Twin Block Functional Therapy Applications in Dentofacial Orthopedics 3

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
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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
• 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
• 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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
Case Report: CH
CH Age 14.1 15.2 19.7

Maxillary Plane –1 –3 –3
Convexity 6 4 4
U/Incisor to Vertical 38 26 27
L/Incisor to A/Po 0 1 1
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.
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.
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.
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.
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.
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.
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
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.
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
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.
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.
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.
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.
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.
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.
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 function 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
(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).
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).
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
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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.
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
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.
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.
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
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.
Case Report: GD
GD Age 13.10 15.2

Maxillary Plane 3 3
Convexity 3 0
L/Lip to Aesthetic Plane –2 –3
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
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.
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.
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.
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
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
Case Report: JS
Figs. 5.8A and B: Profile and tracing before

A B treatment.
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
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
Case Report: KH
KH Age 9.5 11.3 14.7

Maxillary Plane 3 2 3
Convexity 5 2 1
L/Incisor to A/Po −1 1 −1
L/Lip to Aesthetic Plane −2 −3 −5
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.
Case Report: ME
ME Age 13.0 13.8 17.1

Maxillary Plane 0 −3 −2
Convexity 8 6 5
L/Lip to Aesthetic Plane 0 0 −3
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.
Case Report: PMcL
PMcL Age 11.6 13.0 17.1

Convexity 2 −1 −1
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.
Case Report: EF
EF Age 12.3 15.2

Maxillary Plane 1 2
Convexity 5 5
L/Incisor to A/Po 0 2
L/Lip to Aesthetic Plane 0 −1
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.
Case Report: WL
WL Age 10.3 11.6 16.1

Convexity 8 6 5
L/Lip to Aesthetic Plane 0 −2 −3
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.
Case Report: AF
AF Age 11.0 14.3 17.5

Convexity 7 4 4
L/Lip to Aesthetic Plane 3 2 1
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.
Case Report: LC
LC Age 9.0 10.0 15.4

Maxillary Plane 1 −1 3
Convexity 6 7 6
L/Incisor to A/Po −4 3 3
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
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
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.
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.
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.

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.
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.
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.
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.
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
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
Case Report: LJ
LJ Age 10.9 11.2 16.11

Convexity 7 6 4
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.
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.
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.
Case Report: PK
PK Age 11.4 11.8 13.4

Convexity 9 5 4
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.
• 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.
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.
• 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.
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.
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).
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.
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.
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.
Case Report: FD
FD Age 9.5 10.9 18.1

Convexity 9 4 4
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.
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.
Case Report: AG
AG Age 9.6 9.9 12.3

Convexity 1 −1 1
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.
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.
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.
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.
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
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.
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.
Case Report: JB
JB Age 9.11 11.4 15.11

Convexity 5 5 3
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.
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.
Case Report: CM
CM Age 7.8 8.7 11.6

Convexity 5 4 2
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).
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.
Case Report: CW
CW Age 7.6 9.4 13.0

Convexity 5 2 3
6 to Pterygoid vertical 9 12 15
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.
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.
Case Report: KH
KH Age 8.9 13.9

Maxillary Plane 5 4
Convexity 6 4
6 to Pterygoid vertical 11 14
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.
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.
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.
Case Report: CD
CD Age 11.1 13.3 16.1

Convexity 6 5 2
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.
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.
Case Report: JS
JS Age 10.2 11.0 15.3

Convexity 2 2 1
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
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.
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.
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.
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.
Case Report: ML
ML Age 12.6 15.3

Maxillary Plane 0 2
Convexity 1 –2
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.
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.
Case Report: CS
CS Age 9.11 14.5

Maxillary Plane 1 0
Convexity 3 1
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.
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.
Case Report: MZ
MZ Age 14.1 16.2

Maxillary Plane 0 –3
Convexity 3 1
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
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.
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.
Case Report: KA
KA Age 9.6 10.7

Maxillary Plane 4 1
Convexity 6 4
L/Incisor to A/Po −6 −4
L/Lip to Aesthetic Plane −5 −4
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.
Case Report: WF
WF Age 9.5 9.11 13.11

Maxillary Plane 1 −3 −1
Convexity 5 5 3
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.
Case Report: KS
KS Age 11.6 13.0 17.9

Convexity 8 5 3
L/Incisor to A/Po −1 −1 −1
L/Lip to Aesthetic Plane −2 0 −3
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.
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.
Case Report: LG
LG Age 10.8 10.11 15.4

F/M P lane Angle 27 27 27
Maxillary Plane −1 1 0
Convexity 10 9 8
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).
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.
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).
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.
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.
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.
Case Report: DP
DP Age 10.10 12.0

Cranial B ase Angle 26 25
Maxillary Plane 1 2
Convexity 5 2
L/Lip to Aesthetic Plane 1 0
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.
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.
Case Report: SS
SS Age 13.11 15.0 18.0

Maxillary Plane −1 −2 0
Convexity 11 8 10
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.
Case Report: HD
HD Age 12.3 16.2

Maxillary Plane 0 0
Convexity 9 8
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.
Case Report: LJ
LJ Age 10.2 11.4 16.10

Convexity 8 6 4
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.
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.
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.
Case Report: BG
BG Age 8.1 8.9

Maxillary Plane –1 –1
Convexity 6 3
6 to Pterygoid vertical 8 8
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.
Case Report: CR
CR Age 9.8 10.9

Maxillary Plane 4 4
Convexity 3 0
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.
Case Report: AM
AM Age 8.8 9.4

Maxillary Plane –1 –1
Convexity 4 1
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.
Case Report: MS
MS Age 10.0 11.1

Maxillary Plane 0 0
Convexity 5 1
L/Incisor to A/Po –5 –1
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Case Report: HK
HK Age 14.8 16.8

Maxillary Plane −3 −5
Convexity 2 2
L/Incisor to A/Po −3 2
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.
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.
Case Report: SW
SW Age 12.9 14.9 16.7

Convexity 3 0 −3
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.
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.
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.
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.
Case Report: JC
JC Age 12.6 17.6 20.1

Convexity –1 –3 –3
L/Incisor to A/Po –5 –3 –3
6 to Pterygoid vertical 11 12 13
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.
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.
Case Report: EC
EC Age 11.11 13.8 21.5

Convexity 2 0 1
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.
Case Report: KC
KC Age 12.8 14.11 18.11

Maxillary Plane –4 –3 –3
Convexity 4 3 4
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.
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 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.
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.
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.
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).
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.
Case Report: TC
TC Age 8.2 10.1 11.4

Maxillary Plane –1 –2 0
Convexity –1 5 4
L/Lip to Aesthetic Plane 0 –2 –3
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.
Case Report: AJ
AJ Age 6.11 8.7 13.7

Convexity 0 1 0
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.
Case Report: ML
ML Age 7.5 7.10 14.3

Maxillary Plane −4 −1 0
Convexity −1 0 −3
L/Lip to Aesthetic Plane −5 –3 −8
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.
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.
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.
W X Y
Z A1 B1
Figs. 14.11W to B1: Facial and profile views before and after treatment.
Nonsurgical Class III Correction

(Figs. 14.12 and 14.13)
A B
D
Figs. 14.12A to D: Nonsurgical Class III correction.
G H
I J K
Figs. 14.12E to K: Nonsurgical Class III correction.
L M
Figs. 14.12L and M: Nonsurgical Class III correction.
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.
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.
C D
E F
G H
I Figs. 14.15C to I: Before and after reverse Twin Blocks.

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.
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.
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
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.
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.
Case Report: SG
SG Age 11.8 18.1

Maxillary Plane 9 6
Convexity 8 4
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.
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.
Case Report: TK
TK Age 14.9 15.10 20.2

Convexity 3 2 0
L/Incisor to A/Po –3 2 1
L/Lip to Aesthetic Plane –1 0 –1
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).
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.
Case Report: CM
CM Age 11.5 13.9 17.0

Convexity 8 4 4
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.
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.
Case Report: AB
AB Age 12.8 14.8 18.1

Maxillary Plane 0 –2 0
Convexity 4 5 2
L/Lip to Aesthetic Plane 3 2 –3
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).
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.
Case Report: NM
NM Age 11.0 12.0 13.10

Convexity 6 2 0
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.
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.
Case Report: GK
GK Age 13.2 14.6

Maxillary Plane 1 2
Convexity 11 6
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
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
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
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.
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).
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.
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.
Case Report: KC
KC Age 11.11 12.7 14.7

Convexity 7 5 2
L/Lip to Aesthetic Plane 4 2 –3
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).
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.
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.
Case Report: NK
NK Age 12.3 13.0 15.10

Maxillary Plane 1 –1 1
Convexity 4 3 1
L/Incisor to A/Po 0 1 –1
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.
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.
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.
Case Report: JS
JS Age 12.3 15.5

Maxillary Plane 0 –1
Convexity 5 2
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.
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.
Case Report: AMcD
AMcD Age 12.9 14.3 15.0

Convexity 5 4 4
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.
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.
Case Report: TS
TS Age 14.0 14.10 17.4

Convexity 5 4 1
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.
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.
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.
Case Report: RG
RG Age 11.5 11.11 14.5

Convexity 10 6 7
L/Lip to Aesthetic Plane 0 –2 –1
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.
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.
Case Report: SM
SM Age 12.4 14.4 19.8

Maxillary Plane 0 1 –1
Convexity 6 3 3
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.
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.
Case Report: KM
KM Age 11.7 12.3 18.10

Maxillary Plane 0 1 −1
Convexity 6 3 3
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.
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.
Case Report: GMcD
GMcD Age 12.1 13.1

Maxillary Plane 1 −2
Convexity 10 8
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.
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.
Case Report: LC
LC Age 10.9 11.5 18.1

Maxillary Plane −4 −6 −2
Convexity 10 9 5
U/Incisor to Vertical −17 16 21
L/Incisor to A/Po −7 −1 2
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.
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.
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.
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.
Case Report: M McK
M McK Age 10.4 10.8 14.3

Convexity 6 6 3
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
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.
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).
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.
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.
Case Report: FH
FH Age 14.7 15.9 17.8

Convexity 5 2 0
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).
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

Maxillary Plane 1 0
Convexity 2 2
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

Convexity –2 –3 –2
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.
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.
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.
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.
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.
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.
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.
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.
Case Report: RD
RD Age 35.11 38.4

Maxillary Plane 1 1
Convexity 5 5
U/Incisor to Vertical −11 14
L/Incisor to A/Po −5 −2
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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 was not the problems that arose during the Twin Block phase.
successful due to incorrect diagnosis. Lengthening of the face should be observed when the
The profile did not improve due to lengthening of the patient postures forward and the imbalance in the occlu-
lower face. In addition the teeth did not interdigitate cor- sion is detected by placing the models together before
rectly when the mandible was advanced. This problem treatment. Treatment was completed in 2 years 4 months.
can be anticipated before treatment by occluding the Final records are at age 15 years 2 months when retention
models with the lower model advanced. In retrospect was continuing.
it would have been preferable to extract premolars and Cranial Base Angle 31°: Facial Axis 25°: Mandibular
align the arches with space closure before advancing the Plane 27° Convexity 10 mm. A severe Class II skeletal base
mandible. A Wilson lower lingual arch was fitted to con- relationship with 10 mm convexity is due to a combina-
trol the incisor position during the fixed appliance phase. tion of maxillary protrusion and mandibular retrusion.
Lower first and upper second premolars were The mandibular plane angle increased during the Twin
extracted followed by space closure with power chain in Block phase due to increased vertical growth. The profile
the upper arch. The lower lingual arch was used to control improved after extractions and space closing mechanics
anchorage while moving lower second premolars mesially in the orthodontic phase to retract the anterior teeth. This
to partially close the extraction space. Lower canines were reduced the prominence of the lips in the profile and
then moved distally to close the space. Finally the lingual improved facial balance (Figs. 22.11 and 22.12).
A B
C D E
F G
H I
Figs. 22.11A to I: (A to H) Facial appearance and occlusion before treatment; (I) The profile does not improve with mandibular advancement.
J K L
M N
O P
Q R
S T U
Figs. 22.11J to U: (J to N) The occlusion is unstable when the mandible is advanced. In spite of an effort to improve arch form with
a lingual arch it is soon evident that extractions are required; (O to U) After extraction of premolars fixed appliances are used to close
spaces and retract the anterior teeth.
A B C
D E F
G H
I J K
L M
Figs. 22.12A to M: (A to H) A change to extraction therapy resolved the problems encoutered in this case and resulted in a stable result
with an improvement in the profile and facial appearance; (I to M) Advancing the mandible moved the lower incisors too far labially and
did not improve the profile. This was resolved following extractions.
REFERENCE Twin Block appliance: a randomized controlled trial. American

O’Brien K, Wright K, Conboy F, et al., (2003). Effectiveness Journal of Orthodontics and Dentofacial Orthopedics. 124(2):
of treatment for Class II malocclusion with the Herbst or 128-37.
New Horizons in Orthodontics 361
Chapter 23
New Horizons in Orthodontics
In research the horizon recedes as we advance........and research is always incomplete.

— Mark Pattison, 1813–1884
INTRODUCTION generations of orthodontists have based their treatment

on the premise that we could not assist the mandible to
The rate of technological change in contemporary society grow beyond its genetic potential. On the basis of the
is accelerating, and orthodontics is not exempt from early cephalometric studies of growth and development,
this process. In a highly developed specialty it is only this view was undoubtedly correct, until such time as
human to be comfortable with familiar concepts, as with new clinical and research techniques were developed to
familiar techniques, and to resist progress. The danger of prove otherwise. Interpretation of the genetic paradigm is
complacency can apply equally in the academic or clinical largely a matter of perspective. If the mandible is locked
environment. In challenging the status quo, the burden of in a distal occlusion, it cannot necessarily fulfill its full
proof rests with the innovator, and understandably there genetic potential of forward growth, because it is trapped
is a time lag between the development of new clinical by an unfavorable functional environment. Unlocking the
techniques and their acceptance by the profession as a malocclusion may either help the mandible to grow or, by
whole. It is encouraging to note that, with increasingly adjusting the direction of growth, allow the mandible to
sophisticated methods of investigation, current research adopt a more forward position. New methods of research
is providing consistent evidence to support the benefits now confirm that full-time functional appliances are
of full-time appliances for functional therapy. unquestionably more efficient in the correction of skeletal
After a century of inconclusive evidence in the exami- discrepancies than conventional fixed appliances.
nation of orthopedic techniques, the question of whether Charting the course of orthodontics in the next century
or not we can modify craniofacial growth by functional presents a challenge to consider alternatives to the
orthopedic techniques still remains to be resolved. A techniques of the present day. While orthodontic practice
new paradigm for successful treatment presents a philo- is well equipped and organized to deliver comprehensive
sophical challenge to combine the benefits of orthodontic treatment in the permanent dentition, the same cannot
and orthopedic techniques in the treatment of malocclu- be said for interceptive techniques, which do not receive
sions which require a combination of dental and skeletal the attention they deserve. Two thirds of facial growth
correction. occurs by the age of 8 years. It is important to identify
The question is fundamental to the organization and the benefits of early treatment to improve the form of
delivery of treatment in the specialty of orthodontics. Past the dental arches. Abnormal developmental factors, if
allowed to persist, are detrimental to both general and Interceptive treatment is related to functional devel-
dental health in the longer term. The importance of opment, and will assume greater importance in ortho-
increasing the airway has been stressed in relation to dontic and orthopedic treatment in future generations.
Twin Block treatment, whereby advancing the mandible Interception and prevention may prove to be one of the
has the beneficial effect of advancing the tongue, thereby most significant factors of change in orthodontics in the
increasing the airway. next century.
Consideration of the transverse dimension is no less
important in relationship to the efficiency of orofacial ARCH DEVELOPMENT
functions. The airway may be restricted either in the
anteroposterior or transverse dimensions. A contracted Maxillary contraction is a common feature in all classes of
maxilla is of particular significance, in view of its rela- malocclusion, which is frequently the primary etiological
tionship to constriction of the nasal passages, with direct factor, with secondary effects on the development of the
implications for the essential function of breathing, and mandible and the lower dental arch. In functional therapy,
fundamental effects on general health. Patients with arch development is often indicated as a preliminary to
restricted airway are subject to nasopharyngeal infection mandibular advancement in cases exhibiting crowding
and allergies, and their general health may be adversely and irregularity in the dental arches.
affected (Timms, 1968, 1976). Development of the maxilla to correct the arch form
Successful treatment of these conditions is firmly is frequently the first step in treatment to unlock the mal-
related to early interceptive treatment and is often associ- occlusion. The maxilla may be contracted anteroposteri-
ated with tooth-size/arch-size discrepancies. (McNamara orly or transversely, and frequently in both dimensions,
& Brudon, 1983). In many respects, this is contrary to the when three-way expansion is indicated. Anteroposterior
present philosophy of a regimen for orthodontic practice contraction is characterized by retroclined incisors, as
based on treatment in the permanent dentition. By the commonly found in Class I bimaxillary retrusion, Class
time the permanent teeth have erupted, the mid-palatal II division 2 and Class III malocclusion. Even in some
suture is closed, together with other sutures in the crani- Class II division 1 malocclusions, the incisors must first
ofacial complex, and the scope for effective maxillary be proclined to allow the mandible to be advanced fully
expansion is reduced. Straight wire technique is based into a Class I relationship.
on treatment in permanent dentition, and is the most In planning treatment of a Class II malocclusion the
common fixed appliance technique of the present day. upper and lower models should be viewed in occlusion
Unfortunately that does not cater for the needs of many with the lower model advanced to a Class I molar rela-
orthodontic patients who require interceptive treatment tionship. If crowding or irregularity is present, the teeth
in mixed dentition. All too often under present regulations do not articulate correctly, and it is evident that the arch
their treatment is delayed to conform with the organiza- form should be corrected first. After a preliminary phase
tion of orthodontic practice, or to meet the restrictive of arch development the functional correction is then
requirements of insurance companies or government achieved more simply and efficiently.
health schemes. The most natural method of arch development is by
Based on histological studies, the prognosis for the gentle pressure from the lingual aspect by the tongue.
treatment of labial segment crowding is better in mixed Lingual appliances for arch development simulate this
dentition than in permanent dentition. Melsen (1972) natural process by applying gentle controlled forces to
carried out an investigation to determine the histologi- the lingual surfaces of the teeth, causing the teeth to
cal effect of rapid expansion of the mid-palatal suture migrate through the alveolar bone toward ideal arch form
in children of various ages. A true stimulation of sutural position. Lingual arch development is well established as
growth was found only in children who had not attained a method of correcting arch form in interceptive treatment
maximum pubertal growth. In older individuals, expan- as a first phase of treatment prior to detailed orthodontic
sion was attended by numerous microfractures in the finishing.
sutural region. The post-traumatic reaction around these There are significant advantages in directing correc-
fractures was of significance for the course of healing, tive forces from the lingual aspect. The management
preventing further growth in the suture from taking place. of malocclusion in mixed dentition is improved by an
efficient first phase appliance system, which can be used

consistently to control a developing malocclusion at a
stage when parents seek interceptive orthodontic treat-
ment. Lingual appliances are used to uncrowd, gain arch
length, and correct arch form prior to functional therapy
or fixed appliance finishing.
Arch development techniques are effective in the
correction of all classes of malocclusion, and may be
indicated from early mixed dentition to adult treatment.
Invisible lingual appliances are “patient friendly”, and
therefore acceptable to patients who might otherwise be A
reluctant to wear orthodontic appliances.
During the past 15 years, the author has been involved
in designing active lingual appliances to achieve these
objectives. An active lingual arch is used to align the
labial segment and improve arch shape in the sagittal
and transverse dimensions. Arch width and arch length
are controlled simultaneously by gentle spring-driven
activation, combining ease of control, and a long range
of action. The appliances are fixed/removable, and are
designed to correct both upper and lower arches. Fixed/
removable appliances are removable by the doctor for
adjustment, but cannot be removed by the patient, thus
eliminating the problem of patient compliance.
In 1998 the author worked with Rocky Mountain B
Orthodontics to develop the Trombone appliance for Figs. 23.1A and B: A sagittal appliance for lingual arch development
was the precursor of TransForce lingual appliances.
lingual arch development. Initial designs were based on
a modified double lingual tube and postassembly as a the slide principle, whereby an inner tube slides freely
means of attachment of the lingual appliance. In 2004, the in an outer tube with the facility to extend or contract
author worked with Ortho Organizers when he developed the length of the appliance. The mechanism is similar to
TransForce lingual appliances using horizontal lingual the slide trombone, from which this appliance derives its
sheaths with enclosed nickel titanium springs. When name (Figs. 23.1A and B).
the springs are compressed TransForce appliances apply The molar section is retained by a double lingual
gentle pressure from the lingual aspect until they are fully post and tube attachment with a vertical insertion.
extended. This refined the technique and has proved to A distally extending occlusal wire is recurved distal to
be an extremely effective method of correcting arch form the molar to pass mesially as a horizontal tube at gingi-
from mixed dentition to adult therapy. val level. Two versions of the Trombone appliance were
Spring-driven forces, applied from the lingual aspect, produced, the first using an elgiloy coil spring and the
are used to activate a preformed lingual arch to extend second used flexible silicone tubing as the activating
arch form by applying gentle pressure to the lingual mechanism. The silicone degraded in the mouth and had
surfaces of the teeth, similar to the forces applied by the to be replaced frequently. Neither gained wide accept-
tongue. Several designs are available specifically to control ance, but the author was able to demonstrate successfully
arch form in the sagittal and transverse dimensions. the concept of lingual arch development using light con-
tinuous forces. This was the precursor of the TransForce
APPLIANCE DESIGN Technique, which provides an elegant system of preacti-
vated appliances for arch development. The absence of
Trombone and Lingual Arch Developer frictional forces allows rapid tooth movement using gen-
This appliance was initially designed with a coil spring as tle controlled lingual forces. The following case reports
the activating mechanism. Appliance design is based on demonstrate this concept.
Case Report: CS Aged 10 Years 1 Month lingual arch developer created adequate space for the
An example of maxillary arch development in a Class III canines, allowing them to erupt in good position, and
malocclusion with upper canines completely blocked to be accommodated in the corrected arch form after
out of the arch. After 9 months of treatment the 14 months of treatment (Figs. 23.2A to L).
Case Report: CS
A B C
D E F
G H I
J K L
Figs. 23.2A to L: Treatment. (A and B) Before treatment; (C) After treatment; (D to F) Arch development is completed after 9 months to
accommodate the canines; (G to L) Fixed appliances to complete treatment after 14 months.
Case Report: SC Aged 8 Years treatment was to improve arch width with upper and
lower anterior arch developers. This was followed by a
Labial segment crowding in both arches is associated 2  4 sectional upper fixed appliance and a Trombone
with narrow arch form, resulting in rotated incisors lingual arch developer to complete the alignment of the
and a Class II division 2 malocclusion. The first step in labial segments (Figs. 23.3A to I).
Case Report: SC
A B C
D E F
G H I
Figs. 23.3A to I: Treatment of Class II division 2 malocclusion in mixed dentition by upper and lower arch development followed by a
2 × 4 sectional fixed appliance.
Case Report: AS Aged 7 Years 7 Months This was combined with an upper sectional fixed
appliance to align the rotated incisors. The radiographs
A patient with severe upper labial crowding and rotation show the anterior expansion after 2 months of treatment.
of all four upper incisors presented for treatment in early Forces of 600 g were applied to achieve 10 mm expansion
mixed dentition. A prototype appliance for transverse between the upper deciduous canines after 5 months
arch development was used to create space by anterior of arch development. The upper intermolar width also
expansion to accommodate the crowded upper incisors. increased (Figs. 23.4A to I).
Case Report: AS
A B C
D E F
G H I
Figs. 23.4A to I: Transverse arch development to correct a unilateral crossbite and resolve anterior crowding.
Case Report: RW Aged 11 Years buccally. Severe crowding in the lower labial segment was
reduced by extraction of one lower incisor.
Severe maxillary contraction with bilateral crossbite was The Trombone lingual arch developer was used first to
associated with a Class III malocclusion with a bilateral make space to accommodate the upper canines, followed
posterior open bite. The only occlusal contact was by a transverse arch developer to expand the upper arch
between the upper and lower central incisors. Upper and correct the bilateral crossbite. Nine months of sagit-
lateral incisors were displaced lingual to the upper tal arch development was followed by fixed appliances
central incisors, which were already in lingual occlusion combined with transverse arch development, and treat-
to the lower incisors. There was insufficient space for the ment in this severe malocclusion was completed after
upper canines, causing them to be displaced mesially and 2 years (Figs. 23.5A to I).
Case Report: RW
A B C
D E F
G H I
Figs. 23.5A to I: Treatment of a severe Class III malocclusion by upper arch development followed by fixed appliances.
INTERCEPTIVE TREATMENT OF CLASS II retroclined upper incisors and proclined lateral incisors
was related to a mild distal occlusion. Interceptive treat-
DIVISION 2 MALOCCLUSION
ment was planned with lingual appliances, developed
Case Report: LM Aged 8 Years with the support of Rocky Mountain® Orthodontics, and
these were the precursors of TransForce Lingual appli-
This patient presents a Class II division 2 malocclusion ances. A sagittal appliance was fitted first for three-way
in mixed dentition. A typical incisor relationship with development of the upper dental arch (Figs. 23.6A to G).
A B
D E
F G
Figs. 23.6A to G: (A to E) Facial appearance and occlusion before treatment; (F and G) Show the occlusal views and the upper appliance
for lingual arch development.
Two months later a lower sagittal appliance was fitted to guide eruption in the transition from mixed to perma-
act as a space maintainer and to resolve mild crowding nent dentition. The lower lingual appliance is left off
in the lower labial segment. This was combined with a after 7 months as the premolars and canines erupt
simple fixed appliance to align the upper incisors and (Figs. 23.7A to G).
A B
D E
F G
Figs. 23.7A to G: Lingual Arch Development is combined with a simple upper fixed appliance and the lower appliance is left out after
7 months.
At age ten years the premolars and canines have erupted is required after the interceptive phase in mixed dentition
and a Class I buccal segment occlusion is established. (Figs. 23.8A to G).
A period of observation follows and no further treatment
A B
D E
F G
Figs. 23.8A to G: Facial appearance and occlusion at age 10.
At age 11 years 7 months the occlusion is stable but there molars it was decided to extract all second molars at this
are early signs of increased pressure in the lower incisor stage. The cephalometric tracing at this age shows the
region as second molars have erupted. To prevent the brachyfacial growth pattern (Figs. 23.9A to H).
possibility of increased crowding with eruption of third
A B C
E F
G H
Figs. 23.9A to H: Facial appearance, cephalometric tracing and occlusion at age 11 years 7 months confirm that the occlusion is stable,
with good facial esthetics.
At age 15 years 11 months stability of the occlusion is Pressure on the lower labial segment has been relieved
confirmed seven years after completion of treatment. by extraction of second molars (Figs. 23.10A to G).
A B
D E
F G
Figs. 23.10A to G: At age 15 years 11 months second molars have been extracted to relieve pressure on the lower labial segment and
to accommodate third molars.
At age 18 years 9 months third molars are beginning to Simple interceptive treatment in mixed dentition proved
erupt with no recurrence of crowding in the lower labial to be effective in controlling the development of this mal-
segment, in spite of a strong brachyfacial growth pattern. occlusion (Figs. 23.11A to G).
A B
D E
F G
Figs. 23.11A to G: At age 18 years 9 months the profile has flattened with further growth and the occlusion is stable as third molars erupt.
TRANSFORCE 2 SAGITTAL EXPANDER The sagittal appliance is pre-activated to achieve the

