal occlusion is
of the upper airway significantly increased (p < 0.01) and frequently associated with a backward tongue position,
the ANB angle significantly decreased (p < 0.001) in all and a restricted airway. These patients cannot breathe
three groups with forward movement of the mandible. properly and, as a result, are subject to allergies, and
After treatment with Twin Block appliance, significant upper respiratory problems due to inefficient respiratory
changes occurred in horizontal dimension (anterior function. Functional therapy to expand the maxilla and
displacement) which resulted in significant increase in advance the mandible increases the airway. This is a
width of the upper pharynx in all three groups. This is fundamental physiological change, extending beyond the
an important finding and it merits repetition that patients limited objective of correcting a malocclusion.

A B C

D E F
Before treatment After 3 months After 11 months

Figs. 8.11A to F: Facial and airway changes before and after Twin Blocks.
118  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

A B C

D E F
Figs. 8.12A to F: Invisible Twin Blocks with preformed blocks.

Treatment of Sleep Apnea and REFERENCES


Snoring: Invisible Twin Blocks with Effects of Twin Block on Pharyngeal Airway Space in Class II
Preformed Blocks Division I Cases: A 3D CT study. Oral Research presentation
Annual Session AAO, 2013 by Dr Parul Temani, research
Simple Twin Blocks are prepared by fitting preformed student in Jaipur.
blocks on models and forming clear appliances with Petrovic A, Stutzmann J, (1977). ‘Further investigations into the
functioning of the “comparator” of the servosystem (respective
Essix material in a Biostar molding machine (Figs. 8.12A
positions of the upper and lower dental arches) in the control
to F). The appliances prevent sleep apnea by posturing of the condylar cartilage growth rate and of the lengthening of
the mandible downward and forward. This advances the the jaw’. in The Biology of Occlusal Development, Monograph
tongue and improves the posterior airway. Appliances like No. 6, Craniofacial Growth series, ed Mc Namara JA, Center
this can be worn by long distance drivers. These appliances for Human Growth & Development, University of Michigan,
pp. 225-91.
may be used as retainers after treatment of Class II
Verma et al, (2012). Cephalometric evaluation of hyoid bone
malocclusion, or in suitable cases for Class II correction. position and pharyngeal spaces following treatment with
This design is suitable for any stage of development, Twin Block appliances compared 3 groups of patients,
including mixed or deciduous dentition through to adult hypodivergent, normodivergent and htperdivergent. J Ortho­
therapy. The preformed blocks simplify the construction dont Sci. 1(3):77-82.
Vinoth SK, Thomas AV, Nethravathy R. (2013). Cephalomteric
and the appliances may be made in house by placing changes in airway dimensions with twin block therapy in
the blocks on models before forming appliances with growing Class II patients. J Pharm Bioallied Sci. 5(Suppl 1):
Essix material. S25-9.
Treatment in Mixed Dentition 119

Chapter 9
Treatment in Mixed Dentition

INTRODUCTION APPLIANCE DESIGN


Treatment of skeletal discrepancies should not be delayed Appliance design may be modified to meet the require-
until the permanent dentition has been established. ments of the mixed dentition, when retention may be
Interceptive treatment is frequently indicated in the limited by deciduous teeth that are unfavorably shaped
mixed dentition to restore normal function and correct with respect to adequately accepting retention clasps of
arch relationships by means of functional appliance removable appliances.
therapy. Twin Block appliance design for Class II division 1
Not all orthodontists favor early treatment, and indeed malocclusion in the mixed dentition is similar to appliance
some are actively opposed to the concept. As a result design for the permanent dentition. Delta clasps may be
treatment may be delayed until the permanent canines fitted on lower first or second deciduous, molars, if they
and premolars have erupted. The straightwire pread- are suitably shaped for retention.
justed appliance is the most popular fixed appliance sys- Alternatively, C-clasps may be used for retention
tem of the present day. It is designed for treatment in on deciduous molars. The C-clasp is well suited to this
the permanent dentition and lends itself to a highly orga- stage of development of the dentition and there are
several ways to improve retention even if the teeth are
nized practice environment. While this is undoubtedly an
unfavorably shaped (Figs. 9.1A and B).
excellent finishing appliance for detailing the occlusion,
The simplest method of improving retention on
it cannot deal effectively with severe skeletal problems.
deciduous teeth is to bond composite on to the buccal
Straightwire technique must therefore be used in combi-
surfaces of these teeth to create an additional undercut.
nation with surgery, or functional correction. Many such
Both cooperation and retention can be improved by
problems can be dealt with more efficiently by early treat- bonding C-clasps directly to deciduous molars for the first
ment and it is important to offer an effective functional week or 10 days before freeing the clasps and rounding
orthopedic technique as a viable alternative to surgery. the edges of the composite that remains attached to the
Prominent upper incisors are vulnerable to accidental teeth to improve retention.
trauma and breakage, and early treatment is advisable to It is also possible to grind retention grooves into the
avoid fracture or damage by placing the incisors within buccal surfaces of deciduous teeth to improve undercuts;
the protection of the lips. Early treatment of crowded for example, gingival to the line of a C-clasp. Alternatively,
dentitions can combine arch development with correction a round bur may be used to grind a concavity to accommo-
of arch relationships. date a ball clasp. Sealant can then be applied to protect
The principles of treatment are unchanged in the the tooth and a readymade undercut has been created.
mixed dentition, although the response to treatment Synthetic crown contours (Truax) which may be bonded
may prove to be slower depending on the patient’s rate to the buccal surfaces of deciduous cuspids and molars
of growth. Bite registration follows the same procedures to reshape these teeth with additional undercuts, in order
as described for treatment in the permanent dentition. to improve the retention of clasps (Figs. 9.2A to H).
120 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

A B
Figs. 9.1A and B: Typical appliance design for mixed dentition.

A B C

D E F

G H
Figs. 9.2A to H: The appliance with crown contours to improve fixation in mixed dentition. (A) Crown contours; (B) Etching deciduous
molars with paper pads soaked in etching fluid; (C) The crown contours bonded to the teeth; (D and E) After cutting off the sprues the
impression is taken to make the appliance; (F to H) The C-clasps are shaped to gain retention from the crown contours.
Treatment in Mixed Dentition 121

Case Report: FD Aged 9 Years 7 Months improve fixation of the lower appliance and it is often not
necessary to trim the blocks at this stage. The Twin Blocks
This is a typical example of a young boy in mixed denti- remain intact and may be continue to be worn at night
tion who has a severe Class II dental relationship with as a retainer and the occlusal inclined planes provide
the lower lip trapped under a large overjet of 12 mm. positive retention.
Early treatment is indicated for many reasons, not least of After treatment in the mixed dentition there is dimin-
which is to protect the upper incisors from injury by plac- ished occlusal support during the transition to the per-
ing them inside the protective envelope of the lips. There manent dentition and functional retention is essential.
is a severe Class II skeletal base with 9 mm convexity, A night-time functional appliance may be selected as
mainly due to maxillary protrusion with proclination of a retention appliance to provide a positive functional
upper incisors and lower incisors which are slightly ret- stimulus to growth during the transitional stage of dental
roclined. On clinical examination the profile improves development.
when the mandible postures forward with the lips closed The occlusoguide is an excellent functional retainer
together. The upper pharyngeal airway is restricted before during the transition from mixed to permanent dentition
treatment to 8 mm and increased to 11 mm during the (Fig. 9.3G). It is a simple preformed appliance, resembling
Twin Block stage of treatment, as a result of mandibular a mini-positioner, which can be worn at night to retain
advancement. the incisor and molar relationship, while maintaining
Twin Blocks: 1 Year. space for eruption of premolars and canines. The occluso-
Support phase: 6 months of full-time wear with an anterior guide should be worn for 1 or 2 hours during the day and
inclined plane. the patient is instructed to actively bite into the appliance.
Retention: continued for 2 years of night-time wear with This is effective in maintaining the vertical dimension
an occlusoguide appliance until the occlusion is fully after correction of deep overbite. The material is suffi-
established in the permanent dentition. ciently flexible to allow correction of minor tooth irregu-
Final records: 5 years out of retention at age 18 years, larities, in addition to acting as a retainer to reinforce the
when the occlusion has settled satisfactorily without sagittal and vertical correction. One version of the appli-
further treatment (Figs. 9.3A to M). ance is specifically designed to engage the upper and
The main objective in mixed dentition is to achieve lower incisors in an edge-to-edge occlusion with troughs
sagittal correction by positive stimulus from the occlusal in the buccal segments to guide the eruption of premolars
inclined plane. Clasps may be placed on lower molars to and canines.

Case Report: FD

A
Fig. 9.3A: Profile at ages 9 years 7 months (before treatment), 11 years 4 months (after retention), and 18 years 7 months.
122 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

B C D

E F G

H I J

K L M
Figs. 9.3B to M: (B to D) The patient has a 12 mm overjet and four tooth smile before treatment due to constricted maxillary arch;
(E and F) The overjet is corrected after 8 months and overbite is reduced; (G) Occlusoguide appliance for retention (H to J) Occlusion at
age 18 years. No further treatment was required after support and retention; (K) Appearance before treatment at age 9 years 7 months;
(L) Appearance at age 11 years 4 months after retention; (M) Appearance at age 16 years 4 months.
Treatment in Mixed Dentition 123

Case Report: FD

FD Age 9.5 10.9 18.1


Cranial Base Angle 28 28 29
Facial Axis Angle 30 29 33
F/M Plane Angle 21 20 13
Craniomandibular Angle 49 48 42
Maxillary Plane 2 2 6
Convexity 9 4 4
U/Incisor to Vertical 35 35 24
L/Incisor to Vertical 35 34 24
Interincisal Angle 110 111 132
6 to Pterygoid Vertical 12 12 23
L/Incisor to A/Po −2 3 −1
L/Lip to Aesthetic Plane −2 −1 −6
124 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

TRANSVERSE DEVELOPMENT

TWIN BLOCKS FOR ARCH DEVELOPMENT phase of treatment was initiated before the growth spurt
during a period of slow growth, to minimize the skele-
Case Report: AG Aged 9 Years 6 Months tal change. No labial bow is used in order to main-
This boy has a mild Class II division 1 malocclusion in tain the labial position of the upper incisors. This case
the mixed dentition but a convexity of 1 mm indicates illustrates the use of upper and lower Schwarz Twin
a normal skeletal base relationship with a brachyfacial Blocks for expansion in both arches in mixed denti-
growth pattern. The maxilla is narrow and crowding in the tion, followed by a lower fixed appliance during support
lower labial segment is related to the restricted maxillary phase (Figs. 9.4 and 9.5).
width. The lower lip is trapped in the overjet, causing Twin Blocks: 8 months
proclination of the upper incisors, while the lower incisors Support appliance: continued while premolars and
are retroclined, at –3 mm to the A-Po line. canines erupted
The straight profile dictates nonextraction therapy and Lower fixed appliance: 6 months
expansion is indicated in both arches. The orthopedic Retention: 1 year.

Case Report: AG

B C D
Figs. 9.4A to D: Treatment: (A) profiles at ages 9 years 6 months (Before treatment) and 13 years 8 months; (B) Increased overjet before
treatment; (C) Lower arch before treatment; (D) Overjet correction after 4 months of treatment.
Treatment in Mixed Dentition 125

E F G

H I J

K L M

N O P
Figs. 9.4E to P: (E) Expansion achieved in the upper arch; (F) Anterior inclined plane with occlusal stops to control vertical dimension;
(G) Expansion achieved in the upper arch; (H) The lower twin block has a midline screw for expension; (I and J) Since the lower arch
crowding a lower fixed appliance with 3-dimensional control is necessary to correct the labial segment (K to M) Occlusion at age 13 years;
(N) Facial appearance at age 9 years 6 months; (O and P) Appearance at age 13 years 4 months.
126 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: AG

AG Age 9.6 9.9 12.3


Cranial Base Angle 26 26 26
Facial Axis Angle 33 32 33
F/M Plane Angle 13 15 12
Craniomandibular Angle 38 41 38
Maxillary Plane 1 3 1
Convexity 1 −1 1
U/Incisor to Vertical 42 32 31
L/Incisor to Vertical 18 22 21
Interincisal Angle 120 126 128
6 to Pterygoid Vertical 13 13 13
L/Incisor to A/Po −3 0 −3
L/Lip to Aesthetic Plane −5 −5 −5
Treatment in Mixed Dentition 127

A B

C D
Figs. 9.5A to D: (A and B) The occlusoguide appliance; (C) Upper and lower incisor are engaged in an edge-to-edge occlusion;
(D) A flexible ruler is used to select the correct size.
Courtesy: Ortho-Tain performed positioners.

OCCLUSOGUIDE APPLIANCE bicuspid and the ruler is bent along the incisal edge of
the incisors to the interproximal area between the right
The occlusoguide is a preformed mini-positioner appli- cuspid and bicuspid, where the size is registered on a
ance designed to fit the upper and lower anterior teeth scale for measurement.
and to act as a functional retainer by engaging the teeth The occlusoguide is designed to fit the anterior teeth
in an edge-to-edge relationship in a slightly open position in well aligned arches. In common with the positioner, it
with an interincisal distance of 3 mm. There is therefore a can accommodate only slight irregularity in the anterior
slight forward positioning of the mandible to maintain the teeth; neither is it sufficiently active to correct significant
corrected overjet after Twin Block treatment. This type of distal occlusion or increased overjet. The construction
appliance may be used as a retainer during the transition is sufficiently robust to permit the appliance to be worn
from mixed to permanent dentition, after correction of comfortably as a long-term retainer. It is important that
arch relationships in mixed dentition with Twin Blocks. the patient is motivated to wear the appliance consistently
The occlusoguide is manufactured in a range of sizes as instructed. The patient and parents should be advised
and the correct size is selected using a flexible ruler that failure to wear the retainer correctly may result
to measure the width of the six upper anterior teeth. in set-back if the inherent growth pattern is allowed
A pointer is placed between the upper left cuspid and to reassert itself.
128 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
5 mm lingual to the upper incisors. Early treatment is
essential in this type of malocclusion to place the upper
incisors safely under lip control.
Mandibular retrusion accounts for a convexity of
9 mm, and this is evident in the profile. There is a vertical
growth tendency with a facial axis angle of 25° and a
Frankfort mandibular plane angle of 29°. The maxilla
is typically narrow with a full unit distal occlusion. The
upper pharyngeal airway is severely restricted at 7 mm,
due to the mandibular retrusion (Figs. 9.7A to T).
Functional correction is planned in two steps to
reduce the excessive overjet of 15 mm. The Twin Blocks
are constructed to a registration bite that reduces the
overjet initially by 8 mm, planning to reactivate the blocks
during treatment to complete reduction of the overjet.
After 4 months, the occlusion has corrected by
8 mm to the position of initial activation of the occlusal
inclined planes and the Twin Block is now reactivated by
Fig. 9.6: The use of upper and lower Schwarz Twin Blocks for expan- the addition of acrylic to the mesial incline of the upper
sion of both arches in mixed dentition. appliance. This adjustment is made at the chairside to
bring the mandible forward to an edge-to-edge incisor
relationship to complete correction of the overjet.
The occlusoguide should be worn for 1 or 2 hours A “gummy” smile necessitates intrusion of the upper
during the day and the patient is instructed to actively incisors during treatment to improve the position of the
bite into the appliance. This is effective in maintaining upper lip relative to the incisors. This improves to some
the vertical dimension after correction of deep overbite. extent when the patient develops a lip seal during the
The material is sufficiently flexible to allow correction Twin Block phase, but a further stage is necessary to
of minor tooth irregularities, in addition to acting as a intrude the upper incisors and detail the occlusion.
retainer to reinforce the sagittal and vertical correction. Orthopedic correction to a Class I occlusion by Twin
One version of the appliance is specifically designed to Blocks was followed in the permanent dentition by a short
engage the upper and lower incisors in an edge-to-edge period of orthodontic treatment during which time fixed
occlusion with troughs in the buccal segments to guide appliances were worn for a year to detail the occlusion.
the eruption of premolars and canines (Figs. 9.6). A utility arch was used to intrude the upper incisors to
improve the “gummy” smile.
TWO-PHASE TREATMENT IN MIXED AND
PERMANENT DENTITION Response to Treatment
The upper pharyngeal space increased from 7 to 11 mm
Case Report: JC Aged 8 Years 9 Months after 1 year of treatment, then to 14 mm 2 years later and,
This boy presents a disfiguring malocclusion in the early finally, to 21 mm after 6 years. Radiographic examination
mixed dentition with the upper incisors extremely vulner- of the temporomandibular joints (TMJ) confirms that
able to trauma, resting completely outside the lower lip. the condyles are in good position in the articular fossa
The lower lip is trapped under an overjet of 15 mm. The at the age of 11 years 11 months, 3 years after the start
lower incisors are biting into the soft tissue of the palate of treatment.
Treatment in Mixed Dentition 129

Case Report: JC

B C D

E F G

H I J
Figs. 9.7A to J: Treatment: (A) Profile at ages 8 years 9 months (before treatment), 10 years 1 month and 14 years 11 months;
(B to D) Occlusion before treatment; (E to G) Twin Blocks were worn for 14 months. Occlusion after 8 months; (H and I) Appearance
before treatment at age 8 years 9 months. Note the “gummy” smile; (J) After treatment at age 10 years 1 month.
130 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

K L M

N O

P Q R

S T
Figs. 9.7K to T: Treatment: (K and L) Upper retainer with an anterior inclined plane; (M) Orthodontic phase-the fixed appliances (N and O)
Radiograph in occlusion confirm the good relationship of the condyles in the glenoid fossae at age 13 years 6 months; (P to R) Occlusion
1 year out of retention at age 14 years 11 months; (S and T) Facial view 1 year out of retention at age 14 years 11 months.
Treatment in Mixed Dentition 131

Case Report: JC

JC Age 8.9 10.1 11.11 14.10


Cranial Base Angle 25 25 26 26
Facial Axis Angle 25 25 28 26
F/M Plane Angle 29 31 28 29
Craniomandibular Angle 54 56 55 55
Maxillary Plane 3 0 2 0
Convexity 9 5 5 5
U/Incisor to Vertical 30 12 23 14
L/Incisor to Vertical 32 41 40 41
Interincisal Angle 118 127 117 125
6 to Pterygoid Vertical 14 14 19 19
L/Incisor to A/Po −1 4 5 3
L/Lip to Aesthetic Plane 0 2 −1 −3
132 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: JB Aged 9 Years 11 Months Growth during support and retention resulted in a
slight return of convexity in the profile. Twin Blocks were
This girl presents a Class II division 1 malocclusion with integrated with fixed appliances for 3 months to improve
a maxillary protrusion contributing to prognathic facial the facial result before detailing the occlusion with fixed
profile in late mixed dentition. The skeletal discrepancy appliances. The additional short orthopedic phase was
is mild, with a 5 mm convexity and the overjet is 7 mm. successful in improving the profile.
A tongue thrust is associated with an incomplete overbite In this case, a two-phase approach combined the
and incompetent lip behavior. The profile improves when advantages of orthopedic and orthodontic treatment to
the mandible postures forward, indicating that functional achieve a satisfactory dental occlusion and a pleasing
therapy will improve the facial appearance in spite of improvement in facial balance. Treatment was initiated
the prognathic growth pattern. Clinical assessment takes in late mixed dentition and completed in permanent
precedence over cephalometric norms in predicting the dentition (Figs. 9.8A to N).
response to functional treatment. Mixed Dentition
During the support phase an upper appliance was
Twin Blocks: 3 months
fitted with a tongue guard formed from heavy gauge Support and retention: 18 months.
wire, which also served as an anterior inclined plane to
retain the corrected incisor relationship. After 18 months Permanent Dentition
of treatment with functional appliances, upper and lower Twin Blocks: 3 months
fixed appliances were fitted to complete the treatment. Fixed appliances: 12 months

Case Report: JB

B C D
Figs. 9.8A to D: Treatment: (A) Profile at ages 9 years 11 months (before treatment) 10 years 8 months and 18 years 6 months;
(B to D) Occlusion before treatment after treatment 6 weeks and after 1 year.
Treatment in Mixed Dentition 133

E F G

H I

J K

L M N
Figs. 9.8E to N: Treatment: (E) The recurved lingual tongue guard acts as an inclined plane; (F) Phase 2–Twin Blocks combined with
fixed appliance; (G) Fixed appliance to finish; (H and I) Occlusal views after treatment; (J and K) Facial appearance at age 9 years
11 months and 15 years 8 months; (L to N) Occlusion at age 18 years 6 months.
134 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: JB

JB Age 9.11 11.4 15.11


Cranial Base Angle 29 29 30
Facial Axis Angle 32 28 28
F/M Plane Angle 16 20 18
Craniomandibular Angle 45 49 48
Maxillary Plane 7 5 4
Convexity 5 5 3
U/Incisor to Vertical 33 20 27
L/Incisor to Vertical 30 28 31
Interincisal Angle 117 132 122
6 to Pterygoid Vertical 17 15 17
L/Incisor to A/Po 0 1 3
L/Lip to Aesthetic Plane 2 1 −1
Treatment in Mixed Dentition 135

Case Report: CM Aged 7 Years 10 Months finishing stage of straightwire technique in the perma-
nent dentition (Figs. 9.9A to R).
This patient presents a prognathic profile with upper inci-
sors proclined and flared in the early mixed dentition. Mixed Dentition
The patient also exhibits a reduced anterior facial height Twin Blocks: 6 months
and deep overbite, associated with a brachyfacial growth Support phase: 7 months
pattern. In spite of the prognathic appearance, the profile Retention: 15 months, awaiting eruption followed by a
improves when the mandible postures downward and period without appliances.
forward. Treatment is accomplished in two-stage: first
with interceptive functional treatment to correct to Class I Permanent Dentition
occlusion in the mixed dentition and, second with a Fixed appliances: 7 months, followed by retention.

Case Report: CM

B C D

E F G
Figs. 9.9A to G: Treatment: (A) Profile at ages 7 years 10 months (Before treatment) 8 years 7 months and 11 years 7 months;
(B to D) Occlusion before treatment; (E) Twin Block appliances; (F and G) Occlusion after 11 months of treatment at age 8 years 7 months.
136 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

H I

J K L

M N O

P Q R
Figs. 9.9H to R: Treatment: (H) Narrow upper arch relative to the lower arch; (I) Expanded upper archform after treatment; (J and L)
Lower archform before and after treatment; (K) Fixed appliances for the orthodontic phase; (M to O) Occlusion at age 10 years before the
orthodontic phase; (P to R) Occlusion after treatment at age 11 years 7 months.
Treatment in Mixed Dentition 137

Case Report: CM

CM Age 7.8 8.7 11.6


Cranial Base Angle 23 22 22
Facial Axis Angle 32 34 36
F/M Plane Angle 22 21 19
Craniomandibular Angle 44 43 41
Maxillary Plane 5 4 8
Convexity 5 4 2
U/Incisor to Vertical 37 25 24
L/Incisor to Vertical 24 27 24
Interincisal Angle 119 128 124
6 to Pterygoid Vertical 16 18 24
L/Incisor to A/Po 1 2 3
L/Lip to Aesthetic Plane 2 0 −2
138 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

PEDODONTIC PRACTICE sucking habit was associated with upward tipping of the
palatal plane and anterior open bite. An anterior open
Pedodontic practice is geared to early correction and the bite in mixed dentition responded well to a short period
following patients are examples of interceptive treatment of treatment with Twin Blocks. An occlusoguide appliance
in mixed dentition carried out by Dr Gordon Kluzak in was used to retain the position pending eruption of
his pedodontic practice in Calgary. In suitable cases no premolars and canines. This appliance was worn every
additional treatment may be required. night and for 2 hours in the day time. Finally a fixed lingual
retainer was fitted to retain the lower labial segment.
Case Report: CW Aged 7 Years 6 Months The occlusion is settling well 3 years of retention when
by Gordon Kluzak permanent teeth have erupted. Extraction of all second
This patient presented a disfiguring malocclusion and molars is planned to relieve potential impaction of third
was successfully treated in the early mixed dentition stage molars, which may otherwise contribute to recurrent late
when the permanent incisors were erupting. A thumb crowding in the lower arch (Figs. 9.10A to K).

Case Report: CW

A
Fig. 9.10A: Treatment: (A) Profile at ages 7 years 6 months (before treatment) and 13 years (after treatment).
Treatment in Mixed Dentition 139

B C

D E

F G H

I J K
Figs. 9.10B to K: (B and C) Occlusion before treatment; (D and E) Archform before treatment; (F to H) After treatment in mixed dentition;
(I and K) Occlusion 3 years out of retention age 13 years; (J) Upper arch after treatment.
140 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: CW

CW Age 7.6 9.4 13.0


Cranial Base Angle 33 32 34
Facial Axis Angle 27 32 29
F/M Plane Angle 24 24 25
Craniomandibular Angle 57 56 59
Maxillary Plane 5 4 0
Convexity 5 2 3
U/Incisor to Vertical 23 28 18
L/Incisor to Vertical 27 28 23
L/Incisor to A/Po 0 4 1
L/Lip to Aesthetic Plane 2 0 2
6 to Pterygoid vertical 9 12 15
Treatment in Mixed Dentition 141

Case Report: KH Aged 8 Years 9 Months occlusoguide was worn for 2 hours during the day and
at nights. The patient was then given the option of wear-
by Gordon Kluzak ing the occlusoguide at nights only, or for 1 hour during
This case is an example of interceptive treatment in mixed the day. During the transition to permanent dentition
dentition for a patient with a favorable growth pattern, when deciduous teeth are shed the occlusoguide is a use-
who responded well to early treatment. This patient had ful functional retainer. Retention was discontinued after
Twin Blocks for 6 months, followed by an occlusogu- 1 year. No further treatment was necessary and the occlu-
ide retainer. During the first 5 months of retention the sion is stable 4 years out of retention (Figs. 9.11A to N).

Case Report: KH

B C D

E F
Figs. 9.11A to F: Treatment: (A) Profile at ages 8 years 9 months (before treatment) and 13 years 9 months (after treatment); (B to D)
Occlusion before treatment; (E and F) Anterior occlusion before treatment.
142 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

G H

I J

K L M

N
Figs. 9.11G to N: Treatment: (G) Appearance before treatment; (H) Appearance after treatment; (I) Archform before treatment; (J) Archform
after treatment; (K to N) Occlusion out of retention at age 13 years 9 months.
Treatment in Mixed Dentition 143

Case Report: KH

KH Age 8.9 13.9


Cranial Base Angle 30 29
Facial Axis Angle 30 30
F/M Plane Angle 20 18
Craniomandibular Angle 50 47
Maxillary Plane 5 4
Convexity 6 4
U/Incisor to Vertical 28 14
L/Incisor to Vertical 30 25
L/Incisor to A/Po –2 1
L/Lip to Aesthetic Plane 1 –3
6 to Pterygoid vertical 11 14
144 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

REFERENCES FURTHER READING


Bergason, EO, (1901). The preformed orthodontic positioner McNamara, JA, Brundon, WL, (1933). Orthodontic and ortho-
and eruption guidance appliance, North Western University pedic treatment in the mixed dentiton. Needham Press, Ann
American Dental Association Library, Chicago. Arboc Michigan.
Bergason, EO, (1985). The eruption guidance myofunctional
appliance: case selection timing, motivation, indications and
contradictions in its use, The Functional Orthodontics. 2:17-13.
Combination Therapy 145

Chapter 10

Combination Therapy

Only the very wise or very foolish marry themselves to but one appliance or method.
—Robert E Moyers

PERMANENT DENTITION Facial convexity reduced from 6 mm to 3 mm dur-


ing treatment by a combination of maxillary retraction
Combination therapy describes the combined use of and mandibular advancement. This improvement was
functional and fixed techniques in the management of maintained by good post-treatment growth which further
malocclusion. In many respects this represents the best reduced convexity to 2 mm by compensatory mandibu-
of both worlds, where orthopedic and orthodontic tech- lar growth after the occlusion had been corrected. The
niques are combined to achieve correction of the skeletal dental and facial improvement was maintained at the
discrepancy and detailing of the occlusion. The timing of age of 18 years 8 months, when third molars erupted into
treatment is a significant factor in planning combination good occlusion.
therapy. By definition this is a one-phase treatment and Twin Blocks: 5 months
should be timed to coincide with eruption of the per- Support phase: 3 months
manent teeth. The optimum timing for this approach is Fixed appliances: 12 months
either in late mixed dentition or early permanent denti- Retention: 12 months
tion. It is then possible to integrate the fixed and func- Final records: 18 years 8 months; 5 years out of retention.
tional therapy into a single phase of treatment, and to
select either commencement with Twin Blocks or a fixed Summary
appliance according to preference or the requirements of
The integration of Twin Blocks and fixed appliances
the individual case. In some cases Twin Blocks may be
combines the benefits of fixed and functional therapy.
adapted for simultaneous use with fixed appliances.
Contrary to many other forms of cosmetic treatment, the
The following examples illustrate alternative approa-
benefits of combined dental orthopedic and orthodontic
ches to combination therapy.
therapy are not temporary but permanent. These tech-
niques improve facial development and are of benefit
Case Report: CD Aged 11 Years 8 Months as the patient grows from childhood into maturity. Inter-
This is a typical example of treatment of a girl in the early ceptive treatment in the growing child by an orthopedic
permanent dentition, using Twin Blocks for initial func- approach to treatment can enhance facial growth. In
tional correction, followed by fixed appliances to detail many cases it helps to avoid surgical correction at a later
the occlusion. Mild mandibular retrusion accounts for stage of development. When required, orthopedic correc-
6 mm convexity with an overjet of 9 mm and a full unit tion is followed by an orthodontic phase of treatment to
distal occlusion (Figs. 10.1A to N). detail the occlusion.
146 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: CD

B C D

E F
Figs. 10.1A to F: Treatment: (A) Profiles at ages 11 years 1 month (before treatment) and 15 years 11 months; (B to D) Occlusion before
treatment; (E and F) Appliances in the orthodontic phase.
Combination Therapy 147

G H

I J K

L M N
Figs. 10.1G to N: (G and H) Upper and lower archforms after treatment at 15 years 11 months; (I to K) Occlusion after treatment;
(L) Appearance before treatment at age 11 years 1 month; (M) Appearance at 15 years 11 months; (N) Appearance at 18 years 5 months.
148 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: CD

CD Age 11.1 13.3 16.1


Cranial Base Angle 24 25 27
Facial Axis Angle 28 28 31
F/M Plane Angle 20 21 17
Craniomandibular Angle 44 46 44
Maxillary Plane 1 0 4
Convexity 6 5 2
U/Incisor to Vertical 35 27 26
L/Incisor to Vertical 41 34 31
Interincisal Angle 104 119 123
6 to Pterygoid Vertical 18 21 22
L/Incisor to A/Po 2 5 4
L/Lip to Aesthetic Plane 1 2 −1
Combination Therapy 149

Case Report: JS Aged 10 Years 3 Months was achieved during the Twin Block phase, this demon-
This case illustrates controlled functional correction of a strates the improvement resulting from detailing the
Class II division 1 malocclusion on a retrognathic Class I occlusion with a finishing stage of straightwire technique
skeletal base to improve the profile without excessive (Figs. 10.2A to Q).
mandibular advancement. An overjet of 7 mm with an Twin Blocks: 7 months
incomplete overbite is due to tongue thrust and there is Support phase: 4 months.
a full unit distal occlusion. Although a good occlusion Fixed appliances: 9 months followed by retention.