The TransForce Sagittal Expander is specifically designed amount of expansion required (Fig. 23.13).
for antero-posterior arch development in upper or lower The Sagittal Expander is provided in seven sizes. The
dental arches, and is often indicated for simultaneous use mesiodistal length of the appliances varies by 2 mm
in both arches (Fig. 23.12). increments throughout the range. The range of action of
Labial movement of the anterior teeth may be com- the sagittal appliance is 6 mm in the larger sizes, which
bined with transverse development of the buccal seg- are used only in the upper arch. The smaller sizes with
ments where indicated byactivating the mesial exten- 4 mm range of action, can be used in the upper or lower
sion wires to move premolars or deciduous molars, or arch. Careful selection is advised to provide the correct
to expand intercanine width. As the modules expand amount of tooth movement required for each individual
this also achieves expansion of the inter-molar width. case (Figs. 23.14A and B).
Fig. 23.12: The TransForce sagittal appliance has enclosed nickel Fig. 23.13: A template is used to select the correct size of appliance,
titanium springs and blade attachments to fit in lingual sheaths on showing the extended and compressed sizes.
molar bands.
A B
Figs. 23.14A and B: The TransForce sagittal appliance is pre-activated with enclosed nickel titanium springs for controlled lingual arch
development of arch length.
Selecting the Correct Size of Before fitting the appliance it is useful to check the
TransForce Sagittal Expander range of activation by placing the assembled appliance on
the model. The bands fit over the molars and the lingual
A clear template is provided by Ortho Organizers show- arch is engaged on the incisors to observe the range of
ing a scale model of the appliance in both compressed action when the coil springs are compressed.
and fully extended forms. The template is placed over the The larger sizes have 6 mm range of activation and are
occlusal surface of a model to measure arch length and only suitable for the upper arch. The smaller sizes have
molar width. 4 mm activation and can also be used selectively in the
The template provides a visual guide to facilitate selec- lower arch (Figs. 23.15A to C).
tion of the appropriate size of the appliance. The com- The template displays an outline of the appliance in
pressed outline of the appliance should fit inside the lin- the fully compressed and fully extended size. The correct
gual outline of the teeth. The extended outline shows the size is selected by overlaying the image of the appliance
amount of pre-activation in the appliance.
A B
Figs. 23.15A to C: The three large sizes have a range of action from 6 mm from fully compressed to fully extended. These are designed
for use in the upper arch, for example, to accommodate a blocked-out canine or premolar. The sagittal appliance is excellent for correction
of dental asymmetry by equalising the space available for eruption of the premolars and canines.
on the model. If required the anterior extension wires lower incisors are retroclined and positioned lingual to
can be adapted to act on individual teeth. Overlaying the A-pogonion line.
the passive image will predict the amount of expansion In planning treatment, calculate the number of mm
that will be delivered by the appliance as the compression of crowding, the Arch Length Discrepancy (ALD), and
units expand (Figs. 2316A to D). The smaller sizes have divide by 2. Each mm of advancement of the lower inci-
a range of action of 4 mm from fully compressed to fully sors will accommodate 2 mm of crowding. This gives an
extended. They may be used in the upper or lower arch. estimate of the final position of the lower incisors relative
They are more likely to be fully compressed in the upper to the A-pogonion line.
arch. This would accommodate up to 8 mm of crowd- The ideal position of the tip of the lower incisor after
ing in the buccal segments by advancing the upper inci- treatment is in the range of +1 to +3 mm to the A-pogonion
sors. When less crowding is present, the next smaller size line. The limit of +3 mm may apply to brachyfacial faces.
of sagittal appliance will accommodate up to 4 mm of In mesofacial faces +1 mm may be the ideal position.
crowding from fully compressed to fully extended. Sagittal advancement of the lower incisor is seldom indi-
Case selection is important, and the sagittal appli- cated in dolichofacial faces with long, thin alveolar pro-
ance should be used only in the lower arch when processes due to a lack of bony support. The sagittal appli-
clination of the lower incisors is indicated, e.g. when the ance is then contraindicated.
A B
C D
Figs. 23.16A to D: The four smaller sizes have a range of action of 4 mm from fully compressed to fully extended and may be used
in the upper arch and selectively in the lower arch. The appliance frequently is not fully compressed when fitted, and if less than 4 mm
expansion is required, a smaller size is selected to give only 2 mm activation.
Measure Sagittal Length

distance between the molars and incisors on both sides
An estimate of the size can be obtained by measuring the (Figs. 23.17A and B).
sagittal length on the model from the mesiolingual sur- This patient was treated by arch development in early
face of the molar to the mid incisal point on the central permanent dentition and the images show the amount of
incisors. This appliance is excellent at resolving dental arch development. Models before treatment on the left
asymmetry because when fully extended it equalizes the and after treatment on the right (Figs. 23.18A to D).
A B
Figs. 23.17A and B: Measure the sagittal length on the models as a guide to the correct size of appliance to fit inside the arch.
A B
C D
Figs. 23.18A to D: (A and B) The template is placed over the upper models before and after treatment to show the change in arch form;
(C and D) The template is placed over the lower model before and after treatment to show the change in arch form.
TRANSFORCE SAGITTAL Sagittal appliances were used to correct arch form and
ARCH DEVELOPMENT align the anterior teeth. The lower appliance was fitted
first to advance the lower incisors and reduce the over-
This boy has a Class I buccal segment relationship with bite before fitting the upper sagittal appliance. This avoids
retroclined upper central incisors and crowding of the having the lower incisors damaging the upper appliance
lower labial segment. Upper and lower TransForce in deep overbite cases (Figs. 23.19A to J).
A B C
D E
F G
H I J
Figs. 23.19A to G: (A to C) The occlusion before treatment with retroclined upper and lower incisors; (D to G) This shows the improvement
in arch form after 9 months sagittal arch development with TransForce Sagittal appliances. This correction is achieved by advancing the
upper and lower incisors. Arch width and inter-molar width is also increased; (H to J) Tracings show the position before treatment at age
13 years 6 months; after retention at age 16 years 1 month; and with superimposed tracings.
Treated with Invisible occur without any frictional resistance. This concept can
TransForce Appliances be used from mixed dentition to adult dentition. In adult
therapy invisible appliances may be used for detailed fini-
This correction was achieved with invisible lingual appli- shing and fixed lingual retainers can be fitted for long-
ances without fixed appliances. Rapid tooth movements term retention (Figs. 23.20A to J).
A B
C D E
F G
H I J
Figs. 23.20A to J: (A and B) Arch form before treatment; (C to E) Occlusion after treatment; (F and G) Arch form after treatment; (H to J)
Facial appearance after treatment with invisible appliance.
Class III—Sagittal Transforce Appliance The lingual occlusion was corrected after 3 months,
Interceptive treatment for a Class III malocclusion in mixed and the appliance was used as a retainer for a further
dentition with an upper sagittal TransForce appliance. 6 months (Figs. 23.21A to H).
A B
D E
G H
Figs. 23.21A to H: (A and B) Facial profile and smile before treatment; (C to E) Occlusion before treatment; (F to H) Occlusion is corrected
after 3 months treatment with an upper sagittal TransForce appliance.
Class III—Sagittal TransForce Appliance after eruption of permanent teeth. The profile and facial
balance has improved after a short period of intercep-
No further treatment was required and the final photo- tive treatment with a Sagittal TransForce appliance
graphs show the occlusion and arch form 3 years later (Figs. 23.22A to G).
A B
D E
F G
Figs. 23.22A to G: (A and B) Final photographs confirm that the profile and smile have improved; (C to G) Correction of the occlusion
and arch form is stable 3 years after interceptive treatment in mixed dentition, without further treatment.
TRANSVERSE ARCH DEVELOPMENT the dental arches before the permanent teeth erupt to
guide the premolars and canines to erupt in a wider arch
Transverse arch development is required to correct nar- form. Correcting tongue position may be a stabilizing fac-
row arch form when arch width is restricted, either in the tor following expansion of narrow arch form.
anterior or posterior segments. Significantly this treatment is carried out when the
Constricted arch width occurs in all classes of mal- maxillary midline suture is more responsive to the forces
occlusion and ideally should be treated in mixed denti- of expansion, and low continuous forces may produce a
tion to promote normal function and encourage correct more stable physiological response.
tongue positioning. A low tongue position is associated Frankel and Cetlin have previously demonstrated
with a narrow palate and is often related to mouth breath- a stable increase in lower inter-canine width following
ing. Correcting arch width in early treatment offers the treatment by a vestibular approach. The addition of a lip
best prognosis for stability as the maxilla is more respon- bumper may be an added advantage when combined
sive to corrective forces before the permanent dentition with slow expansion from the lingual aspect (Fig. 23.23).
is fully developed.
A narrow maxilla is a primary etiological factor of
upper anterior crowding, and may be responsible for sec-
ondary crowding in the lower dental arch. Maxillary con-
striction may predispose the patient to a distal occlusion
and may restrict mandibular development in the sagittal
or transverse dimensions.
On the basis of present concepts of dentofacial growth
it is advisable to treat incisor crowding in the mixed
dentition, when the incisors are erupting and the dental
arches are amenable to transverse development. Parents
frequently request treatment when they observe perma-
nent incisors erupting in crowded positions.
Research has established that after the permanent
canines have erupted the lower inter-canine width is an
extremely stable dimension, and expansion in this region
Fig. 23.23: The TransForce appliance has a single compression
is unlikely to remain stable in the long term. The concept module with an enclosed nickel titanium spring delivering a force of
of interceptive treatment in mixed dentition is to expand 200 grams for transverse arch development.
TRANSFORCE 2® TRANSVERSE EXPANDER molar width without tipping the molars, by delivering a
low continuos force generated by the enclosed nickel tita-
The Transverse Expander has an expansion module to nium spring.
increase the inter-canine width in upper or lower arches The Transverse Expander is provided in four sizes
to accommodate crowding in the labial segments, or to and the appropriate size can be selected for use in the
correct arch width in contracted arches. This is an ideal upper or lower arch. The intercanine width and inter-
replacement for the upper or lower Schwarz plate, by molar width is adjusted accordingly. The range of action
achieving a similar effect with a fixed/removable appli- of the Transverse appliance is 8 mm. The anterior trans-
ance, thus eliminating problems with the non-compliant verse width of the appliance increases in 2 mm incre-
patient. The Transverse Expander is pre-activated to ments throughout the series. The mesiodistal length also
achieve the required amount of inter-canine expansion. increases by 2 mm to allow for variation in tooth width
The appliance inserts in horizontal lingual sheaths on (Fig. 23.24).
the molar bands and incorporates a gingival step mesial
to the molar, placing the body wire close to gingival level.
A recurved wire extends mesially from the molar sheath
and may be used to align irregular anterior teeth from
the lingual aspect. This facility is particularly useful when
insufficient space exists to place brackets on lingually
displaced teeth. The space is created first by transverse
expansion before improving alignment prior to bonding
brackets on the anterior teeth.
The expansion unit is positioned lingual to the incisors
and is very effective in creating space in a crowded labial
segment. However, it is equally effective in expanding
inter-molar width and widening the arch in the deciduous
molar or premolar region. The body wire extends from the
expansion module to be inserted in a horizontal lingual
sheath on the molar band. Although the force delivered
Fig. 23.24: The TransForce Transverse appliance has an enclosed
to the molar is reduced by the long lever arm, it is nev- nickel titanium spring and blade attachments to fit in lingual sheaths
ertheless an extremely efficient mechanism to increase on molar bands.
The process of selecting the correct size of the Trans- Alternatively the arch width before treatment may
verse Expander uses a similar clear template showing a be measured using the millimeter scale on the tem-
scale model of the appliance in both compressed and plate, measuring the inter-molar width from the gingi-
fully extended forms. The template is laid over a study val margin of the molar and the inter-canine width from
model to select the size to fit the individual patient. The the gingival margin of the canines. This distance may
compressed outline of the appliance should fit inside be compared with the compressed width and extended
the lingual outline of the teeth. The extended outline width of the transverse appliance on the template to
shows the amount of preactivation in the appliance determine the correct size and the range of activation
(Figs. 23.25A to D). (Figs. 23.26A to C).
A B
C D
Figs. 23.25A to D: The template illustrates four sizes of the TransForce expander with measurements when fully compressed and fully
extended. The enclosed nickel titanium spring exerts low physiological force for continuous slow expansion of arch width. This approach
is excellent for correction of anterior crowding.
A B C
Figs. 23.26A to C: Measure the transverse width on the models as a guide to the correct size of appliance to fit inside the arch.
TRANSFORCE TRANSVERSE ARCH left on closure requires interceptive treatment by arch

DEVELOPMENT IN MIXED DENTITION development to restore symmetry and improve function
in the transition from mixed to permanent dentition. A
An 8-year-old girl with a contracted maxilla, resulting in a TransForce Transverse Expander is fitted to correct the
unilateral crossbite and mandibular displacement to the crossbite and expand the maxilla (Figs. 23.27A to G).
A B
C D E
F G
Figs. 23.27A to G: (A and B) Facial appearance and profile before treatment; (C to E) Occlusion before treatment; (F) The maxilla is
contracted and an upper TransForce appliance is compressed to deliver transverse expansion; (G) Lower arch form before treatment.
Maxillary arch development at age 8 years 4 months of permanent teeth the Transverse appliance was fitted
with a transverse expander corrected the crossbite and again with an upper fixed appliance for 9 months to com-
improved arch form. After a short period of retention the plete treatment. Typically the time in fixed appliances is
appliance was left out. A period of observation followed reduced by 50% (Figs. 23.28A to K).
in the transition to permanent dentition. After eruption
A B
C D E
F G H
I J K
Figs. 23.28A to K: (A and B) Facial appearance and profile after maxillary arch development; (C to E) Occlusion after treatment to correct
the lateral crossbite; (F) The maxilla is contracted and an upper TransForce appliance is compressed to deliver transverse expansion;
(G) Maxillary arch form after 9 months treatment; (H) Upper arch form after eruption of premolars and canines; (I to K) Lower arch form
before and after treatment.
Final photographs show the occlusion and arch form at lower incisor crowding. This is particularly effective if it
age 12 years 4 months. At this stage, an Occlus-o-Guide is worn when playing computer games, as the patient
was fitted as a retainer, to be worn when convenient in actively bites into the appliance (Figs. 23.29A to G).
the evening and at night to apply pressure to resolve slight
A B
C D E
F G
Figs. 23.29A to G: (A and B) Facial appearance and profile after completion of treatment; (C to G) Occlusion and arch form at age
12 years 4 months.
Transverse TransForce Appliances 8 Months TransForce Transverse Expansion Appliances. Active

treatment was completed in 8 months and the TransForce
A Class 111 malocclusion with severe upper labial crow- appliances remained in place for 3 months to retain
ding treated in mixed dentition with upper and lower (Figs. 23.30A to H).
A B
C D
E F
G H
Figs. 23.30A to H: (A and B) Facial appearance before and after treatment with TransForce Transverse appliances to correct arch form;
(C and D) Anterior crowding is corrected after 8 months arch development; (E to H) Upper and lower arch form before and after treatment.
Fixed Appliances to Detail Occlusion

This was followed by a short period of treatment with fixed treatment in mixed dentition to resolve anterior crowding
appliances after eruption of permanent teeth. Interceptive simplified the finishing stage (Figs. 23.31A to G).
A B
D E
F G
Figs. 23.31A to G: (A and B) Profile and facial appearance after detailing the occlusion with fixed appliances; (C to G) The finished
occlusion and arch form after treatment.
Transverse Arch Development fixed appliances over a period of 5 months with appoint-
Rapid improvement by maxillary arch development with ments at 10 weeks intervals. Final photographs are 3 years
a Transverse Expander allows efficient progression to later (Figs. 23.32A to J).
Occlusion before treatment
A
Before treatment 4 months treatment After arch development
B C D
E F G
Before treatment After transverse expansion After arch development
H I J
Figs. 23.32A to J: (A to G) Severe upper labial crowding quickly responds to transverse arch development; (C) After 4 months treatment
this shows spontaneous distal movement of the upper canines to accommodate the lateral incisors. At this visit the upper fixed appliance
was fitted; (H to J) The occlusion 3 years later.
development. She enjoyed having invisible appliances for

Adult Therapy—Arch Development
11 months while her smile noticeably improved before
This young adult with severe maxillary contraction was progressing to a short period with aesthetic fixed appli-
treated with TransForce Appliances for lingual arch ances to complete treatment (Figs. 23.33A to H).
A B
C D
E F
G H
Figs. 23.33A to H: (A and B) There is a noticeable improvement in this patient’s smile after 4 months treatment with an invisible TransForce
appliance to expand the upper arch and advance the lateral incisors; (C and D) Maxillary contraction with anterior crowding and bilateral
crossbite of rotated upper molars; (E and F) After 11 months treatment the upper arch form and molar rotation have improved; (G and H)
Lower arch form is controlled with a lower sagittal appliance combined with a lower fixed appliance.
simplify treatment using biocompatible forces for gen-
Fixed Appliances to Complete Treatment
tle arch development. Typically the time in fixed appli-
The lingual approach presents minimum discomfort and ances is reduced by 50%. Treatment was completed in
inconvenience for adults. Invisible lingual appliances 19 months (Figs. 23.34A to H).
A B
C D
E F
G H
Figs. 23.34A to H: (A and B) The profile before and after treatment; (C and D) The occlusion after treatment; (E and F) An upper fixed
appliance was fitted to complete treatment after 11 months of arch development; (G and H) The passive lower sagittal appliance was used
as a retainer and a fixed upper lingual retainer was fitted.
Transverse and Sagittal Arch Development 9 months a lower fixed appliance was fitted. This severe
This patient was unwilling to have fixed appliances, but malocclusion showed a marked improvement with sim-
was happy to wear lingual appliances. Upper Trans- ple treatment and was completed in 7 visits followed
verse and lower sagittal appliances were used and after by retainer (Figs. 23.35A to L).
Occlusion before treatment
A B C
Before treatment After transverse expansion After arch development
D E F
G H I
Before treatment After transverse sagittal After arch development
J K L
Figs. 23.35A to L: Transverse maxillary development combined with a TransForce lower sagittal appliance unlocked this malocclusion, and
a lower fixed appliance was used to complete treatment. The patient declined further treatment with an upper fixed appliance.
SUMMARY may be overexpanded in mixed dentition to encourage

the permanent teeth to erupt in a wider arch.
This chapter illustrates the author’s experience over a The ideal time to resolve anterior crowding is when the
period of 15 years from 1999 to 2014 during which he incisors are erupting. This approach is equally effective in
developed first the Trombone appliance and later refined the lower arch, where there is no midline suture and light
the technique with TransForce appliances for lingual arch continuous forces are appropriate for arch development.
development. This is equally effective in the upper arch and more
Prior to that the author had 20 years’ experience from research is required to establish the histological changes
1979 to 1999 in lingual arch development using the quad in the midline suture and the outer alveolar plate as a
helix and bi-helix as taught by Dr Ricketts and Guigino result of the application of light forces for slow expansion.
in the bioprogressive philosophy. He then adopted and There may also be significant implications for the airway
taught the Wilson system of modular lingual appliances, as a result of increasing the inter-maxillary space and
which he used for 15 years. altering tongue position. New technology is now avail-
The Bioprogressive approach first introduced the able to investigate these factors.
author to interceptive treatment in mixed dentition and The sagittal appliance is particularly effective in cor-
this revolutionized his approach to the management of rection of dental asymmetry by equalizing the space
malocclusion. This proved to be efficient in chair time between the molars and incisors on both sides of the den-
and it suited his environment, practicing orthodontics tal arch. It is effective in lengthening the arch to accom-
within the National Health Service in Scotland. The modate buccal segment crowding.
time spent in full bonded fixed appliances was typically The application of TransForce appliances for arch
reduced by 50% and the incidence of breakage was sig- development is described more comprehensively in a
nificantly reduced by using arch development to correct new e-book, “Advances in Fixed Appliance Technique”.
deep overbite before progressing to bonded fixed appli- For further details please visit the author’s website at
ances to detail the occlusion. www.twinblocks.com.
The motivation to investigate new appliances for
lingual arch development arose when it was evident in REFERENCES
teaching the Bioprogressive and Wilson system that there
was scope to simplify and improve the appliances by tak- McNamara JD, Brudon WL, (1983). Treatment of toothsize/
arch-size discrepancy problems, Orthodontic and Orthopedic
ing advantage of new technology to design more efficient
Treatment in the Mixed Dentition. Needham Press, Ann
appliances. Arbor. pp. 67-93.
The description “New Horizons in Orthodontics” is Melsen B, (1972). A histological study of the influence of sutural
appropriate because this approach simplifies the treat- morphology and skeletal maturation on rapid palatal expan-
ment of all classes of malocclusion. Interceptive treat- sion in children, European Orthodontic Society. 499-507.
Timms DJ, (1968). An occlusal analysis of lateral maxillary
ment in mixed dentition is extremely effective in dealing
expansion with midpalatal suture opening, Dental Practitioner
with transverse discrepancies in arch width when the and Dental Record. 18:435-41.
sutures and the supporting dental tissues are responsive Timms DJ, (1976). Long term follow up of cases treated by rapid
to the application of light continuous forces. The dentition maxillary expansion, European Orthodontic Society.211-5.
Fixed Twin Blocks 395
Chapter 24
Fixed Twin Blocks
TREATMENT CONCEPTS AND PROTOCOL are removed and the Fixed Twin Block components may
be added. This phase may be combined with fixed appli-
Any orthodontic or orthopedic appliance system requires ances.
sufficient versatility to treat a wide range of malocclu-
sions, and the facility to adapt to meet differing clinical
requirements.
DEVELOPMENT OF FIXED TWIN BLOCKS
Compared to removable appliances fixed appli- The author has intended to produce Fixed Twin Blocks
ances do not rely on patient compliance. It has been an for over twenty years. This is an early drawing of the
objective of the author for many years to design Fixed concept prepared by the author in 1990 (Fig. 24.1).
Twin Blocks, using pre-formed components as an effec- This is not the final design but the concept remains the
tive guidance mechanism for mandibular advancement. same, to integrate orthodontic and functional orthopedic
Fixed Twin Block components have now been designed techniques in the correction of malocclusion.
to achieve these objectives and have undergone clinical
testing and evaluation. The system may be combined
with conventional fixed appliances or TransForce lingual
appliances for arch development using lingual and buccal
tube attachments to facilitate integration with existing
appliance mechanisms.
Three distinct objectives of treatment may be defined
as follows:
1. Interceptive treatment and arch development
2. Mandibular advancement with Fixed Twin Blocks
3. Detailing of the occlusion with fixed appliances.
It is recommended that the correct arch form is estab-
lished in both dental arches as a preliminary to fitting
fixed Twin Blocks for functional orthopedic correction.
This ensures that the arches will occlude together cor-
rectly when the mandible is translated to a forward
position. When this has been achieved, the lingual arches Fig. 24.1: Prototype Fixed Twin Block Design dating from 1990.
EVOLUTION OF FIXED TWIN BLOCKS PHASE 1—INTEGRATION WITH FIXED

PHASE 1—2008 APPLIANCES
Preformed Occlusal Blocks The preformed blocks were bonded to the occlusal
and lingual surfaces of the teeth and were designed to
The design of Fixed Twin Blocks has changed over a be attached to molar bands and integrated with fixed
period of eight years evolving in the light of experience appliances.
and adapting to a changing pattern of technology and Elastic chain was attached to buccal buttons and
clinical practice. excess composite flowed into the interdental undercuts
In 2008, the first design of preformed blocks was based on the buccal surface to provide additional stability. This
on attachment to molar bands using a blade attach- was especially indicated in the lower arch where the
ment inserted in a lingual sheath. The blocks covered blocks were secured only on the lower premolars. The
the occlusal and lingual surfaces of the teeth, leaving the lingual attachment to the molars was an essential feature
buccal surfaces free for attachment of brackets. It was felt at this stage.
that attachment to molar bands was necessary to improve Although this design proved to be effective it was
stability. challenging to fit the blocks correctly and it was soon
The blocks were checked and adjusted on models realized that attachment to molar bands was a limiting
before fitting in the mouth (Figs. 24.2A and B). factor (Figs. 24.3A to C).
A B
Figs. 24.2A and B: Phase 1 Fixed Twin Blocks were attached to a lingual sheath on molar bands.
B C
Figs. 24.3A to C: Fixed Blocks integrated with fixed appliances.
INDIVIDUAL FIXED BLOCKS Buccal tubes may be added to the first molars to
accommodate arch wires. The blocks are effectively a
Individual Fixed Blocks may be customized on models temporary anchorage device to apply occlusal forces to
to fit in each quadrant using a construction bite prior correct the occlusion with excellent anchorage to control
to fitting in the mouth (Figs. 24.4A to F). The block is the anterior teeth.
adapted to fit on the model, making allowance for the When used with fixed appliances correction of overjet,
thickness of the Essix material. A pressure molded cover overbite and alignment of the labial segments is facili-
is applied over the blocks. Fitting the blocks by this tated by the improved anchorage, without any invasive
method is similar to fitting bands and new cements have techniques.
been developed that adhere to plastic materials and can
bond metal to plastic.
A B C
D E F
Figs. 24.4A to F: Preformed blocks are adapted and fitted on models and Essix material is molded over the blocks to produce individual
blocks to fix in each quadrant. They can then be fitted in the mouth as easily as cementing a band using a new type of cement that
bonds to plastic and to the tooth surface. (e.g. Bond Aligner, with Assure Universal Bonding Agent. Contact: www.relianceorthodontics.
com for further information).
PHASE 2—2010: ELIMINATES The upper blocks cover the second premolar and
ATTACHMENT TO MOLAR BANDS extend distally to the second molar region. The lower
blocks cover the premolars, with lingual extensions on
This change in design reflected a move away from molar the canine and first molar. Elastic chain was attached
bands to bonded buccal tubes. Upper and lower blocks to buccal buttons and excess composite flowed into the
are bonded directly to the teeth. The blocks are designed interdental undercuts to provide additional stability and
to cover the lingual and occlusal surfaces of the teeth, fixation on the buccal surface (Figs. 24.5A to F).
leaving the buccal surfaces clear for attachment of
bonded brackets. The concept was to integrate fixed and
functional therapy.
A B
C D
E F
Figs. 24.5A to F: (A and B) Upper Blocks; (C and D) Lower Blocks; (E and F) Blocks are bonded with fixed appliances.
PHASE 3—2014: THE ULTIMATE SOLUTION of the preformed blocks. The blocks fit over the teeth
and are filled with Triad material for an accurate fit. The
New Designs for Fixed Twin Blocks technique is similar to the construction of a temporary
These schematic drawings illustrate a new concept in the crown or bridge and may be used as a direct or indirect
design of Fixed Twin Blocks (Figs. 24.6A to F). Buccal technique after first checking the fit of the blocks on
extensions are added to improve stability and fixation models
A B
C D
E F
Figs. 24.6A to F: (A to D) Preformed blocks have buccal and lingual extensions; (E and F) Blocks are filled with Triad material and
customized to fit on models before being transferred to the mouth.
FIXED TWIN BLOCKS PHASE 3—2014 Preformed occlusal blocks cover the lingual, occlusal
and buccal surfaces of the upper and lower teeth. They
The Ultimate Solution for Fixed will be available in 3 sizes, large, medium and small, with
Functional Therapy a simple protocol for clinical application or by indirect
technique in orthodontic laboratories.
Fixed Twin Blocks have evolved over a period of 15
New materials are now available to bond metal to
years. Experience in using the earlier versions allowed
plastic. This enables the blocks to be customized by
the author to progressively refine the technique. Finally
adding buccal tubes, so that orthodontic correction of
a new design has evolved to resolve all the objectives to
the labial segments can proceed simultaneously with
combine fixed and functional therapy.
functional mandibular advancement (Figs. 24.7A to D).
A B
C D
Figs. 24.7A to D: (A) Diagram of upper and lower blocks with buccal tubes added for integration with fixed appliances; (B to D) Upper
and lower blocks are fitted on models to check the fit and occlusion before filling with Triad material and transfer to the mouth. The lower
block extends mesially to engage the lower canine.
GUIDELINES FOR CASE SELECTION correction of a Class II malocclusion with a Class II

skeletal relationship it is recommended that the blocks
Orthopedic Correction stay in place for 6−9 months, again related to the severity
Guidelines for case selection are similar to those for of the malocclusion. This is to allow sufficient time for
removable Twin Block appliances. Early permanent den- bony remodeling in the condyle and glenoid fossa.
tition is an ideal stage for favorable growth, and treat- Before removing the blocks a panoramic radiograph
ment at this stage simplifies clinical management. This should confirm that the condyles are relocated in the
stage of development also allows integration with fixed glenoid fossa.
appliances. The preformed blocks are not ideal for use
in mixed dentition and the transitional stage should be Orthodontic Correction
avoided when deciduous teeth are being shed. Less severe Class II malocclusion requiring orthodontic
Typical features of a candidate for the Fixed Twin correction can also be treated by wearing Fixed Twin
Block for orthopedic correction are Class II division 1 Blocks for a shorter period. The full time functional
malocclusion with mandibular retrusion having a favora- appliance gives rapid correction of distal occlusion and
ble growth potential for mandibular advancement. The modifies muscle behavior in the early stages of treatment.
profile should improve with the mandible postured for- This is sufficient to treat a mild Class II division 1 or Class II
ward with the lips lightly closed together. The patient division 2 malocclusion without producing orthopedic
should have good arch form and complete dental arches effects. The shorter period of treatment does not allow
before treatment with a distal occlusion and an increased time for significant bony remodeling, but is effective in
overjet. Any irregularity in the posterior segments should correcting the distal occlusion.
be corrected before fitting Fixed Twin Blocks. For orthodontic correction of a Class II malocclusion
It is recommended that correct arch form is estab- Fixed Twin Blocks are in place for 3 to 6 months,
lished in both dental arches as a preliminary to fitting depending on the severity of the distal occlusion.
Fixed Twin Blocks for functional orthopedic correction. Fixed Twin Block produce rapid correction of dis-
If the arches are irregular or crowded an initial phase tal occlusion with a full time fixed functional appliance
of treatment is required, either by arch development or that is comfortable to wear and can be combined with
conventional fixed appliances to correct arch form prior to fixed appliances at any stage of treatment. This has been
fitting the Fixed Twin Blocks. This ensures that the arches confirmed by 8 years of clinical testing during the deve-
will occlude together correctly when the mandible is lopment of Fixed Twin Blocks. Occlusal blocks bonded
translated to a forward position. In an uncrowded Class to the teeth produce consistent results similar to those
II division 1 malocclusion, Fixed Twin Blocks may be observed in treatment with removable Twin Blocks or a
fitted as the first step in treatment. For orthopedic fixed Herbst appliance.
INTEGRATING ORTHODONTIC AND

ORTHOPEDIC THERAPY
The patients used to illustrate this chapter were treated correct an uncrowded Class II division 1 malocclusion.
over a period of 15 years with earlier designs of fixed The skeletal relationship presents a mandibular retrusion
Twin Blocks, first with customized prototype appliances with a convexity of 8 mm and a 10 mm overjet. The first
and later with preformed occlusal blocks. These versions step in treatment was to bond the blocks to the posterior
covered the occlusal and lingual surfaces of the teeth and teeth using composite so that the inclined planes on the
were bonded to the teeth with composite. blocks posture the mandible forward. This applies func-
This is an early example of treatment with Fixed Twin tional forces 24 hours a day to maximize the propriocep-
Blocks to combine orthopedic and orthodontic therapy to tive response (Figs. 24.8A to H).
A B
C D E
F G H
Figs. 24.8A to H: Facial appearance, occlusion, arch form and cephalogram before treatment at age 12 years 8 months.
The facial appearance and profile improve immediately a result of eating and drinking with the appliances in the
on the day the Fixed Twin Block is fitted. The patient is mouth. Prototype appliances attached to molar bands
able to close the lips together comfortably and quickly were used in this case to test the response before arriving
develops competent lip posture. This occurs naturally as at the first design for manufacture (Figs. 24.9A to G).
A B
C D E
F G
Figs. 24.9A to G: (A and B) The facial appearance improves on the day Fixed Twin Blocks are fitted; (C to G) The blocks are attached
to molar bands and bonded directly to the lingual and occlusal surfaces of the teeth with composite. Excess composite flows into the
interdental areas buccally to give additional fixation.
The facial appearance and the profile are improved to close the slight posterior open bite. The occlusion
after 8 months when the blocks are removed. The is fully corrected to Class I buccal segments after 10
upper fixed appliance is fitted during the Twin Block months treatment with a combination of Fixed Twin
phase and the lower fixed appliance is added on the Blocks and fixed appliances to detail the occlusion
day the blocks are removed. Vertical elastics are used (Figs. 24.10A to H).
A B
C D E
F G H
Figs. 24.10A to H: (A and B) Facial appearance after 8 months with Fixed Twin Blocks; (C to E) Vertical box elastics were used to settle
the occlusion on removal of the blocks; (F to H) The occlusion after 10 months treatment.
The period of treatment was reduced by integrating provision to expand the maxilla to compensate for mandi-
Fixed Twin Blocks and fixed appliance therapy. Treatment bular advancement. The upper retainer included a midline
was completed after 14 months followed by retention with screw to reinforce the transverse arch development achi-
removable retainers. Treatment protocol should include eved during the fixed appliance phase (Figs. 24.11A to G).
A B
C D E
F G
Figs. 24.11A to G: Facial appearance and occlusion after 14 months treatment.
Facial changes during treatment and cephalometric
changes before and after Fixed Twin Blocks and 21
months after completion of treatment (Figs. 24.12A to H).
A B C
D E F
Before Treatment: Cranial base angle 25°: Facial axis 27°: Mandibular plane 25° Convexity 8 mm.
G H
Figs. 24.12A to H: Facial changes before, during, and after treatment.
Final records confirm the long term stability five years maintained out of retention with ideal occlusion and arch
after completion of treatment at age 19 years 6 months. form (Figs. 24.13A to G).
The improvement in facial balance and the profile are
A B
C D E
F G
Figs. 24.13A to G: Facial appearance and occlusion at age 19 years 6 months, six years after completion of treatment.
ARCH DEVELOPMENT BEFORE treatment should aim to expand the upper arch to accom-
MANDIBULAR ADVANCEMENT modate the permanent canines when they erupt and pro-
vide space to align the upper anterior teeth. There is also
This boy presents a Class I malocclusion with narrowing mild crowding in the lower arch which can be controlled
of the upper arch and labial displacement and irregularity with a lower lingual appliance to maintain space as the
of the upper incisors. Upper arch width is reduced and remaining permanent teeth erupt (Figs. 24.14A to G).
A B
C D E
F G
Figs. 24.14A to G: Facial appearance, occlusion and arch form before treatment at age 11.
Maxillary expansion with a TransForce appliance activity in the mid palatal suture coincident with slow
effectively changes the vault of the palate from V-shaped expansion using gentle continuous forces. This concept
to a wider contour. Palatal X-rays show evidence of merits further investigation (Figs. 24.15A to H).
A B C
D E F
G H
Figs 24.15A to H: (A to C) Correction of arch form after 3 months treatment with the Transverse TransForce appliance; (D and F) There
is evidence of change in the mid palatal suture, which is more clearly defined after 3 months treatment; (E) Lower arch form is corrected
with a Wilson lower lingual arch and a lower fixed appliance; (G and H) The anterior view before treatment and after 6 months.
After one year’s treatment the upper canines are second molars erupt during this phase and an open bite
erupting and a distal occlusion has developed with an is present on removing the blocks, with contact only on
increased overjet. Customized Fixed Twin Blocks are the second molars. Vertical elastics are applied to close
worn for 4 months to correct the distal occlusion. The the posterior open bite (Figs. 24.16A to I).
A B C
D E F
G H I
Figs. 24.16A to I: (A to C) The upper arch is expanded before advancing the mandible to correct the distal occlusion; (D to F) Prototype
customized fixed occlusal blocks are attached to molar bands; (G to I) The occlusion four months later on removal of the blocks. Second
molars have erupted, causing an open bite.
The occlusion has settled at the next visit into a Class I

buccal segment relationship. Treatment continues with
fixed appliances to detail the occlusion (Figs. 24.17A to G).
A B
C D E
F G
Figs. 24.17A to G: The profile has improved and the occlusion is settling. Arch form is now consolidated.
This is followed by an Occlus-o-Guide for night retainer by posturing the mandible forward to an edge-
time retention. The Occlus-o-Guide acts as a functional to-edge incisor relationship (Figs. 24.18A to G).
A B
C D E
F G
Figs. 24.18A to G: (A and B) Facial appearance after treatment and out of retention; (C to E) The occlusion after treatment and the
Occlus-o-Guide retainer used in this case.
Final records show a slight relapse of the upper in the lower arch before fixed retention was introduced.
incisor irregularity, perhaps because the retention was There are pros and cons for fixed retainers and the
inadequate. This is referred to as ghosting when the long term effects have still to be confirmed, especially
original irregularity returns to a lesser degree than the with regard to oral hygiene and periodontal condition
original condition. This was relatively common, especially (Figs. 24.19A to G).
A B
C D E
F G
Figs. 24.19A to G: The final occlusion and arch form out of retention is stable. Arch development in the first phase of treatment completely
changed the shape of the palate. Slow continuous expansion with light force is worthy of more research.
CONCURRENT ARCH DEVELOPMENT AND

with support from Rocky Mountain Orthodontics. Upper
FIXED TWIN BLOCKS transverse and lower sagittal arch development was
This is an early example of arch development com- followed two months later with prototype Fixed Twin
bined with mandibular advancement. Treatment of a Block appliances attached to the lingual appliances. It
severe Class II division 1 malocclusion with an overjet was necessary to demonstrate the effectiveness of this
of 12 mm and anterior open bite began at age 15 years. approach before any company would agree to manufac-
Lingual appliances for arch development were designed ture Fixed Twin Blocks (Figs. 24.20A to F).
A B
C D
E F
Figs. 24.20A to F: (A and B) Facial appearance before treatment and in mid treatment; (C to F) Customized Fixed Twin Blocks are
attached to an upper transverse expander and lower sagittal appliance.
After 5 months of mandibular advancement combined continue with light intermaxillary traction for six months
with arch development Fixed Twin Blocks were removed. to reinforce the Class II correction. Finally the fixed appli-
An upper fixed appliance was fitted with Synergy low fric- ances remain in place for 6 months to stabilize the posi-
tion brackets (Courtesy: RMO). At this stage the arch form tion before debonding and fitting removable retainers
has improved, the distal occlusion is corrected and the (Figs. 24.21A to G).
overjet is reduced from 12 mm to 2 mm. Fixed appliances
A B C
D E
F G
Figs. 24.21A to G: The occlusion and arch form is corrected after 5 months with a combination of arch development and mandibular
advancement.
Treatment was completed in 2 years followed by reten- to accommodate the third molars. Interdental stripping
tion. Lower third molars were potentially impacted and all of the lower anterior teeth was carried out to improve
second molars were extracted on completion of treatment stability of the lower labial segment (Figs. 24.22A to G).
A B
C D E
F G
Figs. 24.22A to G: Facial and dental views after treatment. Removable retainers were fitted.
The patient returned at age 25 years as a return of a lower incisor. A Wilson lower lingual arch was fitted and
lower labial crowding resulted in lingual displacement of activated to align the lower incisors (Figs. 24.23A to H).
A B C
D E F
G H
Figs. 24.23A to H: (A to F) The facial appearance and occlusion seven years out of retention is good; (G and H) Mild lower labial crowding
is corrected with a Wilson lower lingual arch.
This was followed by a fixed lower lingual retainer. The retention with a good esthetic and functional occlusion
long term benefits of treatment combining orthodontic (Figs. 24.24A to G).
and orthopedic therapy are confirmed 8 years out of
A B
C D E
F G
Figs. 24.24A to G: This was followed by a fixed lower lingual retainer. The long term benefits of treatment combining orthodontic and
orthopedic therapy are confirmed 8 years out of retention with a good esthetic and functional occlusion.
INTEGRATED FIXED AND

fitted first, followed by an upper fixed appliance at the
FUNCTIONAL THERAPY next visit. The__°/
5 is rotated and this must be corrected
A 12-year-old girl presents an uncrowded Class II division 1 before fitting Fixed Twin Blocks in order to achieve
malocclusion with 5 mm convexity and a favorable correct inter-digitation of the occlusion on the right side
growth pattern. A TransForce transverse expander is (Figs. 24.25A to H).
A B C
D E F
G H
Figs. 24.25A to H: Facial appearance, occlusion and arch form before treatment. The rotated premolar must be corrected before fitting
Fixed Twin Blocks.
Arch development and initial alignment are completed mandible is advanced, and is an aid to diagnosis. Fixed
after 6 months. At this stage photographs are taken to Twin Blocks are now bonded to the teeth to guide the
record the change in the profile when the mandible is mandible forward to an edge-to-edge incisor relationship
postured forward with the lips closed lightly together. (Figs. 24.26A to P).
This shows the predicted change in the profile when the
A B
C D E
F G H
Mandible retruded Mandible postured forward Twin Block fitted
I J K
L M N
O P
Figs. 24.26A to P: (A and B) Transverse arch development is combined with an upper fixed appliance to correct the rotated premolar;
(C to H) The distal occlusion is corrected when Fixed Twin Blocks are fitted, bringing the incisors to an edge to edge occlusion; (I to K)
Clinical photographs are taken to predict the profile change an after insertion of Twin Blocks; (L to N) A lower fixed appliance is fitted to
intrude lower incisors and level the lower arch; (O and P) Occlusal view of customized prototype Fixed Twin Blocks.
When the Fixed Twin Blocks are removed after six resolves and a Class I occlusion is established at the next
months the distal occlusion is corrected and there is visit, with a favorable improvement in the profile and
a slight open bite in the premolar region. This quickly facial appearance (Figs. 24.27A to H).
A B
C D E
F G H
Figs. 24.27A to H: Appearance on removal of Fixed Twin Blocks showing settling of the occlusion.
Treatment is completed in 18 months followed by night cases it acts as a functional retainer after mandibular
time retention with an Occlus-o-Guide appliance. This is advancement (Figs. 24.28A to G).
a preformed positioner in a range of sizes. In suitable
A B
C D E
F G
Figs. 24.28A to G: The finished result.
Final records show the facial appearance and a Twin Blocks proved to be an efficient method of correcting
stable occlusion three years out of retention at age 17. this Class II division 1 malocclusion (Figs. 24.29A to H).
Combining fixed and functional therapy with Fixed
A B C
D E F
G H
Figs. 24.29A to H: Post treatment stability after combined fixed/functional therapy.
MANAGEMENT OF SEVERE CLASS II

and a severe vertical growth pattern with convexity of
DIVISION 1 MALOCCLUSION 15 mm are associated with a facial axis angle of 16° and
Initial and final dental photographs are not available for mandibular plane angle of 34º. Fixed appliances are used
this patient who presented a severe Class II division 1 first to level and align the arches using counterforce nickel
malocclusion with an 11 mm overjet and anterior open titanium arch wires. Arch form was corrected before the
bite due to lip trap and tongue thrust. Mandibular retrusion Twin Block phase (Figs. 24.30A to G).
A B
Before treatment: Cranial base angle 28°: Facial axis 16°: Mandibular plane 34° convexity 15 mm.
C D E
F G
Figs. 24.30A to G: (A and B) The profile shows extreme mandibular retrusion before treatment; (C to G) This shows the occlusion and
arch form after the first stage of treatment with fixed appliances to level and align the arches.
After 18 months treatment Fixed Twin Blocks were in place for 14 months. When the blocks were removed
fitted to advance the mandible. In view of the severity a super Class I occlusion was achieved in the buccal
of the mandibular retrusion Fixed Twin Blocks remained segments (Figs. 24.31A to G).
A B C
D E
F G
Figs. 24.31A to G: (A to E) Prototype Fixed Twin Blocks were integrated with fixed appliances. (F and G) Arch form is consolidated after
removal of the occlusal blocks.
Treatment continued with fixed appliances for spite of efforts to contact her it was not possible to
3 months after removal of the Fixed Twin Blocks and obtain final records. The response observed during
was nearing completion with a settled Class I occlusion treatment combining fixed appliances and Fixed Twin
and improvement in the profile and facial appearance. Blocks was encouraging in this complex malocclusion
Unfortunately, the patient emigrated to Brazil and in (Figs. 24.32A to J).
A B C D
E F G
H I J
Figs. 24.32A to J: The facial and profile changes in this severe malocclusion from age 12 to 15 were encouraging. The occlusion was
edge to edge on the incisors when the blocks were removed and fixed appliances were continuing before the patient emigrated and contact
was lost. This was an extremely difficult malocclusion which responded well to combined orthodontic and orthopedic treatment.
Fixed Twin Blocks in Mixed Dentition due to lip pressure. The skeletal pattern is mandibular
retrusion and as a result the profile improves when the
This 9 years old boy presents a Class II division 1 mandible is advanced. Early treatment was indicated
malocclusion with an overjet of 12 mm and a slight as the prominent incisors are vulnerable to breakage
anterior open bite. The lower lip is trapped lingual to and he was being teased about his prominent teeth
the upper incisors, and the lower incisors are crowded (Figs. 24.33A to I).
A B C
D E F
G H I
Figs. 24.33A to I: (A to F) There is a clear indication in this 9-year-old boy for early treatment when the upper incisors are exposed
outside the lips and are vulnerable to injury; (G to I) Arch development is an important aspect od treatment in early mixed dentition to
resolve labial segment crowding. Transverse arch development appliances are fitted first to improve arch form, before occlusal blocks are
added to advance the mandible.
A short period of arch development was required stage and a removable appliance was fitted to retain
to expand the upper and lower arches and improve the the position and reduce the overjet. Mixed dentition is
alignment of the lower incisors. Fixed Twin Blocks were not ideal for using Fixed Twin Blocks as the occlusion
then fitted to advance the mandible and correct the molar of the flat deciduous teeth offers no retention by cuspal
relationship. The overjet was not fully corrected at this interdigitation (Figs. 24.34A to H).
A B
C D E
F G H
Figs. 24.34A to H: At age 9 years 9 months Fixed Twin Blocks were fitted for six months.This improved the facial appearance and the
profile, but did not establish a stable buccal segment occlusion at this transitional stage of dental development. An upper removable
appliance was fitted as a retainer.
A second phase of treatment is often required after the Fixed appliances with Delta Force brackets and
transition to permanent dentition. The distal occlusion Class II mechanics were used to complete treatment after
and overjet were not fully corrected in the mixed dentition eruption of the permanent teeth (Figs 24.35A to H).
phase.
A B
C D E
F G H
Figs. 24.35A to H: (A to E) A removable upper retainer was successful in retaining the position until the transition to permanent dentition.
(F to H) Fixed appliances were fitted to detail the occlusion and complete treatment.
A Wilson lower lingual arch was added to increase were applied during the fixed appliance phase to reinforce
anchorage in the lower arch. Light inter-maxillary elastics the correction of the distal occlusion (Figs. 24.36A to G).
A B
C D E
F G
Figs. 24.36A to G: (A to E) The patient’s facial appearance and profile are improving and arch form is consolidated as we move into the
finishing stages (F and G).
Retention was by an upper Essix retainer and a Wilson slight recurrence of lower incisor crowding, which may
lower lingual arch. The main objectives of treatment were have been prevented by early extraction of second molars
achieved in improving facial balance but there was a to accommodate the third molars (Figs. 24.37A to H).
A B C
D E F
G H
Figs. 24.37A to H: Treatment is completed at 12 years 9 months, having retained the position during the transition from mixed to permanent
dentition. There is slight residual crowding in the lower labial segment that will have to be addressed in a later stage of treatment. This is
a valid alternative in case management after early correction of a Class II division 1 malocclusion.
Two Phase Treatment and The lower lip is trapped lingual to the upper incisors.
Extraction Therapy The lower center line is displaced to the left due to
early loss of the left deciduous canine. The skeletal discre-
A 9-year-old girl presents a Class II division 1 malocclu- pancy is due to mandibular retrusion and as a result
sion with an overjet of 8 mms and a slight anterior open the profile improves when the mandible is advanced
bite. There is no history of thumb or finger sucking. (Figs. 24.38A to H).
A B C
D E F
G H
Figs. 24.38A to H: Pretreatment records. An upper transverse expander is fitted first to expand the maxilla.
An upper Transverse expansion appliance was fitted with wire extensions to control arch form. The facial
first for maxillary expansion before advancing the man- appearance and profile improved during the Twin Block
dible. Fixed Twin Blocks were attached to molar bands phase (Figs. 24.39A to H).
A B C
D E
F G H
Figs. 24.39A to H: Facial appearance and occlusion after Fixed Twin Block therapy justifies early intervention.
After 5 months Fixed Twin Blocks were removed and upper canines to move distally and they erupted into
replaced with an upper retainer. Upper canines were the arch. At this stage, lower third molars were not yet
crowded mesially and buccally and first premolars were confirmed present and a decision on extractions in the
extracted to accommodate the canines. This enabled the lower arch was deferred meantime (Figs. 24.40A to G).
A B C
E F G
Figs. 24.40A to G: Facial appearance and profile are improving. It is too early to confirm the presence of third molars but upper first
premolars are extracted to accommodate the buccally displaced canines.
A Wilson lower lingual arch was fitted next with an radiographs were taken to confirm the presence and
upper fixed appliance (Figs. 24.41A to G). A decision on position of lower third molars.
extractions in the lower arch was deferred until further
A B C
D E
F G
Figs. 24.41A to G: An upper fixed appliance is fitted and space is maintained in the lower arch until the position is reviewed regarding
extractions to relieve crowding in the lower arch.
Lower second premolars were extracted to balance over corrected when the fixed appliances were removed
the loss of upper premolars. Power chain was used to (Figs. 24.42A to H).
close extraction spaces. The overjet and overbite were
A B C
D E
F G H
Figs. 24.42A to H: (A to E) Lower second premolars have been extracted and fixed appliances with Delta Force brackets are used to
close spaces and retract the anterior teeth; (F to H) The occlusion is slightly overcorrected when brackets are removed.
The post treatment occlusion is stable as retention been achieved and this supports the decision to extract
continues with removable retainers. Two phase therapy premolars. The patient’s mother reports that everyone
to combine functional and fixed phases of treatment melts when she smiles. That is one of the lasting benefits
has resulted in a straight profile. Facial balance has of orthodontic treatment (Figs. 24.43A to H).
A B C
D E F
G H
Figs. 24.43A to H: Facial balance is achieved after early functional therapy in mixed dentition followed by extraction of four premolars and
fixed appliances to detail the occlusion.
CONSTRUCTION BITE AND INDIRECT

BONDING TECHNIQUE Prior to fitting, the blocks were first prepped with
a plastic conditioner to allow the bonding material to
A registration bite is taken using the Projet bite gauge
adhere to the blocks by chemical union. The blocks were
with the mandible postured forward. The earlier designs
fitted using an etch or non-etch technique. An etch tech-
required an indirect technique for accurate transfer of the
nique requires an additional step of applying a sealant.
blocks from the models to the mouth in pressure molded
delivery trays. However a non-etch technique is preferred, especially
The appliance was customized in the laboratory and when using light cure materials for easy removal of the
delivered ready to fit in the mouth in order to simplify the blocks after treatment.
chair side technique. The subtleties of placement can be The non-etch technique uses a drying agent (Reliance
handled in the laboratory environment, leading to better- Assure), which is painted on the teeth twice, then blown
positioned blocks and significantly reduced chair time to dry before applying the blocks. This is to ensure that the
seat the blocks. blocks are bonded to a clean, dry tooth surface. Either a
The blocks were placed on the models using a sticky light cure or chemical cure composite was selected for
plastic adhesive in a trial set up to bring the molars to a the bonding process.
Class I or super-Class I relationship. In an indirect techni- In indirect technique the lower block is fitted first
que the occlusion and fit of the blocks can be checked on to establish the position of the inclined planes over the
models and minor adjustments can be made as required. second premolars. Finger pressure is applied, and excess
For vertical control of deep overbite the upper blocks fixative is removed with cotton buds, allowing a small
may be trimmed to allow eruption of lower molars, as amount to flow in the interdental areas between the teeth
described in the removable technique. The distal exten- on the buccal aspect for additional retention and secure
sion on lower molars is removed and trimmed clear of fixation. The upper blocks are then fitted to occlude with
second molars to allow the molars to erupt. the lower blocks (Figs. 24.44A to E).
A B C
D E
Figs. 24.44A to E: (A to C) An early example of preformed blocks bonded to the teeth with composite to advance the mandible and correct
a Class II division 1 malocclusion; (D and E) Fixed Twin Blocks and fixed appliance.
LABORATORY PREPARATION OF over the blocks and trimmed so that they can be easily
TRANSFER POSITIONING TRAYS removed after fitting the blocks. The tray is kept clear of
the upper anterior teeth to allow for fitting brackets. In
The blocks are first placed on models using a sticky plastic this case, the lower incisors are well aligned and the tray
adhesive, for example UHU tac. Check the occlusion is designed to cap the lower incisors. If lower brackets are
and adjust the blocks to fit and to correct the molars to to be fitted the tray would be kept lingual to the incisors
Class I occlusion. Essix type positioning trays are formed (Figs. 24.45A to G).
A B
C D E
F G
Figs. 24.45A to G: (A and B) Fit the blocks on the model; (C to E) Design and apply a pressure moulded positioning tray that is removable
after fitting; (F and G) The tray is kept clear of anterior teeth to allow brackets to be fitted.
INDIRECT TECHNIQUE FOR BONDING

with an overjet of 8 mm and a full unit distal occlusion.
FIXED TWIN BLOCKS A convexity of 8 mm is due to mandibular retrusion.
This 13-year-old boy presents an uncrowded Class II The first step in treatment is to fit Fixed Twin Blocks to
division 1 malocclusion in early permanent dentition advance the mandible (Figs. 24.46A to H).
A B
C D E
F G H
Figs. 24.46A to H: Occlusion, arch form and cephalometric tracing before treatment: Cranial Base Angle 29°: Facial Axis 31°: Mandibular
Plane 17° Convexity 8 mm.
There is an immediate improvement in facial appear- reduced chair time to seat the blocks. The indirect tech-
ance when the blocks are fitted. The subtleties of place- nique eliminates errors in fitting Fixed Twin Blocks.
ment can be handled in the laboratory environment, The process is similar to indirect bonding of brackets
leading to better-positioned blocks and significantly (Figs. 24.47A to H).
Before treatment With fixed Twin Blocks
A B
C D E
F G H
Figs. 24.47A to H: (A and B) There is a dramatic improvement in the facial profile immediately when the blocks are fitted; (C to H) The
position of the blocks on models is replicated in the mouth by the indirect technique.
Fixed Twin Blocks were in place for 5 months. The arches are leveled first with fixed appliances. It is planned
photographs show the occlusion and facial appearance to fit fixed appliances one week later, by which time the
on the day the blocks were removed. At this stage, there open bite is beginning to close (Figs. 24.48A to I).
is a slight posterior open bite. This can be avoided if the
Before Treatment Fixed Twin Blocks Fitted Fixed Twin Blocks Removed
A B C
D E F
G H I
Figs. 24.48A to I: (A to C) The profile has improved as predicted when the blocks were fitted; (D to F) Brackets are placed on the lower
premolars and elastic chain is attached to the buccal button for additional fixation; (G to I) This is the occlusion after 5 months on the
day the blocks were removed.
A Class I buccal segment occlusion is well established wires. Treatment is continuing with fixed appliances to
at the first visit for adjustment after fitting initial arch detail the occlusion (Figs. 24.49A to H).
A B C
D E
F G H
Figs. 24.49A to H: (A to E) One week later fixed appliances were fitted; (F to H) The buccal segment occlusion settles in to Class I
relationship.
Counterforce Nitinol arch wires are used to reduce approaching the finishing stage to detail the occlusion
the overbite at this stage. After one year’s treatment the (Figs. 24.50A to H).
objectives of treatment have been achieved and we are
A B C
D E F
G H
Figs. 24.50A to H: After one year’s treatment the improvement in the profile is established and counterforce arch wires are used to correct
deep overbite.
The appearance on debond shows an improved Treatment was completed in 15 months followed by
profile and the corrected occlusion with good arch form. retention (Figs. 24.51A to H).
A B C
D E F
G H
Figs. 24.51A to H: Integration of functional orthopedics and orthodontics achieves improved facial balance and detailed finishing of the
occlusion.
FIXED TWIN BLOCKS IN CLASS II

related to retroclined upper and lower incisors and deep
DIVISION 2 MALOCCLUSION overbite. The first stage of treatment with fixed appliances
This 11-year-old girl has a typical Class II division 2 maloc- aims to correct a rotated upper premolar and improve
clusion with a brachyfacial skeletal pattern. There is a full the upper arch form before correcting the distal occlusion
unit distal occlusion and Class I skeletal base relationship (Figs. 24.52A to H).
A B
C D E
F G H
Figs. 24.52A to H: Before treatment the facial appearance, occlusion and cephalometric tracing are typical of a Class II division 2
malocclusion with a straight profile and a Class I skeletal base relationship. Cranial Base Angle 26°: Facial Axis 31°: Mandibular Plane
20° Convexity 1 mm.
Carriere Self-Ligating Brackets level and align the on the rotated premolar. It is difficult to insert the arch
arches in the first phase. A conventional twin bracket is wire in Self-Ligating Brackets on severely rotated teeth.
fitted on the rotated premolar with power chain passing The rotated premolar is aligned before proceeding to
from the canine and first premolar to the mesial tyewing correct the distal occlusion (Figs. 24.53A to H).
A B C
D E
F G H
Figs. 24.53A to H: Fixed appliances are fitted to correct arch form and align the rotated premolar. After 14 months the distal occlusion is
still present before fitting Fixed Twin Blocks.
The profile improved when Fixed Twin Blocks after 3 months. Vertical box elastics closed the slight
were fitted. The blocks were bonded to the teeth with open bite in the premolar region within a week as the
composite, causing the mandible to posture forward on occlusion settled in a Class I relationship (Figs. 24.54A
inclined planes. The Fixed Twin Blocks were removed to H).
A B C
D E
F G H
Figs. 24.54A to H: (A to H) Only dental correction was required in this case and 3 months with fixed Twin Blocks was sufficient to correct
the occlusion to class I; (F and G) Show the occlusion on the day the blocks were removed.
In view of the Class I skeletal relationship only ortho- in place for only 3 months. Treatment was completed
dontic correction of the distal occlusion was required in in 2 years. This was followed by removable retainers
this case and for this reason the Fixed Twin Blocks were (Figs. 24.55A to G).
A B
C D E
F G
Figs. 24.55A to G: The objectives of facial balance and harmony and detailed finishing are achieved by combining the benefits of fixed
and functional therapy.
POSITIONING TRAYS FOR CLASS II on the models using a sticky plastic material. Check
DIVISION 2 MALOCCLUSION the occlusion and make any adjustment required to
the blocks by trimming if necessary to improve the fit
This is to illustrate the steps in construction of positioning on the models or the occlusion of the inclined planes
trays for Fixed Twin Blocks. The blocks are first positioned (Figs. 24.56A to H).
A B C
D E
F G H
Figs. 24.56A to H: In Class II division 2 malocclusion a construction bite is taken with the incisors edge to edge and the models are
mounted in the construction bite before fitting the occlusal blocks on the models.
Positioning trays may cover the lower anterior teeth. not cover the irregular anterior teeth, crossing the palate
The trays may be worn at night to improve anchorage and lingual to the upper incisors (Figs. 24.57A and B).
fixation in the lower arch. In the upper arch the trays do
A B
Figs. 24.57A and B: Essix positioning trays are constructed over the preformed occlusal blocks. They must be easily removed after fitting
the blocks.
FIXED TWIN BLOCKS IN SEVERE and the underlying skeletal pattern is severe dolichofacial
DOLICHOFACIAL PATTERN (Figs. 24.58A to H).
Constricted upper arch form is evident in the facial
This young girl presents a Class II division 1 malocclusion appearance. This severe malocclusion needs careful
with severe maxillary contraction, resulting in anterior management with a combination of arch development,
crowding. Upper lateral incisors are severely rotated. An functional mandibular retrusion and detailed finishing
anterior open bite tendency is related to tongue thrust with fixed appliances.
A B
C D E
F G H
Figs. 24.58A to H: Before treatment: (A and B) A long narrow face is related to maxillary contraction and the profile shows mandibular
retrusion; (C to H) A severe dental malocclusion and constricted arch form are related to a dolichofacial pattern in the cephalometric tracing
before treatment. Cranial Base Angle 27°: Facial Axis 22°: Mandibular Plane 30° Convexity 6 mm.
Maxillary expansion is an essential factor in treat- Maxillary arch development with the TransForce
ment and an upper TransForce Transverse expansion Transverse expander is crucial in the successful treatment
appliance is fitted first, followed by an upper fixed of this severe malocclusion. The anterior compression
appliance. Arch development creates space to align the module of the TransForce expander is a very effective
anterior teeth in combination with the fixed appliance. mechanism. From fully closed to fully open the appliance
Favorable effects on the facial contours by maxillary expands the inter-canine width by 8 mm in creating space
arch development are evident after 8 months treatment to correct labial segment crowding. The inter-molar width
(Figs. 24.59A to H). is also increased by 8 mm without tipping of the molars.
A B
C D E
F G H
Figs. 24.59A to H: (A and B) Maxillary expansion significantly improves the facial appearance after 8 months treatment; (C to E) Delta
Force brackets are the most effective available for controlled correction of severe rotations; (F to H) The shape of the palate changes as
space is made to accommodate the anterior crowding. For further information on Delta Force brackets and TransForce appliances contact
www.orthoorganizers.com.
Significant problems remain of a severe anterior to buccal buttons on the blocks for additional bucco-
open bite and full unit distal occlusion. At this stage lingual stability. The addition of vertical box elastics worn
mandibular advancement is required to correct the distal at night is an important factor in closing the anterior open
occlusion and improve the profile. Fixed Twin Blocks are bite by applying intrusive forces to the posterior teeth
bonded directly to the teeth and power chain is extended (Figs. 24.60A to I).
A B C
D E F
G H I
Figs. 24.60A to I: (A to C) The occlusion after arch development with anterior open bite and distal occlusion; (D to I) Fixed Twin Blocks
are fitted and chain elastic is attached to buccal buttons. Excess composite flows into interdental undercuts for additional buccal fixation.
The Fixed Twin Blocks were removed after 6 required to detail the occlusion with fixed appliances
months, when the distal occlusion is corrected and the (Figs. 24.61A to G).
profile has improved significantly. Further treatment is
A B
C D E
F G
Figs. 24.61A to G: (A and B) The profile improves after 6 months with fixed Twin Blocks; (C to G) The occlusion and arch form on the
day the fixed Twin Blocks are removed.
Profile photographs show the progress at this stage. Fixed appliance treatment is continuing in this case as
In the middle photograph the mandible is postured a rotation wedge improves the rotated incisor. At this
forward to anticipate the expected change in the profile stage the patient moved from Portugal to England. No
after treatment. This is a preview of the expected result. completed records are available (Figs. 24.62A to J).
Before treatment Mandible postured forward After Twin Blocks
A B C
D E F
G H
I J
Figs. 24.62A to J: (A) The profile with the mandible retruded before fitting Twin Blocks; (B) The patient has postured forward with the
lips closed. this is an accurate prediction of the end result; (C) The improvement is evident 6 months later after removal of Twin Blocks;
(D to F) The occlusion is corrected to Class I; (G to J) The shape of the palate is completely remodeled compared to before treatment.
Crowding is resolved in both labial segments with an excellent response to arch development.
TRANSFORCE FIXED TWIN BLOCKS