Case Report: JS

B C D

E F G
Figs. 10.2A to G: Treatment: (A) Profiles at ages 10 years 3 months (before treatment), 11 years 3 months (after the Twin Blocks phase)
and 17 years; (B to D) Occlusion before treatment; the anterior view shows the tongue thrust; (E to G) After 11 months of treatment.
150 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

H I J

K L

M N O

P Q
Figs. 10.2H to Q: (H to J) Fixed appliances phase (K and L) Upper and lower archforms; (M to O) Occlusion at age 17 years;
(P) Appearance before treatment at age 10 years 3 months; (Q) Appearance at age 17 years.
Combination Therapy 151

Case Report: JS

JS Age 10.2 11.0 15.3


Cranial Base Angle 27 28 26
Facial Axis Angle 27 25 26
F/M Plane Angle 28 31 30
Craniomandibular Angle 56 59 55
Maxillary Plane 0 0 0
Convexity 2 2 1
U/Incisor to Vertical 20 12 14
L/Incisor to Vertical 31 32 32
Interincisal Angle 129 136 134
6 to Pterygoid Vertical 13 13 18
L/Incisor to A/Po 1 2 2
L/Lip to Aesthetic Plane −3 −6 −7
152 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

CONCURRENT STRAIGHTWIRE AND THE Where a deep overbite is present this technique
TWIN BLOCK THERAPY first aligns the maxillary dentition sufficiently to create
adequate clearance before placing bands and brackets
An alternative approach is to initiate treatment with fixed to align the mandibular teeth. When both arches have
appliances, correcting archform and applying torque to progressed to .018 round wires an orthopantomograph is
correct incisor angulation prior to fitting Twin Blocks, taken to assess proper root tip and carry out any necessary
which are integrated with straightwire technique. This is rebracketing. In cases where the maxillary incisors are
a useful modification of technique, and one which many retroclined, the arch is taken to 0.020 × 0.020 straight wire
practitioners would appreciate. The following account (2–3 months) which widens the arch and torques out the
is based on material provided by Dr Gary Baker and is incisors. Finally a 0.021 × 0.025 rectangular wire is placed
illustrated by patients treated in his dental practice in to develop the arch as much as possible prior to the
Vancouver, Canada. addition of Twin Blocks. This arch wire, by stabilizing and
anchoring the maxillary teeth, also mitigates the retracting
Timing is Everything forces of the Twin Block appliances on the upper anterior
by Gary Baker DMD and Beverly Ireland CDA teeth, thereby facilitating a more complete advancement
Classically described, the Twin Block technique corrects of the mandibular arch to Class I relationships.
skeletal discrepancies first, both in the anteroposterior The mandibular arch is taken to a 0.020 round wire
and vertical dimensions (development of the mandibular or, less frequently, a 0.020 × 0.020 square wire. Anchorage
posterior segments), followed by alignment of the teeth. control, to decrease the proclining effect on the mandibu-
Depending on the timing of treatment, the two-stage may lar incisors from the mandibular Twin Block, is improved
frequently be separated by many months, resulting in two by figure eighting a 0.009 metal ligature from second pre-
separate and distinct phases of treatment. The first phase molar to second premolar. The archwire is then placed on
(skeletal correction) may occur in mixed dentition, and top of this ligation, using conventional elastic ligatures.
the second phase (dental correction) may follow when The dental phase of treatment requires approximately
all, or most of the adult dentition has erupted. 8–12 months, at which time the Twin Block appliances
Experience suggests that this approach is more time are placed. The maxillary appliance is designed with
consuming, and more demanding on patient cooperation 0.028 ball clasp wires mesial and distal to the cuspids
than a single continuous phase of treatment. In addition, and mesial to the first molars. An open palate design is
the delay between the first and second phases of treat- used where possible to facilitate increased tongue space
ment may allow time for the inherent Class II skeletal and better speech. The mandibular appliance has 0.028
growth pattern to reassert itself, necessitating a further ball clasps mesial and distal to the cuspids and between
phase of functional correction. As well, early treatment the bicuspids in a full dentition case.
with only Twin Blocks, especially in cases where the max- To ensure patient cooperation these appliances are
illary incisors are retroclined (e.g. Class II/2) may not fixed in place for a period of 2–3 weeks, using metal
allow for complete mandibular advancement. ligatures from 0.024 fixation loops on the appliances to
A valid alternative in order to minimize the time the brackets. After this time the ligatures and fixation
required, and therefore improve patient cooperation, is loops are removed to free the appliance. A soft 0.0175
to wait until all or most of the permanent dentition has braided wire is placed in the mandibular arch (over
erupted before commencing with treatment. At this stage the 5–5 ligation) extending to the molars to maintain
in development the straight wire appliances are fitted first arch control during their eruption. At this appointment,
to achieve dental correction, followed concurrently by the and subsequent monthly appointments, the maxillary
correction of skeletal deficiencies with Twin Blocks. Initial pads are relieved. To measure accurately the amount
dental alignment, especially incisor torque to advance the of clearance for eruption of the lower molars a double
maxillary incisors helps to create optimal “overjet-power” layer of thick articulating paper (700 microns) is used
and thus gain greater control in achieving full mandibular to mark the posterior maxillary blocks. In order to
advancement and posterior occlusal development. There ensure molar eruption the patient wears short Class II
is the additional advantage in that this protocol usually interarch elastics from hooks on the mandibular molars
coincides with the pubertal mandibular growth spurt, to hooks on the second maxillary premolars.
thus enhancing the response to functional mandibular The molars are generally in occlusion within a further
advancement. 6–8 months of treatment and the incisors ideally exhibit
Combination Therapy 153

an open bite of approximately 0–2 mm depending on mandibular teeth into occlusion. During this phase the
the amount of overbite initially present. The mandibular mandibular teeth are levelled and aligned back to 0.018
5–5 ligation is now removed and clearance is made for or 0.020 round wires, and the 5 to 5 ligation is removed.
lower second premolars to erupt with elastics passing The maxillary 0.021 × 0.025 wire is downsized to a 0.020
from these teeth to the upper first premolars, at times in or 0.018 round arch to allow increased closure. This final
conjunction with the original elastic bands. During all of interdigitation is generally achieved within 2–3 months
these adjustments the integrity of the inclined planes is without the use of a support appliance, and treatment is
maintained to ensure that the mandible is held forward. concluded usually within a 24–30 months period, with the
After 2–3 months of further eruption, adding new braided placement of conventional Hawley retainers.
wires as needed to maintain mandibular arch integrity, Figures 10.3A to N illustrate the approach to this
the appliances are discontinued and short Class II technique and the (following) three case reports refer to
elastics are continued from the mandibular premolars patients treated by Gary Baker and Beverly Ireland in Dr
to the maxillary premolars and canines to bring the Baker’s practice in Vancouver, Canada.

A B

C D

E F G
Figs. 10.3A to G: The approach to the concurrent straightwire Twin Block therapy technique. (A) Mx aligned to 0.021, 0.025 and Md to
0.020 wire at initial insertion of appliances; (B) Mx 028 ball clasps mesial to Mx 6s and mesial and distal to Mx 3s. Md 028 ball clasps
mesial and distal to Md 3s and Md 4s; (C and D) Appliances fixed in place for 2 6s and mesial and distal to Mx 3s. Md 028 ball clasps
mesial and; (E) Open palate design for ease of wear and to facilitate tongue and freedom of speech; (F) Md appliance extends distally
2 m of speechial and distal to Mx 3s. Md; (G) Loops are ligated to brackets and wire using 0.009 metal ligatures. The approach to the
concurrent straightwire Twin Block therapy technique.
154 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

H I

J K

L M N
Figs. 10.3H to N: (H and I) After the break-in period the Mx pads are relieved monthly using double thickness of thick articulating paper
placed distal to the Md pad; (J) Mx pads are marked and relieved until paper no longer marks on the pads. Barrel shaped acrylic bur
used in slow-speed handpiece; (K) Approximately 1–1.5 mm of clearance is created. Note Md 4/4 metal ligation under 0175 braided wire
extended to molars; (L) Intra-arch rubber bands initially worn from Mx 5s to Md 6s to predictably erupt lower 6s; (M) When lower 6s are
mostly in contact with Mx 5s and 6s, an additional rubber band is added from Mx 4s to Md 5s. Clear acrylic around Md 5s to allow for
this eruption; (N) Appliances then discontinued; rubber bands worn from Mx 3s and 4s to Md 4s and 5s to complete dental closure.
Combination Therapy 155

Case Report: ML Aged 12 Years 6 Months pattern with a horizontal growth vector in the mandible.
This boy is treated in early permanent dentition at an The facial change after treatment shows a much stronger
appropriate stage to commence treatment with fixed profile, as a result of a good mandibular growth response
appliances. The dental relationship is dictated by retro- made possible by the proper torquing of the maxillary
clination of all four upper incisors with deep overbite, incisors. There is a significant increase in lower facial
causing a distal occlusion by restricting mandibular deve- height brought about by mandibular posterior develop-
lopment. There is mild crowding of the upper canines ment, which contributes to improved facial balance and
and minimal crowding in the lower arch. Cephalometric resolution of the deep overbite (Figs 10.4A to O).
analysis reveals a retrognathic profile with a Class I skel- Total active treatment: 27 months
etal base relationship, and in profile the retrognathic pat- Fixed appliances: upper arch, 22 months; lower arch,
tern is evident, especially in the mandible. A long anterior 18 months
cranial base is a factor in the retrognathic appearance. Twin Blocks: 11 months
The growth potential is good in view of a brachyfacial Final detailing/Hawley retainers: 5 months.

Case Report: ML

B C D
Figs. 10.4A to D: Treatment: (A) Profiles at ages 12 years 6 months (before treatment) and 15 years 3 months (after treatment);
(B to D) Occlusion before treatment.
156 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

E F

G H

I J K

L M

N O
Figs. 10.4E to O: Treatment: (E and F) Archforms before treatment; (G and H) Appearance before treatment at age 12 years 6 months;
(I to K) Occlusion after treatment; (L and M) Archforms after treatment; (N and O) Appearance after treatment at age 15 years 3 months.
Combination Therapy 157

Case Report: ML

ML Age 12.6 15.3


Cranial Base Angle 26 25
Facial Axis Angle 26 26
F/M Plane Angle 22 23
Craniomandibular Angle 48 48
Maxillary Plane 0 2
Convexity 1 –2
U/Incisor to Vertical 9 23
L/Incisor to Vertical 28 27
L/Incisor to A/Po –1 1
L/Lip to Aesthetic Plane 0 –4
6 to Pterygoid Vertical 13 14
158 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: CS Aged 9 Years 11 Months and correct the occlusal relationship to Class I. There
is a pleasing improvement in facial appearance, and
This young girl presents a Class II division 1 malocclusion
occlusal detailing is completed with fixed appliances to
in late mixed dentition with crowding in the upper and
lower labial segments. The appearance confirms severe an excellent result. The growth response is positive during
mandibular retrusion. This is an appropriate time to initiate treatment with a significant increase in mandibular length
treatment for a girl, as it is important to start treatment and a resulting improvement in the mandibular retrusion
in good time to allow for arch development to proceed (Figs. 10.5A to O).
and still be able to take advantage of the pubertal growth Total active treatment: 27 months
spurt. Treatment was initiated with upper fixed appliances, Fixed appliances: upper arch, 23 months; lower arch,
followed 3 months later by lower fixed appliances. When 20 months
the arches were aligned, with correct maxillary incisor Twin Blocks: 10 months
torque, Twin Blocks were fitted to advance the mandible Final detailing/Hawley retainers: 4 months.

Case Report: CS

B C D

E F
Figs. 10.5A to F: Treatment: (A) Profiles at ages 9 years 11 months (before treatment) and 14 years 5 months; (B to D) Occlusion before
treatment; (E and F) Archforms before treatment.
Combination Therapy 159

G H

I J K

L M

N O
Figs. 10.5G to O: (G and H) Appearance before treatment; (I to K) Occlusion after treatment; (L and M) Archforms after treatment;
(N and O) Appearance after treatment.
160 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: CS

CS Age 9.11 14.5


Cranial Base Angle 28 27
Facial Axis Angle 28 27
F/M Plane Angle 22 21
Craniomandibular Angle 50 48
Maxillary Plane 1 0
Convexity 3 1
U/Incisor to Vertical 13 26
L/Incisor to Vertical 29 35
L/Incisor to A/Po 1 2
L/Lip to Aesthetic Plane 3 –2
6 to Pterygoid Vertical 10 12
Combination Therapy 161

Case Report: MZ Aged 14 Years 8 Months vertical positive vertical changes in the lower face, in
addition to mandibular advancement by Twin Blocks
by Gary Baker DMD
(Fig. 10.6).
This case illustrates the protocol for combination therapy
following extraction of premolars. Mandibular retrusion Total active treatment: 24 months
is evident in the facial appearance of this patient who Fixed appliance: Upper arch 21 months; lower arch
previously had four first premolars extracted as part of 14 months
a serial extraction program to relieve severe crowding in Twin Blocks: 6 months
both arches. Final detailing/Hawley retainers: 3 months
Favorable improvement in the profile is accounted
for by a good mandibular growth response with positive

Case Report: MZ

B C D

E F
Figs. 10.6A to F: Treatment: (A) Profiles at ages 14 years 1 month (before treatment) and 16 years 2 months (after treatment); (B to D)
Occlusion before treatment; (E and F) Archforms before treatment.
162 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

G H

I J K

L M

N O
Figs. 10.6G to O: Treatment: (G and H) Appearance before treatment; (I to K) Occlusion after treatment; (L and M) Archforms after
treatment; (N and O) Appearance after treatment.
Combination Therapy 163

Case Report: MZ

MZ Age 14.1 16.2


Cranial Base Angle 28 29
Facial Axis Angle 22 21
F/M Plane Angle 29 28
Craniomandibular Angle 57 57
Maxillary Plane 0 –3
Convexity 3 1
U/Incisor to Vertical 6 27
L/Incisor to Vertical 20 31
L/Incisor to A/Po –3 1
L/Lip to Aesthetic Plane –2 –1
6 to Pterygoid Vertical 10 11
The Twin Block Traction Technique  165

Chapter 11

The Twin Block Traction Technique

ORTHOPEDIC TRACTION for extraoral traction on the upper appliance to be worn


at night so as to reinforce the functional component for
In most cases, full functional correction of occlusal correction of a Class II buccal segment relationship.
relationships can be achieved with Twin Blocks without
A method was developed to combine extraoral and
the addition of any orthopedic or traction forces. Where
intermaxillary traction by adding a labial hook to a
the response to functional correction is poor, the addition
conventional facebow and extending an elastic back
of orthopedic traction force may be considered. In the
to attach to the lower appliance in the incisor region
early stages of development of the Twin Block technique
(Clark, 1982). This development was based on previous
a method was devised to combine functional therapy
experience of functional appliances that were worn part
with orthopedic traction. This approach should be limited
time and were slow and unpredictable in correcting arch
to the treatment of severe malocclusion, where growth is
relationships.
unfavorable for conventional fixed or functional therapy.
The Concorde facebow is a new means of applying
Functional therapy combined with traction achieves
intermaxillary and extraoral traction to restrict maxillary
rapid correction of malocclusion.
growth and, at the same time, to encourage mandibular
The indications are confined to a minority of cases
growth in combination with functional mandibular pro­
with growth patterns where maxillary retraction is the
trusion. A conventional facebow is adapted by solde­ring
treatment of choice. For example:
a recurved labial hook to extend forward to rest outside
• In the treatment of severe maxillary protrusion; to
the lips as an anchor point to combine intermaxillary
control a vertical growth pattern by the addition of
and extraoral traction. Patient comfort and acceptance
vertical traction to intrude the upper posterior teeth;
is similar to a conventional facebow. Intermaxillary trac­
• In adult treatment where mandibular growth cannot
tion was added to the appliance system to ensure that
assist the correction of a severe malocclusion.
if the patient postured out of the appliance during the
night, the intermaxillary traction force would increase.
THE CONCORDE FACEBOW This ensured that the appliance was effective 24 hours/
Before Twin Blocks were developed, the author used day (Figs. 11.1A to C).
extraoral traction with removable appliances as a means The labial hook is positioned extraorally, 1 cm clear
of anchorage to retract upper buccal segments to correct of the lips in the midline. This enables an elastic back
Class II malocclusion (Cousins & Clarke, 1965). In the to pass intraorally to attach anteriorly to the lower
early years using Twin Blocks, tubes were added to clasps appliance to apply intermaxillary traction as a horizontal
166  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
excellent before any orthopedic force is applied to a
removable appliance, and poor fixation contraindicates
the addition of traction, except to a fixed attachment.
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 trac­
tion force is automatically increased to compensate and
to ensure that favorable intermaxillary forces are applied
continuously. The aim is to make the appliances active
24 hours/day to maximize the orthopedic response.
Careful case selection is essential before using a
combination of Twin Blocks with orthopedic traction.
This is a very powerful mechanism for maxillary retraction
A and, as the majority of Class II malocclusions are due to
mandibular retrusion, it is contraindicated in most cases.
The headgear effect tends to tip the occlusal plane and
palatal plane down anteriorly and to retrocline the upper
incisors, which may cause unfavorable autorotation of the
mandible. Extraoral traction should be used selectively,
bearing in mind that most patients respond to treatment
without the addition of traction components.
Later experience in using Twin Blocks confirmed that
B C the addition of a traction component was not necessary
Figs. 11.1A to C: Concorde facebow. to achieve correction of the buccal segment relationship,
and extraoral traction is no longer used to reinforce the
force vector. This has the advantage of eliminating the action of the inclined planes. Study of early cases showed
unfavorable upward component of force in conventional that the headgear effect caused unnecessary maxillary
intermaxillary elastic traction, which can extrude lower retraction (Orton, 1990).
molars and cause tipping of the occlusal plane. Occasionally, high pull traction may be indicated to
When distal extraoral traction is applied to a removable intrude the upper posterior teeth in cases with a severe
appliance, the outer bow of the facebow should be vertical growth pattern, in an effort to achieve a forward
adjusted to lie slightly above the inner bow in order to mandibular rotation by intruding upper molars. The same
apply a slight upward component of force to help retain objective can be achieved more simply by using vertical
the upper appliance. Fixation of the appliance must be intraoral elastics to intrude the posterior teeth.
The Twin Block Traction Technique  167

TWIN BLOCKS COMBINED WITH ORTHOPEDIC TRACTION

TREATMENT OF MAXILLARY PROTRUSION with extraoral and intermaxillary traction applied a


retraction force to the maxilla, while the action of the
Case Report: KA Aged 9 Years 6 Months occlusal inclined planes advanced the mandible. This
A severe Class II skeletal base relationship is due to combination of mechanics resulted in a rapid response
maxillary protrusion. A previous thumb sucking habit has to treatment, in spite of spasmodic appliance wear
resulted in an anterior open bite which is perpetuated (Figs. 11.2A to D).
by a tongue thrust and the lower lip is trapped in a Twin Blocks & Concorde facebow: 8 months
14 mm overjet. The addition of the Concorde facebow Support and retention: 6 months

Case Report: KA

B C D
Figs. 11.2A to D: Treatment: (A) Profiles at ages 9 years 6 months (before treatment) and 10 years 7 months (after 8 months of treatment);
(B and C) Occlusion before treatment at age 9 years 6 months (note the anterior open bite); (D) Occlusion after 8 months of treatment.
168  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: KA

KA Age 9.6 10.7


Cranial Base Angle 29 28
Facial Axis Angle 29 32
F/M Plane Angle 24 23
Craniomandibular Angle 53 51
Maxillary Plane 4 1
Convexity 6 4
U/Incisor to Vertical 27 24
L/Incisor to Vertical 29 28
Interincisal Angle 124 128
6 to Pterygoid Vertical 19 18
L/Incisor to A/Po −6 −4
L/Lip to Aesthetic Plane −5 −4
The Twin Block Traction Technique  169

Case Report: WF Aged 5 Years 9 Months also limited. In appropriate cases maxillary retraction
may be required to contribute to the correction of a dis­
This patient presents a 12 mm overjet and deep over­ tal occlu­sion. The Concorde facebow with intermaxillary
bite with a full unit distal occlusion in the mixed denti­ and extraoral traction is effective in accelerating cor­
tion. At this stage of development there may be a rest­ rection to compensate for a lack of mandibular growth
ing phase in growth, when the patient does not gain (Figs. 11.3A to C).
significantly in height. The mandible follows the growth Twin Blocks and Concorde facebow: 8 months
pattern of a long bone, therefore mandibular growth is Support and retention: 6 months.

Case Report: WF

B C
Figs. 11.3A to C: Treatment: (A) Profiles at ages 9 years 5 months (before treatment) and 9 years 11 months (after treatment); (B and C)
Occlusion after 5 months of treatment at age 9 years 11 months.
170  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: WF

WF Age 9.5 9.11 13.11


Cranial Base Angle 25 24 27
Facial Axis Angle 32 29 33
F/M Plane Angle 19 21 19
Craniomandibular Angle 44 44 46
Maxillary Plane 1 −3 −1
Convexity 5 5 3
U/Incisor to Vertical 32 18 16
L/Incisor to Vertical 30 34 39
Interincisal Angle 118 128 125
6 to Pterygoid Vertical 14 11 16
L/Incisor to A/Po −3 0 1
L/Lip to Aesthetic Plane 1 −2 −2
The Twin Block Traction Technique  171

Case Report: KS Aged 11 Years 6 Months loss of 6, and was treated by extraction of 4 4 and 4 to
The growth response slows significantly in girls after the achieve better symmetry (Figs. 11.4A to G). Treatment was
onset of menstruation. This tends to reduce the man­ effective in reducing an overjet of 12 mm and an exces­
dibular response to functional treatment. The addition sive overbite of 9 mm to produce an acceptable occlusion.
of orthopedic traction may be required to achieve cor­ A Concorde facebow resulted in flattening of the profile
rection of a severe distal occlusion. by maxillary retraction, combined with a favorable man­
This is an early example of Twin Block treatment for dibular advancement. The skeletal correction reduced the
a girl with a severe Class II division 1 malocclusion with convexity from 8 mm before treatment to 3 mm out of
excessive overbite. The case was complicated by previous retention at age 18.

Case Report: KS

B C D

E F G
Figs. 11.4A to G: Treatment: (A) Profiles at ages 11 years 6 months (before treatment) and 14 years 2 months (after treatment);
(B and C) Occlusion before treatment; (D) Occlusion 2 years out of retention; (E) Facial appearance before treatment; (F) Concorde facebow
used during treatment; (G) Facial appearance after treatment: aged 14 years 2 months.
172  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: KS

KS Age 11.6 13.0 17.9


Cranial Base Angle 27 28 28
Facial Axis Angle 26 28 29
F/M Plane Angle 24 25 20
Craniomandibular Angle 50 53 48
Maxillary Plane 2 2 0
Convexity 8 5 3
U/Incisor to Vertical 32 14 17
L/Incisor to Vertical 26 20 17
Interincisal Angle 122 146 146
6 to Pterygoid Vertical 17 22 20
L/Incisor to A/Po −1 −1 −1
L/Lip to Aesthetic Plane −2 0 −3
The Twin Block Traction Technique  173

DIRECTIONAL CONTROL OF postures forward and an anterior seal is formed by clos­


ORTHOPEDIC FORCE ing the lips together over the teeth. The soft tissues adapt
quickly to full-time appliance wear as the patient eats
Additional orthopedic forces may help to control vertical with the appliance in the mouth. This produces an effec­
growth by applying an intrusive orthopedic force to the tive anterior oral seal, whereby it is more economical for
upper posterior teeth. A high pull headgear is used to the circumoral muscles to form the seal by lip closure
apply an intrusive force to the upper molars to resist the than by lip to tongue contact.
vertical component of growth and to reduce the anterior The overjet reduced from 10 mm to 2 mm in
open bite. The Concorde facebow is a unique method 3 months. During this period a slight posterior open bite
of delivering an intrusive force to upper molars and, at developed. To maintain an intrusive occlusal force on
the same time, a protrusive force to the mandible and the posterior teeth, Twin Blocks continued to be worn
the lower dentition. The direction of extraoral force is full time without reducing the occlusal blocks. This helps
especially important in the treatment of patients with to resolve an anterior open bite. The Concorde facebow
a vertical growth pattern. A vertical orthopedic force to
was worn at night for the first 6 months of treatment.
the upper appliance applies an intrusive force to the
During the support phase an anterior inclined plane was
upper posterior teeth and palate, and limits downward
designed for retention with the lower incisors occluding
maxillary growth.
on the cingula of the upper incisors as the buccal teeth
Intrusion of the upper posterior teeth allows the bite
settle into occlusion. The rapid correction occurred in
to close by a favorable forward rotation of the mandible,
this case mainly by mandibular advancement, and was
and facilitates correction of mandibular retrusion in
accompanied by an increase in the upper pharyngeal
vertical growth discrepancies.
space from 3 mm to 10 mm after 4 months of treatment
The addition of traction is optional in reduced over­
(Figs. 11.5 and 11.6).
bite cases, and many cases respond well to treatment
without traction. Traction is indicated in severe discrep­ Twin Blocks and Concorde facebow: 4 months
ancies with vertical growth which are unfavorable for Support phase: 6 months
functional correction. A vertical component of traction Retention: 4 months
force is particularly effective in controlling this type of Treatment time: 14 months
malocclusion. Final records: 6 years 9 months out of retention.
The Concorde facebow is adjusted so that it lies just
below the level of the upper lip at rest, with the ends of
the outer bow sloping slightly upward above the level of
the inner bow. The resulting extraoral traction applies
an upward component of force that helps to retain the
upper appliance.

Case Report: LG Aged 9 Years 1 Month


This girl presented a severe mandibular retrusion with
10 mm convexity and mild maxillary protrusion. An over­
jet of 10 mm was perpetuated by a tongue thrust and a
tooth apart swallow, resulting in an incomplete overbite.
The lower incisors normally erupt into contact with the
upper incisors or the soft tissue of the palate, unless they
are prevented from doing so by intervening soft tissues or
by a thumb or finger sucking habit. Reduced overbite may
present as a small separation of the lower incisors from
the palate. This is due to an atypical swallowing pattern as
the tongue thrusts between the teeth to contact the lower
lip to form an anterior oral seal in a “tooth apart” swallow. Fig. 11.5: Vertical extraoral traction force to intrude upper posterior
The soft-tissue pattern improves when the mandible teeth.
174  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: LG

B C D

E F G

H I J

K L M

N O P
Figs. 11.6A to P: Treatment: (A) Profiles at ages 10 years 8 months (before treatment), 10 years 11 months (after 3 months treatment)
and 18 years 4 months; (B) Occlusion before treatment; (C) Twin Blocks; (D) Occlusion before treatment; (E to G) Occlusion after 3 months
of treatment; (H) Concorde facebow and combination headgear with high pull; (I) Occlusion after 9 months of treatment; (J) Addition of an
anterior inclined plane; (K to M) Occlusion at age 11 years 6 months; (N) Facial appearance before treatment at age 10 years 8 months;
(O) Facial appearance after 3 months of treatment; (P) Facial appearance at age 18 years 4 months.
The Twin Block Traction Technique  175

Case Report: LG

LG Age 10.8 10.11 15.4


Cranial Base Angle 25 26 26
Facial Axis Angle 27 26 26
F/M P lane Angle 27 27 27
Craniomandibular Angle 52 52 52
Maxillary Plane −1 1 0
Convexity 10 9 8
U/Incisor to Vertical 19 18 17
L/Incisor to Vertical 46 47 41
Interincisal Angle 115 115 122
6 to Pterygoid Vertical 22 20 23
L/Incisor to A/Po 0 4 3
L/Lip to Aesthetic Plane 1 3 −1

REFERENCES
Cousins AJP, Clark WJ, (1965). Extraoral traction. Theoretical
Clark WJ, (1982). The Twin-Block traction technique, European considerations and the development of the removable
Journal of Orthodontics. 4:129-38. appliance system, Trans BSSO. 29-38.
Clark WJ, (1988). The Twin-Block technique, American Journal Orton HS, (1990). Functional appliances in orthodontic
of Orthodontics and Dentofacial Orthopedics. 93:1-18. treatment, Quintessence, London.
Treatment of Anterior Open Bite and Vertical Growth Patterns 177

Chapter 12
Treatment of Anterior
Open Bite and Vertical
Growth Patterns

INTRODUCTION soft-tissue behavior patterns. Tongue thrust is often a


necessary functional adaptation required to form an
The anterior open bite is frequently due to a combina- effective anterior oral seal by means of tongue contact
tion of skeletal and soft-tissue factors. A full clinical and with a trapped lower lip. This type of tongue thrust is usu-
cephalometric diagnosis is necessary to establish the ally adaptive after expanding the maxilla and correcting
etiology of the problem. This includes evaluation of the arch relationships. Learning to eat with Twin Blocks in
airway, which is a factor in achieving lip competence the mouth encourages the formation of a good lip seal.
after treatment. When the overjet is reduced, a lip seal can be formed
Airway obstruction may be due to enlargement of ton- more efficiently without the support of the tongue. The
sils or adenoids and should be referred for evaluation or oral musculature then adapts accordingly.
treatment when required. The upper pharyngeal airway is A more persistent anterior open bite is related
measured from the posterior pharyngeal wall to the out- occasionally to a tongue thrust which does not adapt to
line of the upper half of the soft palate. An upper airway corrective treatment and can be one of the most difficult
of 12 mm is typical in the mixed dentition. This increases orthodontic problems to resolve. This condition is related
with age to a mean of 17.4 mm in the adult (McNamara frequently to a lisp and a habitual forward tongue position,
& Brudon, 1993). Narrowing of the pharyngeal airway causing a bimaxillary protrusion. Some patients have a
appears to be improved by mandibular advancement pernicious habit of licking the lips, which may be dry and
during the first few months of Twin Block treatment. cracked as a result. This is often associated with a tongue
Long-term observation after treatment confirms that the thrust and may be difficult to resolve.
increase in upper pharyngeal width is maintained and Reduced overbite or anterior open bite is often related
lip competence is also achieved consistently during Twin to unfavorable vertical growth and requires careful man-
Block treatment. agement. Elastic bands worn at night apply vertical forces
The prognosis for correction of anterior open bite to maintain contact of the occlusal blocks. This encour-
depends on the degree of skeletal and soft-tissue imbal- ages a favorable mandibular rotation to reduce lower
ance. In addition, assessment of the direction of facial facial height by intruding posterior teeth (Fig. 12.1A). In
growth to identify a horizontal or vertical growth ten- treatment of anterior open bite and vertical growth it is
dency helps to establish the prognosis for treatment. important to avoid over-eruption of posterior teeth, as
Early treatment is frequently effective in controll- this would open the bite even more and accentuate the
ing the functional imbalance associated with adverse vertical growth tendency (Fig. 12.1B).
178 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