A new concept in the evolution of Fixed Twin Blocks pre-
sents the possibility to combine transverse arch develop-
ment simultaneously with mandibular advancement. The
original removable Twin Block typically incorporated a
midline screw to expand the maxilla and at the same time
advance the mandible. The Transverse Fixed Twin Block
combines the benefits of the TransForce appliance for
arch development and the Fixed Twin Block to advance
the mandible. When expansion is not required in the
lower arch the lower blocks may be attached to a pas-
sive lower lingual arch.
Construction is by an indirect technique, whereby the
TransForce appliance is fitted on the models first before
adding the blocks. Triad temporary crown material is
used to fill the blocks and adapt them to the model over
the TransForce appliance. This material is suitable for use
intra-orally and it forms a chemical bond with the blocks.
It also adheres to the occlusal wire on the TransForce
appliance and to the molar band. This produces a secure
appliance that can be fitted in the mouth with a luting
cement.
An indirect technique simplifies the fitting process
by preparing an Essix type positioning tray to deliver the
appliance in the mouth. This is an accurate positioning
mechanism to ensure that the blocks are placed correctly
in the mouth in accordance with the construction bite.
Brackets may be added to align the anterior teeth as Fig. 24.63: Preformed occlusal blocks are attached to TransForce
required (Fig. 24.63). appliances.
FIXED TWIN BLOCKS AND SAGITTAL

distal occlusion, and buccally displaced upper canines.
ARCH DEVELOPMENT Separators are placed before fitting an upper TransForce
This 12-year-old girl presents a Class II division 1 appliance for sagittal arch development as the first step
malocclusion with retroclined upper incisors, a full unit in treatment (Figs. 24.64A to G).
A B
C D E
F G
Figs. 24.64A to G: Facial appearance, occlusion and arch form before treatment.
Sagittal arch development advances the retroclined In this case, there is more crowding on the patient's
incisors to accommodate the upper canines. At this left side and the canine has erupted buccally. This is
stage in treatment the overjet increases as the arch form resolved as the appliance extends to equalize the space
improves. The sagittal appliance achieves rapid correc- on both sides between the molars and the incisors. This
tion of arch form by advancing the upper incisors. The feature enables the sagittal appliance to work bilaterally or
sagittal appliance is compressed when it is fitted and unilaterally depending on the degree of crowding on each
expands until fully extended as the enclosed nickel tita- side of the arch. For that reason the sagittal appliance is
nium springs exert light continuous forces. excellent for correction dental asymmetry in either arch
(Figs. 24.65A to H).
A B C
D E
F G H
Figs. 24.65A to H: The sagittal appliance achieves rapid correction of arch form by advancing the upper incisors to accommodate the
buccally displaced upper canines.
COMBINING FIXED TWIN BLOCKS AND After 6 months the Fixed Twin Blocks were removed
FIXED APPLIANCES and the distal occlusion has been corrected. A slight
open bite in the buccal segments is quickly closed with
Fixed Twin Blocks are now used to advance the mandible vertical elastics as the teeth settle into a Class I occlusion.
in combination with fixed appliances to align the anterior Treatment continues with fixed appliances to detail the
segments. occlusion (Figs. 24.66A to I).
A B C
D E F
G H I
Figs. 24.66A to I: (A to C) Fixed Twin Blocks are fitted with Delta Force brackets to combine fixed and functional therapy; (D to I) Vertical
elastics are applied to settle the buccal segments into Class I occlusion on removal of the occlusal blocks.
Profile Change with Mandibular mandible postured forward before fitting the Fixed Twin
Advancement Blocks. The right profile shows the change on removal of
The profile photographs show the changes in the profile the Fixed Twin Blocks, when the occlusion was slightly
as a result of mandibular advancement. The left profile over corrected to an edge-to-edge incisor relationship
is after arch development. The middle profile is with the (Figs. 24.67A to H).
Before Fixed Twin Blocks Mandible postured forward After Twin Blocks
A B C
D E F
G H
Figs. 24.67A to H: Improved facial balance is combined with detailing of the occlusion and improved arch form.
Combining Fixed and Functional Therapy rely on patient compliance and can be integrated with
The occlusion is corrected to Class I by mandibular arch development and fixed appliances. This approach
advancement, as shown on the cephalometric images, combines the benefits of fixed and functional therapy for
which are superimposed on basion with Frankfurt plane orthodontic and orthopedic correction.
horizontal. Cephalometric records and facial photographs confirm
The response to treatment is similar to that observed that the changes are stable 2 years after completion of
with removable twin blocks. Fixed Twin Blocks do not treatment (Figs. 24.68A to G).
Before Treatment: Cranial base angle 26°: Facial axis 26°: Mandibular plane 25°: Convexity 7 mm.
A B C
D E F
G
Figs. 24.68A to G: Cephalometric films and tracings with profiles at age 11 years 9 months and 16 years, 2 years after completion of
treatment.
FIXED TWIN BLOCKS IN POST-

The overjet is 7 mm with a full unit distal occlusion and
PUBERTAL STAGE a narrow upper arch. Secondary crowding in the lower
This 18-year-old girl has a Class II malocclusion and a labial segment is due to maxillary contraction. It was
Class I skeletal relationship with a brachyfacial growth decided to correct the distal occlusion as the first step in
pattern in the post-pubertal stage of development. treatment (Figs. 24.69A to H).
A B
C D E
F G H
Figs. 24.69A to H: Facial appearance, occlusion and arch form before treatment. Cephalometric values are: Cranial base angle 29°: Facial
axis 32°: Mandibular plane 15°: Convexity 1 mm.
Fixed Twin Blocks were fitted as the first step in This is a preview of the end result and is similar to the
treatment. The profile photos show the profile before profile on the right when the Fixed Twin Blocks are fitted
treatment. The middle photograph is before treatment (Figs. 24.70A to H).
with the mandible postured forward with the lips closed.
Before treatment Mandible postured forward Twin Blocks fitted
A B C
D E F
G H
Figs. 24.70A to H: (A) Profile before treatment; (B) Profile before treatment with the mandible postured forward; (C) Profile on the day
Twin Blocks were fitted; (D to F) Occlusion on the day Twin Blocks were fitted; (G and H) Occlusal view of Fixed Twin Blocks.
In this case, the patient was already comfortable eating in an improved profile as the patient adapts to the new
and speaking within one week after fitting the Fixed Twin functional mechanism. Elastic chain is attached to the
Blocks and she elected to have the fixed appliances fitted. buccal button on the blocks for improved bucco-lingual
After two months treatment muscle adaptation results stability (Figs. 24.71A to G).
Before treatment 2 months later
A B
C D E
F G
Figs. 24.71A to G: (A and B) The improvement in the profile after 2 months treatment. There is good soft tissue adaptation within
2 months as treatment progresses; (C to G) Fixed Twin Blocks are combined with fixed appliances. .
Profile changes are reinforced as we pass through improvement in the alignment of the lower anterior teeth
treatment. Fixed Twin Blocks are removed after 8 months and progress is slow. Arch development is required to
treatment. Vertical box elastics are applied to close the relieve anterior crowding (Figs. 24.72A to I).
slight posterior open bite. At this stage there is little
Before treatment 2 months treatment 8 months treatment
A B C
D E F
G H I
Figs. 24.72A to I: (A to C) Improvement in the profile is confirmed after 8 months when Fixed Twin Blocks were removed; (D to I) Vertical
box elastics are applied on removal of Twin Blocks and the occlusion settles in class I buccal segment relationship.
TransForce appliances are fitted to expand the arch therapy has corrected the distal occlusion to a Class I
form and provide space to align the upper and lower relationship and treatment is continuing with fixed
anterior teeth. After 14 months treatment fixed/functional appliances to detail the occlusion (Figs. 24.73A to G).
A B
C D
E F G
Figs. 24.73A to G: (A to D) TransForce Lingual appliances were used to develop arch form and to align the anterior teeth; (E to G)
Occlusion and corrected arch form after 14 months of treatment.
The fixed appliance phase, including arch development slow until TransForce appliances were fitted to create
is extended over a period of 2 years. After removal of the space to align the teeth. Final records show the position
Fixed Twin Blocks treatment continued with Straight Wire on removal of the fixed appliances before fitting fixed
Technique, but correction of lower labial crowding was lingual retainers (Figs. 24.74A to H).
A B C
D E F
G H
Figs. 24.74A to H: After 2 years of treatment the mandibular retrusion is corrected and a class I occlusion is established with wide arch
form after removal of fixed appliances.
RETENTION A lower fixed retainer is bonded with lingual pads on

the lower canines. There is slight residual crowding of the
Retention is always important, and especially so in treat- lower incisors and lower premolar on the left side.
ment of lower labial crowding in adult dentition. In this This has still to be dealt with by interdental stripping
case, the patient has an upper removable retainer, which to relieve pressure at the contact points and to allow the
she wears every night. She is instructed to return imme- displaced lower premolar to settle lingually.
diately if it feels tight, which would be a sign of tooth Another option is a flexible invisible retainer which
movement. has the advantage of re-aligning the teeth by increasing
to full time wear if it becomes tight (Figs. 24.75A to F).
A B C
E F
Figs. 24.75A to F: (A to C) Facial appearance and profile have improved; (D to F) Retention is continuing with a removable upper and lower
fixed retainer. Interdental stripping is required in the lower arch in the buccal segments to allow the displaced lower premolar to settle lingually.
FURTHER READING For Further Information on

Chintakanon K, Turker KS, Sampson W, et al, (2000). A prospective Fixed Twin Blocks Please Visit
study of Twin-block appliance therapy assessed by magnetic Author’s website: www.twinblocks.com
resonance imaging, American Journal of Orthodontics and
Dentofacial Orthopedics. 118:494-504.
Fixed Twin Blocks Kits are available from:
Wadhawan N1, Kumar S, Kharbanda OP, et al. (2008). Temporo- Organización Ortho SA de CV
mandibular Joint adaptations following two phase therapy: a Contact: orthorg@prodigy.net.mx
MRI study, Journal of Orthodontics and Craniofacial Research,
11:235-50.
Fixed Functional Appliances 471
Chapter 25
Fixed Functional Appliances
FORM AND FUNCTION Herbst published very little on the appliance except
for a text published in 1910 and a series of articles in
The “form and function” philosophy was the basis for the
1934. Although achieving some initial popularity, there
work of Edward Angle (1907) and Pierre Robin (1902) in
are very few references to Herbst’s treatment technique
the development of fixed and functional therapy at the
in the orthodontic literature prior to its reintroduction by
beginning of the 20th century. Wolff ’s (1892) “Law of
Pancherz (1979, 1981), Pancherz and Anehus-Pancherz
Transformation of Bone” states: “The architecture of a
(1980).
bone is such that it can best resist the forces which are
In these early studies, Pancherz used a banded
brought to bear upon it with the use of as little tissue as
Herbst appliance made from heavy band material with
possible”. Thus, not only is the quantity of bone tissue the
bands on upper molars and premolars, connected by
minimum that would be needed for functional require-
a lingual wire. In the mandible, bands were placed on
ments, but also the structure is that which is best suited
lower first premolars and were connected by a lingual
for the forces exerted upon it. The internal architecture
arch. The appliance mechanism is a tube and plunger
of bone is modified to absorb efficiently the functional
assembly that operates on the same principle as a
stresses to which the bone is subjected. Thereafter fixed
piston to drive the mandible into a protrusive position.
and functional philosophies evolved separately, partly
More recent banded versions have been modified to
due to socioeconomic factors as fixed appliances were
incorporate more anchor units, extending to all first
more widely used in America, while during the war years
premolars and first molars with buccal and lingual
functional appliances were more suited to the prevailing
connecting wires. Further modification resulted in the
economic climate in Europe. Over the years, the “form
cast ticonium Herbst appliance (Weislander, 1984), and
and function” philosophy has been reviewed to take into
the bonded Herbst appliance (Howe, 1982); (Howe and
account current concepts of growth and development.
McNamara, 1983). Pancherz continued to study the long-
term effects of the Herbst appliance in its various forms
THE HERBST APPLIANCE and later the resulting growth modification in the condyle
Emil Herbst (1910) developed the Herbst appliance in and glenoid fossa using magnetic resonance imaging
the early 1900s. This device was one of the early attempts techniques. McNamara et al. (1990) compared the effects
to produce a mechanical “jumping of the bite”. Herbst of Herbst and Frankel therapy, and McNamara and
introduced the original banded design at the International Brudon (1993) gave an account of modifications to these
Dental Congress in Berlin in 1905. appliances.
The Original Herbst Appliance

This example of original Herbst appliances is shown The basic concepts of the Herbst technique have
(Courtesy: Dentalhistorisches Museum, Zschadrab, near not changed, although many variations have been tried
Leipzig in Germany). It is a remarkable example of inven- and tested since the technique was rediscovered and
tiveness, which was only possible because of the avail- investigated by Pancherz. The Herbst remains one of the
ability of advanced engineering techniques in Germany most popular fixed functional appliances of the present
in the early part of the 20th century. day (Figs. 25.1A to E).
A B
C D E
Figs. 25.1A to E: An early example of a suaged Herbst appliance, the result of excellent engineering technique.
The Jasper Jumper The Jasper Jumper was available in a kit with different
The Jasper Jumper was the next development in fixed sizes of spring with instructions on selecting the size by
functional appliances after the Herbst was reintroduced measuring the distance from the mesial of the molar
by Pancherz. A coil spring was enclosed in a plastic tube tube to the embrasure between the lower canine and first
and was attached to the upper molar band, extending to premolar. A pin was inserted to attach the spring to the
be attached to the lower arch wire distal to the canine. molar tube (Figs. 25.2A to D).
A B
C D
Figs. 25.2A to D: (A and B) The Jasper Jumper, Measuring to select the size; (C and D) Jasper Jumper kit and components.
Fitting the Jasper Jumper (Figs. 25.3A to D) 3. Cinch the distal end of the arch wire distal to the
second molar before attaching the Jumper to the
1. Slide the ball pin through the distal end of the Jumper and
molar tubes.
then through the molar headgear tube from the distal.
4. Make a bayonet bend in the arch wire distal to the
2. The ball pin wire can be bent up to secure it in
canines to act as a stop, then slide the lower ball stops
place. The mesial end has been annealed to facilitate
on to the arch wire.
bending.
A B
C D
Figs. 25.3A to D: (A to C) Assembling and fitting the Jasper Jumper; (D) The arch wire with offset bends in the molar and canine region.
EXAMPLES OF FIXED wires, extending from the upper molar to the lower canine
FUNCTIONAL APPLIANCES region. Of the appliances illustrated only the Herbst and
the Mara can claim to have an orthopedic effect. All of the
In recent years, a large number of fixed attachments others, by virtue of being attached to the lower arch wire,
have been developed to integrate functional mandibular produce mainly dentoalveolar changes by advancing the
advancement with fixed appliance therapy. The majority lower dentition. The activating mechanism is similar to
of these are spring driven devices that are attached to arch intermaxillary traction (Figs. 25.4A to I).
A B C
D E F
G H I
Figs. 25.4A to I: (A) Herbst Appliance; (B) Forsus Fatigue Resistant Device-EZ Module; (C) Bite Fixer; (D) Twin force bite corrector;
(E) Jasper Jumper; (F) Sabbagh Universal Spring; (G) MARA; (H) Eureka Spring; (I) Flex Developer.
This girl presents a Class II division I malocclusion with archform. This increased the overjet and was followed by
a half unit distal occlusion in the buccal segments and fixed appliances. A Jasper Jumper was added to advance
retroclined upper and lower incisors. This is responsible the mandible, correct the distal occlusion and reduce
for crowding in the lower arch. The first stage in the the overjet. Maximum anchorage is required in the lower
treatment was arch development using lingual appliances arch at this stage. Final records are not available in this
to advance the upper and lower incisors and correct the case (Figs. 25.5A to O).
A B
C D E
F G
H I J
K L M
N O
Figs. 25.5A to O: (A) Non-extraction therapy is indicated to support the lips and improve the facial appearance and profile; (C to G)
Lingual arch development is the first stage in treatment to improve arch form; (H to J) This is followed by fixed appliances with a lower
utility arch to reduce overbite and level and align; (K to O) Final a Jasper Jumper is added to correct the distal occlusion. A lower lingual
arch helps is retained to reinforce anchorage.
Twin Force Bite Corrector The locking mechanism is a sophisticated design with a
The Twin Force Bite Corrector is a more recent version universal joint, permitting the patient to move in lateral
of a spring driven appliance to advance the mandible. It excursion, while at the same time maintaining the man-
consists of twin compression tubes with enclosed nickel dible in an advanced position. The Bite Corrector has the
titanium coil springs attached by a double lock to the additional advantage that it can be reversed and used for
arch wire mesial to the molar and distal to the canine. Class III correction (Figs. 25.6A to E).
A B C
D E
Figs. 25.6A to E: The Twin Force Bite corrector has a double spring action with a locking mechanism to attach to the arch wire.
Class II Correction Class III Correction

See Figures 25.7A and B. See Figures 25.8A and B.
A A
B B
Figs. 25.7A and B: The spring action may be reversed for (A) Class Figs. 25.8A and B: The spring action may be reversed for (A) Class
II or Class III correction; (B) The appliance is assembled in the mouth II or Class III correction; (B) The appliance is assembled in the mouth
and attached to the arch wires for Class II correction. and attached to the arch wires for Class II correction
Arch Development and crossbite of the deciduous teeth on the left side. There is
Twin Force Bite Corrector also a tendency to bilateral crossbite. Appliance treatment
is indicated at this stage to control thumb- sucking and
This presents a severe Class II division I malocclusion correct the crossbite in order to normalize arch develop-
with characteristic prominence of the upper incisors ment. Light continuous force is applied by a transverse
which is associated with a thumb-sucking habit. This has expander developed with support from Rocky Mountain
resulted in narrowing of the maxilla, causing a lateral Orthodontics (Figs. 25.9A to G).
A B
C D E
F G
Figs. 25.9A to G: Lingual arch development is the first stage in treatment. The appliance prevents thumbsucking and is effective in
expanding the maxilla.
The maxillary expansion appliance effectively controls align the arches before advancing the mandible to correct
the thumb-sucking habit and expands the intercanine the half unit distal occlusion. The skeletal pattern is Class I
width by 10 mm. After the archform is corrected, a second and the distal occlusion and overjet are not severe.
stage of treatment is required to reduce the protrusion Only dental correction is required and the Twin Force
of the upper incisors and the buccal segment occlusion. Bite Corrector is selected to advance the mandible
Upper and lower fixed appliances are fitted to level and (Figs. 25.9H to P).
H I J
K L M
N O P
Figs. 25.9H to P: (H to J) Fixed appliances level and align the arches; (K to M) A Twin Force Bite Corrector is fitted to correct the distal
occlusion; (N to P) The mandible is guided forward to an edge to edge occlusion.
The occlusion is edge-to-edge on the incisors when canines are then retracted followed by the lower incisors
the Twin Force Bite Corrector is removed after 3 months. as the buccal segments settle in Class I occlusion. This
The lower anterior teeth have been proclined and position is retained before removing the fixed appliances
spaces are present distal to the lower canines. The lower (Figs. 25.9Q to Y).
Q R S
T U V
W X Y
Figs. 25.9Q to Y: Inevitably spring loaded appliances advance the lower incisors. Residual space distal to the canines is closed, first
retracting the canines, followed by lingual movement of the incisors.
At age 15 years, there is a settled occlusion with and the Twin Force Bite Corrector has improved the facial
bonded upper and lower fixed retainers on the anterior appearance and the profile (Figs. 25.9Z to FF).
teeth. Maxillary expansion followed by fixed appliances
Z AA
BB CC DD
EE FF
Figs. 25.9Z to FF: Fixed lingual retainer are fitted to support the finished occlusion. There is a favourable improvement in the face and
the profile.
At age 21 years, the objectives of treatment have been early stages of treatment. The end result is a well-balanced
achieved. Maxillary arch development was an important face and a confident smile (Figs. 25.9GG to MM).
factor in reversing the effects of thumb-sucking in the
GG HH
II JJ KK
LL MM
Figs. 25.9GG to MM: Several years later stability of the end result is confirmed.
Forsus Fatigue Resistant Device

(Figs. 25.10 and 25.11)
A rapid palatal expander was fitted first followed by Proclination of lower incisors is a common feature
fixed appliances and a Forsus appliance to advance the of spring driven devices attached to fixed appliances to
mandible. advance the mandible.
A B C
Figs. 25.10A to C: The forsus appliance is attached to upper and lower fixed appliances.
Courtesy: Dr Ramesh Sabhlok, Dubai, United Arab Emirates.
A B C
D E F
G H
Figs. 25.11A to H: A class II Division I malocclusion with deep overbite and lower incisor crowding.
I J
K L M
N O
P Q R
S T
U V W
Figs. 25.11I to W: A rapid palatal expander is followed by fixed appliances and a forsus appliance to advance the mandible.
X Y
Z AA BB
CC DD
EE FF
GG HH
Figs. 25.11X to HH: Dental views show the arch development and facial photographs confirm a favorable improvement in the profile.
Cephalograms confirm that there is proclination of lower incisors at this stage.
Mild Class II Division I Forsus Appliance

See Figures 25.12A to W.
A B C
D E F
G H I
J K L
Figs. 25.12A to L: Increased overjet with a half unit distal occlusion is associated with a favorable facial pattern which is within the scope
of this method of treatment.
M N O
P Q
R S
T U
V W
Figs. 25.12M to W: Final records confirm an excellent reponse to treatment with the forsus appliance. Fixed lingual retention is essential
after using spring loaded appliances for orthodontic correction.
Appliances for Mandibular Advancement incisors and mesial movement of the lower dentition.
It is important to recognize the potential of this approach
In recent years, a large number of fixed attachments
to produce unstable results with dehiscence of bone
have been developed to integrate functional mandibular
labial to the lower incisors. Case selection is extremely
advancement with fixed appliance therapy. The majority
important in using the entire range of spring-loaded fixed
of these are spring-loaded devices that are attached to
functional appliances. They are not suitable for correction
arch wires, extending from the upper molar to the lower
of severe malocclusion with mandibular retrusion and
canine region. Of the appliances illustrated, only the
a full unit distal occlusion. Case selection is similar to
Herbst and the Mara can claim to have an orthopedic
treatment with Class II intermaxillary elastics.
effect. All of the others, by virtue of being attached to the
A distinction must be made between orthodontic
lower arch wire, produce mainly dentoalveolar changes by
correction with spring-loaded appliances, and orthopedic
advancing the lower dentition. The activating mechanism
is similar to intermaxillary traction. correction, as demonstrated by the author using fixed or
removable Twin Blocks.
Intermaxillary Traction
The use of Class II elastics in correction of Class II malo- REFERENCES
cclusion is controversial in view of their side effects. Loss Angle EH, (1907). Treatment of Malocclusion of the Teeth, 7th
of mandibular anchorage has long been recognized as an edition. SS White Dental Manufacturing Co, Philadelphia.
undesirable side effect related to labial tipping of lower Buchner HJ, (1949). Maintaining mandibular anchorage in
Class II Division I treatment, Angle Orthodontist. 19:231-49.
incisors and mesial movement of lower molars (Buchner,
Bien SM, (1951). Analysis of the components of force used
1949; Bien, 1951; Ellen et al., 1998). Tweed and Begg to effect distal movement of teeth, American Journal of
gained universal acceptance of extraction therapy for Orthodontics. 37:508-21.
correction of Class II malocclusion using intermaxillary Ellen EK, Schneider BJ, Selke T, (1998). A comparative study
traction. of anchorage in bioprogressive versus standard edgewise
treatment in Class II correction with intermaxillary elastic
Extractions were required to counteract loss of anchor-
force, American Journal of Orthodontics and Dentofacial
age in the lower arch. The extraction protocol was based Orthopedics. 114:430-6.
on stability of the lower labial segment by positioning the Herbst E. Developed the Herbst Appliance in 1905I cannot find
lower incisors over basal bone. Early cephalometric stud- a reference in 1905 or 1910.
ies confirmed that intermaxillary traction does not move Howe RP, (1982). The bonded Herbst appliance, Journal of
the upper dentition distally, and the principal effect is to Clinical Orthodontics. 16:663-7.
Howe RP, McNamara JA, (1983). Clinical management of the
move the lower dentition mesially. Extraction therapy was
bonded Herbst appliance, Journal of Clinical Orthodontics.
introduced to prevent undesirable proclination of lower 17:456-63.
incisors and mesial movement of the lower dentition. McNamara JA, Bruden WL, (1993). Orthodontic and Orthopedic
There is a danger that the lessons of the past have been Treatment in the Mixed Dentition, Needham Press, Ann Arbor.
forgotten as we move into an era of spring-loaded fixed N Wolff J, (1892). Das Gesets der Transformation der Knochen,
functional appliances which mimic the effects of inter- Hirschwald, Berlin.
Pancherz H, (1979). Treatment of class II malocclusions by
maxillary traction.
jumping the bite with the Herbst appliance. A cephalometric
investigation, American Journal of Orthodontics. 76:423-42.
Spring-Loaded Fixed Functional Appliances Pancherz H, (1981). The effect of continuous bite jumping
Spring-loaded fixed functional appliances are worn on the craniofacial complex: a follow up study after Herbst
appliance treatment of class II malocclusions, European
24 hours per day and apply continuous light forces,
capable of moving the teeth through alveolar bone. Pancherz H, (1980). Anehus-Pancherz M. Muscle activity in
The major response is dentoalveolar with forward dis- class II, division I malocclusions treated by bite jumping with
placement of the lower dentition. the Herbst appliance. An electromyographic study, American
Since the development of the Andrews Straight Journal of Orthodontics. 78:321-9.
Wire technique there has been a major change in the Robin P, (1902). Demonstration practique sur la construction
et la mise en bouche d’un nouvel appareil de redressement,
proportion of patients treated by non-extraction therapy.
Revue de stomatology. 9.
If this is combined with the attachment of spring-loaded Weislander L, (1984). Intensive treatment of severe Class II
fixed functional appliances to conventional fixed applia- malocclusions with a headgear-Herbst appliance in the early
nces, this will undoubtedly cause proclination of lower mixed dentition, American Journal of Orthodontics. 86:1-13.
Treatment of Sleep Apnea Using Mandibular Repositioning Appliances 491
Chapter 26
Treatment of Sleep
Apnea Using Mandibular
Repositioning Appliances
This chapter is written by Dr Derek Mahony. by a common goal, i.e. to increase the diameter of the
airway and reduce the resistance of the UA, thus ensur
INTRODUCTION ing an immediate improvement in the quality of life for
many patients. These patients recover to normal sleep
Snoring can be defined as an inspiratory noise produced
patterns and reduce the risks to their health, no longer
by the passage of air, in a narrow area of the upper airway
triggering apneic events that would decrease their life
that makes the soft palate vibrate with the surrounding
expectancy.
tissues. The prevalence of snoring, in the general popu
lation, is 25% for men and 14% in women. Upon reaching
adulthood, this figure increases dramatically, especially
EVOLUTION OF INTRAORAL APPLIANCES
after the fourth decade, where it increases proportionally The treatment of OSA varies according to the specific
with age. So we can say that the prevalence of snoring in constraints of each patient and can include conservative
the age range of 40–65 years is 60% for males and 40% in treatments such as weight reduction or postural changes.
women. That means that almost half the adult population Current therapies include in more severe cases, continu
snores or has snored sometime in their lives. ous positive airway pressure (CPAP) and surgery (uvulo
When snoring is accompanied by a clinical picture of palatopharyngoplasty). For patients requesting noninvasive
breathing pauses and daytime sleepiness, the condition treatments, oral appliances are the most effective option
is diagnosed as sleep apnea-hypopnea syndrome. This and produce very acceptable results. Snoring and/or sleep
is characterized by episodes of obstruction of the upper apnea affects 3 million Australians. A CPAP device is the
airway during sleep resulting in a reduction (hypopnea) gold standard for treating this condition. CPAP stands for
or complete cessation of airflow (apnea). continuous positive airway pressure and this is facilitated
Prevalence of obstructive sleep apnea (OSA) in by a machine that increases air pressure in the throat.
Australia is 4–6% in men and 2–4% in women. In Spain, The air is forced through with a mask that covers the
the prevalence is 2–4% according to various studies and nose, the nose and mouth or prongs that fit into the nose.
the condition is more common in individuals over 40 Increasingly, patients often do not find success with this
years old. It is estimated that between 1,250,000 and device for a variety of reasons, and for some this results
2,500,00 patients suffer from these ailments, however, in a really diminished quality of life.
OSA has only been diagnosed and treated in only 5–9% For those patients, alternatives such as dental appli
of the population. Currently, there are a variety of effec ances and surgery are available, but determining which
tive and fully documented treatment modalities avail option is ideal can be taxing on patients, often causing
able. All treatments, for snoring and OSA, are governed them to see a variety of specialists separately. The use
of oral appliances for the treatment of snoring and
OSA is not new. The use of intraoral appliances in the
treatment of obstructive sleep pathologies dates from a
very long time ago. Pierre Robin describes in 1902 the
use of a functional appliance called the “monobloc”
which positions the jaw forward, thereby preventing the
tongue from falling backward (glossoptosis). He used this
in patients with severe mandibular hypoplasia. Robin’s
earlier designs were applied in cases of mandibular
micrognathia with mandibular hypoplasia in children.
In the 80s the generalized use of these devices, as an
alternative to the monopoly of CPAP, has offered patients
a new therapeutic dimension. These appliances overcame
the drawbacks of the irreversible and invasive surgery and
the annoying mechanisms of positive ventilation (CPAP) Fig. 26.1: Continuous positive airway pressure.
that have low levels of acceptance.
Since the introduction of oral devices for the treatment
of snoring and OSA, numerous devices have been desig The dropout rate of long-term CPAP therapy is very
ned and are currently available on the market. These oral high (around 70% use it less than 4 hours per night). This
appliances include intraoral mandibular advancement lack of compliance is primarily due to the inconvenience
appliances, positioners of the tongue, lifting devices of of this treatment option. Patients complain of dry mucous
the soft palate and uvula, repositioning and oral positive membranes, irritation by misalignment of the mask, the
pressure devices. restriction of movements in bed, discomfort to turn over
Clinical trials of existing oral applications demonstrate during sleep or psychological reasons increasing their
that the mechanisms of mandibular advancement (with anxiety and claustrophobia.
titration) have the highest level of efficiency. The literature Polysomnography remains the gold standard to quan
now describes more than 300 devices aimed at solving tify the results because it records not only cardiorespira
the problem of snoring and sleep apnea. Prosthetic mandi tory signals (such as flow, respiratory rate and oxygen
bular advancement treatment is the easiest option, as it saturation) but also shows an increase for slow wave
causes the patient less pain and better levels of adaptation deep sleep stages and REM (Figs. 26.3 and 26.4). However,
and acceptance. Intraoral appliances are less cumbersome polysomnography sometimes fails to extend into clinical
than the bulky continuous pressure masks. practice for all patients suspected of OSA due to the high
Continuous positive airway pressure has been the treat economic costs. The positive pressure CPAP therapy is
ment of choice for decades (Fig. 26.1), but it has its dis the treatment of choice for this problem even though
advantages, e.g. rejection and intolerance. This impedes intraoral devices provide better comfort.
optimal patient compliance with therapy so this therapeutic In the case of oral appliances, cross-sectional studies
approach has lost its competitive edge over other avai have highlighted that the levels of compliance are well
lable alternatives. These shortfalls have led to the need to above CPAP users. Studies assessing the long-term moni
work on other solutions that are equally effective but more toring of the use of intraoral appliances highlight 6.8
tolerable. There is a growing interest in the use of oral pros hours per night.
theses and more specifically mandibular advancement There are many types of oral appliances with poten
devices. These systems have undergone major technologi tial advantages over CPAP. Dental splints do not generate
cal developments in recent years and now constitute one annoying noises, do not need a power supply and are
of the best treatments of choice for people with snoring potentially less expensive and more portable with a
and OSA. The success of such appliances is based on the lower psychological impact. There is also a growing
fact that advancement of the mandible has a very positive evidence base to support the use of oral appliances in
impact in increasing the diameter of the upper respiratory the treatment of OSA. Recent data from randomized
tract and in the recovery of its functionality. controlled trials suggest that oral appliance therapy is
effective in controlling OSA in over 80% of patients, Table 26.1: Candidates for treatment with intraoral appliances
including patients with more severe forms of the dis • Patients with mild OSA who do not respond favorably to
ease. This is associated with a significant improvement in conservative measures.
symptoms such as snoring and daytime sleepiness. Based • Patients with moderate or severe OSA who refuse or do
on the subjective experience of patients who have used not respond well to treatment with CPAP, who refuse or are
unfit for surgery and those who do not improve after surgical
both appliances, the greater acceptance has been for oral treatment.
devices.
With the more recent appliances used and with the
via the UPPP. An important factor was that most
patient being in charge of a clearly outlined protocol of
patients preferred to use oral appliances versus CPAP.
titration, the results are far better. This was well demon
The use of oral appliances improves daytime function:
strated in the research by Almeida et al. in which a titration
the Epworth sleepiness score dropped from 11.2 to 7.8
mandibular advancement splint (MAS) study achieved
in 854 patients.
success in over 90% of patients.
A significant improvement is seen with little mandi
bular repositioning, even without major changes in the
PATIENT SELECTION FOR airways. This is achieved by simply avoiding the retro
INTRAORAL APPLIANCES positioning of the mandible to be stabilized by the intra
oral device.
Guidelines issued by the American Academy of Sleep
In summary, if snoring is the most striking symptom
Medicine (AASM) and published in the February 2006
and there is an absence of excessive hypoxemia, intraoral
edition of “Sleep”, state that “the use of oral appliances
devices are the treatment of choice. The patient should
are indicated in patients with mild to moderate OSA.
have the ability to advance the mandible and open
These patients may have had failed attempts with CPAP” their mouth fully without significant limitations. Serious
(Table 26.1). The guidelines also state that oral appliances problems in the TMJ disorders or insufficient capacity of
should be installed by qualified dental personnel trained protrusion may be a contraindication for therapy with
and experienced in the general care of oral health, tem oral devices.
poromandibular joint (TMJ) dysfunction, dental occlusion
and oral structures.
A sleep study is needed to verify the effectiveness of
POSSIBLE SIDE EFFECTS
oral appliance therapy and is especially necessary when In the short term, side effects of intraoral appliance use
symptoms worsen or persist. OSA patients who are treated can include excessive salivation and sensitivity of the
with oral appliances should have regular follow-up visits teeth or jaws. These are the most common complaints
with the dental clinic to monitor proper patient wear, in oral appliance users. These setbacks usually disappear
assess possible damage to the device and to assess the over time. In the longer term, changes to the occlusion are
health of the oral structures plus the integrity of the more common. A 1 mm change in dental occlusion occurs
occlusion. Regular monitoring is also necessary to assess in about a third of patients after five years, but these
patient signs and symptoms, or the potential worsening changes are not serious.
of the OSA. Repositioning of the mandible for airway management
It was concluded that the success rate, defined as the takes advantage of the attachment of the tongue to the
ability of oral appliances to reduce sleep apnea hypopnea mandible. This new position shortens the lateral pterygoid
index (AHI) to less than 10, was 54%. The response rate, muscle and regular exercise is needed to stretch the
defined as at least 50% reduction in the initial AHI muscle back to its full working length.
(although it remained above 10), was 21%. Snoring was
reduced by 45%. DAILY EXERCISE TO STRETCH THE
In studies comparing oral appliances with CPAP
LATERAL PTERYGOID MUSCLE
systems and uvulopalatopharyngoplasty (UPPP), the
intraoral device reduced the initial AHI by 42%, CPAP • Open the mouth wide
reduced the AHI by 75% and there was a 30% reduction • Place the tip of the tongue back toward the soft palate
• Keep the tongue back and close slowly until the first appliances. These results were reviewed and summarized
tooth contact in 2005 and 2006.
• Continue to close until the posterior teeth come into When qualified dentists make the oral appliance,
occlusion. 50–70% of patients still keep using them for many years.
Ten percent of people using a sleep device will expe Although its efficacy is inferior to CPAP, it is similar to
rience a bite change. Of those, less than 1% will be surgical procedures, but without invasive therapy or the
bothered by it or require treatment, but clearly it needs fact that surgical intervention is often irreversible.
to be covered as part of informed consent. Snoring treatment is where intraoral devices have
Discomfort is more frequent in monoblock devices. been proven to be the most effective. Patients have
Adverse effects are more significant in mandibular advan found total disappearance of snoring in 50% of cases or
cement appliances. In patients who are given a further a decrease in 90–100% of cases. Snoring is present in a
advancement, we would expect more complications but disease entity called upper airway resistance syndrome
this has not been demonstrated by the long-term research (UARS), which coexists with total or partial snoring and
with intraoral appliances. airflow obstruction. These arousals are not accompanied
The success of oral appliance therapy can vary based by oxygen desaturation. In these cases, oral appliances
on treatment indications, the manufacturing process, and are strongly indicated.
adaptation and monitoring. The whole process may take This review concluded that intraoral devices are a
weeks or months and should be done in collaboration with clear alternative to CPAP in reducing sleep apnea, snoring
a sleep unit. Adjustments should be made periodically, and sleepiness. They have a definite role in the treatment
depending on the case and reviews performed on an of snoring and OSA with levels of adaptation, acceptance
annual basis especially in the more difficult to control and choice of patients exceeding the levels of other
cases. therapeutic alternatives currently available.
Regardless of what treatment is prescribed, proper and
STUDIES OF THE EFFECTIVENESS close follow-up is essential for all sleep apnea patients,
OF INTRAORAL APPLIANCES IN THE including repeat sleep tests (Figs. 26.2 to 26.4).
Cone beam CT scans confirm three-dimensional
MANAGEMENT OF SNORING AND OSA
expansion of the post-pharyngeal airway in patients
Since the 1980s, there have been many publications from wearing an intra-oral device to posture the mandible
the AASM, reviewing the treatment of OSA with oral downward and forward (Figs. 26.5 and 26.6).
A B
Figs. 26.2A and B: Airway. Anatomical evaluation. Measuring volumes with applied orthoapnea.
Fig. 26.3: Polygraphic record of untreated OSA patients. Fig. 26.4: Polygraphic recording of the same patient after treatment
with mandibular advancement appliance.
A B C D
Figs. 26.5A to D: Cone beam CT for patients without and with intraoral device.
A B C D
Figs. 26.6A to D: Expansion of the airway is observed in frontal and transverse planes with an intraoral device.
TYPES OF ORAL APPLIANCES FOR Devices for Lifting of the Soft

TREATMENT OF SNORING AND OSA Palate and Uvula Repositioning
The American Stroke Association recently linked severe These devices act by raising the soft palate and uvula to
sleep apnea to increased risk of silent strokes and small a higher position, thus eliminating the snoring.
lesions in the brain. A proper diagnosis is the key to seek
treatment, and if a CPAP device does not work for what OPAP Devices (Oral Pressure Appliance)
ever reason, dental appliances present a viable alternative.
Depending on the mechanism of action, oral appliances They are a combination of mechanical ventilation from
are divided into sets: repositioning of the tongue [tongue- the CPAP and oral appliances. Oral devices are connected
retaining device (TRD)], anterior repositioning devices of to the tube of the CPAP (Figs. 26.7 to 26.17).
the mandible (MAP or MRAs), lifting the soft palate and 1. Appliances for repositioning the mandible represent
uvula repositioning (ASPL) and oral appliances applying the most useful design in the range of oral appliances.
positive pressure (OPAP). Their mechanism of action is to anteriorly reposition
the mandible and indirectly reposition the tongue,
Tongue-Retaining Device with the aim of expanding the size of the upper airway
These devices have a cavity in the anterior part of the during sleep.
device that keeps the tongue in a more advanced position, 2. There are two types of appliances, depending on whe
increasing the distance between it and the posterior ther the bite is fixed or adjustable, i.e. the mandibular
pharyngeal wall. advancement can be titrated (adjusted progressively).
Fig. 26.7: Tongue retaining device. Fig. 26.8: Soft palate appliance.
Fig. 26.9: OPAP device, oral pressure appliance. Fig. 26.10: Fixed splint.
Fig. 26.11: Adjustment splint. The position of the mandible can be Fig. 26.12: One piece MRA. The position of the mandible is set in
titrated. the construction bite with provision for positive airflow.
Fig. 26.13: Two piece MRA. Fig. 26.14: Herbst splint.

Fig. 26.15: EMT appliance. Fig. 26.16: SomnoMed MAS.
Fig. 26.17: Orthopnea appliance.

PROTRUSIVE BITE REGISTRATION malocclusion. This registration is effective in increasing

the airway by positioning the tongue forward as the
Selection of an oral appliance, for the patient, is of para mandible advances.
mount importance, as is the taking of a precise and This amount of activation would apply corrective
accurate “sleep bite”. There are various ways for taking this forces to move the mandible forward to correct a distal
bite. There are different protrusion gauges on the market, occlusion, but would be inappropriate for appliance cons
with the George gauge being the most popular.
truction for control of snoring in a Class I or Class III
The projet is also popular in Europe and is known as
dental occlusion. In such cases anterior activation should
the Exactobite in the USA.
be minimal and tongue space is increased by vertical
Deciding the maxillomandibular position for optimal
activation.
airway stenting is a major clinical decision. The literature
is sorely lacking in principles of scientific clinical guidance
on this subject of MMR. THE PHONETIC BITE
Common sense principles for registering the maxillo-
A round instrument, rather than a flat surfaced one is
mandibular relationship are:
highly recommended for anterior stabilization during the
• The maximum vertical that still permits the lips to be
registration of the phonetic bite. A flat surfaced instru
comfortably closed during sleep, so the patient is nose
ment promotes creation of an artificial cant. The round
breathing; and
instrument allows the clinician to brace the mandible in
• The maximum comfortable protrusive position, presu
a three dimensionally corrected position with its natural
mably with the proper combination of vertical and
cant. Round instruments with different diameters rang
protrusive to stent the airway open.
ing from 1 mm to 6 mm are readily available in dental
• The George Bite Gauge has a millimeter gauge to
practices.
measure the protrusive path of the mandible and to
The patient is seated in an upright position and is
determine accurately the amount of activation regis
invited to count while the clinician observes the interincisal
tered in the construction bite (Figs. 26.18 and 26.19).
The total protrusive movement is calculated by first space and any midline shift. The most common numbers
measuring the overjet in centric occlusion and then in the for maximum opening are usually 5’s ,8’s and 9’s
position of maximum protrusion. The protrusive path of This helps in selecting the appropriate diameter
the mandible is the difference between the two measure of round instrument to place between the incisors to
ments. Functional activation within normal physiological register the bite in a comfortable vertical dimension.
limits should not exceed 70% of the protrusive path (Figs. For many OSA patients, more vertical is desired and the
26.20 and 26.21). bite registration would record the jaw position during a
The protrusive path of the mandible is a measure more open movement, for example during the “nine” of
of the individual’s freedom of movement in protrusive saying 69.
function. This records the difference between the most For TMD patients only, a more minimal vertical may
retruded position and the most protrusive position of the be acceptable, and effective, at ideally positioning the
mandible. condyles in the temporal fossae. This is usually more
Rocabado quantifies normal physiological TMJ move comfortable for speech and daytime function if wearing
ment as 70% of total joint displacement. Beyond this point, an orthotic appliance during the day. This would be the
the medial capsular ligament begins to displace the disc bite position during the sibilant (…SSS) sound.
by pulling the disc medially and distally off the condyle. Simply saying “S” does not position the mandible as
This guideline allows us to measure the total mandibular effectively as speaking words that contain the “S” sound,
displacement and relate the amount of activation to the for example “Mississipi”. Note the most vertically open
freedom of movement of the joint for each individual position in their arc of closure. The “nine” sound in 69 will
patient. drop their mandible vertically and gives their full natural
The George Gauge may be locked in the desired opening.
position of protrusion. This is typically 50–70% of the In deep bite Class II cases a very small round instru
protrusive path of the mandible for correction of Class II ment is required in the anterior for the bite registration,
A B
Figs. 26.18A and B: George gauge zeroed as the first step in determining the protrusive position.
A B
Figs. 26.19A and B: Recording the bite in the most protrusive position to measure the protrusive path of the mandible to help in establishing
the correct protrusive bite.
A B
Figs. 26.20A and B: The bite is recorded in mms in the most retruded position.
A B
Figs. 26.21A and B: The gauge is locked in the desired protrusive position for appliance construction and bite registration paste is applied
to the fork.
while the vertical opening, in the posteriors, will look an impact on patient acceptance”. Dr Isono, on the other
significantly larger. Conversely a larger inter-incisal space hand, showed an improved response with more vertical
may be required in open bite cases with a smaller advan (up to a certain amount). The increased (posterior) vertical
cement of the mandible. dimension does, however, have greater use in TMD cases.
These patients have weak musculature and have more In these cases, decompression is often needed to reduce
difficulty in maintaining a large forward posture. The symptoms of capsulitis or retrodiscitis.
inter-incisal space is confirmed in the phonetic test and Rocabado cautions that the dentist must not create
should be repeated several times. too much vertical or horizontal activation in order to
Once the instrument is positioned, helping stabilize stay within the physiological limits of movement in the
and maintain the phonetically positioned mandible, the TMJ. While this position may be estimated in recording
bite registration material can be injected between all the a construction bite for treatment of snoring and sleep
teeth, to record the ideal position. apnea, it is important to monitor the response to any
After taking the bite registration, have the patient lay appliance and modify the vertical and horizontal activation
back and try to snore. If it is difficult or impossible to if required. If the patient reports headache or undue
snore this is a good indicator that the bite registration is muscular tension the activation must be reduced until
correct and will eliminate snoring. Also, make sure the a comfortable position is reached in muscle balance.
patient feels comfortable in that position.
In recording a construction bite in sleep therapy the
TENS unit low frequency stimulation is used to relax
THE NEUROMUSCULAR BITE
the muscles. This likely to be more effective than a high
The transcutaneous electrical nerve stimulation (TENS) frequency which is used to block pain due to muscle
machine is used by some dentists to record a “neuro spasm. Some clinicians believe that the neuromuscular
muscular bite” to establish the vertical dimension for full bite reduces the need for titration of the appliance, but
mouth reconstruction. the same may be said of the phonetic bite. The indi
In regards to dental sleep medicine, the importance vidual response of the patient is the important factor in
of vertical dimension has had mixed reviews. Pitsis, et al. determining the optimum occlusion and a method of
stated that “the amount of bite opening does not have a titration of the appliance is a necessary component for
significant impact on treatment efficacy, but does have successful treatment.
THE MOSES APPLIANCE AND If the patient has a functional shift to the left or the
THE MOSES BITE right, this position may be more comfortable for the
patient, or necessary for TMJ function. This should be
Dr Allen Moses’ bite technique is a combination of the noted on the lab prescription for proper fabrication of
three philosophies: Anteroposterior, phonetic and neuro the appliance in that position.
muscular. He uses his patented bite shims to adjust the Bite registration material is injected between the
vertical. posterior segments overlapping the anterior segment to
When the vertical position is established ask the
hold it together in one piece to record the entire arch
patient “Can you comfortably keep your lips together
length with registration material.
or is it a strain?” If the patient is straining, the stack of
The Moses appliance (Figs. 26.22A and B) may be
shims are removed one by one, until the desired vertical
appropriate for patients who can tolerate the upper and
is achieved and the patient feels comfortable.
lower jaws being “locked” together. There is a lot of tongue
Mark the skeletal midlines (upper and lower) with
space and for many patients, that is extremely important.
a wax pencil. Then instruct the patient to slide the
For TMJ patients however, this can be problematic, as it
mandible forward to a comfortable protrusive position.
is the motion of the mandible that circulates the synovial
Dr Moses’ sleep appliance is easily titratable, so post
fluid in the joint capsule.
appliance-insertion adjustments can be made to adjust
this somewhat arbitrary protrusive position.
A B
Figs. 26.22A and B: Moses appliance and bite.
TWIN BLOCKS IN TREATMENT OF TWIN BLOCKS INCREASE THE AIRWAY

SLEEP APNEA
Recent research supports the view that Twin Blocks
Robin’s Monobloc increase the pharyngeal airway. A recent article, “Cephalo
metric evaluation of hyoid bone position and pharyngeal
Pierre Robin (1902) used the Monobloc to treat patients spaces following treatment with Twin Block appliances”
with severe mandibular retrusion, in the condition now compared 3 groups of patients, hypodivergent, normo
defined as the Pierre Robin syndrome. The orthodontic divergent and hyperdivergent. (Verma et al, Journal of
aim of correcting Class II malocclusion was only addressed Orthodontic Science, Vol 1, Issue 3 2012).
later when Andresen developed the activator. This study concluded that the width of the upper
Robin’s Monobloc (Fig. 26.23) was the original sleep airway significantly increased (p < 0.01) and the ANB angle
apnea appliance. We tend to forget that functional significantly decreased (p < 0.001) in all three groups with
therapy developed, not to correct a dental malocclusion, forward movement of the mandible.
but to keep patients alive! Improving the airway delivers After treatment with Twin Block appliance, significant
holistic benefits that profoundly affect a patient’s health changes occurred in horizontal dimension (anterior
and function. displacement) which resulted in significant increase in
Accommodating the tongue in a forward position by width of the upper pharynx in all three groups.
expanding the maxilla and advancing the mandible is This is an important finding and it merits repetition
fundamental in improving the pharyngeal airway. This that patients with an excessive overjet and overbite before
remains the basic concept of functional therapy. treatment are typical of this effect. Before treatment many
patients with severe Class II division 1 malocclusions
have a typical listless appearance, evident in the dull
appearance of the eyes and poor skin tone. After only
3 months treatment patients undergo a dramatic change
in facial appearance. They appear more alert and there is
a marked improvement in the eyes and the complexion.
A large overjet with a distal occlusion is frequently
associated with a backward tongue position, and a
restricted airway. These patients cannot breathe properly
and as a result are subject to allergies and upper res
piratory problems due to inefficient respiratory function.
Functional therapy to expand the maxilla and advance
the mandible increases the airway. This is a fundamen
tal physiological change, extending beyond the limited
Fig. 26.23: Pierre Robin’s original Monobloc. objective of orthodontic correction of a malocclusion.
TWIN BLOCKS IN CLASS II THERAPY planes and this has the immediate effect of moving the
This is an example of treatment with Twin Blocks to cor tongue forward and improving the pharyngeal airway. In
rect a severe Class II malocclusion. Before treatment the addition to the facial improvement the patient experi
overjet is 17 mm and the patient has the typical listless ences holistic benefits due to improved respiration and
appearance, evident in the eyes, due to sleep apnea. effective treatment of sleep apnea. This is a fundamental
Remarkable improvements are observed in facial appear physiological change and underlines the value of full time
ance and the profile within three months of starting treat appliances for functional therapy, beyond the limits of
ment. THe mandible is guided forward by occlusal inclined conventional orthodontic treatment (Figs. 26.24A to J).
Facial and airway changes before and after Twin Blocks
A B C
D E F
Before treatment After 3 months After 11 months
G H
I J
Figs. 26.24A to J: This patient with a severe Class II division 1 malocclusion experienced dramatic changes in facial appearance and
profile within the first 3 months of treatment with Twin Blocks. After 11 months the occlusion was corrected to Class I; (B) The profile
before treatment, after 3 months, after 11 months, and 5 years later out of retention; (A and C) Cephalometric films before and after
Twin Block therapy confirm that there is a significant improvement in the post-pharyngeal airway.
TWIN BLOCKS IN TREATMENT OF interrupting normal function or affecting the speech. This
SLEEP APNEA is a “patient friendly” approach using appliances that are
The occlusal inclined plane is an ideal mechanism to aesthetic and comfortable and are ideal for treatment of
open the bite and guide the mandible and tongue for sleep apnea and other day time breathing disorders due
ward to improve the airway. Recent research confirms to a restricted airway.
that Twin Blocks are proven to increase the pharyngeal Breathe Easy Twin Blocks may be worn by day or night
airway in hypodivergent, normodivergent and hyperdi for treatment of sleep apnea. Nocturnal wear is effec
vergent patients. tive in controlling snoring and daytime wear can assist
Breathe Easy Twin Blocks are separate upper and patients with more severe sleep disorders associated with
lower appliances allowing freedom of movement of the a restricted airway. Buttons may be added for elastics to
mandible, as an alternative to the range of one piece be worn at night if required. Motor vehicle drivers who
appliances which restrict normal function. suffer from sleep apnea can wear these appliances com
When used to correct a Class II malocclusion Twin fortably by day or night to avoid accidents when driving
Blocks can be worn full time including for eating without (Figs. 26.25A to D).
A B
C D
Figs. 26.25A to D: (A and B) Breathe Easy Twin Blocks use the occlusal inclined plane to posture the mandible down and forward to
eliminate snoring and improve the airway; (C and D) Buttons may be added for elastics to be worn at night if required.
BREATHE EASY TWIN BLOCKS

The author has personally tested “Breathe Easy Twin Titration is simple, either by trimming the blocks
Blocks,” as illustrated here and can confirm that they are to reduce activation or by or adding Triad material
more comfortable to wear than a one piece appliance if further activation is required. This allows fine tun
and are effective in controlling snoring when worn at ing to achieve a balanced occlusion and to optimize
night. Preformed occlusal blocks are placed on models comfort. These appliances are aesthetic and can be
and mounted to the construction bite, allowing space for worn during the day to correct Class II malocclusion,
the pressure molded material to form virtually invisible or as an aid for drivers who suffer from sleep apnea
Twin Blocks. (Figs. 26.26A to E).
B C
D E
Figs. 26.26A to E: Virtually invisible Breathe Easy Twin Blocks can be worn by day or night in the treatment of snoring and sleep apnea.
Preformed occlusal blocks are available from orthorg@prodigy.net.mx.
Examples of Treatment with Twin Blocks by Dr Dillip Patel with Positive

Changes in the Airway and Facial Aesthetics (Figs. 26.27 to 26.30)
A B C D
E F G H
Before and after 12 months Twin Block therapy
I J
Figs. 26.27A to J: Twin Blocks achieve nonsurgical correction of severe Class II division 1 malocclusion with beneficial holistic improvement
of the post-pharyngeal airway.
A B C D
E F G H
I J
A B C D
E F G H
I J
A B C D
E F G H
I J
SLEEP APNEA AND HEALTH George PT, (2001). Selecting sleep-disordered-breathing appli
ances: Biomechanical considerations, Journal of the American
In recent years intraoral appliances are used increasingly Dental Association. 132:339-47.
to treat sleep disorders. This approach has great potential Gotsopoulos H1, Chen C, Qian J, et al. (2002). Oral appliance
to improve general health by increasing the pharyngeal therapy improves symptoms in obstructive sleep apnea: a
randomized controlled trial, American Journal of Respiratory
airway. Improving the airway helps reduce the risk of
and Critical Care Medicine. 166:743-8.
serious and potentially fatal diseases such as hypertension, Hans MG, Goldberg J, (1995). Cephalometric examination in
stroke, and myocardial infarction. obstructive sleep apnea, Oral & Maxillofacial Surgery Clinics
From Robin’s monobloc in 1902 to the present day, of North America. 7:269-81.
improving the airway is vitally important in keeping Hoffstein V, (2007). Review of oral appliances for treatment of
patients alive. This is the most important aspect of func sleep disordered breathing, Sleep Breath. 11:1-22.
tional therapy, in addition to improving facial aesthetics, Isono S, Remmers JE, (1994). ‘Anatomy and physiology of
upper airway obstruction’ in Principles and Practice of Sleep
restoring facial balance and correcting malocclusion. Medicine, WB Saunders and Co, Philadelphia. pp. 642-56.
From early treatment to adult therapy functional therapy Koskenvou M, Partinen M, Kaprio J, (1985). Snoring and disease,
delivers holistic benefits of enormous significance for a Annals of Clinical Research. 17:247-51.
patient’s general health. Kushida CA, Morgenthaler TI, Littner MR, et al. (2006). Practice
parameters for the treatment of snoring and obstructive
sleep apnea with oral appliances: an update for 2005, Sleep.
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The Flat Earth Concept of Facial Growth 513
Chapter 27
The Flat Earth
Concept of Facial Growth
Medicine remains too often one-dimensional in its approach.