B C

D F
Figs. 12.1A to F: (A) Elastic bands apply vertical forces to maintain contact of the occlusal blocks. This is effective in intruding posterior
teeth in treatment of anterior open bite and vertical growth; (B) Maintain occlusal contact to intrude posterior teeth; (C) Pitfall: Do not allow
second molars to overerupt. Extend occlusal cover or occlusal rests distally to second molars; (D) Appliance design with spinner; (E) Upper
appliance with tongue guard (recurved wires); (F) Lower appliance with clasps extended to lower molars.
Treatment of Anterior Open Bite and Vertical Growth Patterns 179

PITFALLS IN TREATMENT OF the protrusive path. The overjet is measured with the
ANTERIOR OPEN BITE mandible retruded and in the position of maximum
protrusion. The activation must not exceed 70% of the
The worst complications of Twin Block treatment of ante- total protrusive path. It is especially important in vertical
rior open bite arise from careless management of the growth patterns to ensure that the patient can maintain
occlusal blocks, by allowing eruption of posterior teeth. comfortably the protrusive position and if necessary, to
This results in an increase in the anterior open bite. settle for a lesser amount of initial activation.
Two common mistakes are therefore to be avoided. The thicker Projet or Exactobite is designed to register
First, it is necessary to be attentive to avoid overeruption a 4 mm interincisal clearance, resulting in approximately
of second molars behind the appliance (Fig. 12.1C). It is 5 mm clearance between the cusps of the first premolars
all too easy to make this mistake by failing to check for or deciduous molars. It is necessary to accommodate
eruption of second molars at every visit. If the patient blocks of sufficient thickness between the posterior
attends once every 6 weeks, a lapse of concentration at teeth to open the bite beyond the free-way space so as
one visit can allow the second molars to erupt unimpeded to intrude the posterior teeth. The objective is to make
for 3 months. Prevention is better than cure for this it difficult for the patient to disengage the blocks. The
problem. Attention to appliance design is effective, and process of bite registration is similar in other respects to
if second molars are likely to erupt during treatment it is the method described for treatment of deep overbite.
appropriate to include occlusal rests, even before these
teeth erupt, in order to control their eruption. Appliance Design: Twin Blocks to
The second complication is equally damaging. If the Close the Bite
upper block is trimmed occlusally in the treatment of
anterior open bite this will allow the lower molars to Appliance design is modified to achieve vertical control
erupt, again propping the bite open and increasing the and close the anterior open bite. The lower appliance
anterior open bite. Fortunately, anterior open bite cases extends distally to the lower molar region with clasps
are in the minority, but as a result it is easy to become on the lower first molars and occlusal rests on the sec-
accustomed to trimming the upper block as a matter of ond molars to prevent their eruption. The acrylic may
routine. To avoid the problem it is strongly suggested that be trimmed slightly to relieve contact with the lingual
a clear note or color code is placed on the patient’s record surfaces of the upper and lower anterior teeth so that
card to draw attention to the anterior open bite and as they are free to erupt to reduce the anterior open bite
a reminder not to trim the blocks at any stage during (Figs. 12.1D to F).
treatment. A palatal spinner may be added to the upper appli-
Patients with anterior open bite and a vertical growth ance to help control an anterior tongue thrust. The
pattern tend to have weak musculature and may have spinner is an acrylic bead that is free to rotate round a
difficulty in consistently maintaining a forward posture transpalatal wire positioned in the palate. The objective
to engage the occlusal inclined planes of the bite blocks. is to encourage the ongue to curl upwards and backwards
They are prone to posture out of the appliance, which instead of thrusting forwards. This is especially effective
reduces the effectiveness in correcting both sagittal and in younger patients and the spinner should be used as
vertical discrepancies. These patients may benefit from early as possible to control tongue thrust.
phased progressive activation to allow the muscles to A spinner may be incorporated in an upper appli-
adapt more gradually to mandibular advancement. Verti- ance with a midline screw without interfering with the
cal elastics worn at night to intrude the upper posterior action of the midline screw to expand the arch. The
teeth overcome this problem. spinner may be mounted on a piece of steel tubing sup-
ported by wires extending from either side of the mid-
BITE REGISTRATION line. Alternatively, the spinner may be attached by a wire
that extends towards the midline from one side, and is
It is important to relate the degree of activation to the then recurved on itself to retain the spinner in position
freedom of movement of the mandible by measuring (Figs. 12.2A to C).
180 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

A C
Figs. 12.2A to C: (A and B) Spinner on tubing; (C) Modified anterior inclined plane with palate-free area to control tongue thrust.

Young children respond to the suggestion that the correct position in swallowing. The upper appliance may
spinner is a toy for the tongue to play with. They learn first incorporate a hole in the area of the palatal rugae and
to spin it with the finger, then with the tongue. Anything the tongue is naturally attracted to this area. This may be
that moves in the mouth is irresistible to the tongue. This combined with a shelf to restrict forward movement of
is a very positive mechanism for controlling tongue thrust the tongue, and with instruction this helps the patient to
by retraining the tongue to move up into the palate rather improve the swallowing pattern. It is necessary to devote
than thrusting forwards between the teeth. a few minutes every day practicing with a glass of water
A tongue guard is a more passive obstruction to in order to train the tongue to adopt the correct position
discourage the tongue from thrusting forwards against in the palate during swallowing. The same target area
the lingual surfaces of the upper incisors. It is in the should be continued in the support appliance.
form of a recurved wire extending from the premolar In treatment of anterior open bite a labial bow is
region towards the midline and is recurved to its point usually added to retract the upper incisors if they have
of attachment. This wire lies in the vertical plane and is been significantly proclined by tongue and lip action.
clear of the lingual surface of the upper incisors to allow In the treatment of reduced overbite it is essential that
them to settle lingually. no trimming is done on the blocks, and that occlusal
An effective method of controlling tongue thrust is contact of the posterior teeth is maintained on the blocks
to provide a target area to train the tongue to adopt the throughout treatment.
Treatment of Anterior Open Bite and Vertical Growth Patterns 181

Case Report: DP Aged 10 Years 10 Months reactivated by the addition of cold cure acrylic to the mesial
aspect of the upper block. During the course of treatment
This boy had a history of thumb sucking and presented the blocks were not trimmed, but were maintained in
an anterior open bite associated with a tongue thrust occlusal contact with all the posterior teeth. This had the
(Figs. 12.3A to M). The underlying skeletal pattern was effect of intruding the posterior teeth to produce a slight
brachyfacial with a convexity of 5 mm and mild mandi- posterior open bite, and allowed a positive overbite to
bular retrusion. The overjet was 10 mm with a full unit develop anteriorly. The upper pharyngeal space increased
distal occlusion. from 6 mm to 10 mm.
The overjet reduced from 10 mm to 4 mm after 3 Twin Blocks: 10 months
months of treatment, at which stage the appliance was Support and retention: 1 year.

Case Report: DP

B C D
Figs. 12.3A to D: Treatment. (A) Profiles at ages 10 years 10 months (before treatment), 11 years 10 months (12 months after treatment)
and 13 years 11 months; (B to D) Occlusion before treatment.
182 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

E F G

H I J

K L M
Figs. 12.3E to M: (E to G) Twin Blocks; (H) Contracted upper arch due to Thumbsucking; (I and J) Upper and lower archforms after
treatment; (K to M) Occlusion at age 13 years 11 months.
Treatment of Anterior Open Bite and Vertical Growth Patterns 183

Case Report: DP

DP Age 10.10 12.0


Cranial B ase Angle 26 25
Facial Axis Angle 31 33
F/M Plane Angle 18 16
Craniomandibular Angle 45 40
Maxillary Plane 1 2
Convexity 5 2
U/Incisor to Vertical 27 23
L/Incisor to Vertical 37 40
Interincisal Angle 116 117
6 to Pterygoid Vertical 16 18
L/Incisor to A/Po 0 5
L/Lip to Aesthetic Plane 1 0
184 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: SS Aged 14 Years 1 Month This is followed by a short period of day- and night-
This patient presented a Class II division 1 malocclusion time wear of the bionator, to encourage closure of the
in the permanent dentition with a severe dolichofacial anterior open bite by preventing the tongue from resting
growth pattern, resulting in a severe mandibular retrusion. between the teeth. The bionator continues as a retainer
A convexity of 11 mm and a high mandibular plane angle with a favorable functional component. This approach
were associated with an anterior open bite and increased observes the principle of using a functional retainer that
lower facial height. Vertical control was achieved by the supports the objectives of treatment.
Twin Block, followed by retention with a bionator to close Twin Blocks: 5 months
the open bite (Figs. 12.4A to M). The upper pharyngeal Bionator: 4 months full time, 12 months night time.
space increased from 9 mm to 14 mm during treatment. This patient has a severe vertical growth pattern which
The Twin Block achieves a more rapid response in is still present after treatment. This limits the improvement
the active phase to correct the anteroposterior arch that can be achieved in the facial profile. The dental
relationships. During this period the patient enjoys the relationship is corrected to class I, however, and a further
freedom of wearing a less restricting two-piece appliance, improvement could be achieved by a genioplasty, which
with better speech and less interference with normal is a simpler approach than major surgical correction
function. involving both the maxilla and the mandible.

Case Report: SS

B C D
Figs. 12.4A to D: Treatment. (A) Profiles at ages 14 years 1 month (before treatment), 14 years 9 months (after 8 months of treatment)
and 18 years; (B to D) Occlusion before treatment.
Treatment of Anterior Open Bite and Vertical Growth Patterns 185

E F G

H I J

K L M
Figs. 12.4E to M: (E) Facial appearance before treatment at age 14 years 1 month; (F and G) Facial appearance and occlusion after
4 months of treatment at age 14 years 5 months; (H to J) Occlusion after 8 months of treatment at age 14 years 9 months; (K to M)
Occlusion out of retention at age 18 years.
186 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: SS

SS Age 13.11 15.0 18.0


Cranial Base Angle 25 25 28
Facial Axis Angle 17 18 20
F/M Plane Angle 35 35 32
Craniomandibular Angle 50 51 51
Maxillary Plane −1 −2 0
Convexity 11 8 10
U/Incisor to Vertical 16 13 16
L/Incisor to Vertical 43 42 45
Interincisal Angle 121 125 119
6 to Pterygoid Vertical 12 12 19
L/Incisor to A/Po 2 4 4
L/Lip to Aesthetic Plane 5 2 3
Treatment of Anterior Open Bite and Vertical Growth Patterns 187

TREATMENT OF VERTICAL GROWTH facebow was used to accelerate the response to treat-
ment (Figs. 12.5A to E).
Case Report: HD Aged 12 Years 2 Months
This patient presented a severe dolichofacial growth
Clinical Management
pattern and was past the adolescent or pubertal growth An alternative approach to consider when a deep overbite
spurt at the start of treatment. Convexity was 9 mm is associated with a vertical growth pattern would be to
due to severe mandibular retrusion with an increased level and align the lower arch with a fixed appliance, so
mandibular plane angle of 28°. As a result the response as to reduce the overbite before the Twin Block stage. The
to treatment was slower than normal due to a limited mandible may then be advanced with a smaller vertical
growth response combined with the vertical direction component of activation in order to reduce the vertical
of growth (facial axis angle = 24°). The overjet was component of growth during treatment.
14 mm with excessive overbite and the lower inci- Twin Blocks: 12 months
sors were 4 mm lingual to the A–Po line. The Concorde Support and retention: 12 months.

Case Report: HD

B C

D E
Figs. 12.5A to E: Treatment. (A) Profiles at ages 12 years 2 months (before treatment) and 15 years 7 months (after treatment);
(B and C) Occlusal change at age 12 years 2 months and 15 years 1 month; (D) Facial appearance before treatment at age 12 years
2 months; (E) Facial appearance at age 15 years 7 months.
188 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: HD

HD Age 12.3 16.2


Cranial Base Angle 25 28
Facial Axis Angle 24 25
F/M Plane Angle 28 28
Craniomandibular Angle 53 56
Maxillary Plane 0 0
Convexity 9 8
U/Incisor to Vertical 22 8
L/Incisor to Vertical 24 36
Interincisal Angle 134 134
6 to Pterygoid Vertical 14 13
L/Incisor to A/Po 4 0
L/Lip to Aesthetic Plane −1 −1
Treatment of Anterior Open Bite and Vertical Growth Patterns 189

Case Report: LJ Aged 9 Years 10 Months vertical growth. The response to treatment was slow in
this case, because the patient did not appear to pos-
This is an example of the response to treatment in a
ture her mandible consistently forward on the inclined
girl with a dolichofacial growth pattern. An overjet of
planes. This was probably related to weak muscula-
11 mm, associated with convexity of 8 mm, is mainly
ture associated with vertical growth. The overjet and
due to maxillary protrusion, with moderate mandibular
distal occlusion were corrected within a year and sup-
retrusion. The Concorde facebow was therefore used to
port and retention with an anterior inclined plane pro-
assist correction. The Frankfort mandibular plane angle
duced a satisfactory result which was stable 5 years out
is 29° and the maxillary plane has an upward cant of 5°
of retention.
resulting in increased lower facial height and a maxillo-
mandibular plane angle of 34° (Figs. 12.6A to I). Twin Blocks: 12 months
Support: 3 months
Clinical Management Retention: 1 year.
The Twin Blocks were made with occlusal contact on all
posterior teeth to apply an intrusive force to minimize

Case Report: LJ

B C D

E F G

H I
Figs. 12.6A to I: Treatment. (A) Profiles at ages 9 years 11 months (before treatment), 14 years (1 year 10 months out of retention)
and 16 years 10 months); (B to D) Occlusion before treatment; (E to G) Occlusion 5 years out of retention; (H and I) Facial appearance
before and after treatment.
190 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: LJ

LJ Age 10.2 11.4 16.10


Cranial Base Angle 33 32 30
Facial Axis Angle 25 22 22
F/M Plane Angle 29 31 31
Craniomandibular Angle 62 63 60
Maxillary Plane 5 4 3
Convexity 8 6 4
U/Incisor to Vertical 28 11 23
L/Incisor to Vertical 31 30 32
Interincisal Angle 121 139 123
6 to Pterygoid Vertical 11 9 11
L/Incisor to A/Po −2 0 1
L/Lip to Aesthetic Plane 0 1 −1
Treatment of Anterior Open Bite and Vertical Growth Patterns 191

Fig. 12.7: Intraoral traction to close anterior open bite. Fig. 12.8: Treatment in this case was slow, and an anterior open
bite persisted because the patient did not close consistently into
the blocks.

A B
Figs. 12.9A and B: (A) Intraoral vertical elastics to intrude posterior teeth. When vertical elastics were added an immediate improvement
in response was noted; (B) The anterior open bite reduced and the overjet and distal occlusion corrected.

A B C

D E F
Figs. 12.10A to F: (A) Occlusion with anterior open bite is not responding after 9 months treatment; (B) Vertical elastics added to accelerate
correction; (C) Progress improved after 4 months with vertical elastics; (D to F) The occlusion is stable out of retention.
192 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

INTRAORAL TRACTION TO CLOSE the response to treatment by assisting muscle action in


ANTERIOR OPEN BITE maintaining contact on the occlusal inclined planes. The
elastics worn in this manner were light and passive as
Intraoral elastics may be used to accelerate bite closure as long as the jaws were closed properly into the appliance.
an efficient alternative to high-pull extraoral traction. This However, as soon as the patient’s mandible dropped
simple mechanism is very effective in closing anterior open, the elastics were stretched, which in turn caused
open bites. The method was brought to the author’s the appliance to become dislodged from either the upper
attention by Dr Christine Mills who first used the system or the lower dentition. The patient was thus reminded of
in orthodontic practice in Vancouver. Vertical elastics were the importance of keeping the mandible closed in the
first applied to help patients maintain occlusal contact on proper forward position while sleeping. This helps by
the appliances overnight. The author observed at a study intruding the posterior teeth and also accelerates the
group in Vancouver that the elastics had the additional correction of distal occlusion (Figs. 12.8 and 12.9). This is
benefit of closing the bite (Fig. 12.7). particularly important in patients with restricted airways
The intrusive effect of the bite blocks is reinforced due to enlarged tonsils and adenoids as well as in those
by running a vertical elastic between upper and lower patients with chronic nasal congestion due to allergies
teeth on both sides. Elastics may be attached directly to or sinus problems. Such patients tend to sleep with the
the upper and lower appliances or to brackets or bands mouth open and this in turn favors vertical growth of the
with gingival hooks. An effective vector is produced by jaws as well as excessive eruption of the dentition.
passing an elastic between the brackets on the upper first
deciduous molar and lower second deciduous molar (or VERTICAL ELASTIC TO CORRECT
the upper first and lower second premolars). The elastics
ANTERIOR OPEN BITE
are worn at night to maintain occlusal contact of the
posterior teeth on the bite blocks to intrude posterior This patient failed to respond to Twin Block treatment
teeth. All posterior teeth must contact the occlusal blocks and the position after 9 months showed an anterior open
to prevent eruption and to deliver intrusive forces. bite with contact only on the first permanent molars. No
To maximize the effects of elastic traction, the elastics adjustment was made to the appliance, except that the
may be worn full time. It is important that the cons- patient was instructed to wear vertical intraoral elastics,
truction bite should open the bite beyond the rest position which passed from clasps on the lower premolars to the
to ensure that the patient cannot comfortably posture out loop of the labial bow on the upper appliance.
of the blocks. This had the immediate effect of improving progress,
Intraoral vertical elastics have the additional advan- and treatment was completed successfully within a
tage of increasing occlusal contact on the inclined further 6 months. The occlusion proved to be stable out
planes. This is an important factor in patients who have of retention for a patient who did not initially respond
weak musculature and do not occlude positively on the to treatment (Figs. 12.10A to F).
occlusal inclined planes. These are generally patients The following patients were treated by Dr Christine
with a vertical growth pattern who do not respond Mills in her orthodontic practice in Vancouver. The
well to functional therapy, because their potential for addition of vertical intraoral elastics is a significant factor
horizontal growth is poor. The addition of a mechanical in the favourable changes observed in these patients.
component of elastic traction is effective in improving The elastics were worn only at night.
Treatment of Anterior Open Bite and Vertical Growth Patterns 193

Case Report: BG Aged 8 Years 1 Month mandibular translation, and the A point, Nasion, B point
(ANB) angle is reduced from 8° to 5°. Mandibular super-
This girl has a retrognathic profile [Sella, Nasion, A point imposition clearly shows that the angulation of con-
(SNA) = 76°] and a facial axis angle of 15°, indicating dylar growth is in a distal direction, thus contributing
an extreme vertical growth pattern. An anterior open to the forward mandibular rotation. This is a very favor-
bite relates to the skeletal pattern and vertical growth. able response in a patient with a difficult growth pattern.
After 8 months of treatment with Twin Blocks the facial The improvement is reflected in the facial profile
axis angle has improved to 18° as a result of forward (Figs. 12.11A to G).

Case Report: BG

B C D

E F G
Figs. 12.11A to G: Case records show the progress during treatment of this severe malocclusion. (A) Profiles at ages 8 years 1 month
(before treatment) and 8 years 9 months (after treatment); (B to D) Occlusion before treatment; (E to G) Occlusion after treatment.
194 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: BG

BG Age 8.1 8.9


Cranial Base Angle 27 28
Facial Axis Angle 15 18
F/M Plane Angle 38 38
Craniomandibular Angle 65 66
Maxillary Plane –1 –1
Convexity 6 3
U/Incisor to Vertical 10 5
L/Incisor to Vertical 33 37
L/Incisor to A/Po 2 1
L/Lip to Aesthetic Plane 1 1
6 to Pterygoid vertical 8 8
Treatment of Anterior Open Bite and Vertical Growth Patterns 195

Case Report: CR Aged 9 Years 8 Months to manage. Treatment is successful in correcting the
open bite, reducing the overjet and correcting the dis-
by Christine Mills tal occlusion. The ANB angle reduces from 5° to 1° and
This patient presents a substantial open bite and exces- the anterior open bite is closed after 1 year of treatment
sive overjet in mixed dentition, which can prove difficult (Figs. 12.12A to G).

Case Report: CR

B C D

E F G
Figs. 12.12A to G: Treatment. (A) Profiles at ages 9 years 8 months (before treatment) and 10 years 9 months (after treatment);
(B to D) Occlusion before treatment; (E to G) Occlusion after treatment.
196 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: CR

CR Age 9.8 10.9


Cranial Base Angle 25 26
Facial Axis Angle 28 29
F/M Plane Angle 27 25
Craniomandibular Angle 52 51
Maxillary Plane 4 4
Convexity 3 0
U/Incisor to Vertical 26 20
L/Incisor to Vertical 23 26
L/Incisor to A/Po –3 1
L/Lip to Aesthetic Plane –4 –3
6 to Pterygoid Vertical 10 8
Treatment of Anterior Open Bite and Vertical Growth Patterns 197

Case Report: AM Aged 8 Years 8 Months skeletal changes are confirmed by an increase in the
facial axis angle from 16° to 20°, while the mandibular
by Christine Mills plane angle reduced from 38° to 35°. The primary factor
A severe vertical growth pattern is related in this case in successful treatment can be attributed to intrusion of
to an anterior open bite with an extreme facial axis the upper molars, which in turn allowed the mandible
angle of 16° and a mandibular plane angle of 38°. This to rotate forward, accounting for a reduction in the ANB
pattern would normally present a very poor prognosis for angle by 4.7°. These are exceptional skeletal changes in a
functional correction, but responded favorably to Twin short period of time, allowing this difficult malocclusion
Block treatment. The overjet of 10 mm was reduced to to be corrected by simple treatment. In esthetic terms
2 mm after 8 months’ treatment and within the same time there is a significant improvement in facial appearance
frame the open bite was completely resolved. Favorable (Figs. 12.13A to G).

Case Report: AM

B C D

E F G
Figs. 12.13A to G: Case records show the progress during treatment of this severe malocclusion. (A) Profiles at ages 8 years 8 months
(before treatment) and 9 years 4 months (after treatment); (B to E) Occlusion before treatment; (F and G) Occlusion after treatment.
198 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: AM

AM Age 8.8 9.4


Cranial Base Angle 28 28
Facial Axis Angle 16 20
F/M Plane Angle 38 35
Craniomandibular Angle 66 63
Maxillary Plane –1 –1
Convexity 4 1
U/Incisor to Vertical 27 20
L/Incisor to Vertical 28 25
L/Incisor to A/Po 0 2
L/Lip to Aesthetic Plane –4 –5
6 to Pterygoid Vertical 7 10
Treatment of Anterior Open Bite and Vertical Growth Patterns 199

Case Report: MS Aged 10 Years form, occlusion and facial appearance (Figs. 12.14A to F).
Functional retention is important in mixed dentition
by Christine Mills treatment. Twin blocks may continue to be worn at night
Vertical growth is again associated with an anterior with vertical elastics to maintain intrusive forces on the
open bite due to a facial axis angle of 22°. After 1 year posterior teeth and to reinforce the sagittal correction.
of treatment the ANB angle is reduced from 6° to 2°, the If necessary this can be followed by a short period with
open bite is closed with positive improvements in arch fixed appliances when the permanent teeth erupt.

Case Report: MS

A B

C D

E F
Figs. 12.14A to F: Treatment. (A) Profiles at ages 10 years 0 months (before treatment) and 11 years 1 month (after treatment); (B)
Occlusion before treatment; (C) Occlusion after treatment; (D) Occlusion before treatment; (E) Appearance after treatment; (F) Facial
appearance several years later out of retention.
200 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: MS

MS Age 10.0 11.1


Cranial Base Angle 26 27
Facial Axis Angle 22 24
F/M Plane Angle 31 29
Craniomandibular Angle 57 56
Maxillary Plane 0 0
Convexity 5 1
U/Incisor to Vertical 14 17
L/Incisor to Vertical 19 24
L/Incisor to A/Po –5 –1
L/Lip to Aesthetic Plane –6 –2
6 to Pterygoid Vertical 12 11
Treatment of Anterior Open Bite and Vertical Growth Patterns 201

TREATMENT OF ANTERIOR OPEN BITE in the upper Twin Block. The range of activation is 6 mm
AND VERTICAL GROWTH (Figs. 12.15 and 12.16).
This may be used for progressive activation in
Screw for Progressive Activation treatment of anterior open bite and vertical growth
of Twin Blocks patterns, but is not advised for treatment of deep bite in
Patients with vertical growth patterns have weak mus- brachyfacial growth where it is necessary to encourage
culature and cannot easily maintain a forward posture eruption of lower molars. The screw in the upper block
of the mandible. It may be necessary to activate the does not permit molar eruption. This is an advantage in
Twin Block occlusal inclined planes progressively. This treatment of open bite where molars are not permitted to
screw was designed by Dr Geserick to be incorporated erupt (Figs. 12.17A to I).

Fig. 12.15: An occlusal screw for progressive activation may be Fig. 12.16: The range of action is 6 mm.
used in treatment of vertical growth. This screw is available from
FORESTADENT.

A B C

D E F

G H I
Figs. 12.17A to I: Treatment of an anterior open bite using occlusal screws for progressive activation. This patient was treated by Dr Mark Geserick.
202 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Screw Advancement System for spacers are placed to support the increased activation.
Progressive Activation This concept is useful in the treatment of vertical growth
This screw advancement system was designed by in Class II malocclusion, when smaller activations are
Carmichael and Banks (1999). The head of the screw more easily tolerated by patients. This screw is not as
is conical in shape and this acts as an inclined plane. thick as the Geserick design to incorporate in the blocks
The screw can be activated at adjustment visits and (Figs. 12.18A to C).

A B C
Figs. 12.18A to C: The screw advancement system designed by Carmichael and Banks for progressive activation.

Kits for Progressive Screw Advancement (Figs. 12.19A and B)

A B
Figs. 12.19A and B: Laboratory and chairside kits are available from ORTHOCARE for progressive advancement using the system
developed by Carmichael and Banks.
Treatment of Anterior Open Bite and Vertical Growth Patterns 203

RESPONSE TO TREATMENT OF are cases that orthodontists tend to view as their greatest
ANTERIOR OPEN BITE (FIGS. 12.20A TO C) challenge. Luck with the growth pattern rarely enters into
the equation when correcting these patients.
by Christine Mills with reference to a thesis by Colleen Adams Some light has been shed on this subject by the findings
of Dr Colleen Adams in her Master’s thesis research at the
Introduction University of Alberta in Edmonton, Canada (Adams 2000).
Dr Adams investigated the role played by the Twin Block
Invariably, when outstanding clinical results are demon-
appliance in controlling the vertical dimension during
strated with functional appliances, skeptics in the pro-
Class II treatment, and she has attempted to clarify the
fession suggest that these results are more likely the result
relationship between changes in the vertical dimension
of a “good growth pattern” than the therapeutic effect
and the anteroposterior correction achieved during Twin
of the appliance itself. Detractors argue that the Class
Block therapy.
II skeletal correction was more a matter of luck than of
actual treatment effect.
The real litmus test of functional appliance therapy
Methods and Materials
comes with the severe skeletal Class II patient who has a In order to test the efficacy of the Twin Block appliance,
vertical growth pattern and an anterior open bite. These eight of the most vertical growers with anterior open

B C
Figs. 12.20A to C: Superimposition of composite tracing, for vertical growth pattern, open bite patients treated with Twin Blocks. (A) Maxilla;
(B) Mandible; (C) Superimposition on anterior cranial base. T1–T2 = 12.6 months.
204 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
bite malocclusions were selected from a group of 59 in achieving correction of these difficult Class II open
consecutively treated severe Class II Twin Block patients bite malocclusions. The Twin Block’s ability to control
from the private practice of the author. The combination the vertical dimension by inhibiting molar eruption was
of a severe Class II skeletal pattern and an unfavorable helpful in preventing any increase in the mandibular
vertical growth pattern in these patients created a plane angle as the mandible grew forward.
challenge for orthodontic treatment. All of the patients While there was no apparent withholding effect on the
were in the mixed dentition stage of development. maxilla, there was a substantial forward growth effect on
A matched control group was obtained from the the mandible.
Bolton-Brush growth study to achieve the best possible
match based on age, sex, severity of the Class II relation Magnetic Force
and vertical skeletal indicators. It was found that there
was a high degree of matching of the vertical indica- Magnetic force is an alternative method of increasing forces
tors with no significant differences between the treat- for intrusion of opposing posterior teeth by incorpora-
ment and control groups. When the Class II indicators ting magnets in the inclined planes on the posterior bite
were compared, there were no significant differences in blocks. Either attracting or repelling magnets may be used
the ANB angles, although there was a trend for higher and both are effective. Repelling magnets increase the
ANB angles in the treatment groups as compared to the opposing forces in the occlusal bite blocks to intrude
control groups. opposing teeth. This principle has been investigated by
Dellinger (1986).
Measurements Attracting magnets increase the frequency of occlusal
contacts on the inclined planes. Occlusal forces are the
A constructed grid as described by Mamandras and activating mechanism of Twin Blocks and increasing
Allen (1990) was incorporated into the customized the forces of occlusion is effective in accelerating both
computer analysis to assess various linear and angular anteroposterior and vertical correction. The application
measurements. A horizontal reference plane was con- of magnets in Twin Block treatment is discussed further
structed through sella at an angle of 8° below sella-nasion in Chapter 19.
to be used as an X-axis for measuring vertical changes in
various skeletal landmarks. A perpendicular plane through
sella served as the Y-axis for measuring anteroposterior
REFERENCES
changes of the various anatomic structures. Adams C, (2000). The Twin Block Appliance: a cephalometric
analysis of vertical control, Master thesis, University of Alberta,
Summary and Conclusions Edmonton, Canada.
Dellinger EL, (1986). A clinical assessment of the active vertical
The fact that the treatment group in this study had more corrector, a non-surgical alternative for skeletal open bite
significant Class II discrepancies than even the most treatment, American Journal of Orthodontics. 89:428-36.
severe cases available from the Bolton-Brush growth McNamara Jr, JA, Brudon WL, (1993). Orthodontic and Ortho-
pedic Treatment in the Mixed Dentition, Ann Arbor, Needham
study is an important consideration. It may be that the
Press.
treatment group and the control groups would have Mamandras AH, Allen LP, (1990). Mandibular response to the
grown differently because of this pretreatment disparity. bionator appliance, American Journal of Orthodontics and
Nevertheless, the Twin Block appliance was effective Dentofacial Orthopedics. 97:113-20.
Treatment of Class II Division 2 Malocclusion 205

Chapter 13
Treatment of Class II
Division 2 Malocclusion

INTRODUCTION
Retroclined upper incisors are responsible for holding the
mandible in a distal position in Angle’s Class II division
2 malocclusion. Twin Blocks have the effect of unlock-
ing the malocclusion by releasing the mandible from an
entrapped position of distal occlusion and thereby enco-
uraging a rapid transition to Class I arch relationship.
The mandible is released downwards and forwards,
encouraging the lower molars to erupt. At the same time,
the upper incisors are advanced to achieve a normal
incisor relationship (Fig 13.1).
The upper lateral incisors are frequently proclined and
rotated in this malocclusion and functional correction of
the distal occlusion is followed by a finishing stage with
fixed appliances to correct incisor rotations and detail the
occlusion. Brackets may be fitted on the upper anterior
teeth during the Twin Block stage and this is effective in
shortening the period of treatment, resulting in an easy
transition into fixed appliances.

Bite Registration
The construction bite in Class II division 2 malocclu-
sion 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. Fig. 13.1: Management of Class II division 2.
206 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
Harvold demonstrated that control of vertical deve- correction of arch-to-arch relationships. Functional cor-
lopment allows the correction of a Class II molar relation- rection may now proceed simultaneously with sagittal
ship to Class I by manipulation of the functional occlusal arch development by adding sagittal screws to upper and
plane. An occlusal table is used to inhibit the eruption lower Twin Blocks to combine the features of Twin Block
of upper molars while the mandibular buccal segments and sagittal appliances.
are allowed to erupt vertically in harmony with vertical The design of the upper Twin Block is modified by
growth of the lower face. the addition of two sagittal screws set in the palate for
Vertical development is the primary factor in correction anteroposterior arch development. The screws expand
of the Class II division 2 malocclusion, with minimum the arch by advancing the upper incisors and at the
advancement of the mandible. The overjet is frequently same time, drive the upper buccal segments distally and
normal, or may be reduced, and the construction bite is buccally along the line of the arch (Figs. 13.2A and B).
registered with the incisors in edge-to-edge occlusion. In appliance construction it is important that the
The amount of mandibular advancement is limited screws are positioned in the horizontal plane and angled
as this malocclusion is normally associated with a mild along the line of the buccal segments to achieve the
Class II skeletal relationship with a horizontal growth desired expansion. If the screws are angled downwards
pattern and a well-developed chin. It is important in anteriorly, the appliance tends to ride down off the upper
treating this malocclusion not to overcorrect the mandi- incisors as the screws are opened.
bular position which would result in a “dished in” or In the lower arch curved or straight screws may be
Class III profile. used in the canine or premolar region. Alternatively
sagittal or transverse TransForce lingual appliances are
TWIN BLOCK SAGITTAL more effective for arch development to treat more severe
labial crowding and lingually displaced incisors. See
APPLIANCE—APPLIANCE DESIGN
Chapter 23 for further information.
Sagittal Development
Combined Transverse and
In the treatment of Class II division 2 malocclusion,
Sagittal Development
sagittal arch development is necessary to increase arch
length and to advance retroclined incisors. Many patients with malocclusion present archforms that
Sagittal appliances were formerly used in antero- are restricted in both transverse and anteroposterior
posterior development of archform as an initial stage dimensions. The Class II division 2 malocclusion and
of treatment to improve archform before functional variations often require a combination of transverse and

A B
Figs. 13.2A and B: Sagittal Twin Blocks for correction of Class II division 2.
Treatment of Class II Division 2 Malocclusion 207

anteroposterior arch development in order to free the The triple-screw sagittal Twin Block appliance is
mandible from a distal occlusion. designed to improve archform in anteroposterior and
Examination of the occlusion and study models in transverse dimensions and simultaneously correct arch
such cases shows retroclined upper and lower incisors. relationships for patients presenting complex problems
Deficient arch width is associated with distal occlusion, of arch development. This appliance is a very powerful
and crowding is present in the upper incisor or canine mechanism for interceptive treatment and arch develop-
region. Sometimes all four upper incisors are retroclined ment (Figs. 13.3A to C).
and the upper canines are crowded buccally. The upper Alternatively, the three-way screw combines transverse
anterior teeth cause interference when the lower model and sagittal arch development. This incorporates two
is advanced and it is not possible to engage the molars screws housed in a single unit and operated independently
in Class I occlusion because of occlusal interference. to expand in the transverse and sagittal dimensions.
Appliances must be designed to improve archform The three-way screw must be positioned in the midline
in order to free the mandible from distal occlusion behind the anterior teeth. It has the disadvantage of being
(Figs. 13.3 and 13.4). It was formerly necessary to complete bulky to accommodate in this area, but is effective if the
separate stages of treatment to improve arch form before patient will tolerate the bulk in the anterior part of the
proceeding to functional correction. palate (Figs. 13.4A and B).

A C
Figs. 13.3A to C: (A and B) Triple screw sagittal appliances; (C) A triple screw sagittal Twin Block appliance.
208 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

A B
Figs. 13.4A and B: Three-way screw for combined transverse and anteroposterior arch development.

THE TWIN BLOCK SAGITTAL APPLIANCE


Case Report: HMcL Aged 14 Years 5 Months
In this typical Class II division 2 malocclusion in the
permanent dentition, the major correction of arch rela-
tionships was achieved in 6 months with Twin Blocks.
Brackets were fitted to improve alignment of the upper
anterior teeth during this stage, before progressing to a
simple fixed appliance to complete treatment.
Major correction of arch relationships is achieved
quickly and consistently with the Twin Block sagittal
appliance. There is the additional advantage of control-
ling the vertical dimension to increase lower facial height.
Subsequent fixed appliance treatment to complete ortho-
dontic correction is simplified by this approach.

Clinical Management
Both palatal screws are opened two quarter-turns/week,
once midweek and once at the weekend. This maintains
contact of the appliance on the lingual of the upper
incisors, and is effective in advancing these teeth to
release the mandible from its retrusive position, locked
in distal occlusion. The palatal acrylic adjacent to the
attached gingiva and rugae of the premaxillary area may
need slight reduction to allow the plate to abut against
the lingual surfaces of the crowns of the upper anteriors.
The same sequence of trimming the occlusal blocks
applies in the management of deep overbite in treatment
of Class II division 2 as in Class II division 1 malocclusion
(Fig. 13.5). The upper bite block is progressively trimmed
posteriorly to clear the occlusion for molar eruption in
the early stages. When the molars are in occlusion, the
lower appliance is gradually trimmed occlusally to allow
lower premolar eruption to reduce the lateral open bite. Fig. 13.5: Sequence of trimming blocks for Class II division 2.
Treatment of Class II Division 2 Malocclusion 209

After 5 months of treatment, brackets were placed lower incisors was worn for 6 months to maintain the
on the upper anterior teeth to initiate alignment at vertical correction and allow the buccal teeth to settle
the end of the Twin Block phase. At the next visit, the fully into occlusion. The removable appliance was then
lower appliance was left out and a Wilson lingual arch discarded and treatment was completed in 6 months with
was fitted to hold the position in the lower arch. An a simple upper fixed appliance, followed by retention
anterior inclined plane with an occlusal stop for the (Figs. 13.6A to J).

Case Report: HMcL

B C D

E F G

H I J
Figs. 13.6A to J: Treatment: (A) Profiles at ages 14 years 5 months (before treatment) and 15 years 2 months (9 months after treatment);
(B to D) Occlusion before treatment; (E and F) Twin Block appliances with screws to advance the upper incisors. Brackets were added
to the upper incisors at the end of the Twin Block phase; (G) Support phase after 4 months of treatment; (H to J) Upper archform and
occlusion after 9 months of treatment.
210 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: HK Aged 14 Years 6 Months anterior teeth concurrently with correction of the distal
occlusion and vertical development to correct the deep
This is another typical Class II division 2 malocclusion
overbite. A simple upper fixed appliance was used with
with a Class I skeletal pattern and a full unit Class II
a Wilson lower lingual arch to complete the treatment
dental occlusion as the mandible is trapped in distal
(Figs. 13.7A to P).
occlusion by retroclined upper incisors. The lower inci-
sors are also retroclined and are positioned 3 mm lin- Twin Blocks: 5 months
gual to the A–Po line. After initial proclination of the Support appliance/lingual arch: 6 months
upper incisors, an upper sectional fixed appliance was Upper fixed appliance: 6 months
added during the Twin Block stage to align the upper Final records: 1 year out of retention.

Case Report: HK

B C D

E
Figs. 13.7A to E: Treatment: (A) Profiles at ages 14 years 8 months (before treatment), 14 years 11 months (after 3 months of treatment)
and 16 years 6 months; (B to D) Occlusion before treatment; (E) Occlusion cleared for molar eruption.
Treatment of Class II Division 2 Malocclusion 211

F G H

I J K

L M N

O P
Figs. 13.7F to P: Treatment (contd…): (F) Upper archform before treatment; (G) Upper fixed appliance in phase 2; (H) Upper archform after
treatment; (I) Lower archform before treatment; (J) Wilson lingual arch in phase 2; (K) Lower archform after treatment; (L to N) Occlusion
after treatment at age 17 years 2 months; (O) Facial appearance before treatment at age 14 years 8 months; (P) Facial appearance after
treatment at age 16 years 6 months.
212 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: HK

HK Age 14.8 16.8


Cranial Base Angle 25 24
Facial Axis Angle 28 27
F/M Plane Angle 20 21
Craniomandibular Angle 44 45
Maxillary Plane −3 −5
Convexity 2 2
U/Incisor to Vertical 12 22
L/Incisor to Vertical 21 43
Interincisal Angle 157 135
6 to Pterygoid Vertical 17 19
L/Incisor to A/Po −3 2
L/Lip to Aesthetic Plane −1 −5
Treatment of Class II Division 2 Malocclusion 213

Case Report: SW Aged 12 Years 9 Months relationship and the upper incisors are advanced dur-
ing the Twin Block stage to develop a positive over-
This girl is an example of treatment of a Class II division 2 jet. Correction of the distal occlusion is achieved by
malocclusion in the late mixed dentition with a combi- encouraging vertical development of the lower molars
nation of Twin Blocks and fixed appliances. There is a that erupt forwards into a Class I occlusion with the
brachyfacial tendency and a mild mandibular retrusion, upper molars.
with a normal maxilla. Anterior brackets are fitted during the Twin Block
phase. This allows an easy transition to a fixed appliance
Bite Registration in the finishing stage. Sectional fixed appliances are
used with utility arches in a bioprogressive approach to
The intention of treatment in this Class II division 2
complete treatment (Figs. 13.8A to O).
malocclusion is to limit forward translation of the man-
dible because the Class II skeletal discrepancy is mild. Twin Blocks: 5 months
Therefore the bite is registered in an edge-to-edge incisor Fixed appliances: 15 months.

Case Report: SW

B C D
Figs. 13.8A to D: Treatment: (A) Profiles at ages 12 years 9 months (before treatment), 13 years 3 months (after 6 months with
Twin Blocks) and 14 years 9 months; (B to D) Occlusion before treatment.
214 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

E F G

H I J

K L M

N O
Figs. 13.8E to O: Treatment (contd…): (E to G) Orthodontic phase after 6 months of treatment; (H to J) Fixed appliances to complete the
treatment; (K to M) Occlusion at age 17 years 3 months; (N) Facial appearance before treatment at age 12 years 9 months; (O) Facial
appearance after treatment at age 14 years 9 months.
Treatment of Class II Division 2 Malocclusion 215

Case Report: SW

SW Age 12.9 14.9 16.7


Cranial Base Angle 25 23 23
Facial Axis Angle 28 27 30
F/M Plane Angle 23 26 24
Craniomandibular Angle 48 48 47
Maxillary Plane 2 −2 0
Convexity 3 0 −3
U/Incisor to Vertical 8 27 29
L/Incisor to Vertical 23 23 20
Interincisal Angle 149 130 131
6 to Pterygoid Vertical 17 18 21
L/Incisor to A/Po −2 1 1
L/Lip to Aesthetic Plane 1 −2 −3
216 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

THE CENTRAL SAGITTAL TWIN BLOCK In this case, lateral expansion in the upper arch was
FOLLOWED BY FIXED APPLIANCES carried out during the support phase, using a three-way
expansion screw to combine anteroposterior and lateral
Case Report: SWn Aged 12 Years 6 Months arch development, with a Wilson lower lingual arch to
This boy presented a Class II division 2 malocclusion in improve the lower archform. The major correction is
the permanent dentition with severely retroclined upper completed during the Twin Block phase, and the over-
incisors and an excessive overbite. A central sagittal Twin bite is controlled in the support phase. This was followed
Block was used to advance the upper incisors, to reduce by fixed appliances to complete the treatment. It is worth
the overbite and to correct the distal occlusion. This noting that consecutive use of removable and fixed appli-
appliance incorporates only a single screw lingual to the ances extends the period of treatment, whereas concur-
upper incisors to advance the retroclined incisors. rent use of fixed appliances with Twin Blocks reduces the
Failure to include lateral expansion during the first treatment time (Figs. 13.9A to R).
phase of sagittal correction can result in the development
of a lateral crossbite in the buccal segments, and it Twin Blocks: 12 months
is normally better to combine transverse and sagittal Arch development: 12 months
expansion during the Twin Block phase. Fixed appliances: 12 months.

Case Report: SWn

A B C

D E F
Figs. 13.9A to F: Treatment: (A and B) Occlusion before treatment at age 12 years 6 months; (C and D) Screw to advance the upper
incisors; (E) Twin Block appliances; (F) Occlusion after 1 year.
Treatment of Class II Division 2 Malocclusion 217

G H I

J K L

M N O

P Q R
Figs. 13.9G to R: Treatment (contd…): (G to I) Phase 2 appliance with a three-way expansion screw; (J to L) Occlusion before fitting the
fixed appliances at age 14 years 8 months; (M to O) Occlusion at age 17 years 11 months; (P to R) Occlusal views and facial appearance
at age 17 years 11 months.
218 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Reports correction of the overbite and the excessive curve of Spee.
During the support phase a bite plate was used with fixed
The following three patients were treated by Dr Forbes
appliances and elastics extending from upper laterals
Leishman in his orthodontic practice in Auckland,
to lower molars and then to upper molars to combine
New Zealand.
vertical closure with a Class II intermaxillary component.
They demonstrate the management of Class II divi-
Leveling of the arches was then completed with fixed
sion 2 malocclusion by a combination of Twin Blocks and
appliances. This approach encouraged a good vertical
fixed appliances.
growth response, which together with the mandibular
Case Report: JC Aged 12 Years 6 Months advancement produced favorable changes in the profile.
Final records show the position out of retention at
A strong brachyfacial pattern is the underlying skeletal
age 20 years 1 month (Figs. 13.10A to L).
configuration for a severe Class II division 2 malocclusion
with reduced lower facial height. Treatment was initiated Upper removable and lower fixed appliances: 5 months
with an upper removable appliance to procline the Twin Blocks: 6 months
upper central incisors in combination with a lower fixed Bite plane: 6 months
appliance to procline the lower incisors. This was followed Fixed appliances: 18 months
by Twin Blocks to correct the distal occlusion and initiate Total treatment time: 3 years followed by retention.

Case Report: JC

B C D
Figs. 13.10A to D: Treatment: (A) Profiles at ages 12 years 6 months (before treatment) and 17 years (after treatment); (B to D) Occlusion
before treatment.
Treatment of Class II Division 2 Malocclusion 219

E F G

H I J

K L
Figs. 13.10E to L: Treatment (contd…): (E to G) Fixed appliance in orthodontic phase; (H to J) Occlusion after treatment; (K) Facial
appearance before treatment; (L) Facial appearance after treatment.
220 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: JC

JC Age 12.6 17.6 20.1


Cranial Base Angle 31 32 28
Facial Axis Angle 30 32 32
F/M Plane Angle 21 19 17
Craniomandibular Angle 52 51 45
Maxillary Plane 1 2 4
Convexity –1 –3 –3
U/Incisor to Vertical 12 22 21
L/Incisor to Vertical 11 16 12
L/Incisor to A/Po –5 –3 –3
L/Lip to Aesthetic Plane –3 –6 –6
6 to Pterygoid vertical 11 12 13
Treatment of Class II Division 2 Malocclusion 221

The following case records show the treatment of facial esthetics by accentuating nasal growth, while
two sisters, both of whom have severe Class II division the dentition and the mandible are not free to develop
2 malocclusions. This type of malocclusion can be effec- normally. Treatment was initiated with an upper remov-
tively treated in late mixed dentition or early permanent able appliance to procline the upper incisors, followed
dentition by a combination of Twin Blocks and fixed by the Twin Block phase, and finally fixed appliances.
appliances, either concurrently or in consecutive phases. Comparison of the profile before and after treatment
demonstrates the improvement in facial esthetics when
Case Report: EC Aged 11 Years 11 Months the angulation of the upper incisors is corrected and the
mandible is released to develop forward. The nasolabial
by Forbes Leishman
angle improves and mandibular development brings the
The first sister is treated in late mixed dentition and
chin forward to improve facial balance (Figs. 13.11A to L).
presents a severe Class II division 2 malocclusion with
a typical brachyfacial pattern and 5 mm convexity due Upper removable appliance: 5 months
to mandibular retrusion. The mandible is trapped in Twin Blocks: 6 months
a distal position by severely retroclined upper central Fixed appliances: 10 months
incisors before treatment, accentuating the retrusive Total treatment time: 1 year 9 months followed by
profile. Typically maxillary width is also contracted, as retention.
an additional factor contributing to deficient mandibular Final records: Show the position out of retention at
development. An obtuse nasolabial angle compromises age 21 years 5 months.

Case Report: EC

B C D
Figs. 13.11A to D: Treatment: (A) Profiles at ages 11 years 11 months (before treatment), 13 years 8 months (after treatment) and
21 years 5 months (out of retention); (B to D) Occlusion before treatment.
222 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

E F G

H I

J K L
Figs. 13.11E to L: Treatment (contd…): (E to G) Orthodontic phase after 21 months of treatment; (H) Facial appearance before treatment;
(I) Facial appearance after treatment; (J to L) Occlusion out of retention.
Treatment of Class II Division 2 Malocclusion 223

Case Report: EC

EC Age 11.11 13.8 21.5


Cranial Base Angle 29 29 29
Facial Axis Angle 23 23 23
F/M Plane Angle 26 28 26
Craniomandibular Angle 55 57 55
Maxillary Plane 2 3 3
Convexity 2 0 1
U/Incisor to Vertical 2 16 13
L/Incisor to Vertical 28 39 22
L/Incisor to A/Po –3 1 –2
L/Lip to Aesthetic Plane –5 –4 –5
6 to Pterygoid Vertical 12 11 15
224 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: KC 12 Years 9 Months a significant contribution to the improvement in facial


balance (Figs. 13.12A to J).
The previous patient’s sister was treated slightly later after
the permanent canines had erupted. Once again the profile Upper limited fixed appliance: 7 months
before treatment shows evidence of mandibular retrusion. Twin Blocks: 7 months
A partial bonded upper fixed appliance was used in the Fixed appliances: 14 months
early stages to correct the alignment and torque values of Total treatment time: 2 years 4 months followed by
the upper labial segment, followed by Twin Blocks, and retention
a final stage with fixed appliances. Vertical development, Final records: Show the position out of retention at age
combined with mandibular advancement, again make 18 years 11 months.

Case Report: KC

B C D

E F G

H I J
Figs. 13.12A to J: Treatment: (A) Profiles at ages 12 years 8 months (before treatment), 14 years 11 months (after treatment) and
18 years 11 months (out of retention); (B to D) Occlusion before treatment; (E to G) Occlusion out of retention; (H and I) Facial appearance
before treatment; (J) Facial appearance after treatment.
Treatment of Class II Division 2 Malocclusion 225

Case Report: KC

KC Age 12.8 14.11 18.11


Cranial Base Angle 25 25 23
Facial Axis Angle 23 23 23
F/M Plane Angle 26 26 24
Craniomandibular Angle 51 51 47
Maxillary Plane –4 –3 –3
Convexity 4 3 4
U/Incisor to Vertical 17 17 16
L/Incisor to Vertical 40 40 32
L/Incisor to A/Po 2 2 1
L/Lip to Aesthetic Plane –3 –4 –4
6 to Pterygoid Vertical 12 12 12

REFERENCES Witzig JW, Spahl TJ, (1987). ‘The great second molar debate’.
in The Clinical Management of Basic Maxillofacial Ortho-
Spahl TJ, (1993). The Spahl split vertical eruption acceleration pedic Appliances, Vol-1 Mechanics, PSG, Massachusetts, pp.
appliance system, Functional Orthodontics. 10:10-24. 155-216.
Treatment of Class III Malocclusion 227

Chapter 14
Treatment of Class III Malocclusion

REVERSE TWIN BLOCKS Case Selection


Functional correction of Class III malocclusion is achieved The skeletal Class III malocclusion is one of the most diffi-
in Twin Block technique by reversing the angulation of cult to treat by an orthodontic or orthopedic approach,
the inclined planes, harnessing occlusal forces as the and case selection is especially important before under-
functional mechanism to correct arch relationships by taking treatment. Early treatment is often indicated in this
maxillary advancement, while using the lower arch as the type of malocclusion to counter the unfavorable develop-
means of anchorage. The position of the bite blocks is mental pattern. In severe cases treatment may be initi-
reversed compared to Twin Blocks for Class II treatment. ated in the deciduous dentition or early mixed dentition.
The occlusal blocks are placed over the upper deciduous Orthopedic correction is more likely to succeed by maxi-
molars and the lower first molars. llary advancement rather than mandibular retraction,
Reverse Twin Blocks are designed to encourage as it is difficult to reduce the potential for mandibular
maxillary development by the action of reverse occlusal growth, except by surgery.
inclined planes cut at a 70° angle to drive the upper teeth The simplest clinical guideline is whether or not the
forwards by the forces of occlusion and at the same time, patient can occlude squarely edge-to-edge on the upper
to restrict forward mandibular development (Fig. 14.1). and lower incisors. The ease with which the patient can
The maxillary appliance should include provision for achieve this position is an indication of the prognosis
three-way expansion to increase the size of the maxilla for correction. The most favorable cases for correction
in both sagittal and transverse dimensions.
Prior to initiation of Class III Twin Block treatment
it is important to ensure that the patient’s condyles
are not displaced superiorly and/or posteriorly in the
glenoid fossae at full occlusion. In treatment with the
reverse Twin Block, the occlusal force exerted on the
mandible is directed downwards and backwards by the
reverse inclined planes. No damaging force is exerted
on the condyles because the bite is hinged open with
the condyles down and forward in the fossae and the
inclined planes are directed downwards and backwards
on the mandibular teeth. The force vector in the mandible
passes from the lower molar towards the gonial angle.
This is the area of the mandible best able to absorb
occlusal forces (Fig. 14.2). Fig. 14.1: Reverse Twin Blocks.
228 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
response to maxillary protraction, perhaps using a reverse
pull headgear. If the patient cannot close edge-to-edge
on the incisors it is likely that surgical correction will be
required. If in doubt a combined orthodontic and surgical
opinion should be sought.
The degree of skeletal discrepancy is an important
diagnostic factor in case selection. When convexity moves
into the negative range the patient should be informed of
the possibility that surgery may be required to achieve
a stable correction. The prognosis reduces in direct pro-
portion to the increase in negative convexity. In some
cases the Class III occlusion may respond to treatment
in the mixed dentition, but relapse may occur during
the pubertal growth spurt, when the position needs to
be reviewed.
Combination therapy with Twin Blocks reinforced
by reverse pull traction to advance the maxilla may be
successful in the younger patient. An initial stage of rapid
maxillary expansion is often indicated to free up the
maxillary sutures prior to applying forward traction to the
maxilla (McNamara 1993). The rapid maxillary expander
may be modified to incorporate reverse blocks designed
to occlude with the lower reverse Twin Block.

Bite Registration
It is not possible to build in the same degree of anter-
oposterior activation in the construction bite for func-
tional correction of a Class III malocclusion compared
to a Class II correction, because there is less scope for
distal displacement of the mandible. The Exacto-Bite is
normally used to register a construction bite with the
Fig. 14.2: Management of Class III malocclusion. teeth closed to the position of maximum retrusion, leav-
ing sufficient clearance between the posterior teeth for
the occlusal bite blocks. This is achieved by recording
present a postural Class III where the incisors can meet a construction bite with 2 mm interincisal clearance in
comfortably edge-to-edge, but the patient is forced to the fully retruded position. In treatment of the brachy-
move the mandible forward in order to occlude on the facial Class III, additional vertical activation may be
posterior teeth. applied by opening the bite further in the construction
If an edge-to-edge occlusion is achieved only with bite if required by using the yellow Exacto-Bite to register
difficulty the prognosis for orthodontic correction is poor, 4 mm interincisal clearance. This may result in a tempo-
while orthopedic correction would depend on a good rary increase in the lower facial height.
Treatment of Class III Malocclusion 229

TREATMENT OF CLASS III MALOCCLUSION clearance. Activation to correct the lingual occlusion
WITH REVERSE TWIN BLOCKS is achieved by opening the bite on the articulator and
constructing the appliances so that contact is made
only on the reverse inclined planes, with no contact on
Case Report: SL Aged 11 Years
the occlusal surface of the blocks. This has the effect of
This case is an example of the response to treatment with increasing the advancing forces on the maxilla as the
reverse Twin Blocks in permanent dentition for a mild forces of occlusion drive the upper appliance forward and
Class III skeletal discrepancy with a postural element. the blocks settle into occlusion with the opposing teeth.
A three-screw sagittal appliance was used in this case. The Treatment was completed in 10 months, followed by
construction bite is registered in the maximum retruded 5 months of retention. The final records show the position
position, which is edge-to-edge with 4 mm interincisal 1 year out of retention (Figs. 14.3A to K).

Case Report: SL

A B

C D E

F G H

I J K
Figs. 14.3A to K: Treatment: (A and B) Occlusion before treatment at age 11 years; (C and D) Registering the construction bite;
(E) Fitting reverse Twin Blocks; (F and G) Occlusal views of reverse Twin Blocks; (H) Occlusal contact is only on the inclined planes;
(I to K) Occlusion after treatment at age 13 years 3 months.
230 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

REVERSE TWIN BLOCKS:


APPLIANCE DESIGN
The sagittal design is used to advance the upper incisors
to correct the lingual occlusion in treatment of Class III
malocclusion (Fig. 14.4).
In many cases, the maxilla is contracted laterally in
addition to occluding in a distal relationship to the man-
dible. This is an indication for combined sagittal and
transverse expansion using a three-screw sagittal appli-
ance which includes a midline screw to complement
the action of the sagittal screws. An alternative design
uses a three-way expansion screw to combine transverse
and sagittal expansion. This is also effective in expand-
ing a contracted maxilla and in correcting lingual occlu-
sion if used in combination with reverse inclined planes
(Figs. 14.5A and B). Alternatively, a triple screw sagittal
may be used for three-way maxillary development, as
described for treatment of Class II division 2 malocclu-
sion (see Fig. 13.4).

REVERSE TWIN BLOCKS: MANAGEMENT


With the sagittal appliance design, because of the curva-
ture 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 Fig. 14.4: Detail of appliance design.

A B
Figs. 14.5A and B: Three-way screw appliance design.
Treatment of Class III Malocclusion 231

of driving the upper molars distally and advancing the Lip Pads
incisors. Distal movement of the upper molars is resisted
To enhance the forward movement of the upper labial
by occlusion of the lower bite blocks on the reverse
segment, lip pads may be added to support the upper lip
inclined planes. Therefore the net effect of opening the clear of the incisors with an action similar to that of the
screws is a forward driving force on the upper dental arch. Frankel III. The lip pads need not be joined in the midline
The position of the cut for the screws will influence their provided they are carried on heavy gauge wires that are
action on individual teeth. The cuts may be positioned self-supporting to hold the pads clear of the gingivae in
distal to the lateral incisors to advance only the four upper order to avoid gingival irritation. It is important to attach
incisors. Positioning the cuts mesial to the upper molars the lip pads to the anterior segment of the appliance so
would increase the distalizing component of force on that they advance as the screws are opened, otherwise
the molars, but distal movement is resisted by occlusion the pads become compressed against the gingivae in
with the lower bite blocks, and the reciprocal force acts the labial segment. In addition, they may be adjusted
to advance the entire upper arch mesial to the molars, forwards clear of the gingivae as the incisors are advanced
using the lower arch as anchorage. (Figs. 14.6A and B).

A B
Figs. 14.6A and B: Lip pads must be supported clear of the gingivae. The action is similar to the upper lip pads on the Frankel III.
232 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: TC Aged 8 Years 2 Months the maxillary response. The favorable improvement in
facial balance was partly due to a clockwise rotation of the
A mild Class III skeletal pattern with negative maxillary mandible, with a significant rotation of the facial axis. The
convexity of –1 mm resulted in lingual occlusion of all facial axis angle changed from 26° before treatment to 19°
four upper incisors and the upper lateral incisors were after treatment, and 22° out of retention. Similar changes
displaced lingual to the central incisors. Retroclined were observed in the mandibular plane angle. The down-
upper incisors were associated with an obtuse nasola- ward rotation of the mandible improved the profile. The
bial angle, and proclination of the incisors improved the lingual occlusion was corrected after 5 months and reverse
profile during treatment. A positive growth response to Twin Block treatment was completed after 12 months,
mixed dentition treatment resulted in an improvement in followed by retention for a further 12 months. Final
convexity to +5 mm. A lip pad was added to the upper records show the position 1 year out of retention after the
reverse Twin Block with twin sagittal screws to improve transition into the permanent dentition (Figs. 14.7A to I).

Case Report: TC

A
Fig. 14.7A: Treatment: (A) Profiles at ages 8 years 2 months (before treatment), 10 years 1 month (after treatment) and 11 years
4 months (out of retention).
Treatment of Class III Malocclusion 233

B C D

E F G

H I
Figs. 14.7B to I: (B to D) Occlusion before treatment; (E) Upper archforms at age before treatment; (F) Occlusion after treatment; (G)
Upper archforms at age after treatment; (H and I) Occlusion out of retention.
234 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: TC

TC Age 8.2 10.1 11.4


Cranial Base Angle 30 29 30
Facial Axis Angle 26 19 22
F/M Plane Angle 26 34 29
Craniomandibular Angle 56 63 59
Maxillary Plane –1 –2 0
Convexity –1 5 4
U/Incisor to Vertical 5 13 14
L/Incisor to Vertical 24 27 27
L/Incisor to A/Po 4 1 1
L/Lip to Aesthetic Plane 0 –2 –3
6 to Pterygoid Vertical 8 6 7
Treatment of Class III Malocclusion 235

Case Report: AJ Aged 6 Years 11 Months maxilla and was completed after 12 months. Retention
Treatment was indicated in early mixed dentition for continued for 1 year to stabilize the position in view of
this young girl, who presented a contracted maxilla with the reduced overbite. Final records show the position
lingual occlusion of the upper incisors and a mild Class III at age 15 years when a settled occlusion has developed
skeletal pattern with a reduced overbite. Treatment with without further treatment in the permanent dentition
reverse Twin Blocks included three-way expansion of the (Figs. 14.8A to L).