— Charles, Prince of Wales, 1998
In the Age of Technology, statistics speak louder than identification of condylar anatomy affects the evaluation
words. Common sense is not so common! of mandibular growth, and that measurement of mandi
bular length following orthodontic therapy should be lim
LIMITATIONS OF ited to cases where the condyle is clearly identified, not
interpreted.
CEPHALOMETRIC ANALYSIS
Given these limitations, it is not surprising that atte
Since the introduction of the cephalostat by Broadbent in mpts to evaluate facial growth from conventional cepha
1937, cephalometric analysis has become the most widely lometric studies are inconclusive and open to differing inter
used diagnostic aid and research tool in the study of facial pretations (DeVincenzo, 1991; Mills, 1991; Nelson et al.,
growth. The method has proved invaluable in diagnosis as 1993; Clark, 1995; Johnston, 1996; Mills and McCulloch,
a means of defining and monitoring skeletal and dental 1998, 2000). All efforts to evaluate growth change from a
relationships. two-dimensional image are subject to bias due to the
However the technique has limitations as a research inherent inadequacies of the method, and the interpre
tool when used to investigate growth and development tation placed on results is of equal importance to the
and to determine the influence of orthodontic treatment recording and measuring of cephalometric data.
as opposed to normal growth and development.
On cephalometric radiographs, with the teeth in RELEVANCE OF STATISTICAL EVIDENCE
occlusion or in rest position the outline of the condyles
and the glenoid fossa is obscured by superimposition of In recent years, “evidence-based” studies have become the
the basal portion of the occipital bone. In addition, the accepted standard of investigation in medical research.
glenoid fossa and the condyle have a cylindrical configu Advances in computer technology facilitated statistical
ration and are disposed at an angle to the median plane. analysis, which now forms the basis for most academic
These bilateral structures may not superimpose exactly studies, to a large extent replacing the philosophical
on a projected image, thus a number of factors cast doubt hypotheses of past generations. In a practical subject such
on the accuracy of defining the outline of the condyles as orthodontics many advances in the past were based on
and glenoid fossae. Ghafari et al. (1993) indicate that clinical experience, usually supported by evidence from
clinical records. The basic principles have not changed, to grow. Alternatively, we may influence the maxilloman
although the investigative techniques have become more dibular relationship by bony remodeling in the glenoid
sophisticated. fossa, or by a positional change of the mandible relative
Depending on the interpretation of results, several to the maxilla. Considering the inherent limitations of
factors serve to limit the usefulness of statistical ana the method of study it is not surprising that attempts to
lysis. Clinical investigation often involves multifactorial resolve crucial questions regarding facial growth by sta
questions, and it is difficult to obtain accurate controls, tistical analysis have produced inconclusive evidence.
or to eliminate individual differences in growth and Opinions differ regarding the extent of genetic control
response from small groups used in statistical studies. versus the influence of environmental factors in the deve
These are unavoidable limitations of the method of study. lopment of the face. At the end of the 20th century many
Nevertheless, it is tempting to accept the results of sta orthodontists remained philosophically divided between
tistical analysis as the best available method of scientific an orthodontic and orthopedic approach to treatment.
investigation. Two schools of thought continued to exist regarding the
This is in spite of an uncomfortable doubt, expressed potential to influence facial growth by orthopedic treat
so eloquently by Mark Twain, that “There are three kinds ment. Such a fundamental division impacts directly on
of lies: lies, damned lies and statistics”. The implication is the organization of orthodontic practice. It is a signi
that, given the appropriate sample, we can prove virtually ficant factor in the timing of treatment, between early or
anything by statistics. Thus the endless conflicting results late intervention, or between orthopedics or surgery to
emerging from studies in almost any subject under resolve skeletal discrepancies.
investigation. Advances in computerized morphometrics may help
ML Moss (1981) observes that “As statistics developed, to resolve questions on craniofacial growth that have
the effects of various types of treatment could be statisti persisted throughout the 20th century, while magnetic
cally analyzed, although at times as various observers resonance imaging is capable of higher resolution than
have pointed out some of the statistical differences have radiographic techniques for the investigation of struc
been found to be clinically meaningless”. tural change. Such fundamental technological advances
take many years to implement and until we can evaluate
THE FLAT EARTH CONCEPT OF three-dimensional images it is possible to arrive at a more
FACIAL GROWTH meaningful interpretation of the results of cephalome
tric analysis by adopting a three-dimensional perspective
In philosophical terms, the “flat earth concept of facial to interpolate volumetric changes from two-dimensional
growth” is an appropriate analogy for the study of facial images.
growth in orthodontics by two-dimensional cephalometric
analysis. The concept underlines the inherent disadvan Two-Dimensional Representation of
tage of attempting to evaluate changes in the form of a
Mandibular Length
three-dimensional structure based on the analysis of a
projected two-dimensional image. This deficiency has long Present methods of measuring increments in mandibular
been recognized, as observed by Moyers and Bookstein, growth by conventional cephalometric analysis tend to
in their paper “The inappropriateness of conventional underestimate growth due to the limitations of the two-
cephalometrics” (1979). dimensional method. The cephalometric image repre
A direct analogy exists between our present state of sents the reflection of a shadow of a three-dimensional
knowledge of facial growth from cephalometric studies, form on a flat surface placed behind the object of study.
and early historical misconceptions regarding the shape A typical enlargement of the image on a cephalometric
and form of the earth. Understanding the concept of film varies between 6% and 13%, and cephalometric
volumetric growth of the face is as important as realizing studies commonly make allowance for enlargement of
that the earth is round and not flat. the image on the cephalometric radiograph by introduc
After a century of investigation, the question is still ing an appropriate correction. In addition, however, the
unresolved as to whether or not we can influence the pat two-dimensional image of the mandible is foreshort
tern of facial development by encouraging the mandible ened relative to its true shape and it is not customary to
make an equivalent allowance for foreshortening of the the bilateral morphology of the mandible, the following
mandible on the projected image. Similarly conventional example illustrates how a relative increase in peripheral
analysis makes no allowance for the fallacy of measuring length would compare to the projected cephalometric
growth increments on the midline projection of a bila image.
teral structure. These fundamental flaws in the method of
study have led us to consistently underestimate the effects Before Treatment
of treatment on facial growth. Mid-sagittal measurement condylion to pogonion =
100 mm.
The Peripheral Length of the Mandible Exterior peripheral measurement condylion to pogo
Given the three-dimensional shape of the mandible, and nion = 120 mm.
its semi-elliptical morphology, measurement from con Bilateral peripheral measurement condylion to pogo
dyle to condyle is a more meaningful representation of nion = 240 mm.
mandibular length than the midline projection of mandi
bular length from condylion to pogonion. An increase in After Treatment
the peripheral length of the mandible is more significant
Mid-sagittal measurement condylion to pogonion =
in the clinical context than a projected midline measure
105 mm.
ment, which has little direct clinical significance. One of
Exterior peripheral measurement condylion to pogo
the basic aims of orthodontic treatment is to accommo
nion = 126 mm.
date the teeth over basal bone in good alignment without
Bilateral peripheral measurement condylion to pogo
crowding. Therefore the peripheral length of the mandible
is a more meaningful factor in the clinical equation than nion = 252 mm.
the midline projection that is commonly used to evaluate An increase of 5 mm in the midline projection of
mandibular length. A line from condylion to pogonion mandibular length is equivalent to an increase in the
around the exterior surface of the mandible represents peripheral length of the mandible of 12 mm. In clinical
the peripheral length of the mandible (Fig. 27.1C). The terms, the difference between the peripheral length and the
distance may be measured from the left condylion to the projected length of the mandible represents a significant
midpoint of the lower border of the mandible. This is factor, which may be important in the resolution of
repeated on the right side and the sum of the two meas crowding and the space available for eruption of second
urements represents the total length of the mandible or third molars.
from condyle to condyle. Measurement of the peripheral It is possible that a method could be devised using a
length of the mandible on the dry skull using a flexible panoramic radiograph to measure the peripheral length
ruler indicates that the peripheral length on each side is of the mandible as an alternative to the projected image
20% greater than the projected cephalometric linear dis of the mandible, in order to evaluate more accurately the
tance from pogonion to condylion. Taking into account true length of the mandible (Figs. 27.1A to C).
A B C
Figs. 27.1A to C: (A) The mid-sagittal axis is used to measure mandibular growth; (B) A simple linear measurement does not represent
the complex bilateral form of the mandible; (C) A line from condylion to pogonion around the exterior surface of the mandible represents
the peripheral length of the mandible.
Comparison of Linear and studies during a course of orthodontic treatment, a 1%

Volumetric Values increase in linear values represents a 3% increase in
volumetric values in the comparison of objects of broadly
Understanding the concept of volumetric growth of the similar shapes. As no fundamental change in facial form
face is as important as realizing that the earth is round and occurs during treatment, this principle may be applied
not flat (Fig. 27.2). In comparing objects of broadly similar with confidence. This does not preclude the modification
shapes, the relationship between linear and volumetric of facial form by subtle changes that may be obvious to
values remains the same. The mathematical formula for the aesthetic senses, without necessarily being statistically
the expansion of an object relating to percentage change significant.
is expressed as:
(1 + r)3 = 1 + 3r + 3r2 + r3 Statistical Evaluation of Aesthetic Factors
where r = % change.
As stated above, Moss observes that “As statistics devel
In mathematical terms r2 and r3 are negligible where
oped, the effects of various types of treatment could be
the percentage change is small. Various recognizable
statistically analyzed, although at times as various observ
three-dimensional forms may be selected to illustrate this
ers have pointed out some of the statistical differences
principle, and it is immaterial whether the selected form
have been found to be clinically meaningless”. Statistical
is spherical, cuboid or ellipsoid, as the same principle
methods are limited as a means of measuring aesthetic
may be applied using any of these models. For example,
factors. Clinical examination supported by photographic
a 1% increase in the radius of a sphere increases the
records may be more effective in interpreting subtle
volume by 3%. Similarly, a 1% increase in the length of
changes in facial form, which may or may not be statisti
the sides of a cube or cuboid results in a 3% increase in
cally significant. This does not deny the value of statisti
volume. The same principle applies to an ellipsoid, where
cal methods, but there is an obvious danger of relegating
the maximum and minimum radii are expressed in the
aesthetic judgment to the level of statistics.
formula.
It is therefore important to relate statistically signi
Linear changes are more significant when converted
ficant changes to the resulting effect on the facial form.
to three-dimensional values. In mathematical terms
For example, an increase in ramus height is a highly signi
linear values should be multiplied by three to convert
ficant finding in many statistical studies of functional
to volumetric values. Within the parameters of growth
technique. Vertical changes are extremely important in
facial aesthetics. An increase in the height of the ramus
has a significant effect on facial appearance. In aesthetic
terms it is an important factor in reshaping the contours
of the lower third of the face. It is frequently accompanied
by an increase in lower facial height, and remodeling of
the circumoral musculature.
The evaluation of growth increments in the mandible
by measurement of the mid-sagittal axis is not a true esti
mate of mandibular growth. The mandible is an extremely
complex three-dimensional structure, and growth of the
mandible is by a combination of cartilaginous and subpe
riosteal apposition. An increase in the mid-sagittal axis is
of minor significance in clinical terms. It may have a lim
ited effect on the contour of the chin in profile. However,
even a small advancement of the mandible may have a
significant effect on the contours of the lower face, in
height and width, in addition to changes in the profile.
Because the mandible is wedge-shaped, the lower third of
the face widens as the mandible is advanced. Therefore,
Fig. 27.2: Understanding the concept of volumetric growth of the volumetric changes in the shape of the face are exponen
face is as important as realizing that the earth is round and not flat. tial relative to linear changes.
A change in the mandibular position may be of equal students of orthodontics who are at the beginning of their
significance compared to an increase in mandibular professional career. Such an approach may deny patients
length in determining the facial contours. This may be the benefits of appropriate treatment for skeletal discrep
related to a small change in the direction of growth at ancies.
the condyle, or remodeling in the glenoid fossa, or a The following quotation is relevant to this discussion:
combination of both of these factors. Measurement of the
Science has tried to assume a monopoly, even a tyranny,
mid-sagittal axis does not take either of these important
over our understanding.
factors into account. As a result of these limitations, the
— Charles, Prince of Wales, 1998
evaluation of growth changes in the face from previous
cephalometric studies is fundamentally flawed. To place this quotation in perspective, it is unreasonable
While clinical technique must have a sound basis in to expect that science can resolve all questions at any time,
scientific research, it is equally important to recognize the therefore it is dangerous to draw dogmatic conclusions
limitations imposed by inadequate methods of investiga from scientific research in a clinical subject. Results must
tion in determining the validity of scientific study. Correct always be viewed with an open mind, taking into account
interpretation of results is an important aspect of cepha the limitations of the method of study. It is essential to
lometric study. This must take into account the limita combine a scientific approach with the pragmatism that
tions of two-dimensional analysis from a projected image. is required to resolve clinical problems.
At present we still adhere to a “flat earth concept of facial
growth” and have failed to adjust our vision to accom VOLUMETRIC ANALYSIS OF FACIAL
modate a three-dimensional perspective. GROWTH BY IMAGING TECHNOLOGY
The efficacy of functional therapy has been the subject
of a great deal of criticism, mostly based on conventional Advances in imaging technology make it possible to
two-dimensional cephalometric studies. However, fun examine three-dimensional images. Recent research at
ctional orthopedics presents a valid alternative to ortho University College, London (JP Moss and coworkers)
gnathic surgery that is more acceptable and less costly employs leading edge technology to investigate three-
for the patient in many borderline Class II skeletal dimensional growth changes. In a technique for optical
cases. In comparison to conventional fixed appliance surface scanning a laser scanner and a video camera are
techniques, functional orthopedics is more effective in used to plot accurate facial masks for a group of patients.
the treatment of severe malocclusions resulting from The technique of optical surface scanning may be used
skeletal discrepancies. Increasing evidence is emerging to illustrate three-dimensional changes in facial form by
to support the positive benefits of full-time functional computer-generated images of facial masks of individual
appliances on facial growth. patients, or groups of individuals with or without treat
An improved method of interpolating volumetric ment by creating a composite facial mask to represent
changes from the study of cephalometric radiographs may the mean facial pattern from a group of patients. At pre
help to clarify the changes that result from treatment, until sent, this technique has been used to show changes in
such time as we can evaluate fully the three-dimensional the soft-tissue mask of the face. Color coding may be used
effects of functional orthopedics by morphometric techni to demonstrate areas of differential growth. Composite
ques. masks of a group of untreated patients are used as con
Science is the study of natural processes by observa trols to examine changes in the soft tissues of the face.
tion, hypothesis and experimentation. In an age of rap The masks are color coded with cold colors representing
idly advancing technology, it is inevitable that results that negative areas of growth, and warm colors showing posi
were accepted as correct at the time of investigation, are tive growth. The consistent pattern of color coding verifies
frequently found subsequently to be incorrect. Methods that no significant volumetric changes occur in the three-
of investigation tend to compartmentalize knowledge of dimensional masks of the untreated patients before and
complex subjects and mechanisms. In our present state after observation (Figs. 27.3A to E).
of knowledge a doctrinaire approach to the teaching and By comparison, the composite masks of Twin Block
study of facial growth and the effects of treatment is dan (TB) patients show positive three-dimensional changes in
gerously misleading. The inherent danger is that undue the face during treatment. Significant volumetric changes
reliance on the statistical evaluation of past two-dimen are registered in the lower third of the face over the entire
sional studies from a negative perspective may prejudice area of the mandible. Improvement in the profile is
A B
C D
Figs. 27.3A to E: (A and B) Composite facial masks of a group of

patients before and after treatment with Twin Blocks; (C) Color coding
is used to illustrate areas of positive and negative growth; (D) The
control group shows no significant growth changes; (E) The Twin
Block group shows positive three-dimensional changes in the face
during treatment over the entire area of the mandible.
E Courtesy: Prof JP Moss.
expressed in the outline of the lips and chin, with changes mandible results in widening of the lower face, affect
in the shape of the mouth affecting the circumoral mus ing both hard and soft tissues, as muscular adaptation
culature and the mentalis region. Increased lower facial occurs to accommodate the underlying bony changes.
height is evident in the ascending ramus, extending for This accounts for the extensive areas of change registered
ward along the lower border of the mandible to the sym over the entire mandible, including the ramus and the
physeal region. outline of the masseter muscle.
The shape of the lower face is equally affected by By contrast, the mid-face maintains a similar pat
remodeling in the transverse dimension. Advancing the tern, indicating no significant changes in the mid-facial
profile. There is some evidence that the remodeling over Scaling Analysis (FESA), Thin Plate Spline (TPS) analysis
the area of the mandible extends upwards into the max and Euclidean Distance Matrix analysis (EDMA) (Singh
illa, indicating slight widening of the maxilla as a result et al., 1998a,b,c). These techniques are registration-free
of midline expansion. Morris et al. (1998) compared approaches that rely upon the relative positions of homol
soft-tissue changes in groups of patients treated by three ogous landmarks rather than linear and angular measure
different functional appliances compared to a control ments (Bookstein, 1981) (Figs. 27.4A to E).
group. Normal growth was associated with only mini Whilst the Class II malocclusion is accepted as a clas
mal changes in the soft-tissue profile and form during sification of the dentition, it does not presuppose a skele
the study period of 9 months. Comparison of Bionator, tal craniofacial relationship (Coben, 1966). Investigations
Bass appliance and TBs with controls showed that each into linear dimensions and facial proportions conclude
of the functional appliance groups produced further that the mandible is of average linear size but proportion
changes in the soft-tissue profile and form than would ally small for the face because the depth of the cranial
otherwise have been expected. Greater anteroposterior base is larger than average (Coben, 1961). In the treatment
changes occurred in the male treatment groups. Upper of Class II malocclusion, functional appliances such as
lip landmarks showed no significant changes in any of the the TB train patients in oral and tongue posture; an early
appliance groups despite the significant overjet reduction phase of functional appliance treatment is commonly
achieved in each appliance group. used to simplify subsequent therapy, and to optimize
The TB appliance group (male and female) achieved the development of the facial skeleton. Unfortunately, this
greater changes in their facial soft tissues in comparison latter expectation enjoys little support in the literature. A
with the other two functional appliances. The most signi prospective trial found no evidence that functional appli
ficant effect found was the advancement and lengthening ances can alter the shape of the mandible.
of the lower lip combined with some forward movement of Indeed, a study (Johnston 1996) that examined mat
the chin point and increase in all face height parameters. ched patients from a two-stage Bionator/Edgewise regi
The subtlety of these volumetric changes is highly men and a conventional one-stage Edgewise treatment
significant in aesthetic terms, and evidently cannot be found that when the two groups were compared, they
interpreted from two-dimensional radiographic images. underwent essentially indistinguishable skeletal changes;
Using similar scanning techniques, it will be possible in the early phase of functional treatment conferred no
the future to obtain measurements of volumetric changes obvious measurable benefits. Similarly, another study
in the hard tissues, and therefore to evaluate more accu reported that the length of the mandible did not increase
rately changes in facial form resulting from orthodontic in young adult patients treated with functional regulator
and orthopedic techniques. therapy.
MORPHOMETRIC ANALYSIS A Morphometric Analysis of Consecutively

Treated Twin Block Patients
by GD Singh and WJ Clark
A morphometric analysis was carried out to evaluate
Kendall’s spherical blackboard used the mathematics of the results of treatment of 138 consecutively treated
spherical space to represent three-dimensional morpho patients in the author’s practice (WJ Clark). The sample
logy (Kendall, 1989). Finite element analysis uses new was subdivided on the basis of age into four groups of
mathematical concepts and computerized morphomet prepubertal and postpubertal males and females. Using
rics to examine growth changes in greater detail from a finite element scaling analysis, it is possible to model
three-dimensional perspective. regions of proliferative growth and remodeling. It appears
As cephalometry does not take size variation into con that TB therapy may involve:
sideration, opinion is emerging that it is perhaps a rela • Developmental modulations at the condylar cartilage.
tively inappropriate method of shape analysis (Bookstein, • Epigenetic remodeling of the ramus and corpus.
1981). Recently, geometric morphometric techniques • Osteogenic deposition that extends from the corpus of
have become useful to facilitate hypothesis testing (Singh the mandible into the dentoalveolar areas.
et al., 1997). These methods include superimposition This latter factor relates to vertical adjustments of the
techniques such as Procrustes analysis, Finite-Element occlusion, in response to the observed increases in ramus
A B
C D
Figs. 27.4A to E: (A) Postpubertal males—analysis of shape. Shape

change is uniform. High isotropy over the entire nodal mesh; (B)
Prepubertal females—analysis of size. Limited positive differential
growth; (C) Postpubertal females—analysis of size. Highly significant
differential growth; (D) Prepubertal males—analysis of size. Highly
significant differential growth; (E) Postpubertal males—analysis of
E size. Highly significant differential growth.
height. A slight increase in the length of the body of the and dentoalveolar areas during the transition from mixed
mandible was observed following TB treatment. Corpus to permanent dentition.
growth made a significant contribution to mandibular Localization of size increase in the condylar neck
development in both prepubertal males and females. region appears to relate to chondrocytic proliferation in
This pattern of development may reflect the natural the growing patient. As might be expected, the contri
process of bony remodeling, which occurs in the corpus bution of condylar growth and remodeling in the ramus
appears to increase during the pubertal stage. The degree a negative allometry that may be associated with the
of cartilaginous enlargement is greater in the adolescent insertion of the mentalis muscle. In the pubertal male,
compared to the prepubertal child. The study also however, no negative allometry is observed in the ramus,
confirmed that the TB appliance combined with extraoral gonial angle or the symphysis, but these areas appear to
traction force have a restricting effect on forward maxillary be isometric during a period of rapid growth. By contrast,
growth, and also restrict forward growth of the maxillary the distal aspect of the condylar neck consistently showed
alveolus. This finding is in common with previous studies positive allometry at all stages examined, in line with the
of the “headgear effect”. lateral pterygoid hypothesis. In normal growth, significant
A morphometric study using both EDMA and TPS bony remodeling is necessary in this area to maintain
analysis suggested that there was very little change in the shape of the mandibular ramus to compensate for
the length of the body of the mandible either following distal condylar extension, vertical extension of the ramus,
TB treatment or during untreated growth. By contrast, and thickening of the posterior border of the ramus.
the height of the ramus was shown by EDMA to increase The high degree of isotropy over the entire nodal mesh
following TB treatment. Similarly, the oblique length of in the analysis of mandibular shape confirms that a
the mandible was found to have increased slightly. Thin similar remodeling process could occur during functio
Plate Spline analysis attempts to show shape changes nal protraction in order to maintain the shape of the
in the form of deformations of grids such as those mandible.
associated with D’Arcy Thompson (1988). Examination In summary, this study attempted to model regions of
of mandibular landmarks confirmed that downward proliferative growth and remodeling using finite element
and forward rotation of the mandible occurred, and analysis. Presumably, localization of size increase in the
this method of investigation seemed to indicate that condylar neck region relates to chondrocytic proliferation
correction of the distal relationship of the mandible is in the growing patient and, perhaps not surprisingly, the
achieved predominantly by altered mandibular position, degree of cartilaginous enlargement was greater in the
rather than by altering mandibular form. adolescent compared to the prepubertal child. These
Affine transformation grids showed downward and geometric changes might reflect increased activity of the
forward rotation of the mandibular landmark configuration lateral pterygoid muscle and subsequent condylar growth
following TB treatment. Non-affine transformation grids that correlates with observed increases in mandibular
indicated that mandibular form was only slightly altered length in patients treated with TB. The morphology
on completion of treatment. This same pattern of non- of the glenoid fossa, however, was not assessed in this
affine mandibular transformation was observed in the particular study, and any translatory changes of the
longitudinal transformation indicating, therefore, that TB mandible require determination by undertaking a similar
treatment had little effect on mandibular form but rather study of the maxillary and soft-tissue matrices in patients
altered mandibular position predominantly. treated with TB.
Similarly, the present study corresponds also with
earlier findings using finite element scaling analysis, CONCLUSIONS
as positive allometry was noted in the mandibular
corpus. Other areas not related to muscle insertions • Localization of growth in the condylar neck with
show positive allometry, such as the posterosuperior concomitant remodeling of the coronoid process may
area of the ramus, the mid-region of the corpus, and reflect the correction of mandibular form achieved
the dentoalveolar process. Indeed, areas exhibiting with TBs.
isometry and negative allometry may be related to muscle • Twin Block therapy may involve developmental
attachment. Specifically, negative allometry at the gonial modulations at the condylar cartilage, remodeling of
angle and antegonial notch relates to the attachments of the ramus and corpus, and osteogenic deposition in
the masseter muscle, while isometry extends over its area dentoalveolar regions.
of insertion on the ascending ramus. Similarly, areas of • Condylar growth is greater in the postpubertal stage.
negative allometry on the coronoid process relate to the • Expansion is located in the neck of the condyle.
insertion of the tendon of the temporalis muscle. The area • Corpus extension is greater in the prepubertal stage.
of the mental protuberance and the symphysis exhibits • Prepubertal changes may relate to dental development.
• Postpubertal changes may relate to cartilaginous pro Mills CM, McCulloch KJ, (1998). Treatment effects of the Twin
liferation. Block appliance: a cephalometric study, American Journal of
• The largest growth increments are localized in post Orthodontics and Dentofacial Orthopedics. 114:15-24.
Mills CM, McCulloch KJ, (2000). Post treatment changes
pubertal males.
following successful correction of Class II malocclusions with
These results should be interpreted with caution until the Twin Block appliance, American Journal of Orthodontics
we fully understand the mechanisms involved in growth and Dentofacial Orthopedics. 118:24-33.
modification. Many studies have concentrated on the Mills JR, (1991). The effect of functional appliances on the
change in length of the mandible compared to untreated skeletal pattern, British Journal of Orthodontics. 18:267-75.
controls. More sophisticated techniques are required Morris DO, Illing HM, Lee RT, (1998). A prospective evaluation
of Bass, Bionator, & Twin Block appliances. Part 2—the soft
to determine the importance of changes in mandibular
tissues, European Journal of Orthodontics. 20:663-84.
position in growth modification. In order to resolve Moss ML, (1981). Genetics, epigenetics and causation, American
questions relating to growth modification by functional Journal of Orthodontics. 80:366-75.
mandibular protrusion, three-dimensional analysis is Moyers RE, Bookstein FL, (1979). The inappropriateness of
necessary to examine changes in mandibular form and conventional cephalometrics, American Journal of Orthodon
these studies are currently underway. tics. 75:599-617.
A similar morphometric study of maxillary growth was Nelson C, Harkness M, Herbison P, (1993). Mandibular changes
during functional appliance treatment, American Journal of
carried out on the original series of patients treated by a
combination of TBs with extraoral traction. A configura Singh GD, McNamara JA, Lozanoff S, (1997). Morphometry
tion of five landmarks encompassing the mid-facial region of the cranial base in subjects with Class III malocclusion,
was used to determine whether TBs with traction restricts Journal of Dental Research. 76:694-703.
growth of the mid-facial complex. This study concluded Singh GD, McNamara JA, Lozanoff S, (1998a). Morphometry of
that TBA treatment resulted in a “normal” Class I occlu the midfacial complex in subjects with Class III malocclusions:
sion. The improvement in facial balance was shown to Procrustes, Euclidean and cephalometric analyses, Clinical
Anatomy. 11:162-70.
be associated with restriction of anterior displacement of
Singh GD, McNamara JA, Lozanoff S, (1998b). Procrustes,
the mid-facial complex. Euclidean and cephalometric analyses of the morphology of
the mandible in human Class III malocclusions, Archives of
REFERENCES Oral Biology. 43:535-43.
Singh GD, McNamara JA, Lozanoff S, (1998c). Craniofacial
Bookstein FL, (1981). Looking at mandibular growth: some new heterogeneity of prepubertal Korean and European -American
geometrical methods. In Craniofacial Biology, ed Carlson D, subjects with Class III malocclusions: Procrustes, EDMA
University of Michigan Press, Ann Arbor, pp. 74-9. and cephalometric analyses, International Journal of Adult
Broadbent H, (1937). The face of the normal child. Angle Orthodontics & Orthognathic Surgery. 13:227-40.
Orthodontist. 7:183-208. Thompson DW, (1988). On the theory of transformations, or the
Clark WJ, (1995). Growth response to Twin Block treatment. comparison of related forms. in On Growth Form, ed Bonner
Twin Block Functional Therapy, Applications in Dentofacial JT, Cambridge University Press, Cambridge.
Orthopaedics. Mosby-Wolfe, London.
Coben SE, (1966). Growth in Class II Treatment American
journal of orthodontics. 52(1):5-26. FURTHER READING
Coben, SE, (1961). Growth concepts. Angle Orthod. 31:194-201.
DeVincenzo JP, (1991). Changes in mandibular length before, Berkowitz BK, Holland GR, Moxham BJ, (1992). A Colour Atlas
during and after successful orthopedic correction of Class II and Textbook of Oral Anatomy, Histology and Embryology,
malocclusions, using a functional appliance, American Journal 2nd edition, Wolfe Publishing, London.
of Orthodontics and Dentofacial Orthopaedics. 99:241-57. Bookstein FL, (1991). Morphometric Tools for Landmark
Ghafari J, Jacobsson-Hunt U, Higgins-Barber K, et al. (1993). Data: Geometry and Biology, Cambridge University Press,
Identification of condylar anatomy affects the evaluation of Cambridge.
mandibular growth: guidelines for accurate reporting and Bookstein FL, (1996). Combining the tools of geometric
research, American Journal of Orthodontics and Dental morphometrics. in Advances in Morphometrics, NATO ASI
Orthopaedics. 109:645-52. Series, eds Marcus LF, Corti M, Loy A, et al, Plenum Press,
Johnston LE, (1996). Functional appliances: a mortgage on man London.
dibular position, Australian Orthodontic Journal. 14:154-7. Chaplain MA, Singh GD, McLachlan JC, (1999). On growth and
Kendall DG, (1989). A survey of the statistical theory of shape, form: Spatio-temporal Pattern Formation in Biology, John
Statistical Science. 4:87-120. Wiley, Chichester.
Cole TM, (1999). Euclidean Distance Matrix Analysis Computer Moss JP, Campos JC, Linney AD, (1992). The analysis of profiles
Program, version 0.1 alpha. using curvature analysis, European Journal of Orthodontics.
Ferrario VF, Sforza C, Miani A, et al, (1993). Dental arch 14:457-61.
asymmetry in young healthy human subjects evaluated by Nute SJ, Moss JP, (2000). Three-dimensional facial growth
Euclidean distance matrix analysis, Archives of Oral Biology. 38: studied by optical surface scanning, Journal of Orthodontics.
189-94. 27:31-8.
Illing HM, Morris DO, Lee RT, (1998). A prospective evaluation Rohlf FJ, (1991). Thin Plate Spline Analysis Computer Program
of Bass, Bionator & Twin Block appliances. Part 1—the hard in Generalised Rotational Fit Computer Program, version 1.0,
tissues, European Journal of Orthodontics. 20:501-16. eds Rohlf FJ, Slice DE.
Lele S, (1993). Euclidean distance matrix analysis (EDMA): Singh GD, Clark WJ, (2001). Localisation of mandibular
Estimation of mean form AND mean form difference, Journal changes in patients with Class II Division I malocclusions
of Mathematical Geology. 25:573-602. treated with the Twin block appliance: finite element scaling
Lele S, Richtsmeier JT, (1991). Euclidean distance matrix analysis, American Journal of Orthodontics and Dentofacial
analysis: A co-ordinate free approach for comparing biological Orthopedics. 119:419-25.
shapes, American Journal of Physical Anthropo logy. 86: Slice DE, Bookstein FL, Marcus LF, et al, (1998). A glossary
415-27. for geometric morphometrics [Available from www.life.bio.
McDonagh S, Moss JP, Goodwin P, et al, (2001). A prospective sunysb edu/morph/ glossary]
optical surface scanning and cephalometric assessment of the Stangl DP, (1997). A cephalometric analysis of six Twin Block
effect of functional appliances on the soft tissues, European patients. A study of mandibular (body and ramus) growth and
Journal of Orthodontics. 23:115-26. development, Functional Orthodontist. 14:4-6, 8-14,17-19.
Growth Response to Twin Block Treatment 525
Chapter 28
Growth Response to
Twin Block Treatment
It is the customary fate of new truths to begin as heresies.