Case Report: AJ

B C D

E F G

H I

J K L
Figs. 14.8A to L: Treatment: (A) Profiles at ages 6 years 11 months (before treatment), 8 years 7 months (after treatment) and 13 years 7
months (out of retention); (B to D) Occlusion before treatment; (E to G) Occlusion after treatment at age 8 years 7 months; (H) Appearance
before treatment at age 6 years 11 months; (I) Appearance out of retention; (J to L) Occlusion out of retention at age 13 years 7 months.
236 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: AJ

AJ Age 6.11 8.7 13.7


Cranial Base Angle 26 27 28
Facial Axis Angle 27 27 23
F/M Plane Angle 30 30 31
Craniomandibular Angle 56 57 59
Maxillary Plane 1 2 2
Convexity 0 1 0
U/Incisor to Vertical 5 15 18
L/Incisor to Vertical 26 21 22
L/Incisor to A/Po 1 0 0
L/Lip to Aesthetic Plane –1 –3 –3
6 to Pterygoid Vertical 12 14 10
Treatment of Class III Malocclusion 237

Case Report: ML Aged 7 Years 5 Months retrusion (Figs. 14.9A to J). A short period of treat-
ment was successful in reversing the Class III growth
This young girl presented a severe dental Class III malo-
tendency, and establishing a Class I occlusion that was
cclusion soon after eruption of the permanent incisors.
maintained 6 years out of retention without further
The 2 2 were displaced lingual to 1 1 , and there was
treatment.
a lingual occlusion of the upper labial segment with
a reverse overjet of 3 mm and no forward posture on Twin Blocks: 5 months
closure. The skeletal relationship showed a convexity of Retention: 3 months
–1 mm with a normal mandible and moderate maxillary Treatment time: 8 months.

Case Report: ML

B C D

E F G

H I J
Figs. 14.9A to J: Treatment: (A) Profiles at ages 7 years 5 months (before treatment), 8 years 1 month (8 months after treatment) and
14 years 3 months; (B to D) Occlusion before treatment; (E) Facial appearance before treatment at age 7 years 5 months; (F) Occlusion
after 8 months; (G) Facial appearance at age 14 years 3 months; (H to J) Occlusion 6 years out of retention at age 14 years 3 months.
238 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: ML

ML Age 7.5 7.10 14.3


Cranial Base Angle 29 29 30
Facial Axis Angle 28 27 31
F/M Plane Angle 27 27 21
Craniomandibular Angle 56 56 52
Maxillary Plane −4 −1 0
Convexity −1 0 −3
U/Incisor to Vertical 11 29 30
L/Incisor to Vertical 26 26 18
Interincisal Angle 143 125 132
6 to Pterygoid Vertical 8 10 20
L/Incisor to A/Po 3 2 2
L/Lip to Aesthetic Plane −5 –3 −8
Treatment of Class III Malocclusion 239

EARLY TREATMENT OF SEVERE REVERSE PULL FACIAL MASK


CLASS III MALOCCLUSION WITH
The reverse pull facial mask applies an additional com-
REVERSE TWIN BLOCKS ponent of orthopedic force to advance the maxilla by
A study to establish the efficiency of reverse Twin Blocks for elastic traction (Delaire, 1971, 1976; Delaire et al., 1972;
the early treatment of Class III malocclusion was carried Petit, 1982, 1983, 1984, 1991; McNamara, 1987, 1993). This
out at University College, London (Kidner, Di Biase et al., mechanism can be attached to the upper Twin Block to
1998). The appliance design did not include any additional maximize the forward component of force on the max-
provision for advancement of the upper incisors. Fourteen illa, converting the technique to a functional orthopedic
subjects with severe Class III malocclusion were selected system. The addition of three-way expansion in the appli-
according to criteria established by Loh and Kerr (1985). ance design enhances treatment of maxillary deficiency.
The treatment effects were as follows: Sagittal screws cut anterior to the upper molars have the
• Retroclination of lower incisors. effect of increasing the activation of the inclined planes to
• Proclination of upper incisors. advance the premaxillary segment by driving the blocks
• Increase in sella, Nasion, A-point (SNA) (mean values distally against the resistance of the lower inclined planes
79.4° before treatment, 79.8° after treatment). (Figs. 14.10A and B).
• Decrease in sella, Nasion, B-point (SNB) (from 81.2°
The elastic force applied should be increased gradually
to 79.6°).
from the time after the facial mask is fitted and as the
• Increase in A-point, Nasion, B-point (ANB) (from –1.9°
patient adapts to the pressure. A starting pressure using
to +0.2°).
bilateral 3/8 in, 8 oz elastics is recommended for the first
• Increase in MM angle (from 25° to 26.5°).
2 weeks. The force may then be increased by using 1/2
• Decrease in overbite.
The study concluded that the appliance was well in, 14 oz elastics, and later to a maximum by 5/16 in, 14
tolerated, and treatment time was 75% less than with the oz elastics. If the patient experiences pain or soft-tissue
FR III (Loh and Kerr, 1985). Compensation was achieved irritation, the elastic force should be reduced to a more
with minimal skeletal changes. Results compared favorably comfortable level.
with the FR III appliance. The superimposed tracings The face mask is most effective if worn for a short
before and after treatment indicate that correction is period of 4–6 months using heavy forces. The additional
achieved by proclining upper incisors, retroclining lower functional forces make it unnecessary to wear the facial
incisors, while the mandible rotates slightly downwards mask during the day and it can be applied as a night-time
and backwards to improve the skeletal relationship. auxiliary force.

A B
Figs. 14.10A and B: An example of facial mask for maxillary advancement.
240 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

CLASS III MALOCCLUSION WITH FACIAL cut mesial to the molars to open the premolar spaces.
ASYMMETRY (FIGS. 14.11A TO B1) Acrylic pads were placed labially to prevent tipping of the
incisors.
This girl has an asymmetrical Class III malocclusion
After 8 months treatment, space is available for
with a unilateral crossbite and a severely contracted and
premolars to erupt and the crossbite has improved. This
crowded maxilla. There is insufficient space for eruption
of upper second premolars and canines and the upper has not been achieved by distal movement of the upper
first molars have drifted nesially and are severely rotated. molars, as this was resisted by the inclined plane of the
The facial view confirms an asymmetry consistent with lower Twin Block. The effect of the sagittal screws is to
the malocclusion. advance the upper labial segment without tipping of the
A sagittal reverse Twin Block was used to develop the upper incisors. The forces of occlusion have been used
maxilla with two diverging screws to incorporate some to assist sagittal and transverse development of the
expansion of upper molar width to assist in correcting maxillary arch.
the crossbite. The construction bite overcorrected the The mandibular displacement and asymmetry is
midlines to counter the asymmetry. The screws were visibly improved after 6 months.

B C D

E F G
Figs. 14.11A to G: Class III malocclusion with facial asymmetry.
Courtesy: Dr Dilip Patel and his patient in Rajkot, Gujarat.
Treatment of Class III Malocclusion 241

H I J

K L M

N O P

Q R S

T U V
Figs. 14.11H to V: (H to J) Appliance design includes labial pads to prevent tipping of the incisors; (K to M) Occlusal view of upper arch
before and after treatment and sagittal appliance design; (N to P) Facial views before and after treatment to show correction of asymmetry;
(Q to V) Models show progress in arch development and occlusion before and after treatment.
Courtesy: Dr Dilip Patel and his patient in Rajkot, Gujarat.
242 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

W X Y

Z A1 B1
Figs. 14.11W to B1: Facial and profile views before and after treatment.
Courtesy: Dr Dilip Patel and his patient in Rajkot, Gujarat.
Treatment of Class III Malocclusion 243

Nonsurgical Class III Correction


(Figs. 14.12 and 14.13)

A B

D
Figs. 14.12A to D: Nonsurgical Class III correction.
Courtesy: Dr Dilip Patel and his patient in Rajkot, Gujarat.
244 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

G H

I J K
Figs. 14.12E to K: Nonsurgical Class III correction.
Courtesy: Dr Dilip Patel and his patient in Rajkot, Gujarat.
Treatment of Class III Malocclusion 245

L M
Figs. 14.12L and M: Nonsurgical Class III correction.
Courtesy: Dr Dilip Patel and his patient in Rajkot, Gujarat.

Lingual Occlusion Bite Registration Reverse Twin Blocks

A D G

B E H

C F I
Figs. 14.13A to I: Nonsurgical Class III correction.
246 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Before and after Reverse Twin Blocks


(Figs. 14.14 and 14.15)

A D G

B E H

C F I
Figs. 14.14A to I: Before and after reverse Twin Blocks.

A B
Figs. 14.15A and B: Before and after reverse Twin Blocks.
Treatment of Class III Malocclusion 247

C D

E F

G H

I Figs. 14.15C to I: Before and after reverse Twin Blocks.


248 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Occlusal Screw for Progressive Activation extends the possibility for progressive correction of
of Reverse Twin Blocks Class III malocclusion using the forces of occlusion to
correct the malocclusion. The lower appliance is used
It is not possible to posture the mandible back to activate as an anchor to apply forces to advance the maxilla. The
the reverse Twin Block, but progressive activation may reverse inclined plane exerts a reciprocal force downwards
be achieved using an occlusal screw (Geserik et al. 2006, towards the gonial angle, with no undesirable effects in
available from Forestadent). The range of action of 6 mm the temporomandibular joint (Figs. 14.16A to C).

B C
Figs. 14.16A to C: Occlusal screw for progressive activation of Reverse Twin Blocks. The range of activation is 6 mm.
Treatment of Class III Malocclusion 249

Forward Maxillary Propulsion Combined resolve anterior crowding and to accommodate the upper
with Arch Development incisors as they erupt (Figs. 14.17A and B).

The occlusal screw may be activated at inspection visits Petit Face Mask for Maxillary Protraction
to progresssively advance the maxilla. Additional screws
may be incorporated in the upper appliance for transverse The reverse pull face mask is combined with rapid
and sagittal arch development. The example on the right maxillary expansion in young patients to treat Class III
shows a three-way screw with a sagittal component malocclusion by the application of orthopedic forces.
to advance the upper incisors and a transverse screw Rapid palatal expansion loosens the sutures prior to
to increase arch width. This combination of activity is the application of the face mask and this enhances the
often indicated in Class III malocclusion with a small action of forces for maxillary protraction, resulting in
contracted maxilla. Early mixed dentition is the ideal an increased skeletal response to improve the maxillary
stage for maxillary development and to make space to position (Figs. 14.18A to C).

A B
Figs. 14.17A and B: (A) The occlusal screw may be adapted for use in Class II or Class III correction; (B) For Class III correction the
screw is placed in the upper block. The appliance is designed for 3-way expansion.

A B C
Figs. 14.18A to C: The reverse pull facemask may be used to reinforce maxillary advancement by attachment to the upper Twin Block.
Courtesy: Dr Jan Cleyndert.
250 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

A B C

D E F
Figs. 14.19A to F: Rapid palatal expander in Class III treatment.

Rapid Palatal Expander in bony sequelae of cleft lip and palate, Revue de Stomatologie
et de Chirurgie Maxillo-faciale. 73:633-42.
Class III Treatment Kidner G, Di Biase A, Bali J, et al, (1998). Reverse Twin Blocks
After treatment by rapid palatal expansion there is a for early treatment of Class III malocclusion, Poster exhibit,
EOS Congress.
central diastema and further treatment is required with Loh MK, Kerr WJ, (1985). The Function Regulator III: effects and
a functional appliance to establish the posterior occlu- indications for use, British Dental Journal. 12:153-7.
sion. Treatment in early mixed dentition requires rein- McNamara JA, (1987). An orthopedic approach to the treatment
forcement, in this case with a Frankel III, and will be of class III malocclusion in young patients, Journal of Clinical
followed by a finishing stage with fixed appliances when Orthodontics. 21:598-608.
McNamara JA, (1993). Orthopedic facial mask therapy, Ortho-
the permanent teeth erupt (Figs. 14.19A to F).
dontic and Orthopedic Treatment in the Mixed Dentition,
Needham Press, Ann Arbor, pp. 283-95.
REFERENCES Petit HP, (1982). The prognathic syndrome: a complete treat-
ment plan around the facial mask, Revista Dental Press de
Delaire J, (1971). Manufacture of the “orthopedic mask”, Revue Ortodontia e Ortopedia Facial. 16:381-411.
de Stomatologie et de Chirurgie Maxillo-faciale. 72:579-84. Petit HP, (1993). Adaptation following accelerated facial mask
Delaire J, (1976). The frontomaxillary suture. Theoretical bases therapy, in Clinical Alteration of the Growing Face, Monograph
and general principles of the application of postero-anterior no. 14, Craniofacial Growth Series, eds McNamara JA, Ribbens
extraoral forces to the orthopedic mask, Revue de Stomatologie JA, Howe RP, University of Michigan, Ann Arbor.
et de Chirurgie Maxillo-faciale. 77:921-30. Petit HP, (1984). Orthopedics and/or orthodontics, L’ Orthodontie
Delaire J, Verson P, Lumineau JP, et al, (1972). Some results Francaise. 55:527-33.
of extraoral tractions with front-chin rest in the orthodontic Petit HP, (1991) Morphogenetic normalization, the contribution
treatment of class 3 maxillomandibular malformations and of of orthodontics, Orthodontie Francaise, 62:549-57.
Orthodontics, Orthopedics or Surgery? 251

Chapter 15
Orthodontics,
Orthopedics or Surgery?

INTRODUCTION be genetically predetermined. According to the genetic


paradigm, the only feasible approach to the treatment of
Treatment of severe Class II malocclusion may involve a retrusive mandible was to retract the maxilla to match
a choice between orthodontic, orthopedic and surgery. the position of the retrusive mandible, or alternatively
Some patients may require a combination of these dis- to correct the skeletal discrepancy surgically, with the
ciplines. A severe skeletal discrepancy cannot normally attendant risk factors and the excessive cost of combined
be treated by orthodontics alone, except to a com- surgical and orthodontic treatment. The latter approach
promise result, where skeletal component is not cor- became more popular in North America, while functional
rected. Correction of severe maxillary protrusion may be appliances remained popular in Europe, partly due to
achieved by application of orthopedic forces through a social and financial factors.
facebow and headgear, aiming to restrict forward max- During the 20th century the debate regarding the
illary growth. This approach is often more successful in potential of functional appliances to stimulate mandibular
the younger child, but has the disadvantage of being time growth remained unresolved. Early experience with night-
consuming, as treatment can be slow and extend over a time functional appliances did not produce encouraging
lengthy period of time. results. The design of functional appliances continued to
Orthodontic force levels are not sufficient to encourage evolve as modifications were made to reduce the bulk
a significant increase in mandibular growth. Treatment of acrylic in order to increase the number of hours of
of mandibular retrusion ideally requires a combination day-time wear. Only in the latter part of the century
of orthodontics with either orthopedic force to stimulate did research begin to examine the effects of full-time
mandibular growth, or surgery to correct the mandibular functional appliances, with more positive results.
deficiency. A choice between these alternatives is usually A fundamental aim of a dentofacial orthopedic app-
made according to the belief and experience of the roach is to enhance mandibular growth by functional
practitioner. Opinions remain divided on philosophical mandibular protrusion. The crucial question remains:
grounds regarding the efficacy of functional mandibular “Does full-time appliance wear bring us closer to achiev-
protrusion as a mechanism for improving the mandibular ing this objective?” Improved functional technique offers
growth response. a more pragmatic solution for the patient who prefers
In the early 1960s the author shared the same experie- not to undergo major surgery. This approach has the
nce as most orthodontists engaged in a postgraduate additional advantage that the cost to the patient and the
orthodontic training program. The perceived knowledge provider of the service is significantly reduced compared
from research on growth seemed to indicate that it was to the more expensive surgical alternative.
not possible to enhance mandibular growth, and the The purpose of this chapter is to examine the potential
existing pattern of craniofacial growth was thought to for an orthopedic/orthodontic correction for patients
252 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
who might otherwise be considered suitable for surgical/ retrusion. A convexity of 8 mm is combined with a Class
orthodontic correction. The following patients were II molar relationship discrepancy of 11 mm, equivalent
treated by Dr Forbes Leishman in his orthodontic practice to a full molar width. In most orthodontic offices surgery
in Auckland, New Zealand. They are examples of the would be considered the best option in a malocclusion
treatment of severe malocclusions by a combination of of this severity. This patient was not keen to embark on
Twin Blocks followed by fixed appliances, demonstrating major surgery, and preferred the functional approach.
the potential of the orthopedic/orthodontic interface as After 8 months of treatment with Twin Blocks the
an alternative to the surgical approach. These cases show overjet reduced to 8 mm, with the lower incisors posi-
a level of expertize in dentofacial orthopedics that offers tioned 3.5 mm lingual to A-Po. A subsequent orthodontic
a valid alternative to the surgical approach. phase of treatment produced an excellent Class I occlu-
sion. A favorable response during treatment resulted in a
reduction in convexity from 8 mm to 4 mm. The patient
CASE REPORTS
was followed through post-treatment to age 23 years 8
Case Report: SG Aged 11 Years 8 Months months, a total of 12 years from the commencement
of treatment. In the post-treatment period the over-
by Forbes Leishman jet increased from 4 mm to 6 mm, while the convexity
The first patient undoubtedly falls within guidelines nor- remained 4 mm. At age 23 years, there is mild crowd-
mally considered for surgical correction. Before treatment ing in the lower arch with excellent stability of the Class
she presented an overjet of 20 mm and an anterior open I occlusion. A functional orthopedic approach followed
bite associated with thumb sucking. The lower incisors by orthodontics achieved facial balance and a good pro-
were retroclined and positioned 7 mm lingual to the A-Po file. These changes were maintained out of retention
line. The skeletal pattern is moderate brachyfacial with and treatment of this severe malocclusion was com-
a combination of maxillary protrusion and mandibular pleted without the need for surgery (Figs. 15.1A to O).

Case Report: SG

B C D
Figs. 15.1A to D: Progress during treatment of this severe malocclusion. (A) Profiles at ages 11 years 8 months (before treatment),
12 years 4 months (after treatment) and 23 years 8 months (out of retention); (B) Overjet of 20 mm before treatment with anterior open
bite; (C and D) Occlusion before treatment.
Orthodontics, Orthopedics or Surgery? 253

E F

G H I

J K L

M N O
Figs. 15.1E to O: (E and F) Corrected occlusion at age 14 years 6 months; (G) Facial appearance before treatment; (H) Facial appearance
after treatment at age 12 years 4 months; (I) Age 23 years, 8 months (J to L) Occlusion after treatment at age 14 years 6 months;
(M to O) Occlusion out of retention at age 23 years 8 months.
254 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: SG

SG Age 11.8 18.1


Cranial Base Angle 28 28
Facial Axis Angle 27 28
F/M Plane Angle 23 20
Craniomandibular Angle 51 48
Maxillary Plane 9 6
Convexity 8 4
U/Incisor to Vertical 24 15
L/Incisor to Vertical 27 42
L/Incisor to A/Po –7 1
L/Lip to Aesthetic Plane –3 –1
6 to Pterygoid Vertical 18 15
Orthodontics, Orthopedics or Surgery? 255

Case Report: TK Aged 14 Years 9 Months The final orthodontic phase repositions the lower incisors
in correct relationship to the anterior limit of the skeletal
This girl was a late starter and was approaching 15 years
base (within the range of +1 to +3 to the A-Po line) to
old when Twin Blocks were fitted. It may be tempting to
improve the contour of the lower lip. Final records show
consider surgery to assist correction for a girl who is past
the position out of retention at age 20 years 2 months
the pubertal growth phase and whose growth is virtually
(Figs. 15.2A to L).
complete, especially as the pretreatment profile is poor.
This is an example of forward positioning of the man-
The convexity of 3 mm is due to maxillary protrusion as
dible due to an alteration in the angle of growth of the
the mandible is well developed and exhibits a brachyfacial
condyle, as clearly shown in the mandibular superim-
growth pattern. This gives the appearance of overclosure,
position.
resulting from reduced lower facial height. The upper
incisors are severely proclined, with the lower lip trapped The distal direction of condylar growth is evident
in an overjet of 13 mm. The lower incisors are retroclined from the increased gonial angle. As a result the mandible
and biting into the palate with an excessive overbite, and rotates forward significantly changing the shape of the
are positioned 3 mm lingual to the A-Po line as a result lower face in profile and full face views.
of lower alveolar retrusion. Twin Blocks: 15 months
In this type of malocclusion the vertical correction is as Bite plane: 3 months
important as sagittal correction. The profile improves with Fixed appliances: 12 months
anterior repositioning of the mandible and adjustment of Total treatment time: 2 years 6 months followed by
the blocks to allow vertical development of lower molars. retention.

Case Report: TK

B C D
Figs. 15.2A to D: Progress during treatment of this severe malocclusion. (A) Profiles at ages 14 years 9 months (before treatment) and
20 years 2 months (out of retention); (B to D) Occlusion before treatment.
256 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

E F G

H I

J K L
Figs. 15.2E to L: (E to G) Occlusion after treatment at age 17 years 3 months; (H) Facial appearance before treatment; (I) Facial appearance
after treatment; (J to L) Occlusion out of retention at age 20 years 2 months.
Orthodontics, Orthopedics or Surgery? 257

Case Report: TK

TK Age 14.9 15.10 20.2


Cranial Base Angle 27 28 27
Facial Axis Angle 33 34 33
F/M Plane Angle 18 19 17
Craniomandibular Angle 45 47 44
Maxillary Plane 4 5 5
Convexity 3 2 0
U/Incisor to Vertical 37 20 18
L/Incisor to Vertical 26 35 27
L/Incisor to A/Po –3 2 1
L/Lip to Aesthetic Plane –1 0 –1
6 to Pterygoid Vertical 17 18 18
258 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: CM Aged 11 Years 5 Months potential for correction with the assistance of growth is
favorable. The convexity is reduced to 3 mm with a fully
by Forbes Leishman
corrected occlusion and the improvement is maintained
This case presents another severe malocclusion, treated
3 years after completion of treatment (Figs. 15.3A to J). This
in early permanent dentition, where surgery might have
case also shows significant distal growth and lengthening
been considered as a possible solution. Altered incisal
of the condyle, resulting in forward positioning of the
angulations contribute to an overjet of 15 mm and
mandible.
excessive overbite with the lower incisors 5 mm lingual
to the A-Po line in this case. Once again the large overjet Twin Blocks: 9 months
can be partly attributed to unfavorable lip posture, as a Bite plane: 5 months
severely trapped lower lip accentuates the problem. Fixed appliances: 12 months
A brachyfacial growth pattern and 8 mm convexity is Total treatment time: 2 years 3 months followed by
due mainly to mandibular retrusion, and at this age the retention.

Case Report: CM

A
Fig. 15.3A: Progress during treatment of this severe malocclusion. (A) Profiles at ages 11 years 5 months (before treatment), 13 years
9 months (after treatment) and 17 years (out of retention).
Orthodontics, Orthopedics or Surgery? 259

B C D

E F G

H I J
Figs. 15.3B to J: (B) Facial appearance before treatment; (C) Facial appearance after treatment; (D) Facial appearance out of retention;
(E to G) Occlusion before treatment; (H to J) Occlusion out of retention. The incisal edges of 1 1 were trimmed to improve the appearance
in the end result.
260 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: CM

CM Age 11.5 13.9 17.0


Cranial Base Angle 27 27 28
Facial Axis Angle 28 28 30
F/M Plane Angle 18 19 18
Craniomandibular Angle 45 46 45
Maxillary Plane 1 1 2
Convexity 8 4 4
U/Incisor to Vertical 30 21 14
L/Incisor to Vertical 20 40 25
L/Incisor to A/Po –5 3 1
L/Lip to Aesthetic Plane –5 –2 –4
6 to Pterygoid Vertical 14 14 18
Orthodontics, Orthopedics or Surgery? 261

Case Report: AB Aged 12 Years 8 Months In a combined orthopedic and orthodontic approach,
correction of the sagittal relationship by advancing the
by Forbes Leishman
mandible produces an improvement in the transverse
This boy has a severe dental Class II malocclusion with
discrepancy, so that the finishing phase with fixed
buccal occlusion of all the upper premolars in addition
appliances is simplified. Excellent stability and improved
to a 12 mm overjet and excessive overbite. The skeletal
facial esthetics is evident at age 18 years, 3 years after
pattern is mesofacial. A retrusive mandible and also slight
completion of treatment (Figs. 15.4A to K). Once again,
maxillary retrusion contribute to a retrognathic profile.
the condylar extension is exceptional, presumably taking
This malocclusion requires careful management in view
advantage of the pubertal growth spurt to maximize the
of the severity of the dental malocclusion. Even taking
orthopedic response to treatment.
into account the dentoalveolar factors in the etiology
of this malocclusion, correction by orthodontic means Twin Blocks: 11 months
alone would be a long and laborious task, to the extent Bite plane: 3 months
that some practitioners may be tempted to resort to the Fixed appliances: 10 months
surgical alternative. Total treatment time: 2 years followed by retention.

Case Report: AB

B C
Figs. 15.4A to C: Progress during treatment of this severe malocclusion. (A) Profiles at ages 12 years 8 months (before treatment),
14 years 8 months (after treatment) and 16 years 6 months (out of retention); (B and C) Occlusion before treatment.
262 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

D E F

G H

I J K
Figs. 15.4D to K: (D to F) Occlusion after treatment; (G) Facial appearance before treatment; (H) Facial appearance out of retention;
(I to K) Occlusion out of retention.
Orthodontics, Orthopedics or Surgery? 263

Case Report: AB

AB Age 12.8 14.8 18.1


Cranial Base Angle 29 29 28
Facial Axis Angle 25 26 28
F/M Plane Angle 29 29 24
Craniomandibular Angle 58 58 52
Maxillary Plane 0 –2 0
Convexity 4 5 2
U/Incisor to Vertical 30 17 19
L/Incisor to Vertical 30 30 20
L/Incisor to A/Po –1 1 2
L/Lip to Aesthetic Plane 3 2 –3
6 to Pterygoid Vertical 14 14 18
264 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: NM Aged 11 Years Correction is achieved by advancing the mandible


by Forbes Leishman to match the protrusive position of the maxilla. This
Severe maxillary protrusion is the main etiological factor produces a slightly prognathic straight profile with good
in this case for a girl who presents a brachyfacial pattern facial balance and an esthetically pleasing result. The
with a normal mandible and excessive overjet of 14 mm. maxillary convexity reduced from 6 mm to 2 mm after
The convexity of 6 mm is due entirely to the maxillary 1 year of treatment and excellent stability is maintained
protrusion as confirmed by a Sella Nasion—A-point 3 years after completion of treatment, with a convexity
angle (SNA) of 90°. This case demonstrates that maxillary of 1 mm (Figs. 15.5A to J). Condylar extension is again
protrusion may be treated effectively by mandibular exceptional.
advancement to produce an excellent balanced profile
and good facial esthetics. It is important to confirm Twin Blocks: 6 months
this before treatment by examining the profile with the Harvold activator as retainer: 5 months
mandible protruded to register a Class I relationship of Fixed appliances: 21 months
the molars. This simple guideline is a preview of the end Total treatment time: 2 years 8 months followed by
result, and helps to confirm the diagnosis. retention.

Case Report: NM

A
Fig. 15.5A: Progress during treatment of this severe malocclusion. (A) Profiles at ages 11 years (before treatment), 13 years 10 months
(after treatment) and 16 years 6 months (out of retention).
Orthodontics, Orthopedics or Surgery? 265

B C D

E F G

H I J
Figs. 15.5B to J: (B to D) Occlusion before treatment; (E to G) Occlusion out of retention; (H) Facial appearance before treatment;
(I) Facial appearance after treatment; (J) Facial appearance out of retention.
266 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: NM

NM Age 11.0 12.0 13.10


Cranial Base Angle 27 28 25
Facial Axis Angle 30 32 32
F/M Plane Angle 21 18 17
Craniomandibular Angle 48 46 42
Maxillary Plane 4 4 4
Convexity 6 2 0
U/Incisor to Vertical 43 25 30
L/Incisor to Vertical 21 22 25
L/Incisor to A/Po –2 2 2
L/Lip to Aesthetic Plane 3 3 1
6 to Pterygoid Vertical 18 15 17
Orthodontics, Orthopedics or Surgery? 267

Case Report: GK Aged 13 Years 2 Months taken to show the position of the condyle in the glenoid
fossa before treatment with the teeth in occlusion, and
by Gordon Kluzak also with the Twin Blocks in position. A second series of
This patient was treated in Calgary by Dr Gordon Kluzak. radiographs recorded the position 16 months later after
Prior to consulting Dr Kluzak he had previously attended completion of treatment. A cephalometric film was taken
two orthodontic offices where he was advised to have at the same visit to show the corrected occlusion. Joint
surgical correction. X-rays recorded the position of the condyles as follows:
A severe malocclusion with a 17 mm overjet and • Before treatment with the teeth in occlusion.
deep overbite was related to a convexity of 11 mm due • At commencement of treatment in occlusion with the
to maxillary protrusion and mild mandibular retrusion. Twin Blocks in place.
There was a mild dolichofacial pattern. This boy lacked • After 16 months of treatment with the teeth in occlu-
confidence because he had a disfiguring malocclusion, sion.
which resulted in him being teased at school. The joint X-rays were examined to measure the distance
His treatment was completed without complications from the nearest point on the condyle to the nearest
within 16 months using Twin Blocks followed by an point on the bony outline of the auditory canal. These
anterior inclined plane. measurements on the X-rays confirmed without doubt
Changes in the temporomandibular joint were recor- that the condyles were repositioned in the glenoid fossa
ded by means of an ORTHOPHOS X-ray unit using a slice after treatment after correction of the distal occlusion and
technique to record standardized joint X-rays. Films were reduction of the 17 mm overjet to 3 mm (Figs. 15.6A to K).

Case Report: GK

B C
Figs. 15.6A to C: Progress during treatment of this severe malocclusion. (A) Profiles at ages 13 years 2 months (before treatment), and
14 years 6 months (after treatment); (B) Occlusion before treatment; (C) Occlusion after treatment. Cephalometric films and joint X-rays
taken before treatment and 16 months later confirm that the occlusion is fully corrected and the condyles are correctly positioned in the
glenoid fossae on completion of treatment.
268 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

D E

F G

H I

J K
Figs. 15.6D to K: (D and E) Cephalometric films; (F and G) Joint X-rays in occlusion before treatment; (H and I) Joint X-rays with Twin
Blocks; (J and K) Joint X-rays in occlusion after treatment. These records confirm that the condyles are relocated in the glenoid fossa
after treatment in the same position as before treatment. This is important information to confirm the stability of the result after functional
therapy with Twin Blocks.
Orthodontics, Orthopedics or Surgery? 269

Case Report: GK

GK Age 13.2 14.6


Cranial Base Angle 30 31
Facial Axis Angle 28 28
F/M Plane Angle 24 27
Craniomandibular Angle 54 58
Maxillary Plane 1 2
Convexity 11 6
U/Incisor to Vertical 28 18
L/Incisor to Vertical 29 43
L/Incisor to A/Po –4 4
L/Lip to Aesthetic Plane 0 –1
6 to Pterygoid Vertical 22 22
270 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

DISCUSSION growth spurt, with the exception of TK (pages 255–257).


Several of the patients illustrated in this chapter were This case illustrates that altering the direction of growth
advised by orthodontists that they required surgical of the condyle is as important as extending condylar
correction. Considering the risks involved, they were not length. The resulting forward rotation of the mandible
willing to have major surgery. They were subsequently significantly changes the contours of the lower face,
treated to excellent results by an orthopedic approach, both in profile and full face views. It is also evident that
when appropriate, combined with orthodontics. increased ramus height significantly alters the facial
All of these patients exhibit an exceptional growth contours. In suitable cases, orthopedic correction is a
response during Twin Block treatment, and it is likely valid alternative to surgery in the growing child or adole-
that the treatment is timed to coincide with the pubertal scent.

ADDITIONAL CASE STUDIES (COURTESY OF DR DILIP PATEL)


15 Months Twin Block Treatment (Figs. 15.7A to G)

A B C

D E F G
Figs. 15.7A to G
Orthodontics, Orthopedics or Surgery? 271

In Support Phase after Twin Blocks (Figs. 15.8A to F)

A B C

D E F
Figs. 15.8A to F

12 Months Treatment with Twin Blocks (Figs. 15.9A to I)

A B C

D E F

G H I
Figs. 15.9A to I
272 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

12 Months Treatment with Twin Blocks the glenoid fossa after 12 months treatment with Twin
(Figs. 15.10A to D) Blocks. Further evidence of accelerated mandibular growth
is shown in the improved position and angulation of the
Cephalometric and panoramic radiographs provide con- third molars after treatment. This is highly significant
vincing evidence of an excellent mandibular growth res- as it can only be explained by extension of mandibular
ponse in the correction of this severe malocclusion. On the length by condylar growth, followed by remodeling of the
panoramic radiograph, measurement of the distance from ramus and corpus of the mandible to accommodate the
the condyle to the auditory canal before and after treatment third molars. This is a typical finding in the author’s serial
is identical. This confirms that the condyle is relocated in cephalometric study of Twin Block therapy.

A B

C D
Figs. 15.10A to D
Orthodontics, Orthopedics or Surgery? 273

Twin Blocks Achieve a Nonsurgical Face Lift (Figs. 15.11A to H)

A B C D

E F G H
Figs. 15.11A to H
Management of Crowding 275

Chapter 16
Management of Crowding

NONEXTRACTION THERAPY the distal occlusion. If forward movement of the mandible


would result in a poor occlusion it may be necessary to
Interceptive Treatment Arch Development correct the archform first before advancing the mandible
Crowding and irregularity of the dental arches may nec- by functional therapy.
essitate an interceptive stage of treatment to align the
arches and improve the archform as a preliminary to Integration of Twin Blocks and
the correction of arch-to-arch relationships. Interceptive Fixed Therapy
treatment should be initiated as early as possible in Combined orthopedic and orthodontic treatment may
the mixed dentition to develop correct archform before be planned in two phases, depending on the age of the
permanent successors erupt. patient at the start of treatment and the degree of severity
Examination of the occlusion prior to treatment esta- of the skeletal and dental problems. Arch development
blishes the necessity for an interceptive phase of arch and functional therapy in the mixed dentition is frequently
development. If significant crowding is present, the upper followed by a finishing phase of orthodontic treatment at
and lower archform does not match and as a result, a later stage of development.
a preliminary stage of interceptive treatment becomes In the permanent dentition, fixed appliance treatment
necessary. may precede Twin Block treatment to correct an irregu-
lar archform where the irregularity is moderate or severe.
Treatment Concept Alternatively, in less crowded cases fixed appliances may
The upper and lower dental arches must be compatible be integrated with Twin Blocks by the addition of brack-
to achieve a stable occlusion. This can be checked before ets to correct anterior alignment. Further integration with
treatment by sliding the lower model forward to eliminate fixed appliances can continue in the lower arch during the
the overjet and correct the buccal segment relationships. support phase, when the lower Twin Block is left out or,
If the archform does not match it is not possible to fit the alternatively, a transition to full fixed appliances may be
models together correctly. It is then necessary to correct made on completion of functional correction. The treat-
the archform before mandibular translation. A similar ment of patients presenting a combination of crowding,
clinical guideline is observed by posturing the mandible dental irregularity and skeletal discrepancy requires more
forward to see if the teeth will interdigitate correctly in time compared to the treatment of uncrowded cases with
good occlusion when the mandible is advanced to correct good archform.
276 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

ARCH DEVELOPMENT BEFORE FUNCTIONAL THERAPY

COMBINATION FIXED/FUNCTIONAL During an initial phase of arch development a quad


THERAPY helix is used to expand the maxillary arch with brackets
on the upper anterior teeth to correct alignment. In the
Case Report: KC Aged 11 Years 2 Months lower arch a bihelix is used to correct the archform with
cross-arch anchorage to accommodate the blocked-out
A severe Class II division 1 malocclusion is complicated
canine. The curve of Spee improves as the lower arch is
by crowding in the lower arch. The position of the lower
leveled during arch development.
incisors 4 mm lingual to the A-Po line compensates for
An overjet of 10 mm and a full unit distal occlusion
the degree of crowding in the lower arch. Each millime-
remains after arch development and is corrected with
tre advancement of the lower incisors results in a gain of
Twin Blocks. A dramatic change in facial balance is evident
2 mm in arch length, equivalent to 1 mm on each side.
after only 8 weeks of treatment with Twin Blocks, and
This permits the lower incisors to be advanced by 4 mm
following the rapid response, the improvement proved to
during arch development to resolve 7 mm of crowd-
be stable 18 months out of retention (Figs. 16.1A to R).
ing prior to functional therapy. The facial pattern is
brachyfacial and retrognathic with mandibular retru- Arch development: 11 months
sion. The dental relationship is severe Class II with a Twin Blocks: 7 months
full unit distal occlusion and an overjet of 13 mm and Retention: 7 months
excessive overbite. A lower canine is excluded from the Treatment time: 25 months
arch buccally, with a resulting displacement of the lower Final records: 18 months out of retention at age
center line. 14 years 9 months.

Case Report: KC

A
Fig. 16.1A: Treatment: Profiles at ages 11 years 11 months (before Twin Blocks), 12 years 2 months (after 8 months with Twin Blocks)
and 14 years 7 months (18 months out of retention).
Management of Crowding 277

B C D

E F G

H I
Figs. 16.1B to I: Treatment (contd…): (B to D) Occlusion before treatment. (E and F) Bihelix to improve the lower archform at age 11
years 2 months and 11 years 11 months; (G) Upper fixed appliance to improve the upper archform; (H and I) Tracing and profile before
arch development.
278 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

J K L

M N O

P Q R
Figs. 16.1J to R: Treatment (contd…): (J to L) Twin Blocks in phase 2; (M to O) Occlusion at age 14 years 7 months; (P and Q) Upper
and lower archform after treatment; (R) Facial appearance at age 17 years 3 months.
Management of Crowding 279

Case Report: KC

KC Age 11.11 12.7 14.7


Cranial Base Angle 26 25 26
Facial Axis Angle 27 25 28
F/M Plane Angle 23 25 21
Craniomandibular Angle 49 50 48
Maxillary Plane –1 0 2
Convexity 7 5 2
U/Incisor to Vertical 31 22 21
L/Incisor to Vertical 37 42 36
Interincisal Angle 112 116 123
6 to Pterygoid Vertical 16 15 18
L/Incisor to A/Po 0 3 4
L/Lip to Aesthetic Plane 4 2 –3
280 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

MANAGEMENT OF CROWDING: advancing the lower incisors from –4 mm behind the A-Po
NONEXTRACTION THERAPY line before treatment to +1 mm to gain 10 mm of arch
length. Extraction of the second molars is planned during
Case Report: NK Aged 11 Years 11 Months the course of treatment to accommodate the third molars
and to relieve the pressure from distal crowding in the
When a Class II division 1 malocclusion is associated
lower arch.
with a severe lip trap, the conspiring labial muscle imbal-
ance can lead to collapse of the lower labial segment Clinical Management
and crowding in the lower arch. The profile determines
An initial stage of treatment with a bihelix and a lower
whether the patient should be treated by extraction or
lip bumper is followed by a bonded lower fixed appliance
nonextraction therapy, taking into account the degree of
over a period of 6 months to align the lower arch in
crowding in the lower arch, the position of the lower inci-
preparation for functional correction. During this stage
sors relative to the anterior limit of the skeletal base and
there is little change in the overjet or the profile.
the lip contour relative to the esthetic line (Figs. 16.2A
Twin Blocks are fitted after correcting the lower arch-
to U).
form. An immediate improvement in profile is observed
Premolar extractions are contraindicated when the
as the facial balance improves dramatically in the early
skeletal growth pattern is severe brachyfacial, with a
stages of treatment. Arch relationships are corrected in
strong horizontal growth tendency in the mandible. Tight
6 months and an anterior inclined plane is fitted with a
lip musculature with the lower lip trapped in the overjet
Wilson lower lingual arch to retain the position. In spite of
is the primary causative factor for the crowding in the
severe crowding in the lower labial segment before treat-
lower labial segment. The strong lip musculature is an
ment, the lower arch proved to be stable out of retention.
indication that extraction of the premolars would be more
It is likely that extraction of second molars contributed to
likely to damage the profile by loss of support for the lips.
the stability of the lower labial segment after treatment by
Examination of the profile with the mandible postured
reducing the mesial component of force that is normally
forward to reduce the overjet confirms that facial balance
associated with the development and eruption of third
would be improved by treatment to place the lower lip
molars.
labial to the upper incisors.
The lower archform must be corrected first, however, Arch development: 6 months
to align the lower incisors prior to mandibular advance- Twin Blocks: 6 months
ment. Lower arch crowding of 9 mm can be resolved by Support and retention: 14 months.

Case Report: NK

A
Fig. 16.2A: Treatment: Profiles at ages 11 years 11 months (before treatment), 13 years (after Twin Blocks) and 15 years 10 months
(out of retention).
Management of Crowding 281

B C D

E F G

H I J
Figs. 16.2B to J: Treatment (cont…): (B to D) Occlusion before treatment; (E) Lower arch crowding before treatment [arch length discrepancy
(ALD) = 9 mm]; (F) Phase 1 arch development—bihelix and lip bumper; (G) Detailing with the fixed appliance; (H) Occlusion after arch
development; (I) Appearance before treatment; (J) Phase 2—Twin Blocks.
282 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

K L

M N O

P Q R

S T U
Figs. 16.2K to U: Treatment (contd…): (K and L) Support phase appliances, anterior inclined plane and lingual arch; (M to O) Occlusion after
support phase at age 13 years 9 months; (P to R) Occlusion out of retention at age 15 years 10 months; (T) Appearance after Twin Blocks at age
13 years; (S and U) Upper and lower archforms at age 15 years 10 months.
Management of Crowding 283

Case Report: NK

NK Age 12.3 13.0 15.10


Cranial Base Angle 25 25 27
Facial Axis Angle 30 30 29
F/M Plane Angle 15 16 17
Craniomandibular Angle 40 42 44
Maxillary Plane 1 –1 1
Convexity 4 3 1
U/Incisor to Vertical 28 23 13
L/Incisor to Vertical 37 25 28
Interincisal Angle 115 132 139
6 to Pterygoid Vertical 13 18 15
L/Incisor to A/Po 0 1 –1
L/Lip to Aesthetic Plane –8 –3 –8
284 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: JS Aged 12 Years 6 Months During treatment, the lower incisor is advanced from
a position 9 mm behind the A-Po line to its final position
This boy presents a Class II division 1 malocclusion with with the tip of the incisor on the A-Po line. This correc-
mild lower labial crowding. The facial type is severe tion is by a combination of incisor proclination during
brachyfacial with mandibular retrusion and a moderate initial arch development, and the forward translation
convexity of 5 mm. Severe retrusion of the lower incisors of the incisors that accompanies mandibular advance-
(9 mm lingual to the A-Po line before treatment) is ment. Intermaxillary traction is applied in the final stage
associated with an excessive overbite of 10 mm, and of treatment to stabilize the incisors and complete the
an excessive curve of Spee. The flattening of the lower correction. The facial appearance changes significantly as
labial segment is due to an active lower lip that is tra- the lower lip moves from its trapped position lingual to
pped in a 15 mm overjet. Arch development is indicated the lower incisors. The lip contour improves as the lower
followed by functional mandibular advancement. It is incisors move labially to give better support to the lips
difficult to design a satisfactory lower Twin Block until the and these changes have a profound influence on the soft-
alignment of the lower arch is improved. The treatment tissue balance of the lower third of the face.
objectives are first to improve the archform, followed Arch development: 3 months
by functional correction to Class I occlusion and a Twin Blocks: 9 months
final stage with fixed appliances to detail the occlusion Support phase: 10 months
(Figs. 16.3A to V). Fixed appliances: 8 months.

Case Report: JS

B C D
Figs. 16.3A to D: Treatment: (A) Profiles at ages 12 years 6 months (before treatment), 13 years 4 months (after 6 months with
Twin Blocks) and 15 years 11 months; (B to D) Occlusion before treatment.
Management of Crowding 285

E F

G H I

J K L

M N
Figs. 16.3E to N: Treatment (contd…): (E and F) Appearance before treatment; (G to I) Phase I—arch development, Wilson quad helix
and lingual arch; (J and K) Occlusion after 3 months of arch development; (L) Occlusion after Twin Blocks; (M) Twin Blocks in Phase II;
(N) Occlusion after Twin Blocks.
286 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

O P Q

R S T

U V
Figs. 16.3O to V: Treatment (contd…): (O) Upper archform at age 15 years 11 months; (P) Fixed appliances; (Q) Lower archform at age
15 years 11 months; (R to T) Occlusion at age 15 years 11 months; (U and V) Appearance at age 15 years 11 months.
Management of Crowding 287

Case Report: JS

JS Age 12.3 15.5


Cranial Base Angle 29 31
Facial Axis Angle 29 28
F/M Plane Angle 15 20
Craniomandibular Angle 44 51
Maxillary Plane 0 –1
Convexity 5 2
U/Incisor to Vertical 27 15
L/Incisor to Vertical 12 33
Interincisal Angle 141 132
6 to Pterygoid Vertical 15 13
L/Incisor to A/Po –9 0
L/Lip to Aesthetic Plane –6 –1
288 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Treatment Concept a partial upper fixed appliance with two molar bands
and four incisor brackets. This is combined with the
Avoiding extraction of premolars generally produces a
Trombone and Lingual Arch Developer (see Chapter 23)
better profile by providing good lip support from well-
to correct archform in the lower arch. This is followed
formed dental arches, thus maintaining better facial bal-
by 8 months of Twin Block treatment, and treatment is
ance. Extraction of premolars is seldom required to relieve
completed in 18 months. The Bergersen Occlus-o-Guide
upper arch crowding, when arch development provides a
is selected as the most appropriate retainer. For the
valid alternative. This patient was treated by Dr Gordon
first 3 months, the Occlus-o-Guide® is worn for 2 hours
Kluzak in his pedodontic practice in Calgary.
during the day and at nights, before reducing to night-
time wear only. This preformed positioner is an exce-
Case Report: AMcD Aged 12 Years 9 Months llent functional retainer which can be used successfully
by Gordon Kluzak to settle and detail the occlusion. Second molars were
Crowding of the upper and lower labial segments is later extracted to accommodate third molars (Figs. 16.4A
resolved in the first phase of arch development using to M).

Case Report: AMcD

B C
Figs. 16.4A to C: Treatment: (A) Profiles at ages 12 years 9 months (before treatment) and 15 years (after treatment); (B and C) Occlusion
before treatment.
Management of Crowding 289

D E

F G

H I J

K L M
Figs. 16.4D to M: Treatment (contd…): (D and E) Models show the buccal segment occlusion before treatment; (F and G) Upper and
lower archforms before treatment; (H to J) Occlusion after treatment; (K and M) Upper and lower archforms after treatment; (L) Facial
appearance after treatment.
290 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: AMcD

AMcD Age 12.9 14.3 15.0


Cranial Base Angle 24 26 26
Facial Axis Angle 24 30 30
F/M Plane Angle 27 20 21
Craniomandibular Angle 51 46 47
Maxillary Plane 2 7 5
Convexity 5 4 4
U/Incisor to Vertical 5 19 19
L/Incisor to Vertical 26 32 30
L/Incisor to A/Po –2 1 1
L/Lip to Aesthetic Plane –1 –3 –3
6 to Pterygoid Vertical 12 13 13
Management of Crowding 291

CLASS II DIVISION 1 MALOCCLUSION WITH CROWDED CANINES

COMBINATION THERAPY BY TWIN BLOCKS The appliance is trimmed clear of the single proclined
AND FIXED APPLIANCES incisor, so that the activation of the screws advances only
the retroclined upper incisors. The palatal acrylic on the
Case Report: TS Aged 14 Years 2 Months upper appliance is trimmed to relieve the pressure on
There are many examples of Class II malocclusion the palatal gingivae lingual to 21/12 during treatment
with crowding in the upper labial segment, resulting which is incidental to screw expansion. It is important
in displacement and irregularity of the incisors, or to maintain appliance contact on the lingual surfaces
alternatively the upper canines may be crowded buccally of the teeth that are being advanced, and therefore
out of the arch. The Twin Block sagittal appliance can no trimming is done where the appliance contacts
be used to treat upper labial segment crowding and, at these teeth.
the same time, will correct distal occlusion and reduce In this case, the transition to fixed appliances was
overjet (Figs. 16.5A to N). made after a short support phase when the buccal teeth
A moderate Class II skeletal pattern with a convexity settled into Class I occlusion, during which period a lower
of 5 mm is due to maxillary protrusion, but the profile lingual arch corrected the lower archform. Subsequent
improves when the mandible is advanced, therefore func- detailing of the occlusion was simple after achieving
tional correction is preferred to maxillary retraction. This the major correction during the Twin Block phase of
allows the crowded canines to be accommodated in the
treatment.
upper arch by advancing the retroclined upper incisors.
Twin Blocks: 8 months
Clinical Management Support phase: 6 months
The palatal screws in the sagittal Twin Block are turned Fixed appliances: 9 months
two quarter-turns per week to align the upper incisors. Retention: 1 year.

Case Report: TS

B C D
Figs. 16.5A to D: Treatment: (A) Profiles at ages 14 years 2 months (before treatment) and 16 years 7 months (1 year out of retention);
(B to D) Occlusion before treatment.
292 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

E F G

H I J

L M N
Figs. 16.5E to N: Treatment (cont…): (E to G) Archform corrected by sagittal Twin Blocks after 9 months; (H to J) Occlusion after 1 year
at age 15 years 2 months; (K) Fixed appliances; (L to N) Occlusion 1 year out of retention at age 16 years 7 months.
Management of Crowding 293

Case Report: TS

TS Age 14.0 14.10 17.4


Cranial Base Angle 26 26 27
Facial Axis Angle 30 30 34
F/M Plane Angle 14 15 10
Craniomandibular Angle 40 40 37
Maxillary Plane 1 −1 2
Convexity 5 4 1
U/Incisor to Vertical 11 22 26
L/Incisor to Vertical 33 33 23
Interincisal Angle 136 125 131
6 to Pterygoid Vertical 18 18 23
L/Incisor to A/Po 0 3 1
L/Lip to Aesthetic Plane 0 1 1
294 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

MANAGEMENT OF CROWDING WITH now stopped. A moderate maxillary protrusion and mild
AN ANTERIOR OPEN BITE mandibular retrusion contribute to a convexity of 10 mm
and an overjet of 9 mm. Mild crowding in the lower labial
Case Report: RG Aged 11 Years 6 Months segment is treated when second deciduous molars are
still present by holding the lower molar position to gain
A girl with an anterior open bite and mild lower labial
Leeway space. The lower Twin Block should incorporate a
crowding presents a brachyfacial growth pattern which
midline screw to assist in alignment of the lower incisors
is favorable for correction by a combination of an initial
(Figs. 16.6A to V).
functional phase to improve the profile followed by
fixed appliances to detail the occlusion. The prognosis Twin Blocks: 9 months
for correction of the anterior open bite is good as the Support appliance: 4 months
primary cause was a thumb sucking habit which has Fixed appliances: 18 months.

Case Report: RG

B C D
Figs. 16.6A to D: Treatment: (A) Profiles at ages 11 years 6 months (before treatment), 11 years 11 months (after 5 months’ treatment
with Twin Blocks) and 15 years 0 months (out of retention); (B to D) Occlusion before treatment.
Management of Crowding 295

E F G

H I J

K L M
Figs. 16.6E to M: Treatment (contd…): (E to G) Correction after 8 weeks of treatment with Twin Blocks; (H) Twin Blocks; (I and J) Upper
archform and appliances; (K and L) Lower archform after expansion with Twin Blocks; (M) Fixed appliances.
296 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

N O

P Q

R S

T U V
Figs. 16.6N to V: Treatment (contd…): (N and O) Fixed appliances; (P) Appearance before treatment; (Q) Appearance after treatment at
age 14 years; (R and S) Upper and lower archforms at age 16 years; (T to V) Occlusion 1 year out of retention at age 16 years.
Management of Crowding 297

Case Report: RG

RG Age 11.5 11.11 14.5


Cranial Base Angle 28 29 27
Facial Axis Angle 30 31 29
F/M Plane Angle 14 12 15
Craniomandibular Angle 41 40 42
Maxillary Plane 2 0 2
Convexity 10 6 7
U/Incisor to Vertical 26 19 30
L/Incisor to Vertical 47 40 40
Interincisal Angle 107 121 110
6 to Pterygoid Vertical 17 18 19
L/Incisor to A/Po –1 4 3
L/Lip to Aesthetic Plane 0 –2 –1
298 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

TREATMENT OF CONTRACTED ARCHFORM a mild retrognathic pattern with convexity of 6 mm and


a vertical growth tendency. The approach to treatment is
Case Report: SM Aged 12 Years 5 Months by a combination of Twin Blocks, arch development and
This is an example of treatment in a girl who has passed fixed appliances.
the pubertal growth spurt. Although growth slows signifi- The upper incisors are vulnerable to damage due to
cantly in females at this stage, it is still possible to correct their exposed position. On account of this, a decision
severe distal occlusion, and to reduce an excessive overjet was made to correct the overjet and distal occlusion with
by functional correction. Twin Blocks in the first stage. This is followed by arch
The upper arch is V shaped in this severe Class II development during the support phase, and a final stage
division 1 malocclusion and the lower arch is constricted with fixed appliances (Figs. 16.7A to R).
within the narrow upper arch with a crowded lower labial
segment. An overjet of 13 mm and excessive overbite are Twin Blocks: 9 months
caused by the lower lip being trapped in the overjet, Arch development: 6 months
with severe protrusion of upper central incisors while Fixed appliances: 2 years.
the lower incisors are retroclined and positioned 5 mm Treatment may sometimes extend over a longer period
lingual to the A-Po line. The skeletal base relationship is at this age, especially if combination therapy is required.

Case Report: SM

B C D
Figs. 16.7A to D: Treatment: (A) Profiles at ages 12 years 5 months (before treatment), 13 years (after 7 months’ treatment with
Twin Blocks) and at 19 years 8 months; (B to D) Occlusion before treatment.
Management of Crowding 299

E F

G H I

J K L

M N O

P Q R
Figs. 16.7E to R: Treatment (contd…): (E) Occlusion after Twin Blocks, in the support phase at age 14 years; (F and K) Fixed appliances
is detail the occlusion; (G and J) Contracted upper and lower archform before treatment; (H) Arch development continues in fixed appliance
treatment; (I and L) Corrected archform at age 19 years 9 months; (M) Appearance before treatment; (N and O) Appearance at age
19 years 8 months; (P to R) Occlusion out of retention at age 19 years 8 months.
300 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: SM

SM Age 12.4 14.4 19.8


Cranial Base Angle 26 29 28
Facial Axis Angle 27 28 24
F/M Plane Angle 22 22 24
Craniomandibular Angle 48 51 51
Maxillary Plane 0 1 –1
Convexity 6 3 3
U/Incisor to Vertical 26 17 16
L/Incisor to Vertical 30 39 34
Interincisal Angle 124 124 130
6 to Pterygoid Vertical 20 20 23
L/Incisor to A/Po –4 1 0
L/Lip to Aesthetic Plane –6 –5 –7
Extraction Therapy  301

Chapter 17
Extraction Therapy

INTRODUCTION significant crowding is present in the lower arch, it may


only be resolved by premolar extractions.
It is unusual to combine extraction of premolars with Examples of extraction therapy are illustrated to demon­
functional therapy. With certain exceptions, premolar strate the management of these problems, which are excep­
extraction therapy and functional appliance therapy are tional rather than typical in Twin Block therapy.
almost contradictory terms. In a minority of cases, the
degree of crowding mesial to the first permanent molars Case Report: KM Aged 11 Years 9 Months
may be so severe that premolar extractions are inevitable,
although the patient may still benefit from functional This is an example of Twin Block treatment for a girl
correction. In other cases, the patient may present too late who presented a Class II division 1 malocclusion in the
to control crowding by interceptive treatment and arch permanent dentition with severe crowding in the lower
development, but may still require functional mandibular buccal segments with second premolars blocked out of
protrusion. In these circumstances, fixed and functional the arch and impacted. Twin Blocks were used to correct
therapy is required to correct archform, close spaces and the distal occlusion and reduce the overjet, followed by
correct arch relationships. extraction of premolars to relieve crowding. Sectional
The protocol for combination of fixed and functional upper fixed appliances were used to close extraction
therapy is illustrated in Chapter 10 with an example of spaces. In the lower arch, 4 4 were extracted to provide
space for 5 5 to erupt (Figs. 17.1A to J).
a treated case following extraction of premolars. (Case
A dramatic change in facial appearance is again
report: M.Z., pages 161–163). It is possible to relieve
observed during the early stages of treatment with Twin
crowding and correct archform with space closure using
Blocks as the large overjet and distal occlusion are cor­
fixed appliances in the first stage of treatment, followed
rected. The improvement in facial balance is maintained
by mandibular advancement in an integrated fixed/
as shown in the final records 5 years out of retention:
functional approach to treatment.
Patients presenting with vertical growth patterns and Twin Blocks: 10 months
a high mandibular plane angle cannot be expected to Support phase: 4 months
grow favorably during treatment. In such cases, when Sectional fixed appliance: 6 months.
302  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: KM

B C D

E F G

H I J
Figs. 17.1A to J: Treatment: (A) Profiles at ages 11 years 9 months (before treatment), 12 years 3 months (after 6 months’ treatment)
and 18 years 10 months; (B) Appearance before treatment; (C) Appearance after 6 months treatment; (E to G) Occlusion before treatment;
(H and J) Occlusion 6 months after treatment; (D and I) Appearance at age 18 years 10 months.
Extraction Therapy  303

Case Report: KM

KM Age 11.7 12.3 18.10


Cranial Base Angle 26 29 28
Facial Axis Angle 27 28 24
F/M Plane Angle 22 22 24
Craniomandibular Angle 48 51 51
Maxillary Plane 0 1 −1
Convexity 6 3 3
U/Incisor to Vertical 26 17 16
L/Incisor to Vertical 30 39 34
Interincisal Angle 124 124 130
6 to Pterygoid Vertical 20 20 23
L/Incisor to A/Po −4 1 0
L/Lip to Aesthetic Plane −6 −5 −7
304  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

TREATMENT OF PATIENTS WITH overbite. Because of the vertical growth pattern, the pro­
UNFAVORABLE SKELETAL file does not significantly improve when the mandible
postures forwards. Extraction of the premolars is indi­
AND DENTAL FACTORS
cated to improve the profile (Figs. 17.2A to M).
The combination of a high mandibular plane angle
Case Report: GMcD Aged 12 Years 1 Month
and deep overbite is a warning sign that facial height
This patient presents a difficult problem with a severe will increase if the mandible is translated forwards.
Class II skeletal relationship, mandibular retrusion, a verti­ This is confirmed in the profile change observed when
cal growth pattern, severe lower labial crowding and deep the patient postures forwards before treatment. In such

Case Report: GMcD

B C D

E F G
Figs. 17.2A to G: Treatment: (A) Profiles at ages 12 years 4 months (before treatment), 13 years 2 months (10 months after treatment
with Twin Blocks), and 15 years 2 months (after treatment); (B to E) Contracted upper and lower archform and occlusion before treatment;
(F and G) Upper and lower archform after extractions and space closure in phase 2.
Extraction Therapy  305

H I J

K L M
Figs. 17.2H to M: Treatment (contd…): (H to J) Occlusion after treatment; (K) Facial appearance before treatment; (L and M) Facial
appearance after treatment.

cases, an alternative approach is to intrude the incisors It is evident when the lower model is advanced to
with fixed appliances, for example using utility arches, reduce the overjet that the resulting occlusion would
before the functional phase of treatment. The mandible be unsatisfactory, as the teeth would not interdigitate
may then be translated forwards without increasing the correctly. In an effort to improve the profile an attempt
facial height. was made to advance the mandible in the first stage of
The degree of crowding in the lower arch and the treatment, followed by the extraction of four premolars
position of the lower dentition relative to the basal bone to relieve crowding and the use of bonded fixed applia­
are the factors which determine whether or not extractions nces to close the spaces and reduce the prominence of
are required, and influence the choice of extraction. If the the lips.
lower dentition is crowded and significantly protrusive The overjet reduced from 8 mm to 2 mm in 4 months
beyond the anterior limit of basal bone, extraction therapy with Twin Blocks. On this occasion, the profile did not
is indicated. The normal position of the tip of the lower improve due to lengthening of the lower facial height.
incisor relative to the A–Po line is +1 mm to +3 mm. The position was retrieved after the extraction of four
Several unfavorable factors contribute to this mal­ premolars, when a Wilson lower lingual arch was fitted to
occlusion. Maxillary protrusion and severe mandibular maintain arch length and align the lower labial segment.
retrusion combine to produce a convexity of 10 mm After closing buccal segment spaces and establishing
with increased lower facial height and a moderate doli­ a Class I occlusion, the upper and lower incisors were
chofacial growth pattern. The lower incisors are severely retracted by space closing mechanics, allowing the profile
crowded and are already positioned at + 3 mm to the A–Po to improve as the lips were retracted.
line. The overjet and overbite are increased, while the Orthopedic phase: 4 months
occlusion of the buccal teeth registers a Class I relation­ Orthodontic phase: 2 years
ship before treatment, due to mesial drift of the lower Retention: 1 year
buccal segments, with lower canines crowded labially. Total treatment time: 1 year 6 months.
306  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: GMcD

GMcD Age 12.1 13.1


Cranial Base Angle 31 30
Facial Axis Angle 25 24
F/M Plane Angle 27 33
Craniomandibular Angle 58 62
Maxillary Plane 1 −2
Convexity 10 8
U/Incisor to Vertical 28 22
L/Incisor to Vertical 36 40
Interincisal Angle 116 118
6 to Pterygoid Vertical 17 17
L/Incisor to A/Po 2 6
L/Lip to Aesthetic Plane 5 3
Extraction Therapy  307

Case Report: LC Aged 10 Years 9 Months Clinical Management


This girl presented a severe Class II division 2 malocc­ The construction bite registered an edge-to-edge
lusion with a typical brachyfacial growth pattern and incisor occlusion. In view of the excessive overbite, no
reduced lower facial height. A convexity of 10 mm is due additional interincisal clearance was necessary in this
to a combination of maxillary protrusion and mandi­ case. Twin Blocks were worn for 16 months to advance
bular retrusion. Severe retroclination of upper and lower the mandible and procline the upper incisors. During this
44
incisors is reflected in an interincisal angle of 175°, and period, 2 4 were extracted to relieve crowding. Towards
the lower incisors are 7 mm behind the A–Po line, with an the end of the Twin Block stage, brackets were fitted
excessive overbite of 10 mm. It is very unusual to extract on the upper anterior teeth to improve alignment. An
premolars in Class II division 2 malocclusion; this case is anterior inclined plane was worn for 2 months to allow
an exception due to the severity of lower arch crowding in the occlusion to settle before fitting the fixed appliances
permanent dentition [arch length discrepancy (ALD) = 19 to complete the treatment. The finishing stage was slow
mm)]. Combination therapy used Twin Blocks to correct and extended over a period of 3 years. Final records show
arch relationships and fixed appliances to close extraction the position at age 18 years and confirm the stability of
spaces and detail the occlusion (Figs. 17.3A to N). the result.