—Thomas Henry Huxley, 1825–1895
INTRODUCTION occur in the absence of skeletal and soft-tissue growth

discrepancies. In these Class II cases, the mandible and
After a century of research, there is not yet a consensus mandibular dental arch are in a distal relationship to the
within the orthodontic specialty regarding the response to maxilla; the maxillary incisor teeth are in labioversion
functional jaw orthopedics. Indeed the benefits of func (Ast et al., 1968), and the maxilla appears to protrude.
tional therapy and the validity of any orthopedic changes In a study of 277 children (8–10-year-olds) with Class II
have frequently been questioned in academic circles malocclusions (McNamara, 1981), it was concluded that
(Mills, 1991; Johnston, 1996, 1998). One of the objec 50–70% of the Class II population had a skeletal mandi
tives of this book is to update information on the effects bular retrusion. The same study determined that there
of Twin Blocks on growth, and to present a summary were more cases of skeletal maxillary retrusion than
of studies on this subject. It is imperative that clinical skeletal protrusion. This was true regardless of whether
technique has a sound basis in scientific research, rather the sella–nasion–A-point (SNA) angle or the relationship
than relying on the empirical opinions that determined of point A to the nasion perpendicular to the Frankfort
our views in the past. In evaluating the results of treat plane was used to assess maxillary position relative to the
ment, it is equally important to take into account limita cranial base.
tions imposed by previous methods of investigation and Treatment philosophy employed in the correction
research, and recognize the potential of new technology of Class II division 1 malocclusions is governed by the
to improve our understanding, and eventually to resolve orthodontist’s concept of the Class II problem, the possi
philosophical differences, which are often based more on bilities of tooth development and the relationship of
sentiment than on logical analysis. growth to treatment (Coben, 1966). To treat this class of
Throughout the past century orthodontists have expres malocclusion the molars can be tipped distally to engage
sed different views on the etiology of malocclusion and the underdeveloped mandible in a normal inclined rela
this has been reflected in the methods of treatment. A tionship, thereby attempting to establish functional and
malocclusion is almost always due to some variation in muscular stimulation to return the face and occlusion to
normal growth and development (Proffit, 1985). Class normal (Coben, 1966), but nevertheless failing to address
II malocclusion with an increased overjet is unlikely to the fundamental skeletal discrepancy.
During the 20th century, a common approach to response. This mechanism was used in the early patients
the treatment of a Class II division 1 malocclusion with in the first study. As a result of adding extraoral traction
crowding was to relieve the anterior crowding by extracting the retraction force on the maxilla was considerably
premolars and then use the available space to retract and increased. Patients exhibited a characteristic headgear
align the maxillary incisors with the mandible. However, effect with maxillary retraction and autorotation of the
this method produces undesired changes in the facial mandible in some cases, and potentially undesirable
profile in some cases, and orthodontists and patients are effects on the profile (Clark, 1988).
becoming more aware of the potential undesirable effects In the first published paper to describe the technique
on the facial profile associated with bicuspid extraction. (Clark, 1982), it was observed that the response to treat
Another approach uses extraoral traction to retract the ment varied according to the growth pattern. Patients
maxillary dentition into Class I relationship with a distally who were growing strongly exhibited a good mandibular
occluding mandible, thus avoiding premolar extractions. response, while patients who were growing slowly showed
This is often a laboriously slow process which may also more maxillary retraction. The most favorable and sus
produce an unsatisfactory profile, as the nose continues tained mandibular response occurred in boys when treat
to grow when the dentition is retracted, sometimes resul ment coincided with the pubertal growth spurt. In all of
ting in an obtuse nasolabial angle, which is not esthe the early cases, there appeared to be a combination of
tically desirable. The other alternative is to use Class II skeletal and dentoalveolar changes. The dentoalveolar
intermaxillary elastics to correct a distal occlusion, but changes appeared to be inversely related to the skeletal
this method produces undesirable anchorage loss in the adaptation and individual response apparently depended
lower arch, and resulting instability of the lower labial on the growth pattern and the timing of treatment. These
segment. As these disadvantages become more widely early conclusions were reached on the basis of clinical
realized, many orthodontists prefer a more functional experience, without the benefits of statistical analysis, but
approach (Counihan, 1998). subsequent analysis has served to confirm the accuracy
The purpose of this chapter is to review the status of of the initial clinical evaluation.
current research on growth modification in Twin Block
functional appliance therapy. Before considering the GROWTH RESPONSE TO
results of past and current research, the background of TWIN BLOCKS WITH TRACTION
development of the technique should be explained.
The first statistical study was completed in 1985 to investi
gate the changes occurring in a group of 74 consecutively
THE TWIN BLOCK TRACTION TECHNIQUE
treated patients with Class II division 1 malocclusion. The
The first Twin Block appliances were fitted in 1977 and in sample consisted of 43 girls and 31 boys aged, before
the early years of development of the technique, the author treatment, from 9 years 6 months to 14 years. The method
did not believe it was possible to enhance mandibular of examination was by serial cephalometric analysis
growth by functional mandibular advancement, on the before and during treatment, at the end of retention, and
basis of the perceived knowledge at that time. Having on average 18 months out of retention. Where possible,
routinely used extraoral traction for maxillary retraction patients were followed through to check the long-term
prior to developing Twin Blocks, the earliest patients were results several years out of retention. Tracings recorded
treated by Twin Blocks with the addition of extraoral 19 angular and 18 linear measurements to assess a range
traction. The Concorde facebow was soon developed to of craniofacial and dental changes for comparison with
apply functional orthopedic forces to enhance the action control values that relate age to growth changes. Allowance
of the inclined planes by a combination of extraoral was made for sexual dimorphism in comparison with
and intermaxillary traction. The direction of pull could controls of untreated patients.
be adapted in vertical growers to intrude the upper
posterior teeth. This was an extremely powerful functional Control Groups
orthopedic mechanism which produced rapid results, Two sets of published cephalometric standards were
and could be used to correct distal occlusion and large selected as the best available basis for comparison as
overjets, almost irrespective of the mandibular growth control values.
Control Group 1 this short period of normal growth before treatment com
menced.
This study was based on examination of 83 individuals,
The average time between the first and second X-ray
47 males and 36 females, with continuous attendance at
was 7.3 months. That included the 6 weeks pretreatment
the University School from their 6th to 16th birthdays,
period in 57 cases. This was equivalent to an average
who were X-rayed on their birthday at yearly intervals.
active stage of treatment of 6 months with Twin Blocks
Source: Riolo ML, Moyers RE, McNamara JA, et al. Cepha in addition to the pretreatment period of 6 weeks.
lometric standards from the University School Growth The control values are based on annual growth
Study, the University of Michigan. An Atlas of Craniofacial increments and in order to allow a direct comparison to
Growth. Monograph No. 2. Craniofacial Growth Series, be made, radiographs were selected as near as possible
Center for Human Growth and Development, 1979. to a year after the initial cephalograms. A correction was
Magnification: The distance from the X-ray target to the made to annualize the changes in comparison to the
mid-sagittal plane of the subject was 5 ft (152.25 cm). control. On average this includes a period of 7.3 months
The distance from the mid-sagittal plane of the head to from the initial cephalogram to the end of the Twin Block
the film surface was 7.625 in (17.84 cm). This geometry phase, followed by 4.7 months of passive support with an
produces a 12.7% enlargement in all linear measurements anterior inclined plane following the Twin Block stage.
reported in this control study.
Statistical Analysis Compared to
Control Group 2 Untreated Control Samples
This control sample examined a group of untreated The results of analysis were subjected to Students t test,
patients biased towards a Class II dental relationship. and changes were assessed as follows:
This was therefore a more appropriate control sample to • P < 0.001 = Highly significant.
use for comparison with a series of patients with Class II • P < 0.01 = Significant.
malocclusion who received treatment. • P < 0.1 = Significant.
Source: Prahl-Anderson B, Kowalski CJ, Heydendael PH.
A Mixed Longitudinal Interdisciplinary Study of Growth Michigan Series Controls (Group 1)
and Development. University of Nijmegen: San Francisco A comparison with Riolo et al. (1979) control values
Academic Press; 1979. revealed the following highly significant changes at the
level of P < 0.001:
Material and Method • Reduction of maxillary protrusion by retraction of the
A-point.
Cephalometric Analysis
• Reduction of anteroposterior skeletal discrepancy by
Serial cephalometric X-rays were taken at the following a combination of maxillary retraction and to a lesser
intervals: degree mandibular advancement.
• Before treatment commenced. • Retraction of the upper incisors.
• When the overjet was reduced. • Increase in the interincisal angle.
• On completion of stage 1—the active Twin Block • Reduction of convexity by retraction of the A-point
phase. relative to the facial plane.
• On completion of stage 2—the support phase. • Advancement of the lower incisor tip relative to
• On completion of stage 3—retention. A-Pogonion.
• Post-retention examination, on average 18 months out • Retraction of the upper molars, measured to the
of retention. pterygoid vertical.
In 57 cases, the first X-ray was taken on average • Increase in mandibular length, except in the age group
6 weeks before treatment commenced. During that 13–13.11 years.
period normal growth occurred. No correction was made • Increase in ramus height, except in ages 11–11.11
for this, and the calculation and summation of growth years and 14–14.11 years.
changes during treatment for statistical analysis includes • Increase in facial height, nasion–menton.
Nijmegen Series Controls (Group 4) Mean facial height after treatment = 123.19 mm.
Increase in facial height during treatment = 6.29 mm.
Highly significant changes were noted in the factors
Mean annual growth rate of control group for this age
compared to controls in the Prahl-Anderson series as
group = 2.58 mm.
follows:
Increased vertical growth in treatment compared to
• Reduction of maxillary protrusion by retraction of the
control = 3.71 mm.
A-point.
• Reduction of anteroposterior skeletal discrepancy by
Mandibular Growth Change in Girls
a combination of maxillary retraction and to a lesser
degree of mandibular advancement. A similar calculation was done for 43 girls, mean age
• Retraction of the upper incisors and reduction of the before treatment = 11.6 years.
overjet. Group 1: Period of treatment:
• Increase in mandibular length in the age group Mean before treatment = 106.81 mm.
10–12.5 years [articulare–gnathion (Ar–Gn)]. Mean after treatment = 110.84 mm.
• Increase in facial height (nasion–menton). Mean annual increase in Ar–Gn = 4.0 mm.
• Increase in the gonial angle, but not throughout the Mean annual growth rate of control for this age group
age range. This factor may relate to altered angulation = 1.83 mm.
of condylar growth. Increased growth compared to control = 2.17 mm.
Evaluation of Mean Growth Changes Group 2: Post-treatment observation period = 23.53 months
Mean after treatment =110.84 mm.
Mandibular Growth Change in Boys Mean after observation = 114.41 mm.
This was assessed by recording the dimension Ar–Gn as Mean annual increase during observation = 1.89 mm.
follows: Mean annual growth rate for control group for this age
group = 1.83 mm.
Group 1: Period of treatment: Growth during the observation period after treatment
For direct comparison with control values the changes was exactly equivalent to the mean growth rate of the
were examined in 31 boys during the first year of treat control sample.
ment (mean age before treatment = 11 years 9 months).
This represented on average 7.3 months of treatment Growth in Facial Height
from the initial cephalogram to the end of the Twin Block
Period of treatment (girls):
stage, followed by 4.76 months of passive support. The
Mean facial height before treatment = 117.40 mm.
mean period examined was 12.06 months, and a slight
Mean facial height after treatment = 122.33 mm.
conversion was made to record the annual change.
Increase in facial height during treatment = 4.93 mm.
Mean before treatment = 109.63 mm.
Mean increase in control for this age group = 1.16 mm.
Mean after treatment = 114.79 mm.
Increased vertical growth in treatment compared to
Mean increase in Ar–Gn = 5.16 mm per annum.
control = 3.77 mm.
Mean annual growth rate of control for this age group
= 2.71 mm. Evaluation of Results
Increased growth compared to control = 2.45 mm.
• Small increases (0.7°–2°) were noted in sella–nasion–
Group 2: Post-treatment observation period = 27.54 months B-point (SNB) angle during the Twin Block phase
Mean at end of treatment = 114.79 mm. throughout the age range with changes at the level of
Mean at end of observation = 121.02 mm. P > 0.1 occurring in the 11–13 years age group.
Mean increase in Ar–Gn = 2.71 mm per annum in • Significant reduction in angle SNA was noted [(−0.6°–
the period of observation, exactly equivalent to the −3°)] in the range of age groups 10–15 years (P > 0.01).
annual growth rate of the control sample. • Highly significant reduction in A-point–Nasion–B-
point (ANB) angle (2.3°–3.2°) in the age range 10–13.5
Growth in Facial Height years (P > 0.001) was by a combination of maxi
Period of treatment (boys): llary retraction, and to a lesser degree, mandibular
Mean facial height before treatment = 116.90 mm. advancement.
• Highly significant vertical changes were recorded in mandibular protrusion is more likely to retract the maxilla
ramus height, and this was reflected in corresponding than advance the mandible.
increases in facial height during treatment. On the question of the timing of treatment, Enlow (1983)
• Both clinical and statistical evidence indicated that stresses that “the utilization of the pubertal growth spurt
the combined functional orthopedic approach over is coming rather late.” This observation applies especially
corrected upper incisor angulation and increased the to the treatment of Class II division 1 malocclusion where
contribution of maxillary retraction in the corrected prominent upper incisors are vulnerable to trauma, and
result. It may be argued that the headgear effect would early treatment may be indicated after the eruption of
cause a secondary clockwise rotation of the mandible, permanent incisors. Class III malocclusion also responds
thus limiting the increase in the SNB angle. to early intervention in the deciduous or mixed dentition,
when the addition of forward pull traction to a facemask
Discussion may be considered to increase the potential for maxillary
advancement.
After completing this study, the author concluded that It is especially important to treat girls early because
the addition of extraoral traction limited mandibular growth slows considerably after menstruation com
advancement and resulted in overcorrection of upper mences. There is more leeway in boys, who mature later
incisor angulation and maxillary retraction. Subsequently, and still show useful growth in their middle and late teens.
the technique was used without extraoral traction, except As a general principle the response to treatment is related
in cases with significant maxillary protrusion, where directly to the patient’s rate of growth. Therefore, after the
maxillary retraction may be indicated, or in vertical mid-teenage years, the older the patient the less growth
growth where high pull traction may be indicated to we should expect and we should not presume growth
intrude upper posterior teeth. Clinical experience subse changes in adults. But this does not preclude muscular
quently confirmed that in most cases correction of advancement of retruded mandibles in adults with func
Class II malocclusion could be achieved without extra tional appliances, which may be indicated if the condyles
oral traction. are displaced posteriorly or superiorly in the glenoid
In addition, it was realized that a labial bow is not fossae.
normally required to retract the upper incisors as the The best growth response is to be expected when
development of a lip seal has the effect of uprighting the treatment coincides with the pubertal growth spurt, and
incisors. The use of a labial bow was now only indicated a comparison of early and late treatment follows later in
to control severely proclined and spaced incisors, and for this chapter.
patients with anterior open bite where incisor retraction A further cephalometric study, completed in 1995,
was required. More emphasis was now placed on compared a larger group of patients treated with Twin
advancing retroclined incisors to enhance the response Blocks with a group of patients treated with fixed appli
to functional mandibular protrusion. It should not be ances, in order to compare the growth response.
expected that all patients who undergo functional therapy
will show increased mandibular growth compared to the
TWIN BLOCKS VERSUS FIXED APPLIANCE
norm for their age. Some patients grow at a rate less
than the norm while others exceed the normal rate of A statistical comparison was made of two groups of
growth, with or without functional therapy. A lack of consecutively treated patients, both treated by the
growth response may be related to the level of endocrine author in his orthodontic practice (Clark, 1998). A group
activity that prevails at the time of treatment. If treatment of 138 Twin Block patients had an average treatment
occurs during a resting phase of growth, the potential for time of 13 months (Fig. 28.1) followed by 6 months of
increased mandibular growth is more limited. retention. A group of 30 patients received an average of
As stated in Newton’s third law of motion: “To every 27 months of treatment with fixed appliances (Fig. 28.2),
action there is an equal and opposite reaction”. Functional followed by 12 months of retention. In order to confirm
appliances, therefore, exert equal and opposite forces in that the improvements registered in mandibular growth
the opposing dental arch and have the reciprocal effect were maintained, 51 of the original group of Twin Block
of restricting the forward component of maxillary growth. patients were reviewed after 33 months (Fig. 28.3), and
If a patient grows slowly during treatment, functional 22 patients after 54 months (Fig. 28.4).
T1–T2 = 13 T/B Age Age T1–T2 = 27 Fixed Age Age

months n = 138 11y 9 m 12y 10 m Difference months n = 30 11y 9 m 14y 1 m Difference
Cranial Base Ba–Na 111.9 113.7 1.8 Cranial Base Ba–Na 107.5 111 3.5
length length
Maxillary length Ba–A 100.7 101.4 0.7 Maxillary length Ba–A 96 98.4 2.4
Mandibular Ba–Pg 108.4 113.4 5.0 Mandibular Ba–Pg 107.4 112.9 5.5
length length
Average treatment time 13 months Twin Blocks. Average treatment time 27 months with Fixed Appliances.
Fig. 28.1: Mandibular length gained 4.3 mm in 13 months compared Fig. 28.2: Mandibular length gained 3.1 mm in 27 months compared
to maxillary length. to maxillary length.
The Twin Block group was severe Class II with an the fixed appliance treatment extended over a period
average convexity of 5.4 mm, an overjet of 10.5 mm and of 2 years 3 months, compared to 13 months of Twin
a full unit distal occlusion. The fixed appliance group was Block treatment. During the period of treatment, the
mild Class II with a mean convexity of 3.9 mm, an overjet rate of mandibular growth in Twin Block treatment was
of 6.2 mm and a cusp to cusp molar relationship. double that observed during fixed appliance treatment.
The point basion was selected to measure the com This accounts for the faster correction in the Twin Block
parative lengths of the cranial base (Ba–Na), maxilla group of the more severe malocclusions compared to
(Ba–A) and mandible (Ba–Pg), and to register changes the milder skeletal and occlusal corrections in the fixed
observed. This method of measurement may make appliance group. The more severe malocclusions were
allowance for positional change in the mandible, rather corrected more quickly, and the improvement observed in
than incremental change in the length of the mandible. mandibular length was maintained by additional growth
Maxillary length, mandibular length and maxillo- increments compared to the maxillary length and cranial
mandibular difference were compared before and after base length on further evaluation out of retention at
treatment. Before treatment maxillary length was slightly 20 months and 41 months after completion of Twin Block
less in the fixed appliance group compared to the treatment. As indicated earlier in this chapter a previous
Twin Block group, while mandibular length was almost study of patients treated with Twin Blocks reinforced
identical. During treatment of the fixed appliance group, by extraoral and intermaxillary traction confirmed that
the mandibular length increased by 3.5 mm, compared to mandibular growth during an observation period of
4.4 mm in the Twin Block group. Significantly, however, approximately 2 years after completion of the Twin Block
T1–T3 = 33 T/B Age Age T1–T4 = 33 T/B Age Age

months n = 51 11y 4 m 14y 1 m Difference months n = 22 10y 9 m 15y 3 m Difference
Cranial Base Ba–Na 110.8 114.8 4.0 Cranial Base Ba–Na 111.0 116.4 5.4
length length
Maxillary length Ba–A 100.5 102.9 2.4 Maxillary length Ba–A 100.4 104.4 4.0
Mandibular Ba–Pg 107.1 115.4 8.3 Mandibular Ba–Pg 105.9 116.7 10.8
length length
Fig. 28.3: Changes 20 months Post Twin Block treatment. Mandibular Fig. 28.4: Changes 41 months Post Twin Block Treatment. Mandible
length gained 5.9 mm compared to maxillary length in 33 months. gained 6.8 mm compared to maxillary length.
phase of treatment was exactly equivalent to the mean Table 28.1: A comparision of cephalometric studies
growth rate of the control sample. Control Mills Leishman Kluzak Clark
In view of the differing opinions expressed in the Mx length 1.9 1.5 1.2 1.5 1.4
literature regarding the effectiveness of a functional increase
orthopedic approach to treatment, it is important to Md length 2.3 6.5 7.3 5.6 6.3
establish the consistency of the growth response achieved increase
by a full-time functional appliance. Data were collected Md length 0.4 5 6.1 4.1 4.9
gain
from a number of sources to record the cephalometric
changes in patients treated consecutively by the Twin Table 28.1 illustrates the mean changes in maxillary
Block technique. The patients were treated by the and mandibular length, and the gain in mandibular
following practitioners, all of whom are experienced in length compared to maxillary length during Twin Block
Twin Block technique, and have contributed examples of treatment. It is significant that Leishman’s group had the
clinical technique in previous chapters in this book. largest overjets, and Kluzak’s group the smallest overjets.
• Mills: Canada. In addition, Leishman’s appliance design incorporates
• Leishman: New Zealand. blocks of 7 mm thickness in the first premolar region. It
• Kluzak: Canada. may therefore be observed that the mandibular growth
• Clark: Scotland. response is related to the size of the overjet, and to the
amount of anterior and vertical activation built into Table 28.2: Comparision of the Twin Block appliance and the
the appliance. To compensate for these factors in the FR-2 appliance of Frankel
treatment of patients with overjets smaller than 9 mm, Control Frankel Twin block
overactivation may sometimes be indicated, either by Md length increase 2.7 4.6 5.7
advancing the mandible beyond an edge-to-edge incisor Md length gain 1.9 3
relationship, or by modifying the thickness of the occlusal
blocks to increase the vertical activation. TWIN BLOCKS FR-2 AND CONTROLS
Bass, Bionator, Twin Block and Controls A comparison of the Twin Block appliance and the FR-2
appliance of Frankel (Toth and McNamara, 1999) came
A prospective cephalometric evaluation of Bass, Bionator
to the following conclusions. Statistically significant
and Twin Block appliances compared to an untreated
increases in mandibular length were observed in both
control group was carried out at the Royal London
treated groups (Table 28.2). The Twin Block appliance
Hospital (Illing et al., 1998). The study concluded:
achieved an additional 3.0 mm of mandibular length,
• All the functional appliances produced a measurable
whereas the Frankel group increased 1.9 mm more than
change in the skeletal and dentoalveolar tissues, with
did the controls. No significant restriction in maxillary
the untreated sample showing minimal change due to
length was observed in either functional appliance
growth alone.
group relative to controls. A significant increase in
• The appliance groups all demonstrated a forward
lower anterior face height was evident in both treated
movement of pogonion and a more pronounced
groups. Vertical increase in the Twin Block patients was
downward movement of menton in comparison with
significantly greater than in the FR-2 group. In general,
the control group. The anterior movement of the
more extensive dentoalveolar adaptation was observed
mandible was greatest in the Twin Block group, fol
lowed by the Bass and Bionator groups, respectively. with the tooth-borne Twin Block appliance than with the
Significant increases in total face height (P < 0.01), more tissue-borne FR-2. Both samples showed significant
suggesting that the Bass appliance, by incorporating retroclination and extrusion (eruption) of the maxillary
headgear, is effective in limiting the vertical develop incisors. The Twin Block patients also exhibited distal
ment of the maxilla. movement of the upper molars; however there was no
• The Twin Block group demonstrated greater restric extrusion. Slight lower incisor proclination was noted in
tion of anterior movement of A-point than the Bass both treatment groups, and lower molar extrusion was
group. Highly significant reduction of ANB compared found to be significantly greater in the Twin Block group
with Bass and controls may be attributed to rotation of compared with the other two samples. No horizontal
the maxillary plane observed in the Twin Block group. differences were detected in the lower molars among
groups. It was concluded that Class II correction with the
Twin Block appliance is achieved through normal growth
TWIN BLOCKS AND MATCHED
in addition to mandibular skeletal and dentoalveolar
NORMATIVE GROWTH DATA changes. Class II correction with the FR-2 is more skeletal
In a comparative study with matched controls, Trenouth in nature, with less dentoalveolar change.
(2000) found an increase in mandibular length of
7.19 mm [condylion–pogonion (Co–Pog)] compared to TWIN BLOCK APPLIANCE
4.0 mm in controls. This study concluded that the Twin TREATMENT EFFECTS
Block appliance not only results in forward positioning
of the mandible, but also lengthening as shown by linear The following account is based on studies by Mills and
measurements. By comparison, restraint of maxillary McCulloch (1998, 2000) to investigate the growth response
growth was shown to be purely minimal and not during Twin Block treatment, with a follow-up to examine
clinically significant. The correction of Class II dental post-treatment changes (Fig. 28.5). A contribution by
base relationship was greater than that reported for the Christine Mills is the source of a summary of the findings
Andresen and Frankel appliances and comparable to that reported here, while the published articles provide a
reported for the Herbst appliance. comprehensive account.
Methods and Materials Treatment Effects on the Maxilla

A comparison was made between a sample of 28 conse The Twin Block appliance had an inhibiting effect on the
cutively treated patients (11 boys and 17 girls) and growth of the maxilla as evidenced by a 0.9° decrease
matched controls selected from the Burlington study. in angle SNA as compared to a 0.1° increase in angle
All of the patients were in the mixed dentition stage of SNA in the untreated control group.
development, had an angle ANB difference of 5° or more,
and a full cusp Class II molar relationship on one side Treatment Effects on the Mandible
and an end-to-end or greater Class II molar relationship The mandibular unit length (as measured from condylion
on the other side. The mean age and sex distribution of to gnathion) increased nearly three times as much in the
this control group was identical to that of the Twin Block Twin Block group as in the controls. Approximately two-
treatment group. In addition, the controls were matched thirds of the overall increase in mandibular length in
to the treatment group with respect to the vertical the treatment group can be attributed to an increase in
facial pattern. mandibular ramus height (Table 28.3).
These mandibular growth changes in turn account for
Statistical Analysis a 1.9° increase in angle SNB in the treatment group as
Detailed statistical analysis involved the calculation of compared to only a 0.3° increase in the untreated control
means and standard deviations for the 31 cephalometric group.
variables. When the composite tracings of the two groups
were superimposed the maxillary structures were almost DENTOALVEOLAR CHANGES
identical, but due to the difficulty in finding severe skeletal
Class II individuals for the control group, the mandibles In spite of the fact that no labial bows were used on
in the Twin Block treatment group were considerably any of the Twin Block appliances in this study, there
more retrognathic at the initial observation time (T1) than was nevertheless an uprighting effect on the upper inci
the mandibles of the control group. sors. The lower incisors proclined 5.2° in the Twin Block
group compared to 1.4° in the control group (Table 28.4).
Although this labial tipping of the lower incisors contrib
utes somewhat to the 5.6 mm of overjet correction that
occurred in the Twin Block group, nearly two-thirds of the
overjet correction was accounted for by forward growth
of the mandible (Fig. 28.6A). The overjet change in the
control group was minimal. In the Twin Block treatment
group the net reduction in the Class II molar relationship
was 6.2 mm compared to a reduction of only 0.4 mm in
Table 28.3: Treatment effects on the mandible

Control Twin Block Twin Block gain
Md length increase 2.3 6.5 4
Ramus height 1.2 4.1 2.9
Md Corpus (Go-Gn) 1.7 3 1.3
SNB Angle 0.3° 1.9° 1.6°
Table 28.4: Dentoalveolar changes

Controls Twin Block
Fig. 28.5: Custom analysis used by Mills and McCulloch to measure Upper incisors + 0.2° – 2.5°
horizontal distances from skeletal and dental landmarks to a vertical Lower incisors +1.4° + 5.2°
reference plane constructed through sella and perpendicular to the
Overjet + 0.3 mm – 5.6 mm
palatal plane.
A B
Figs. 28.6A and B: Skeletal and dental changes in the (A) Twin Block treatment group between T1 and T2 and (B) in the control group
between T1 and T2.
the control group. Approximately 50% of the molar cor Results

rection was accomplished by skeletal improvement in the
lower jaw and 50% by dentoalveolar change in the upper A study was completed of 31 cephalometric variables to
and lower molars (Fig. 28.6B). assess post-treatment changes in the Twin Block group
compared to untreated Class II controls. Only 5 of the
31 variables showed statistically significant differences
POST-TREATMENT STABILITY between the two groups when Student’s t-tests were used
To better understand the impact of this appliance on to compare rates of change.
growth and development over the long term, the patients Of the five variables showing statistically significant
from the Twin Block study outlined above were followed differences, four were dental measurements. The only ske
for approximately 3 years post-treatment (Mills and letal variable that showed a statistically significant diffe
McCulloch, 2000). rence in growth rate during the post-treatment follow-up
was the ramus height as measured from condylion to
Methods and Materials gonion (Co–Go).
Of the original sample of 28 consecutively treated severe