Case Report: LC

B C D
Figs. 17.3A to D: Treatment: (A) Profiles at ages 10 years 9 months (before treatment), 12 years 3 months (after the Twin Block phase) and
16 years 7 months; (B to D) Occlusion before treatment.
308  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

E F G

H I J

K L M

Figs. 17.3E to N: Treatment (contd..): (E and F) Archform before treatment, 19 mm crowding


in the lower arch; (G) Brackets on the upper anterior teeth during the Twin Block phase;
(H and I) Archform at age 18 years 3 months; (J) Phase 2—fixed appliances; (K to M)
Occlusion at age 18 years 3 months; (N) Appearance after treatment at age 16 years
N 7 months.
Extraction Therapy  309

Case Report: LC

LC Age 10.9 11.5 18.1


Cranial Base Angle 27 27 26
Facial Axis Angle 27 27 26
F/M Plane Angle 16 16 16
Craniomandibular Angle 43 42 42
Maxillary Plane −4 −6 −2
Convexity 10 9 5
U/Incisor to Vertical −17 16 21
L/Incisor to Vertical 22 35 40
Interincisal Angle 175 129 119
6 to Pterygoid Vertical 15 19 21
L/Incisor to A/Po −7 −1 2
L/Lip to Aesthetic Plane −6 −3 −4

It is never ideal to resolve a Class II division 2 malocc­ causing impaction of the lower second premolars. Arch
lusion by premolar extractions, but this was an exception development at an earlier stage might have allowed treat­
to the general rule. In this case, the severe lower arch ment to be completed without extractions, with a better
crowding resulted from extraction of lower deciduous improvement in the profile.
molars, allowing the first molars to drift mesially and
Treatment of Facial Asymmetry  311

Chapter 18
Treatment of Facial Asymmetry

INTRODUCTION symmetry. The construction bite is registered with the


incisors edge-to-edge with 2 mm vertical clearance, and
The occlusal inclined plane is an ideal functional mech- the center lines correct. The objective is to improve the
anism for unilateral activation, and Twin Blocks are facial asymmetry and correct the mandibular retrusion
extremely effective in the correction of facial and dental at the same time.
asymmetry. The sagittal Twin Block is the appliance of
choice for correction of asymmetry because the sagittal Appliance Design
design allows unilateral activation to restore symmetry in
An upper Twin Block sagittal appliance with two palatal
buccal and labial segments.
screws is designed to advance retroclined upper inci-
sors and drive upper molars distally. The screw is turned
CASE REPORT: M McK AGED more frequently on the side that requires more distal
10 YEARS 4 MONTHS movement. The mechanical action of the palatal screws
is reinforced by occlusal forces on the inclined planes,
This girl presented facial and dental asymmetry with the favoring the working side to correct the midline displace-
lower center line displaced to the right. In the anterior ment (Fig. 18.1).
facial view the chin point was displaced to the right in
open and closed position, confirming a true skeletal Clinical Management
asymmetry. The skeletal pattern shows a moderate Class II
The initial response to treatment resulted in rapid correc-
discrepancy with 6 mm convexity due to mandibular
tion of the asymmetry and reduction of the overjet. After
retrusion. The distal occlusion is more marked on the
7 weeks of treatment, at the second visit for adjustment,
right side. Combination therapy is the treatment of choice
the center lines were corrected and the overjet was fully
with Twin Blocks to improve the asymmetry, followed
reduced. A new muscle balance position was established
by an orthodontic phase of detailed finishing with fixed
whereby it was not possible for the patient to retract the
appliances.
mandible into its former retruded asymmetrical position.
The rapid improvement in muscle balance is evident in
Bite Registration
the facial photographs at this stage and there is already
Correction of asymmetry in the construction bite ensures a marked improvement in the facial asymmetry and
that the occlusal forces activate the appliance to restore profile.
312  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
At this stage the lateral open bite is increased on
the right side. Asymmetry is normally associated with a
vertical discrepancy, which can be identified when the
center lines are corrected in the construction bite. The
vertical space between the posterior teeth is more marked
on the side to which the mandible is displaced. The height
of the occlusal blocks in the premolar region on the right
side was slightly reduced over a period of 2 months to
encourage vertical correction.
After 6 months of treatment the buccal segment occlu-
sion was corrected to Class I with the overjet and over-
bite reduced. The center lines were now correct, and the
lateral open bite was closed sufficiently to proceed to the
next stage.
The lower Twin Block was replaced by a lower fixed
appliance to commence orthodontic correction in the
lower arch. An upper appliance with an anterior inclined
plane was fitted to support the corrected incisor relation-
ship, leaving the posterior teeth free to erupt fully into
occlusion.
Brackets were placed on the upper anterior teeth to
improve alignment during the support phase. A full tran-
sition to fixed appliances was made after 10 months of
treatment, when the distal occlusion and dental asymme-
try was corrected, and there was considerable improve-
ment in the facial asymmetry. Treatment continued in
an orthodontic phase with full-bonded fixed appliances,
followed by retention (Figs. 18.2A to W).
Fig. 18.1: Sagittal Twin Blocks give better control for correction of
The rapid improvement in facial and dental asymmetry
dental or facial asymmetry. Good fixation is necessary in the lower in this case was achieved by unilateral activation of
arch. the occlusal inclined planes. This improvement was
maintained out of retention.
At the start of treatment the upper bite block was
trimmed occlusodistally to encourage lower molar erup- Twin Blocks: 6 months
tion. At the second visit the inclined planes on the left Support phase: 5 months
side were trimmed out of contact in order to reinforce Fixed appliances: 1 year
the corrective occlusal forces on the active right side. Retention: 1 year.
Treatment of Facial Asymmetry  313

Case Report: M McK

B C D

E F G

H I J
Figs. 18.2A to J: Treatment: (A) Profiles at ages 10 years 4 months (before treatment), 10 years 6 months (after 6 weeks’ treatment)
and 15 years 4 months (1 year out of retention); (B to D) Asymmetrical occlusion before treatment; (E) Appearance before treatment at
age 10 years 4 months; (F) Construction bite corrects the asymmetry; (G) Improvement in asymmetry after 10 weeks at age 10 years
6 months; (H to J) Correction of occlusion at age 10 years 7 months.
314  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

K L M

N O

P Q R

S T

U V W
Figs. 18.2K to W: Treatment (contd...): (K to M) Fixed appliances to detail the occlusion; (N and O) Arch form after treatment; (P to R)
Occlusion at the end of treatment; (S) Appearance after treatment; (T to W) Appearance and occlusion 1 year out of retention at age
15 years 4 months.
Treatment of Facial Asymmetry  315

Case Report: M McK

M McK Age 10.4 10.8 14.3


Cranial Base Angle 27 27 27
Facial Axis Angle 27 29 28
F/M Plane Angle 22 23 22
Craniomandibular Angle 49 49 49
Maxillary Plane 2 0 0
Convexity 6 6 3
U/Incisor to Vertical 19 22 27
L/Incisor to Vertical 24 36 35
Interincisal Angle 137 122 118
6 to Pterygoid Vertical 13 13 13
L/Incisor to A/Po −3 0 0
L/Lip to Aesthetic Plane −4 −3 −5
Magnetic Twin Blocks  317

Chapter 19
Magnetic Twin Blocks

INTRODUCTION Similar experiments using a magnetic appliance with


an adjustable screw for maxillary advancement showed
The role of magnets in Twin Block therapy is specifically midfacial protraction with horizontal maxillary displace-
to accelerate correction of arch relationships. The purpose ment and anterosuperior premaxillary rotation (Vardimon
of the magnets is to encourage increased occlusal contact et al., 1989, 1990).
on the bite blocks to maximize the favorable functional Clinical investigations are now proceeding to develop
forces applied to correct the malocclusion. new appliance systems to utilize magnetic forces. The
Two types of rare earth magnet (samarium-cobalt author has modified Twin Blocks by the addition of
and neodymium-boron) have been used to examine the attracting magnets to occlusal inclined planes, using
response to attracting magnetic forces in Twin Block treat- magnetic force as an activating mechanism to maximize
ment. Both are effective, but neodymium-boron delivers the orthopedic response to treatment. Darendeliler and
a greater force from a smaller magnet. At this stage no Joho (1993) have described similar appliances which are
statistical comparison has been made by the author to essentially based on the magnetic Twin Block.
evaluate the response to magnetic and non-magnetic
appliances, and the following observations are based on
clinical evaluation.
ATTRACTING OR REPELLING MAGNETS
Attracting magnets incorporated in occlusal inclined The first consideration on the use of magnets in inclined
planes may be effective in maintaining forward mandi­ planes is whether the opposing poles should attract or
bular posture when the patient is asleep. Patients who repel. There are logical reasons to support the use of
have magnets added to Twin Blocks during treatment both systems. The advantages of both methods may be
report increased occlusal contact by day and observe also summarized as follows, with examples of current clinical
that the blocks are in contact on waking. research.

MAGNETIC FORCE Attracting Magnets


Magnetic force is a new factor under investigation as an In favor of attracting magnets it may be said that increased
activating mechanism in orthodontic and orthopedic activation can be built into the initial construction bite
treatment. Animal experiments in mandibular advance­ for the appliances. The attracting magnetic force pulls
ment (Vardimon et al., 1989, 1990) indicate an improved the appliances together and encourages the patient to
mandibular growth response to magnetic functional app­ occlude actively and consistently in a forward position.
liances compared to nonmagnetic appliances of similar The functional mechanism of Twin Blocks stimulates
design. a proprioceptive response by repeated contact on the
318  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
occlusal inclined planes. Attracting magnets may acceler- Treatment of Facial Asymmetry
ate progress by increasing the frequency and the force of
contact on the inclined planes, thus enhancing the adap- Magnetic force may be used to counteract asymmetrical
tive response to functional correction. muscle action in the development of facial asymmetry.
The author has used rare earth attracting magnets in Mandibular displacement responds rapidly to correc-
five different clinical situations, described below. tion with attracting magnets in the occlusal inclined
planes on the working side. The nonactive side may be
Class II division 1 malocclusion with a large overjet:
activated to a lesser degree to encourage center line
1. This resulted in more rapid correction of distal
correction.
occlusion than would normally be expected without
magnets. After 1 month of treatment, the overjet
reduced from 10 mm to 6 mm, and after 2 months of Repelling Magnets
treatment, a further reduction to 2 mm was observed Repelling magnets may be used in Twin Blocks with less
(Figs. 19.1A to V). mechanical activation built into the occlusal inclined
2. Mild residual Class II buccal segment relationship: planes. The repelling magnetic force is intended to apply
This was proving difficult to resolve and was mainly
additional stimulus to forward posture as the patient
a unilateral problem. Magnetic inclined planes were
closes into occlusion.
used to accelerate correction of the buccal segment
In 1990, Moss and Shaw reported at the European
relationship to a “super Class I” relationship, which
Orthodontic Congress on a controlled study of 12 patients
was quickly achieved (see Fig. 6.13).
with repelling magnets placed in occlusal inclines of Twin
3. Mild Class II division 1 malocclusion with an overjet
Block appliances. The results indicated a 50% increase in
of 7 mm: The patient was failing to posture forwards
the rate of correction of overjet compared to a similar
consistently with conventional Twin Blocks and, as
group of patients where magnets were not used, although
a result, was making slow progress. The addition of
an improved growth response was not established.
attracting magnets noticeably improved occlusal
The repelling magnets were intended to induce addi­
contact on the bite blocks, and progress improved
tional forward mandibular posture without reactivation
as a consequence. Patients with weak musculature
of the blocks.
fail to respond to functional therapy because they
do not make the muscular effort required to engage The appliances used in this study were not designed
the appliance actively by occluding on the inclined to allow vertical development in the buccal segments
planes. It appears that attracting magnets will benefit and, therefore, produced a large posterior open bite
this type of patient by increasing the frequency of which subsequently had to be closed by fixed appli­
favorable occlusal contacts. ances. These appliances did not conform to the basic
4. Unilateral Class II adult patient with temporomandi­ principles of Twin Block design for control of the vertical
bular joint pain: Magnets were fitted unilaterally to dimension.
correct the mandibular displacement to the affected After a short period of investigation it appears that
side. This was immediately effective in resolving the magnetic Twin Blocks may help to resolve some of the
symptoms, and occlusal correction is proceeding to problems encountered in the management of difficult
produce a long-term resolution of the problem. cases. It is still to be established whether attracting or
5. Skeletal Class III malocclusion with persistent crossbite, repelling magnets are more effective, although attracting
failed to resolve with conventional mechanics: Class magnets would appear to have an advantage by increasing
III magnetic Twin Blocks were used to apply ortho­ contact on the inclined planes.
pedic forces to correct mandibular displacement and Magnets should be used only where speed of treatment
to advance the maxilla, with an additional sagittal is an important consideration, or where the response to
expansion component. This was effective in resolving nonmagnetic appliances is limited. Similar results may be
quickly the mandibular displacement. The initial res­ achieved by the addition of vertical elastics, as described
ponse to Class III correction is excellent. in Chapter 12.
Magnetic Twin Blocks  319

Case Report: FH Aged 14 Years 11 Months observed as the overjet reduced from 10 mm to 2 mm
This boy attended for treatment in his mid-teens and in 2 months. The Twin Blocks were worn for a further
presented labial segment crowding and irregularity in 3 months to stabilize the corrected occlusion before
both arches. A traumatic occlusion was related to gingival discarding the lower appliance and fitting an upper
recession of a lower central incisor with an overjet of appliance with an anterior inclined plane. There was a
10 mm and an excessive overbite. short period of passive retention at this stage, during
Although cephalometric analysis indicated mild which the lower labial frenum was resected to improve
maxillary protrusion and a normal mandible, the pro- the gingival recession on the lower central incisor.
file improved significantly when the patient postured the Detailing of the occlusion was carried out with
mandible forwards to reduce the overjet and correct the bonded fixed appliances. Lingual root torque was applied
distal occlusion. This clinical guideline always takes prec- to position the root of the central incisor in alveolar bone
edence over cephalometric evaluation in assessing suit- in order to stabilize the incisor relation­ship and improve
ability for functional therapy.
the gingival attachment of this tooth (Figs. 19.1A to V).
An initial stage of arch development with a Wilson
quad helix and lower lingual arch was combined with Arch development: 6 months
brackets on the upper anterior teeth. This was followed Twin Blocks: 5 months
by Twin Blocks with attracting magnets to accelerate Fixed appliances: 20 months
the orthopedic stage of treatment. Rapid progress was Retention: 1 year.

Case Report: FH

A
Fig. 19.1A: Treatment: Profiles at ages 14 years 7 months (before treatment), 15 years 9 months (after Twin Blocks) and 19 years 4 months
(out of retention).
320  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

B C D

E F G

H I J
Figs. 19.1B to J: Treatment (contd…): (B to D) Occlusion before treatment—note the gingival recession of 1; (E and F) Phase 1—arch
development (quad helix and Wilson lingual arch); (G) Improved lower archform after arch development; (H) Occlusion before Twin Blocks;
(I) Phase 2—magnetic Twin Blocks in edge-to-edge occlusion; (J) Correction of the overjet and distal occlusion after 2 months.
Magnetic Twin Blocks  321

K L M

N O P

Q R S

T U V
Figs. 19.1K to V: Treatment (contd...): (O) Correction of the overjet and distal occlusion after 2 months; (K) Appearance before treatment;
(L and M) Appearance at age 19 years 4 months; (N and P) Occlusal view of magnetic Twin Blocks; (Q and S) Corrected archform at
age 19 years 4 months; (R) Fixed appliances to detail the occlusion; (T to V) Occlusion 1 year out of retention at age 19 years 4 months.
322  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: FH

FH Age 14.7 15.9 17.8


Cranial Base Angle 26 26 25
Facial Axis Angle 32 34 32
F/M Plane Angle 16 15 16
Craniomandibular Angle 42 45 43
Maxillary Plane –4 2 0
Convexity 5 2 0
U/Incisor to Vertical 21 21 27
L/Incisor to Vertical 24 31 29
Interincisal Angle 135 128 126
6 to Pterygoid Vertical 16 15 15
L/Incisor to A/Po –2 0 1
L/Lip to Aesthetic Plane –1 –1 –5
Magnetic Twin Blocks  323

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 Twin Blocks have
the potential to accelerate the rate of correction achieved
by conventional functional appliances (Fig. 19.2).

REFERENCES
Darendeliler MA, Joho JP, (1993). Magnetic activator device
II (MAD) for correction of Class II Division I malocclu-
sions, American Journal of Orthodontics and Dentofacial
Orthopedics. 103:223-39.
Vardimon AD, Stutzmann JJ, Graber TM, et al, (1989).
Functional Orthopedic Magnetic Appliance (FOMA) II–modus
operandi, American Journal of Orthodontics and Dentofacial
Orthopedics. 95:371-87.

Fig. 19.2: Magnetic Twin Blocks can accelerate the rate of correction.
Adult Treatment  325

Chapter 20
Adult Treatment

INTRODUCTION dentoalveolar response in adult treatment where peri­


odontally compromised teeth are the weakest link in
Tooth movements are slower in older patients, and the the biological chain of reaction due to lack of bony
skeletal response diminishes with the patient’s age. support. Combined extraoral and intermaxillary traction
In adult orthodontic treatment we should anticipate a were applied at night during the orthopedic phase of
dentoalveolar response with limited skeletal adaptation. treatment, using the Concorde facebow to accelerate
This still leaves scope for significant facial change, but tooth movements. This was followed by an orthodontic
only when the skeletal discrepancy is not severe. Surgical phase with fixed appliances. Finally, upper and lower
correction should be considered for cases of severe Rochette splints were fitted as fixed lingual retainers.
skeletal discrepancies in adults. These served the dual purpose of orthodontic retainer
and splint to stabilize the anterior teeth for periodontal
Case Report: HC Aged 42 Years 8 Months support (Figs. 20.1A to M).
This patient attended for treatment at the age of 42 years Twin Blocks: 4 months
because her upper incisors were migrating labially Support phase: 3 months
due to loss of bony support. This case shows a typical Fixed appliance: 8 months.

Case Report: HC

A
Fig. 20.1A: Treatment: Profiles at ages 42 years 8 months (before treatment) and 44 years 8 months (after treatment).
326  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

B C D

E F G

H I J

K L M
Figs. 20.1B to M: Treatment (contd…): (B to D) Occlusion before treatment—note the gingival recession; (E) Appearance before treatment
at age 42 years 8 months; (F) Twin Block appliances; (G) Appearance after treatment; (H) Phase 1—Twin Blocks—change after 4 months;
(I) Phase 2—fixed appliances; (J) Fixed lingual retainer (Rochette splint); (K to M) Occlusion after treatment at age 44 years 8 months.
Adult Treatment  327

Case Report: HC

HC Age 41.8 43.3


Cranial Base Angle 25 26
Facial Axis Angle 23 22
F/M Plane Angle 22 21
Craniomandibular Angle 48 47
Maxillary Plane 1 0
Convexity 2 2
U/Incisor to Vertical 26 21
L/Incisor to Vertical 39 45
Interincisal Angle 115 114
6 to Pterygoid Vertical 13 13
L/Incisor to A/Po 1 3
L/Lip to Aesthetic Plane –2 –4
328  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics
Superimposed X-rays confirm that the correction was malocclusion with a Class I skeletal base and a strong
due to dentoalveolar compensation, with no skeletal brachyfacial growth pattern. In this case dental correction
change. The upper dentition was retracted and the lower only was required, and there was a rapid response to
dentition moved mesially. Significant growth changes treatment as the overjet reduced from 10 mm to 6 mm
should not be anticipated in the treatment of adults who within the first 6 weeks, and to 4 mm after 4 months of
are beyond the growth stage. The response to treatment treatment. The patient declined a final stage of treatment
is likely to be dentoalveolar, especially where there is a to detail the occlusion with fixed appliances. The result
loss of periodontal support. proved to be stable although no significant growth
changes are recorded at this age.
TREATMENT OF A YOUNG ADULT Growth continues into middle and late teens in boys
and Twin Block treatment can be very successful in this
Case Report: PW Aged 17 Years 4 Months age group provided the appliances are worn full time
(Figs. 20.2A to E).
This is an example of a young adult who was treated in
his late teens by Twin Blocks after the pubertal growth Twin Blocks: 9 months
spurt. He presented a severe dental Class II division I Support and retention: 9 months.

Case Report: PW

B C

D E
Figs. 20.2A to E: Treatment: (A) Profiles at ages 17 years 4 months (before treatment) and 18 years 4 months (after treatment);
(B) Occlusion before treatment; (C) Occlusion after 6 weeks of treatment; (D) Occlusion after 18 months of treatment; (E) Occlusion after
3 years, at age 20 years 4 months, 18 months out of retention.
Adult Treatment  329

Case Report: PW

PW Age 17.2 17.10 18.7


Cranial Base Angle 28 29 30
Facial Axis Angle 32 32 33
F/M Plane Angle 9 10 7
Craniomandibular Angle 37 39 37
Maxillary Plane 1 0 2
Convexity –2 –3 –2
U/Incisor to Vertical 31 25 20
L/Incisor to Vertical 23 24 26
Interincisal Angle 126 131 134
6 to Pterygoid Vertical 25 19 23
L/Incisor to A/Po –2 0 –1
L/Lip to Aesthetic Plane –2 –4 –3
330  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: GJ Aged 27 Years 6 Months An overjet of 10 mm was due to proclined upper incisors
and the skeletal base relationship was Class I, so that only
When this patient attended for examination she asked if
dental correction was required (Figs. 20.3A to F).
treatment to improve her smile could be completed before
her wedding in 7 months time. Twin Blocks were fitted Twin Blocks: 9 months
and sufficient progress was made to meet her request. Support phase: 5 months, followed by retention.

Case Report: GJ

B C D

E F
Figs. 20.3A to F: Treatment: (A) Profiles at ages 27 years 6 months (before treatment), 27 years 6 months (immediate change in profile
when appliance is fitted) and 28 years 8 months; (B and C) Occlusion before treatment and with Twin Blocks; (D) Occlusion after 6 months
of treatment; (E) Appearance before treatment; (F) Improved smile after treatment.
Temporomandibular Joint Pain and Dysfunction Syndrome  331

Chapter 21
Temporomandibular Joint Pain and
Dysfunction Syndrome

INTRODUCTION muscle abnormalities. Beyron (1954) also related occlusal


interferences to asymmetrical abrasion of the tooth
Occlusion is inevitably related to the health and function surfaces. Graf (1975) showed that occlusal interferences
of the temporomandibular joint (TMJ). No dental con­ altered the deglutition reflex and concluded that a stable
dition is more distressing for a patient than chronic TMJ occlusal contact relationship in maximum intercus­
pain. A rationale of treatment is therefore important in pation seems to be essential for adequate masticatory
dental and orthodontic practice. This is a litigious area function.
of dental practice and second opinions should be sought Bakke and Moller (1980) have documented significant
before embarking on any treatment which may worsen an changes in muscular activity from induced occlusal
already established pathological condition. interferences as thin as 50 μm. The alteration of even
The dental profession is increasingly aware of a multi­ one tooth incline has the potential for disrupting the
disciplinary approach, recognizing the role of chiro­ balance and thus the stability of the entire system. Such
practors and craniosacral osteopaths in the diagnosis and minute incline interferences often occur in occlusions
resolution of TMJ dysfunction. Muscle spasm and joint that appear to have ideal intercuspation. Therefore it is
pathology cannot be considered in isolation from a holistic necessary to take mounted casts to identify these small
examination of other possible causes in body posture and occlusal interferences. Following orthodontic treatment
alignment of the vertebral column. Co-operation should it is important to check the functional occlusion with
be encouraged in interdisciplinary programs of diagnosis articulating paper and to examine cuspal guidance in
and management. anterior and lateral excursions.

THE IMPORTANCE OF OCCLUSION Case Report: JK Aged 43 Years


From a dental perspective an excellent functional occlu­ by Mel Taskey
sion is the cornerstone of treatment for temporoman­ This female was referred for examination of severe
dibular dysfunction (TMD). Ramfjord and Ash (1983) headaches that resulted from a motor vehicle accident.
documented the relief of pain and related its timing with Professionals had told her that nothing could be done for
the return to symmetrical muscle activity when occlusal her because all of her pain existed in her head, and that
interferences were removed in patients with pain and she should seek psychiatric care.
muscle dysfunction. Upon examination the patient was able to open just
Krogh-Poulson and Olsson (1968) demonstrated the enough to determine that the problem was occlusal. She
relationship between specific interferences and functional could open a total of 12 mm.
332  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: JK Case Report: KW

A B A B
Figs. 21.1A and B: Treatment. (A) The occlusion appeared to be Figs. 21.2A and B: Treatment. (A) Retroclined upper incisors caused
normal; (B) Interference at a single occlusal contact caused chronic overclosure and distal condylar displacement; (B) Temporomandibular
pain. dysfunction (TMD) pain was relieved by advancing the incisors and
leveling the occlusal plane to improve the vertical dimension.

A major deflection from the contact of 1.8 and • Good vertical support for the joints to function freely
4.7 moved the mandible off the disk. The deflection without compression of the articular disc.
on the mesial lingual cusp of 1.8 was removed. Within • Freedom of movement with cuspid guidance and
2 minutes the patient was able to open a total of 22 mm. incisal guidance when the mandible moves from cen­
This illustrates the importance of occlusion in the dental tric occlusion.
equation. This facilitated the taking of impressions to • Tripoding of occlusal contacts in the final balanced
make splints, and to manage the patient’s chronic pain occlusion.
by resting the muscles (Figs. 21.1A and B). Detailing of the occlusion following orthodontic treat­
ment does not always achieve all of these goals. In the
Case Report: KW Aged 26 Years past othodontic results have been assessed on the basis
of a static view of the finished occlusion, with insufficient
by Mel Taskey attention to balancing the occlusion to remove interfer­
This female was referred regarding the anterior crowding ences and achieve ideal function. Occlusal prematurities
of her teeth and accompanying TMD pain. Retroclined or crossarch interferences in the finished case perpetu­
upper incisors are frequently related to these symptoms ate disruption by steering the TMJ. This promotes the
in adult dentitions. Twin Block appliances were used tongue to act as a physiological protector and re-enter
for a period of 2 years to advance the upper incisors the occlusal equation. This potentially results in a regres­
and to level the occlusal plane to improve the vertical sion of therapy as it undoes the previously established
relationship. During this time, she was completely pain tooth relationships. It may be argued that after ortho­
free (Figs. 21.2A and B). dontic treatment the occlusion should be examined and
balanced to achieve ideal function.
RELIEF OF PAIN The abbreviation for TMJ might equally refer to
teeth, muscles and joints, and successful orthodontic
Clinical experience has proved that it is necessary to treat treatment depends on achieving balanced function of all
the patient to a comfort zone. the components of the stomatognathic system.
Relief of pain requires that the patient is treated to a The treatment of adult patients is often undertaken
“comfort zone”, whereby a functional occlusion provides by a prosthodontist, or a practitioner who specializes in
adequate support for traumatized joint tissues. The the management of temporomandibular discomfort.
fundamentals of treatment are as follows: In adult treatment the occlusion is often already com­
• Balanced occlusal support to relieve muscle spasm in promised, and it may not be feasible to achieve an ideal
the initial stage of treatment. The patient should be occlusion. The primary objective of treatment is relief of
pain free before adjusting the occlusion. pain, and to resolve occlusal interference to an acceptable
• Removal of cuspal interferences causing mandibular position where the teeth, muscles and joints can work in
displacement on closure. synergy.
Temporomandibular Joint Pain and Dysfunction Syndrome  333

CASE HISTORY AND DIAGNOSIS closing. The opening click is louder than the closing click.
Although the clicking joint may be otherwise asympto­
Excellent record taking is an essential part of clinical man­ matic, it is nevertheless already compromised internally
agement and treatment. A full case history is neces­sary and liable to present pathology at a later date due to the
to establish any cause-and-effect relationship of occlusal chronic displacement of the articular disk.
disharmony and mandibular displacement to pain and The timing of a click on opening is significant in the
restriction of mandibular movement. This includes an prognosis for resolution:
assessment of any injury, headache, neck and back pain, • Early opening clicks: Up to 22 mm opening are usually
neuromuscular tension, and tenderness to palpation. easy to resolve.
Clinical and radiographic examinations of the TM • Mid opening clicks: 22–35 mm opening are moderate
joint are used to identify the position of the condyle in to resolve.
the glenoid fossae in the closed position, at rest and in the • Late opening clicks: Over 35 mm opening are difficult
open position. Any radiographic evidence of flattening or to resolve.
irregularity in the shape of the condyle is a sign of patho­ Case selection for anterior repositioning of the man­
logical change, and patients with signs of osteoarthritic dible to relieve TMJ dysfunction is based on the severity
change in the joint should be referred for comprehensive of symptoms and condylar position at full occlusion. The
investigation, and expert advice and treatment. prognosis is better for recapturing the disk for an early
Some of the major signs and clinical symptoms of opening click. It becomes progressively more difficult for
TM joint dysfunction of a functionally induced nature the mid and late opening click, when pathological osteo­
are diagnosed as pain, muscle tension, joint sounds arthritic change is likely to have occurred in the joint.
and limitation of movement. A displace disc is often Spahl (1993) stresses that, nevertheless, disk recap­
associated with clicks and limited opening. In unilateral ture is not the main goal of treatment for patients with
disc displacement there is displacement of the mandible functionally induced TMJ pain dysfunction problems.
to the affected side, and limited transverse movement. The true goal is reduction of symptoms via condylar
It is sometimes possible to manipulate the mandible decompression procedures involving muscular advance­
downwards and forwards to recapture the disc. If ment of the mandible followed by reconstruction of the
successful, this would have the immediate response of occlusion in some manner to support the mandible/
increased opening. However, manipulation to recapture condyle in that advanced position.
the disk does not eliminate the cause of disk displacement,
which may then recur. Limited opening is also a sign of The Closed Lock
disk displacement. Limitation of movement on opening is diagnostic of a
disk which is displaced, usually anteromedially to the
Freedom of Mandibular Movement condyle, and is not recaptured on opening. In the initial
It is essential to diagnose any limitation of movement stages, the patient may be pain free and may complain
relative to the normal range of movement: only of restriction of movement. This may be an episodic
• Normal opening is 48 mm (the three-finger test). experience, where the disk is displaced from time to time
• Transverse movement is 12 mm to each side, mea­ and the patient may be able periodically to recapture
suring the lower midline displacement in maximum the disk until the displacement becomes more severe.
lateral movement. If not detected and treated, the disk may gradually
become folded forwards and not recapturable, leading
eventually to painful function and restricted opening
The Reciprocal Click
due to osteoarthritis. A “closed lock” should be diagnosed
A clicking joint is symptomatic of displacement of the early from restricted movement and should be treated by
articular disk off the head of the condyle. A reciprocal anterior or vertical repositioning to recapture the disk.
click describes the condition where a click is heard when Treatment should then be effected to create vertical space
the disk is recaptured by the head of the condyle on in the joint by positioning the condyles downwards and
forward translation, and a reciprocal click is heard when forwards in the glenoid fossae, and to establish balanced
the condyle is again displaced off the articular disk on occlusal support.
334  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

A B

Figs. 21.3A to C: (A) A clicking joint: the sequence of opening


and closing; (B and C) The closed lock with a folded articular disk.
Courtesy: Reproduced from Solberg WK. Temporomandibular
C Disorders. London: British Dental Journal; 1986.pp.91-3.

Internal Derangement Conservative clinical treatment of joint dysfunction is


based on the concept of the need to reduce loading within
The three stages of temporomandibular internal derange­
the joint itself in order to achieve satisfactory long-term
ment are: results, and to maintain the relationship of the meniscus
Stage 1: Painless clicking is caused when an anteriorly to the condylar head.
displaced disk is recaptured on the condyle during Conservative management of joint conditions ranging
opening translation. from arthritic degeneration to internal joint derangement
Stage 2: Locking—persistent displacement of the disk is directed towards:
which arrests condyle motion at mid opening. • The reduction of functional loads exerted on the TMJ
Stage 3: Disk displacement through all phases of jaw by restoration of interarch support.
function. The anteromedially displaced disk becomes • The correction of the closing pathway as determined
distorted and folded on opening, with chronic pain and by tooth contacts. The constraints imposed on jaw
signs of osteoarthritis. The disk remains permanently movement in a sagittal plane by tooth contacts have
a major effect on the movement of both the condyle
unrecapturable.
and the meniscus during mandibular closure.
Stages 1 and 2 respond to splint therapy and anterior
Temporomandibular joint pain and dysfunction are
repositioning to recapture the disk subject to correct case
frequently related to occlusal disharmony with premature
selection (Solberg, 1989) (Figs. 21.3A to C).
occlusal contact, causing posterior or lateral shift of the
mandible from centric relation and distal displacement
Treatment Rationale of the condyles in the joint. Distal displacement of the
Hawthorn and Flatau (1990) summarize the approach to condyle in occlusion is associated with anterior displace­
joint dysfunction as described below. ment of the articular disk.
Temporomandibular Joint Pain and Dysfunction Syndrome  335

The management of treatment in the past has been in dimension), and centric occlusion (the maxilla and man­
three phases: dible relationship when the teeth are in maximum inter­
1. Sagittal expansion to advance the upper incisors, with cuspation). Mandibular deflection upon closure, and the
occlusal cover to take the mandible out of occlusion lack of posterior tooth support to protect the jaw during
and relieve pain. trauma, only compounds the occlusal instability and per­
2. Functional therapy to advance the mandible with a petuation of myalgia. The importance of cuspid guidance
one-piece functional appliance. cannot be overstated. Composite dental material may be
3. Vertical development of the posterior teeth using placed to restore cuspid guidance or group function, thus
vertical elastic forces provided by appliances such as reinforcing posterior support for the joints.
the Spahl vertical corrector or the biofinisher (Lynn, Anterior guidance can be likened to the steering wheel
1985), with occlusal reconstruction if required to of a car as it provides direction for the mandible thro­
increase the vertical dimension and to stabilize and ughout all movements of the jaw, including deglutition
balance the occlusion. and mastication. When the teeth are considered in the
stomatognathic system, there is a unique influence on
TEMPOROMANDIBULAR JOINT THERAPY the entire interbalance of the occlusion and TMJs. If the
intercuspation is not in harmony with the joint-ligament
Our efforts in treatment must not move the mandible
muscle balance, a stressed and exhausting protective role
back, or restrict the joint space. If occlusal imbalance
is forced onto the muscles. Therefore it is important to
is present, the muscles are the prime movers in causing
ensure posterior occlusal support, anterior guidance and
mandibular displacement to avoid unfavorable premature
proper group function while maintaining the TMJs in
occlusal contacts. Disk displacement and muscle spasm
their most comfortable physiological position.
are secondary features of chronic occlusal imbalance,
which cause the condyle to be displaced distally.
Twin Blocks in Temporomandibular
The goals of therapy are:
Joint Therapy
• Relieve the pain caused by distal displacement of the
condyle. Case Selection
• Retrain the muscles to a healthy pattern. A full diagnosis and case history is essential before pro­
• Recapture the disk when possible by advancing the ceeding to corrective treatment in TMJ therapy. If any
displaced condyle. signs of joint pathology are detected, expert advice should
• Move the teeth that are causing occlusal imbalance be sought. If in doubt, a diagnostic splint should first be
and mandibular misguidance. supplied to resolve the pain and rest the joint before
• Increase the vertical dimension to reduce deep over­ proceeding to more active therapy.
bite. Twin Blocks are most likely to be indicated to resolve
an early click when the condyle is displaced distal to the
Splint Therapy disk and the disk is recaptured at an early stage in the
The occlusal splint is a valuable diagnostic tool that opening movement.
can deal effectively with most patient pain problems. Twin Blocks then achieve the following objectives in
Splints that are carefully monitored in approximately the first phase of treatment:
4-week intervals provide valuable information. Judicious • Pain is relieved immediately when Twin Blocks are
adjustment on the splint can determine the vertical fitted or, in more difficult cases, within 4–7 days.
dimension that will be comfortable for the patient; also • The muscles are retrained automatically to a healthy
all muscles of mastication can be assessed as they lose pattern. A consistent feature of Twin Block therapy
their varied spasm. Patient compliance and attention to is the rapid improvement in facial balance. Muscle
their problems can be ascertained before any major work spasm is relieved when Twin Blocks are fitted, by
is undertaken. changing the pattern of muscle activity to achieve a
Subsequent to diagnostic splint therapy, with the new position of equilibrium in muscle balance.
muscles of mastication relaxed, there usually remains a • The disk is recaptured by posturing the mandible
significant difference between centric relation (the rela­ downwards and forwards to advance the condyles.
tionship of the mandible and maxilla when the condyle- • Rather than act as a passive splint, Twin Blocks are
disk assemblies are in their most superior position against designed to move the teeth that are causing occlusal
the eminentia irrespective of tooth position or vertical imbalance.
336  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

A B
Figs. 21.4A and B: The three-screw sagittal Twin Block to develop archform.

• The upper block may be trimmed selectively over the simultaneously to correct the center line and restore sym­
lower first molars only, using molar bands with vertical metry may help to resolve this type of occlusal imbalance.
elastics to accelerate eruption of the first molars. To
continue to rest the joint, a posterior occlusal stop APPLIANCE DESIGN
is maintained by occlusal contact of the blocks with
the second or third molars to support the vertical The sagittal Twin Block is used to relieve compression
dimension. on the joint by posturing the mandible downwards and
The Twin Block sagittal appliance is usually appro­ forwards and advancing retroclined upper incisors. In
priate to achieve all these objectives (Figs. 21.4A and B). sagittal appliance design, the further forwards the screws,
In bite registration the Exactobite is used to guide the the more anterior the movement; the further back the
mandible downwards and forwards to a comfortable screws, the more posterior the movement.
position. It is important to recognize that if pain is
not relieved by forward posture, and the disk does not CLINICAL MANAGEMENT
appear to be recaptured, there may be internal derange­
ment, or folding of the disk, which will not respond to In the management of deep overbite, the occlusal cover is
Twin Block therapy. trimmed progressively over the first molars only to allow
A common cause of unilateral condylar displacement the eruption of posterior teeth, without creating enough
is occlusal interference causing a mandibular displace­ vertical clearance to allow the tongue to spread laterally
ment and sideways shift, with the condyle displaced between the teeth. Only after the first molars have erupted
distally on the affected side, often associated with a uni­ fully into occlusion may the blocks be trimmed selectively
lateral distal occlusion. Unilateral sagittal activation to to encourage eruption of premolars or second or third
drive upper molars distally and advance the mandible molars as required.
Temporomandibular Joint Pain and Dysfunction Syndrome  337

It is especially important in the treatment of TMJ Pain is relieved when the appliance is worn and the
dysfunction to maintain posterior occlusal support at condyle is positioned downwards and forwards in the
all times in order to relieve compression in the joint. joint. If the patient takes the appliance out for eating, or
A transition may be made to an anterior inclined plane for any other reason, the condyle is again displaced up
to support the corrected occlusion after good posterior and back in the glenoid fossa and the pain returns.
occlusal support is restored. This approach can be It is important not to introduce splint dependency,
usefully combined with the Spahl vertical corrector in but to endeavor to resolve the occlusal imbalance related
the support phase to accelerate correction of the vertical to temporomandibular disorders. Successful TMJ treat­
dimension. ment requires a full-time commitment from the patient
to see the treatment through until the occlusion is recon­
Traction to Open the Bite structed with the condyles positioned correctly in the
glenoid fossae. Depending on the etiology of the condition,
Vertical elastics may be used to accelerate the bite opening
this may involve orthopedic repositioning, orthodontic
by stretching elastics from the upper appliance to hooks
balancing of the occlusion, occlusal reconstruction or a
bonded to the lower posterior teeth, having first relieved
combination of these disciplines.
occlusal acrylic to encourage selective eruption. This is
not generally required in the treatment of the growing Case Report: RD Aged 36 Years
child, where eruption occurs naturally to close a posterior
open bite. The addition of elastics is especially useful in This patient presented a severe Class II division 2 malo­
adult treatment to accelerate eruption in patients who cclusion and a history of chronic headaches three or
are no longer actively growing. Vertical traction assumes four times a week for as long as he could remember. He
an increasingly important role as an effective method had come to accept this as part of normal life until he
of increasing the vertical dimension in the treatment of learned that the headaches might be related to his dental
patients who have TMJ dysfunction due to overclosure. occlusion, at which stage he presented for treatment.
Upper and lower incisors were severely retroclined
Stages of Treatment with an interincisal angle of 180°, while the incisal edges
of the lower incisors were 10 mm behind the A–Po line,
Treatment may be divided into three separate objectives
resulting in a traumatic deep overbite lingual to the upper
of sagittal development, functional repositioning and ver­
incisors.
tical development. Sagittal Twin Blocks are designed to
The aim of treatment was to relieve the compression
allow all three corrective phases to proceed simultane­
in the TMJ by releasing the mandible from its trapped
ously to relieve a distally displaced condyle. Progressive
position in distal occlusion. This required upper anterior
trimming to encourage vertical development is crucial to
arch development followed by functional correction to
the success of the treatment.
advance the mandible. The objective was then to build the
Detailed finishing of the occlusion to achieve a fun­ vertical dimension and position the condyles downwards
ctional balance is necessary for long-term stability of joint and forwards in the glenoid fossae. Vertical elastics were
symptoms. A finishing stage of treatment with bonded used to accelerate eruption of the molars and premolars
fixed appliances is frequently required to achieve this during the Twin Block and support phases of treatment.
objective. When this is not possible, the alternative of A final restorative stage of treatment was anticipated to
occlusal rehabilitation by restorative means may be pre­ increase the width of the upper incisors to correct the
ferred if the occlusion is compromised by loss of teeth. Bolton relationship after correcting the canines to a Class
I occlusion. A fixed lingual retainer was fitted in the lower
Round Tripping arch (Figs. 21.5A to L).
In the care of injured joints it is never effective to wear The patient quickly experienced a remission of head­
crutches part time and sometimes discard them—this aches during the first stage of treatment as the upper inci­
results in relapse. This principle applies equally in TMJ sors advanced. The improvement continued throughout
therapy, whether a splint or a more active appliance is the treatment and the headaches did not return.
being used to rest the joint. Intermittent appliance wear • Twin Blocks: 9 months
only relieves the pain temporarily, and under certain • Support phase: 9 months
circumstances may worsen it! • Fixed appliances: 1 year.
338  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Case Report: RD

B C D

E F G

H I

J K L
Figs. 21.5A to L: Treatment. (A) Profiles at ages 36 years 0 months (before treatment) and 38 years 3 months (after treatment); (B)
Occlusion before treatment; (C) Magnetic sagittal Twin Block; (D) Lower magnetic Twin Block with lower molar bands; (E and F) Vertical
traction to elevate the molars; (G) Molars in occlusion after 4 months of traction; (H and I) Archform correction after treatment; (J to L)
Occlusion after treatment. The upper anterior teeth are restored with veneers to maintain the increased intercanine width to stabilize the
corrected occlusion.
Temporomandibular Joint Pain and Dysfunction Syndrome  339

Case Report: RD

RD Age 35.11 38.4


Cranial Base Angle 26 26
Facial Axis Angle 28 28
F/M Plane Angle 14 14
Craniomandibular Angle 40 40
Maxillary Plane 1 1
Convexity 5 5
U/Incisor to Vertical −11 14
L/Incisor to Vertical 14 28
Interincisal Angle 177 138
6 to Pterygoid Vertical 20 16
L/Incisor to A/Po −5 −2
L/Lip to Aesthetic Plane −10 −10
340  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

ANTERIOR OPEN BITE It is necessary to restore incisal and cuspal guidance


TEMPOROMANDIBULAR JOINT to resolve the cycle of chronic pain.
Twin Blocks were inserted to mitigate the patient’s
DYSFUNCTION
pain and align the arches. Vertical elastics were passed
from the labial bow on the upper Twin Block to brackets
Case Report: ML Aged 38 Years on the lower canines and premolars to close the open
bite, while the occlusal blocks applied an intrusive force
by Mel Taskey
to the posterior teeth. In 6 months the open bite was
This 38-year-old female suffered from constant head­ closed. Finished casts illustrate good posterior cusp
aches and could not chew her food because of the fossa/relationship, giving good joint support. The patient
anterior open bite. Joint symptoms in anterior open has been comfortable without retention for 5 years. The
bite relate to the lack of anterior and cuspal guidance, position is stable because the posterior teeth are in a
placing more strain on the muscles to maintain the cusp-fossa relationship and group function exists in the
occlusal relationship of the teeth during normal function. bicuspids (Figs. 21.6A to C).

Case Report: ML

A B C
Figs. 21.6A to C: Treatment. (A) Anterior open bite contracting only on posterior molars; (B) Brackets for vertical elastics; (C) The open
bite closed after 6 months of treatment and is stable 5 years out of retention.
Temporomandibular Joint Pain and Dysfunction Syndrome  341

Case Report: LJ Aged 44 Years in occlusion after 10 months and posterior support with
brackets and elastics continued to be used for the next
by Mel Taskey 10 months. Finally an elastodent finishing appliance was
This 44-year-old female presented suffering from severe worn for 1 year. No retention appliance has been worn
headaches following whiplash injury in a motor vehicle for 3 years.
accident. After 5 years, she had no definitive diagnosis to Treatment has resulted in leveling of the curve of Spee,
this point. A diagnostic mandibular splint was inserted with correction of the vertical dimension and reduction
and this reduced her severe headaches. The use of Twin of the excessive overbite. The distal occlusion has been
Blocks was explained to the patient and treatment was corrected and, most importantly, the chronic pain has
initiated. The patient was pain free after 1 week, and been eliminated. In treatment of TMJ dysfunction, the
continued to wear Twin Blocks for 18 months. In phase 2, results are not based on the standard of orthodontic
a Spahl vertical corrector was selected to increase the finishing, but on successfully getting the patient free of
vertical dimension and restore posterior support. Brackets pain. Compromise is often necessary in the treatment of
were placed on all posterior teeth with vertical elastics to adult patients, as ideal occlusion is often not a feasible
increase the vertical dimension. The posterior teeth were objective (Figs. 21.7A to I).

Case Report: LJ

A B C

D E F

G H I
Figs. 21.7A to I: Treatment: (A to C) Occlusion before treatment; (D) Deep overbite with excessive curve of Spee in the lower arch; (E)
Registering the construction bite; (F) Twin Blocks fitted; (G) Curve of Spee leveled after treatment; (H and I) Occlusion settles after retention.
342  Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

ACKNOWLEDGMENTS Hawthorn R, Flatau A, (1990). A Textbook and Colour Atlas of


the Temporomandibular Joint Diseases, Disorders, Surgery,
The sections on “The Importance of Occlusion” and eds Norman B, Bramley P, Wolfe Medical Publications,
“Splint Therapy” are contributed by Dr Mel Taskey, who London.
has 40 years experience in practice in Edmonton, Alberta, Krough-Poulson WG, Olsson A, (1968). ‘Management of the
specializing in the treatment of TMJ dysfunction, and occlusion of the teeth, background, definitions, rationale’ in
the management of traumatic injuries. Dr Taskey also Facial Pain and Mandibular Dysfunction, eds Schwartz L,
supplied examples of treatment for four patients: KW, Chayes C, WB Saunders, Philadelphia.
JK, LJ and ML. Lynn JM, (1985). Biofinisher, Functional Orthodontics. 2:36-41.
Ramfjord S, Ash MM, (1983). Occlusion, 3rd edition, WB
REFERENCES Saunders, Philadelphia.
Riise C, Sheikholeslam A, (1984). Influence of experimental
Bakke M, Moller E, (1980). Distortion of maximal elevator
interfering occlusal contacts on the activity of the anterior
activity by unilateral premature tooth contact, Scand Journal
of Dental Research. 88:67-75. temporal and masseter muscles during mastication, Journal
Beyron H, (1954). Occlusal changes in adult dentition, Journal of Oral Rehabilitation. 11:325-33.
of the American Dental Association. 48:674-86. Solberg WK, (1989). Temporomandibular Disorders, 2nd edition,
Graf H, (1975). ‘Occlusal forces during function’. in Occlusion British Dental Journal, London. pp. 91-2.
Research in Form and Function, ed Rowe NH, University of Spahl TJ, (1933). The Spahl split vertical eruption acceleration
Michigan Press, Ann Arbor. appliance system, Functional Orthodontics. 10:10-24.
Pitfalls and Problems: Contraindications for Functional Therapy 343

Chapter 22
Pitfalls and Problems:
Contraindications for
Functional Therapy

PITFALLS IN DESIGN AND


MANAGEMENT OF TWIN BLOCKS Incorrect bite registration, appliance design and clini-
A prospective multi-center randomized controlled trial cal management cause problems of patient acceptance.
(O’Brien et al. 2003), comparing the effectiveness of Patients cannot wear appliances with excessively thick
treatment for Class II malocclusion reported a failure occlusal blocks. They cannot eat or speak with the appli-
to complete rate of 33.6% for Twin Blocks and 12.9% for ances in the mouth. If clasps are placed on lower first
Herbst. The RCT study concluded that “the Twin Block, molars no provision is made for vertical control to reduce
perhaps because of the bulky acrylic blocks, caused more deep overbite. At the end of the Twin Block phase there
problems than did the Herbst appliance in eating and is a posterior open bite with contact only on the upper
speaking. Arguably, the patient might repeatedly remove incisors. There is no support for the temporomandibular
the appliance, thus influencing the success of treatment”. joint and the incisor occlusion can guide the mandible
Excessively thick occlusal blocks were used in this study distally and cause relapse or may displace the condyles
and this was responsible for the high failure rate. distally in the glenoid fossa (Figs. 22.1A to D).

A B

C D
Figs. 22.1A to D: Incorrect construction bite and unaesthetic appliances with excessively thick occlusal blocks contribute to a high failure
rate. Clasps on lower molars fail to control the vertical dimension and produce a posterior open bite after treatment.
344 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

PITFALLS AND PROBLEM PATIENTS


Contraindications for Functional Therapy The alveolar processes are long and thin, with no
This girl presents in early permanent dentition with a significant chin eminence. Advancing the mandible
severe skeletal discrepancy and convexity of 10 mm. Severe did not improve the profile in this case, indicating this
vertical growth of the mandible is a major etiological factor patient was not suitable for functional therapy. Instead
in this case. The facial axis angle is 17° with a Frankfurt she was treated with extraction of premolars and fixed
mandibular angle of 39° and maxillomandibular angle of appliances.
43°. This results in a severe sagittal skeletal discrepancy Moderate crowding was present in the lower arch. In
and 10 mm convexity. The maxilla is correctly related to profile the lips are protrusive and extraction therapy is
the cranial base, while the mandible is severely retrusive indicated to relieve crowding in a small mandible. Treat-
due to vertical growth. ment was carried out in the early 1980s with fixed appli-
Patients presenting with vertical growth patterns and ances with Standard Edgewise brackets over a period of
a high mandibular plane angle cannot be expected to 18 months following extraction of four first premolars
grow favorably during treatment. (Figs. 22.2A to C).

A B C
Figs. 22.2A to C: (A and B) Profile and tracing before treatment; (C) Profile after treatment following extraction of first premolars and
fixed appliance therapy.
Pitfalls and Problems: Contraindications for Functional Therapy 345

Dolichofacial Class II Division I Malocclusion by predicted mandibular growth. Extraction therapy is


This boy presents a severe malocclusion and a vertical indicated to resolve crowding in the lower arch and reduce
growth pattern. This is an example of a protrusive profile, dental protrusion in the profile.
but in this case a convexity of 11 mm is due to maxillary Upper and lower first premolars were extracted
protrusion. Increased lower facial height is accentuated followed by upper and lower fixed appliances to close
by an upward tilt of the maxillary plane of 7°, and a extraction spaces and retract the upper canines and
maxillomandibular angle of 36°. The lips protrude beyond incisors. Treatment was completed in 19 months followed
the aesthetic line before treatment. by removable retainers for 1 year. Extraction therapy
A vertical growth tendency again limits the improve- results in a significant improvement in facial appea-
ment observed in the profile when the mandible is advan- rance and the dentition is less protrusive in the profile
ced as the degree of convexity would not be compensated (Figs. 22.3A to G).

A B C

D E

F G
Figs. 22.3A to G: (A and B) Profile and tracing before treatment; (C) Profile after treatment following extraction of first premolars and fixed
appliance therapy; (D to G) Occlusion and lower arch form before and after treatment.
346 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Bimaxillary Dental Protrusion profile does not improve when the mandible is advanced.
This contraindicates the functional approach to advance
This patient presents a severe malocclusion and a vertical the mandible.
growth pattern with a combination of maxillary protrusion Upper and lower first premolars were extracted follo-
and mandibular retrusion. The lower incisors are 4 mm wed by upper and lower fixed appliances to close extrac-
ahead of the A-pogonion line and the lips protrude tion spaces and retract the upper canines and incisors.
beyond the aesthetic line before treatment. Extraction therapy results in a significant improvement
Differential diagnosis again depends on examining in facial appearance and the dentition is less protrusive
the profile change when the mandible is advanced. The in the profile (Figs. 22.4A to G).

A B C

D E

F G
Figs. 22.4A to G: (A and B) Bimaxillary dental protrusion results in protrusive lips in the profile; (C) The profile improves after extraction
of premolars and treatment with fixed appliances; (D to G) Show the changes in arch form before and after treatment.
Pitfalls and Problems: Contraindications for Functional Therapy 347

Problem Patients
The profile improved dramatically, but we now faced
Severe Tongue Thrust the problem of retention and stability using a tongue
The first serious challenge in controlling a severe tongue guard and lip bumper to control the tongue thrust.
thrust presented in 1981. An overjet of 15 mm was associ- Unfortunately, the tongue thrust persisted and the lip
ated with an anterior open bite. The patient had a perni- trapped behind the incisors as the overjet increased and
cious habit of licking her lips, which were dry and cracked the distal occlusion returned. In retrospect it may have
as a result. The tongue was seldom at rest in the mouth. been more successful to continue with Twin Blocks full
Extraoral traction was added to reduce the maxillary time for functional retention, but treatment extended
protrusion and over a period of 2 years the overjet was over 3 years and the patient’s cooperation was exhausted
reduced and the distal occlusion was corrected. (Figs. 22.5A to P).

A B

C D E

F G H
Figs. 22.5A to H: (A to E) Facial appearance, profile and occlusion before treatment; (F to H) Corrected occlusion after Twin Block stage.
348 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

I J

K L M

N O P
Figs. 22.5I to P: (I) A tongue guard and lip bumper were used to attempt to improve the tongue thrust and lip posture; (J) The profile
has improved at this stage; (K to M) Expressive lip behavior and a persistent tongue thrust caused the overjet to increase and this is
reflected in the profile; (N to P) Cephalometric tracings before and after treatment and the superimposed final tracings.
Pitfalls and Problems: Contraindications for Functional Therapy 349

Unstable Occlusion after mandible. The traction component was worn at night. It
Mandibular Advancement was observed that a lateral open bite was present when
the mandible moved forward to an edge-to-edge occlusion
This young girl has previously lost all four first premolars and this was the position after 18 months treatment.
and has an anterior open bite and a strong tongue It was evident that this patient could still retract her
thrust. Twin blocks were used with extraoral traction to mandible and had adopted a convenient forward posture
retract the upper dentition in addition to advancing the (Figs. 22.6A to H).

A B

C D E

F G H
Figs. 22.6A to H: This patient previously had first premolars extracted and presented with tongue thrust and anterior open bite. The patient
adopted a forward posture as the occlusion was not stable after mandibular advancement.
350 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

A “Sunday Bite” The open bite is due to a persistent tongue thrust.


The anterior teeth have been aligned but there is no
This can be detected by asking the patient to close the improvement in the occlusion. The photographs show
teeth together with the tip of the tongue touching the profile with the mandible advanced and retracted.
the back of the palate. There is only minimal contact on This was referred to as “A Sunday bite” indicating that the
the molars in occlusion and the occlusion is unstable due occlusion was not corrected as the patient could posture
to the lack of positive contacts in the buccal segments. forward or back (Figs. 22.7A to F).

A B

C D

E F
Figs. 22.7A to F: Profile and dental photographs demonstrate a “Sunday Bite” as the patient can posture forward or back due to an
unstable occlusion with no cuspal inter-digitation.
Pitfalls and Problems: Contraindications for Functional Therapy 351

Relapse due to Soft Tissue and Skeletal Factors tongue thrust persisted and there was a partial relapse of
Twin Blocks and extraoral traction were used to reduce the overjet and distal occlusion after treatment. It appears
maxillary protrusion for a patient with vertical growth. that only a postured correction may have been achieved
Initially, she appeared to respond to treatment as the in this case due to unfavorable skeletal and soft tissue
overjet reduced and the occlusion improved. However the factors (Figs. 22.8A to H).

A B

C D E

F G H
Figs. 22.8A to H: This patient has a dolichofacial growth pattern with anterior open bite and tongue thrust. Although she responded well
to treatment the tongue thrust persisted and resulted in a partial relapse of the distal occlusion and overjet.
352 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Limited Growth Response occlusion and reducing the overjet. The growth response
Dental development is well advanced at age 9 years during prepubertal treatment is limited, although the
7 months when Twin Blocks are fitted. The profile is ret- occlusion is corrected to Class I. Four years after com-
rognathic and the chin eminence is not well developed. pletion of treatment the occlusion is stable and profile
This is a limiting factor, which reduces the effect of func- is still retrognathic, although it has improved slightly.
tional therapy. This may be anticipated in such cases by A genioplasty may be considered when growth is com-
examining the profile before treatment with the mandi- plete to improve the profile. The lack of a chin eminence
ble advanced. In this case, Twin Blocks were effective is an important factor in anticipating the aesthetic result
in achieving the dental objective of correcting the distal of mandibular advancement (Figs. 22.9A to Q).

A B

C D E

F G H

I J K
Figs. 22.9A to K: A flat chin does not improve in profile in spite of a good dental response in correcting the occlusion.
Pitfalls and Problems: Contraindications for Functional Therapy 353

L M N

O P Q
9 years 7 months 10 years 10 months 15 years
Figs. 22.9L to Q: (L to N) Superimposed tracings before and after treatment confirm a limited growth response; (O to Q) The profile does
not improve during treatment. Four years later the profile has flattened with further growth.
354 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

A Late Developer the facial profile. Although dental correction is achieved,


the facial change is a compromise and the appearance of
This boy was a late developer. At the age of 13 years mandibular retrusion remains after treatment.
5 months he had the stature of an 8 year old. Lower first Post-treatment growth is more favorable and appro-
premolars had been extracted previously to relieve crowd- aching the age of 17 years he has grown in stature and
ing and upper first premolars were extracted before treat- improved mandibular growth contributes to a signifi-
ment with Twin Blocks. Growth was slow during treat- cant improvement in the facial appearance and profile
ment and this limits the possibility for improvement in (Figs. 22.10A to U).

A B C D

E F G

H I J
Figs. 22.10A to J: Facial appearance and profile before and after treatment.
Pitfalls and Problems: Contraindications for Functional Therapy 355

K L M

N O P
13 years 5 months 14 years 3 months 16 years 10 months

Q R

S T U
Figs. 22.10K to U: Facial and cephalometric changes before and after treatment and out of retention confirm that this boy was a late
developer. The facial appearance improved after treatment was completed.
356 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Incorrect Diagnosis arch was removed as traction was applied to retract the
lower incisors and move lower molars mesially, using the
This boy presents a difficult problem with a severe Class II
canines and premolars as an anchor unit. An upper arch
skeletal relationship, mandibular retrusion, a vertical
was then fitted with vertical loops, which were activated
growth pattern, severe lower labial crowding and deep
overbite. In an effort to improve mandibular growth an by pulling the arch distally through the molar tubes to
attempt was made to advance the mandible with Twin retract the incisors.
Blocks, to be followed by the extraction of four premolars Treatment was complicated by failing to anticipate
to improve the profile, but the Twin Block phase