Maxillary Changes Post-Treatment
skeletal Class II patients (mean age at start of treatment
9 years 1 month), a total of 26 individuals were available None of the three cephalometric variables used to assess
for follow-up cephalometric tracings at a mean age of maxillary growth showed any statistically significant diffe
13 years 1 month (T3). Of these 26 patients, 11 were males rences in the post-treatment phase. However, there was
and 15 were females. a trend toward reduced forward growth of the maxilla in
A comparison group of 24 Class II individuals (11 the Twin Block group from T2 to T3. The measurements
males, 13 females) obtained from the Burlington group for angle SNA, maxillary unit length (Co–SubANS) and
provided data for the control group. This control group the horizontal distance from point A to the vertical refer
had a mean age of 9 years 1 month at the time of the ence plane, all suggest that slightly less forward maxillary
initial observation (T1) and 12 years 11 months at the growth was taking place in the Twin Block group than in
time of the final follow-up cephalometric tracing (T3). the untreated controls at the same age.
Table 28.5: Mandibular changes post-treatment 1.2 mm in the Twin Block group as compared to almost
Control Twin Block no change (0.1 mm) in the control group (P < 0.05).
Md length increase 6.7 6 0.7 Control gain
• The Twin Block appliance as used in this study pro
vided mandibular growth increments greater in mag
Ramus height 4.3 2.7 1.6 Control gain
nitude than those obtained with other removable
Md Corpus (Go-Gn) 4.5 5.2 0.7 TB gain
functional appliances described in the literature. In
addition, the direction of the mandibular growth was
Mandibular Changes Post-Treatment (Table 28.5) favorable and thus contributed substantially to the
anteroposterior skeletal correction.
Most of the mandibular changes in the Twin Block group
• Johnston (1996, 1998) has suggested that functional
during the post-treatment phase indicate a tendency
appliances work temporarily by using up the man
toward reduction of the growth rate compared to the
dibular growth potential in advance. In fact, he pro
controls. However, only one of the variables used to poses that there is a limited or preordained amount
assess mandibular growth changes in this study showed of mandibular growth that can occur in any particular
a significant difference between the two groups. This patient.
variable was the ramus height as measured from con • By contrast, the present study indicates that much of
dylion to gonion (Co–Go). In the 3 years post-treatment, the gain in mandibular length achieved during the
this measurement increased 2.7 mm on average in the active treatment with the Twin Block appliance was
Twin Block group and 4.3 mm on average in the control maintained 3 years later (Figs. 28.7A and B). When
group. The net 1.6 mm difference was statistically compared post-treatment, the Twin Block and con
significant at the P < 0.05 level. trol group experienced similar growth characteristics
A decline in growth rate in the mandibular unit in the mandible (Figs. 28.8 to 28.10).
length of 0.7 mm in the Twin Block group compared to
the controls is compensated by a corresponding increase Conclusion
in corpus length of the same amount. Although this
This study has shown that the Twin Block appliance can
difference was not statistically significant, it may have the
achieve substantial skeletal improvement in young grow
effect of offsetting some of the rebound seen elsewhere in
ing Class II individuals. Much of this skeletal improve
the mandible so that the net change in angle SNB is not
ment is related to increases in mandibular length and
much different in the two groups (0.3°).
these changes are, for the most part, stable 3 years post-
treatment.
Dental Changes Post-Treatment
The greatest differences between the Twin Block and
control groups in the T2–T3 phase were seen in the molar
INTERPRETATION OF GROWTH CHANGES
and incisor measurements. In particular, there was an Superimposed composite tracings of the mandible from
uprighting tendency for the lower incisors in the Twin the study CM Mills and KJ McCulloch (1998, 2000) of
Block group. patients treated with Twin Blocks in comparison with
The net residual proclination of the lower incisors in matched controls show evidence of elongation of the
the Twin Block group compared to the control group was condylar neck in addition to a change of direction of the
thus only 1.7°. growth of the condyle to a more distal vector.
The upper incisors showed some tendency to rebound An interesting pattern is observed, whereby the gonial
as well but this difference in response was not statistically angle frequently increases during the Twin Block stage of
significant. treatment and this is followed by an increase in corpus
These changes in incisor angulations contributed an length during the post-treatment period.
increase in overjet of 1.0 mm on average in the Twin This may be interpreted as indicating a change in the
Block group compared to a slight decrease (−0.1 mm) in direction of condylar growth to a more distal direction during
the controls. This difference was statistically significant at the period of active mandibular propulsion, followed by
the P < 0.01 level of confidence. The molar relationship as remodeling of the mandibular ramus in the post-treatment
measured in the sagittal plane showed a mean relapse of period to restore the original shape of the mandible.
During the Twin Block phase there is significant consistently during support phase and retention when
increase in ramus height (red line) compared to con the posterior border of the ramus remodels to restore the
trols. An increase in corpus length (blue line) occurs original shape of the mandibular outline.
A B
Figs. 28.7A and B: Controls, T1: 9 years 1 month; T2: 10 years 2 months; T3: 12 years 11 months. Twin Blocks, T1: 9 years 1 month;
T2: 10 years 2 months; T3: 13 years 1 month.
A B
Figs. 28.8A and B: Controls, T1: 9 years 1 month; T2: 10 years 3 months; T3: 13 years 1 month. Twin Blocks, T1: 9 years
1 month; T2: 10 years 2 months; T3: 12 years 11 months.
A B
Figs. 28.9A and B: Skeletal and dental changes in the Twin Block treatment group during active treatment (T2–T1) and following treatment
(T3–T2).
A B
Figs. 28.10A and B: Skeletal and dental changes in the untreated Class II control group from ages 9 years 1 month to 10 years 2 months
(T2–T1) and from age 10 years 2 months to 12 years 11 months (T3–T2).
TEMPOROMANDIBULAR JOINT condyle changes as the anterior notch is lost and the
ADAPTATIONS FOLLOWING TWO condylar head becomes rounded as the condyle becomes
carrot shaped. This is clear evidence of accelerated con
PHASE THERAPY: A MAGNETIC
dylar growth.
RESONANCE IMAGING STUDY
The carrot shape of the condyle is reminiscent of
Wadhaven, Kumar, Kharbanda, et al. the early studies of the pig mandible using madder and
Recent research by magnetic resonance imaging reveals alizarin staining by Brash (1924) (Fig. 28.11B).
the pattern of bone remodeling that occurs in the man After treatment the head of the condyle regains the
dibular condyle during Twin Block therapy. anterior notch and the flat contour of the posterosupe
Before treatment the head of the condyle has a pro rior surface (Fig. 28.11C). This is important new evidence
nounced anterior notch and a flattened contour on the of accelerated growth of the condyle during Twin Block
posterosuperior surface (Fig. 28.11A). The shape of the therapy.
A B
Figs. 28.11A to C: Magnetic resonance imaging reveals the pattern

of bone remodeling that occurs in the mandibular condyle during Twin
Block therapy. (A) Condyle before treatment—pronounced anterior
notch, flat posterosuperior contour; (B) Condyle after Twin Blocks—
carrot shaped, head has rounded contour; (C) After treatment—
shape of condyle is restored, pronounced anterior notch and flat
C posterosuperior contour.
TWIN BLOCK THERAPY TREATMENT mandible in the late-treated group was concomitant with
significant changes in the direction of condylar growth.
The following report is based on a published paper by Late-treated individuals showed significantly more back
Franchi et al. (2000) on the subject of treatment timing ward direction of growth in the mandibular condyle, as
in Twin Block therapy. This cephalometric study evalu revealed by the significant opening of the angle formed by
ated skeletal and dentoalveolar changes induced by the the condylar line in relation to the mandibular line (cl–ml,
Twin Block appliance in two groups of subjects with 2.8°/year). This growth modification has been described
Class II malocclusion treated at different skeletal matu previously as “posterior mandibular morphogenetic rota
ration stages (before and during the pubertal peak in tion” (Lavergne and Gasson, 1977), a biological mecha
mandibular growth) in order to define the optimal tim nism leading to greater increments in total mandibular
ing for this type of therapy. Skeletal maturity in individual length and thus, efficiently improving the skeletal sagittal
patients was assessed on the basis of the stages of cervical relationships in Class II malocclusion.
vertebrae maturation. The method of determining skeletal Further investigation, however, is needed in order to
maturity is described in detail in a published article refer clarify the role of glenoid fossa modifications following
ring to this study. The findings of this short-term cephalo protrusive mandibular function in groups treated at diffe
metric study indicate that optimal timing for Twin Block rent stages of skeletal maturation.
therapy of Class II disharmony is during or slightly after
the onset of the pubertal peak in growth velocity. When Comparison of Herbst and Twin Block (Table 28.7)
compared with treatment performed before the peak, late
Twin Block treatment produces more favorable effects Due to the similarity in skeletal maturation at the start
that include: of treatment and in the nature of control groups, the
• Greater skeletal contribution to molar correction. results of the present study with regard to the late-
• Larger increments in total mandibular length and in treated group can be contrasted with the effects induced
ramus height. by the acrylic splint Herbst appliance as analyzed in a
• More posterior direction of condylar growth, leading previous investigation by the authors of this study. Twin
to enhanced mandibular lengthening and to reduce Block therapy is able to produce greater increments in
forward displacement of the condyle in favor of mandibular length and in the height of the mandibular
effective skeletal changes. ramus (Franchi et al., 2000).
• The importance of the biological evaluation of skel
etal maturity in individual patients with Class II dis Comparison of Frankel and Twin Block (Table 28.8)
harmony to be treated with functional appliances is Of some interest also is the comparison of the Twin Block
emphasized. treatment results with those produced by the Fränkel
Late treatment with the Twin Block starting during appliance by McNamara (1981).
or slightly after the onset of the peak in mandibular Although the significance of a direct comparison
growth appears to be more effective than early treatment, among different appliances in separated investigations is
as it induces more favorable mandibular skeletal modi limited by a series of factors, two major considerations
fications. may still be deducted:
1. The assessment of the growth potential and of the
Supplementary Elongation of the Mandible stage of skeletal maturation in individual patients
Compared to Controls (Table 28.6)
The amount of supplementary elongation of the mandible Table 28.7: Comparison of Herbst and Twin Block
in the late-treated group was more than twice that of the Increase (mm/year) Herbst Twin Block
early-treated group. The greater additional growth of the Mandibular length 2.7 8
Ramus height 1.2 2.7
Table 28.6: Supplementary elongation of the mandible compared
to controls Table 28.8: Comparison of Frankel and Twin Block
Gain vs controls mm/year Early treatment Late treatment Supplementary bi-annual increments of growth with Twin Blocks
Mandibular length (Co–Pg) 1.88 4.75 vs Frankel
Ramus height (Co–Go) N.S. 2.73 Mandibular length 3.6 mm/2 years
Corpus height (Co–Pg) N.S. 1.66 Ramus height 3.1 mm/2 years
definitely is important for treatment effectiveness, To catch dame Fortune’s golden smile
regardless of the functional/orthopedic appliance that Assiduous wait upon her,
is used to correct the skeletal disharmony. And gather gear for ev’ry wile,
2. Both the Twin Block and the FR-2 appear to be more That’s justified by honour.
effective in inducing supplementary mandibular leng Epistle to a young friend
thening than the acrylic splint Herbst appliance. (Robert Burns 1759–1796)
SUMMARY REFERENCES
Optimum treatment timing for Twin Block therapy of Ast DB, Carlos JP, Cons NC, (1965). The prevalence and charac
Class II disharmony appears to be during or slightly after teristics of malocclusion among senior high school students
the onset of the pubertal peak in growth velocity. Major in upstate New York, American Journal of Orthodontics. 51:
437-45.
favorable effects induced by functional therapy at this
Clark WJ, (1998). The Twin Block Technique: a functional
time in comparison with earlier phases are: orthodontic appliance system, American Journal of Ortho
• Greater skeletal contribution to the correction of the dontics and Dentofacial Orthopedics. 93:1-18.
molar relation. Clark WJ, (1982). The Twin Block Traction Technique, European
• Larger and clinically significant increments in total Journal of Orthodontics. 4:129-38.
mandibular length and in ramus height. Coben ES, (1966). Growth and Class II treatment, American
• More posterior direction of condylar growth, a biolog
Enlow DH, (1983). Enlow on craniofacial growth, ICO interviews,
ical mechanism enhancing supplementary mandibu ICO. 17:669-79.
lar lengthening and reducing the amount of forward Franchi L, Baccetti T, McNamara JA, (2000). Mandibular growth
condylar displacement in favor of effective mandibu and cervical vertebrae maturation and body height, American
lar growth and reshaping. Journal of Orthodontics and Dentofacial Orthopedics. 118:
335-40.
CONCLUSION Franchi L, Baccetti T, McNamara JA, (2000). Treatment timing
for Twin-block therapy, American Journal of Orthodontics
As stated in the Preface, the purpose of this book is to and Dentofacial Orthopedics. 118:159-70.
advance the recognition of dentofacial orthopedics as the Illing HM, Morris DO, Lee RT, (1998). A prospective evaluation
treatment of choice for correction of malocclusion that of Bass, Bionator and Twin Block appliances, Part 1—the hard
tissues, European Journal of Orthodontics. 20:501-24.
results from abnormal skeletal developments. As new
Johnston LE, (1998). ‘Early and often: growing jaws for fun
information becomes available from research, philo and profit.’ in Salzmann Lecture, 98th Annual Session of the
sophical differences expressed in the past will surely be American Association of Orthodontists, San Diego.
resolved in the application of dentofacial orthopedics. Johnston LE, (1996). Functional appliances: a mortgage on
mandibular position, American Journal of Orthodontics. 14:
Time’s Glory is to calm contending kings to unmask 154-6.
falsehood and bring truth to light. Lavergne J, Gasson N, (1977). Operational definitions of mandi
The Rape of Lucretia bular morphogenetic and positional rotations, Scandinavian
(William Shakespeare 1564–1616) Journal of Dental Research. 85:185-92.
McNamara JA, (1981). Components of Class II malocclusion
In the pursuit of ideals in orthodontics, facial balance in children 8-10 years of age, Angle Orthodontist. 51:
and harmony are of equal importance to dental and 177-202.
occlusal perfection. We cannot afford to ignore the Mills CM, McCulloch KJ, (2000). Post treatment changes
importance of orthopedic techniques in achieving these following successful correction of Class II malocclusions with
goals by growth guidance during the formative years of the Twin Block appliance, American Journal of Orthodontics
facial and dental development. and Dentofacial Orthopedics. 118:24-33.
Mills CM, McCulloch KJ, (1998). Treatment effects of the Twin
At the dawn of a new century, the integration of
Block appliance: a cephalometric study, American Journal of
orthodontic and orthopedic techniques offers a new Orthodontics and Dentofacial Orthopedics. 114:15-24.
challenge in restoring facial balance for patients who Mills JR, (1991). The effect of functional appliances on the
present skeletal growth discrepancies. skeletal pattern, British Journal of Orthodontics. 18:267-75.
Prahl-Anderson B, Kowalski CJ, Heydendael PH, (1979). A FURTHER READING

mixed longitudinal interdisciplinary study of growth and 434
Twin Block Functional Therapy—Application in Dentofacial Carmichael GJ, Banks PA, Chadwick SM, (1999). A modification
Orthopedics development, Academic Press University of to enable progressive advancement of the Twin Block appli
Nijmegen, San Francisco. ance, British Journal of Orthodontics. 26:9-13.
Proffit WR, (1986). On the aetiology of malocclusion, British Chadwick SM, Banks P, Wright JL, (1998). The use of myofunc
Journal of Orthodontics. 13:1-11. tional appliances in the UK: a survey of British orthodontists,
Riolo ML, Moyers RE, McNamara JA, et al, (1979). An atlas of Dental Update Publication. 25:302-8.
cranofacial growth. Monograph No. 2. Craniofacial Growth Lund DI, Sandler PJ, (1998). The effects of Twin Blocks: a
Series, Center for Human Growth and Development, prospective controlled study, American Journal of Orthodontics
University of Michigan. and Dentofacial Orthopedics. 113:104-10.
Symons NB, (1981). Studies on the growth and form of the Petrovic A, Stutzmann J, Lavergne J, (1990). ‘Mechanism of cran
mandible, Journal of Dental Research. 71:41. iofacial growth and modus operandi of functional appliances:
Toth LR, McNamara JA, (1999). Treatment effects produced by a cell-level and cybernetic approach to orthodontic decision
the Twin-block appliance and the Fr-2 appliance of Frankel making’. in Craniofacial Growth Theory and Orthodontic
compared with an untreated Class II sample, American Treatment, Craniofacial Growth Monograph series, vol. 23,
Journal of Orthodontics and Dentofacial Orthopedics. 116: ed Carlson DS, Center for Human Growth and Development,
597-609. University of Michigan, Ann Arbor.
Trenouth MJ, (2000). Cephalometric evaluation of the Twinblock Turner M, Guiltan AS, (1999). Comparison of the effects of
appliance in the treatment of Class II division 1 malocclusion monobloc and twin-block appliances on the skeletal and
with matched normative growth data, American Journal of dentoalveolar structures, American Journal of Orthodontics
Orthodontics and Dentofacial Orthopedics. 117:54-9. and Dentofacial Orthopedics. 116:460-8.
Art and Science in Orthodontics 543
Chapter 29
Art and Science in Orthodontics
It is the customary fate of new truths to begin as heresies.

—Thomas Henry Huxley, 1825–1895
DENTAL CHESS Equally important is the board on which we play our

dental chess (Figs. 29.1 and 2).
Orthodontics combines Art and Science, and each is of “The study of orthodontia is indissolubly connected
equal importance. We have gone full circle and return to with that of art as related to the human face. The mouth
the analogy of orthodontics as the dental equivalent of is a most potent factor in making or marring the beauty
chess. The game is played with 32 ivory pieces that are and character of the face, and the form and beauty of
arranged symmetrically about the midline on a board the mouth largely depend on the occlusal relations of the
in two equal and opposing armies. If we concentrate teeth”.
too much on the individual pieces we lose the game. — Edward Angle, 1907
Fig. 29.1: We play dental chess with 32 ivory pieces set on a board. Fig. 29.2: Equally important is the face, the board on which we
It is a mistake to concentrate exclusively on the pieces. play and the ultimate objective is to produce balance and harmony
in the face.
THE ROLE OF SCIENCE IN ORTHODONTICS TWIN BLOCK STUDIES

It has long been recognized that science plays an impor In recent years “evidence-based” studies have become the
tant part in the study of orthodontics, and the findings of accepted standard of investigation in medical research.
scientific research have direct implications in orthodontic Advances in computer technology facilitated statistical
practice. analysis, which now forms the basis of many academic
In mechanical terms orthodontic tooth movement is studies, to a large extent replacing the philosophical hypo
governed by the laws of physics. The principle of anchor theses of past generations. In a practical subject such as
age is based on Newton’s third law of motion, “To every orthodontics many advances in the past were based on
action there is an equal and opposite reaction”. Leverage clinical experience, usually supported by evidence from
and torque are essential elements in the design and func clinical records in retrospective studies. The basic princi
tion of orthodontic appliances. ples have not changed, although the investigative tech
Many scientific techniques have been employed in niques have become more sophisticated.
research to advance our knowledge of the biological and
mechanical aspects of orthodontics. Histological studies Retrospective Statistical Studies
have made important contributions to our understand
ing of growth and development. Cephalometrics is used All of the early studies were retrospective as the available
extensively as a diagnostic tool and as a means of moni data was collected prior to the advent of desktop or laptop
toring progress and evaluating the results of treatment. computers. Provided the selection criteria were clearly
This has been a major tool in the study of facial growth defined and rigorous, using a large sample of consecu
in treated and untreated subjects to determine the effect tively treated patients, with appropriate controls, retro
of orthodontic and orthopedic treatment on facial growth. spective studies provided useful information. By today’s
More recent studies using magnetic resonance imag standards they were relatively inexpensive.
ing give more detailed information on growth mecha The author defended a DDSc thesis “New Horizons in
nisms. Electromyography has been used to study the Orthodontics: Aspects of Twin Block Functional Therapy”
action and interaction of muscles and to examine the in 2010, based on statistical analysis of all patients trea
relationship between form and function. New laser and ted with Twin Blocks in his practice between 1977 and
computer techniques are beginning to shed light on 1990. The retrospective study examined 148 consecutively
three-dimensional imaging in growth studies. Biological treated patients and reported a failure rate of 6.7%. In
research with advances in biochemistry and genomics 13 years, 10 patients failed to complete treatment.
are improving our knowledge of the underlying factors The original statistical work was completed using a
controlling growth mechanisms at cellular and molecular program written on a mainframe computer, before desk
level. top or personal computers were in common use. The
The list is endless and the role of scientific studies in results were verified in the department of statistics at the
many fields is of utmost importance in the development University of Dundee. Since that time statistical studies
of our speciality. In research it is important to differentiate have become the accepted standard as a mainstay of aca
between pure science and statistics. It is inevitable that demic research. This is a dangerous trend in a clinical
computers have made statistical analysis accessible as an discipline as it can divert attention away from treatment
easy option in academic research in almost any field. of the individual patient.
LIMITATIONS OF STATISTICAL ANALYSIS A Randomized Controlled Trial

ML Moss (1981) observes that: A prospective multicenter randomized controlled trial
“As statistics developed, the effects of various types of (RCT) (O’Brien et al. 2003), compared the effectiveness
treatment could be statistically analyzed, although at times of treatment for Class II malocclusion with the Herbst
as various observers have pointed out some of the statistical or Twin Block appliances. This study reported a failure
differences have been found to be clinically meaningless”. to complete rate for the functional phase of treatment
Statistical methods are limited as a means of measur of 12.9% for Herbst and 33.6% for Twin Blocks. In the
ing aesthetic factors. Clinical examination supported by discussion of results, the authors reported that provision
photographic records may be more effective in interpret of treatment at no cost to the child and parents, and
ing subtle changes in facial form, which may or may not poor socioeconomic background may be factors in poor
be statistically significant. This does not deny the value cooperation and failure to complete treatment. However,
of statistical methods but there is an obvious danger of
appliance design was identified as a major factor in
relegating aesthetic judgment to the level of statistics.
patient acceptance.
Statistical analysis as a means of evaluating the results
The multicenter RCT concluded that “the Twin Block,
of orthodontic treatment represents a revolution that has
perhaps because of the bulky acrylic blocks, caused more
occurred during the author’s career in orthodontic prac
problems than did the Herbst appliance in eating and
tice. The presentation and publication of case records
speaking. Arguably, the patient might repeatedly remove
is no longer an accepted regimen in clinical research.
the appliance, thus influencing the success of treatment”.
Instead many orthodontic journals might easily be mis
Incorrect bite registration, appliance design and clini
taken for journals on statistics, with little reference to
cal management cause problems of patient acceptance.
the daily practice of orthodontics. There is a danger that
A failure rate of 33.6% is unacceptable and would rep
by relegating clinical study of the individual patient we
lose touch with the fundamental basis of the speciality resent a financial and ethical disincentive to use the
of orthodontics. Statistical study is not capable of solving technique.
all clinical problems. In separate studies the failure to complete rate is
Perhaps it is time to pause and reflect whether clini reported as 9% (Illing et al., 1998) and 15% (Harradine and
cal orthodontic experience remains a valid alternative Gale, 2000). A study by the author of 148 consecutively
to statistics in evaluating the merits of different ortho treated patients by the Twin Block traction technique in
dontic techniques, especially as they apply to individual the period from May 1979 to May 1990 found a 6.7% failure
patients. We can learn as much from the study of indi to complete treatment (Clark, 2010). This represents the
vidual patients as we can from a cross-sectional study of success rate in an efficiently run orthodontic practice
a group of patients. If we demonstrate truth by a single where patients did not contribute to the cost of treatment,
example the onus is on a contestant to disprove the con compared to the failure rate experienced in a series of
trary. Bayes’ theorem states that a probability may be sub public authority clinics.
jectively assessed and revised in the light of experience. Aesthetic appliances with comfortable blocks are well
Illustrated case reports are relevant in this context and tolerated by patients and this results in a low failure rate.
that is the fundamental basis for this book. THe author was not consulted in the protocol for the RTC
Diagnosis, treatment planning and clinical protocol on Twin Blocks, and the results do not represent the cor
for the individual patient remain the most important rect design and management of Twin Block technique
aspect of successful treatment. (Figs. 29.3A to D).
PITFALLS IN DESIGN AND MANAGEMENT

OF TWIN BLOCKS In addition, clasps were placed on the lower molars
Appliance design and clinical management are crucial and they were covered with acrylic. This approach does
factors in the protocol for any academic study. Shortly not address correction of the vertical dimension, and
after the author developed Twin Blocks the appliances resulted in a large posterior open bite at the end of the
were modified with excessive height of the occlusal blocks Twin Block phase. Unfortunately the protocol of exces
in a study to accommodate magnets (Figs. 29.3A and B). sively thick blocks and failure to manage the vertical
This departed from the original concepts of design and dimension was perpetuated in subsequent academic
management. studies. When used correctly Twin Blocks are comfort
The bite opening is excessive and it is difficult or able and aesthetic appliances with high patient accept
impossible for patients to eat and speak with the appli ance and a low failure rate. Clinical management should
ances in the mouth. Appliances that are not aesthetic permit control of the vertical dimension, so that correc
and comfortable are not worn consistently. Facial height tion is achieved in the sagittal, transverse and vertical
is increased excessively and the patient looks and feels dimensions throughout the Twin Block stage. The molars
uncomfortable with these appliances. This results in a should be in occlusion at the end of the Twin Block phase
high failure rate. to support the temporomandibular joint.
Unaesthetic Appliances with Excessively Thick Occlusal Blocks

Clasps on Lower Molars Prevent Eruption for Vertical Control
A B
C D
Figs. 29.3A to D: Twin Blocks with excessively thick blocks to accommodate magnets. Courtesy of J.P. Moss (Personal communication,
European Orthodontic Congress, 1980). This approach did not control the vertical dimension as it prevented lower molar eruption and
produced a large posterior open bite after the Twin Block stage.
ERRORS IN BITE REGISTRATION Block appliances. The authors propose that an ideal wax
bite should be “at least 7 to 8 mm thick” in the premolar
The same errors in appliance design and clinical manage region (Figs. 29.4A to C).
ment are still evident 30 years later as excessively thick This method of recording a construction bite shows a
blocks were responsible for the high failure rate in the 10 mm vertical interincisal space. Large blocks produce
multicenter randomized controlled trial (RCT). a large posterior open bite after the Twin Block phase.
An article “How to …. take a wax bite for a Twin Clasping lower molars fails to control the vertical dimen
Block appliance” (Shah and Sandler, 2009) identifies fac sion in treatment of deep overbite, resulting in a large
tors that cause problems in patient acceptance of Twin posterior open bite after the Twin Block stage.
Incorrect Bite Registration
A B C
Figs. 29.4A to C: This method of bite registration produced appliances with excessively thick blocks. This was responsible for the high
failure rate in the Twin Block Multicentre Randomized Controlled Trial. (O’Brien K, Wright K, Conboy F, et al, 2003).
Correct Bite Registration and A typical bite registration for a Class II division 1
Aesthetic Appliance Design malocclusion with an overjet of up to 10 mm and deep
overbite is edge to edge with a small inter-incisal space
When used correctly, Twin Blocks are comfortable and of 2 mm. The basic principle of appliance design is
aesthetic appliances with high patient acceptance and to provide a comfortable aesthetic appliance that the
a low failure rate. Clinical management should permit patient can wear full time. This allows the patient to eat
control of the vertical dimension so that correction is and speak with Twin Blocks in the mouth and eliminates
achieved in the sagittal, transverse, and vertical dimen problems of patient compliance and failure to complete
sions throughout the Twin Block stage. The molars should treatment (Figs. 29.5A to D).
be in occlusion at the end of the Twin Block phase to
support the temporomandibular joint.
A B
C D
Figs. 29.5A to D: This is a typical bite registration for Class I division 1 malocclusion with an overjet of up to 10 mm. Appliance design
for aesthetic Twin Blocks in the author’s practice. Correct bite registration and aesthetic appliance design improves the success rate with
Twin Blocks.
CONTROL OF THE VERTICAL The correct construction bite in Class II Division 2

DIMENSION malocclusion with excessive overbite is edge to edge on
the incisors.The upper appliance should include springs
An essential feature of treatment of Class II Division 1 and or screws to procline upper incisors in preference to
Division 2 malocclusion with deep overbite is to develop torquing springs. There is a large posterior open bite after
the vertical dimension by encouraging eruption of lower the Twin Block stage with contact only on the retroclined
molars to reduce the overbite and level the excessive upper incisors, with no occlusal support for the temporo
curve of Spee (Figs. 29.6A to F). mandibular joint.
A B
C D
E F
Figs. 29.6A to F: Incorrect design and management. Excessively thick occlusal blocks and lack of vertical control produce a posterior open
bite at the end of the Twin Block Stage.
VERTICAL CONTROL OF DEEP OVERBITE During the support phase a retainer with an anterior
inclined plane is worn to support the corrected incisor
Vertical control is essential in management of deep over
and molar relationship and allow the premolars and
bite for stability after treatment to prevent relapse and to
canines to erupt into occlusion.
protect the temporomandibular joint (Figs. 29.7A and B).
In mixed dentition treatment Twin Blocks may con
The upper block is trimmed at each visit to encourage
tinue to be worn at night as retainers, allowing the occlu
eruption of lower molars during the Twin Block stage. The
sion to settle during the day, while maintaining functional
molars should be in Class I occlusion at the end of the
correction at night.
Twin Block stage and the overjet and overbite should be
corrected.
A B
Figs. 29.7A and B: (A) In treatment of deep overbite the upper block is trimmed progressively at each visit to encourage eruption of lower
molars. The molars are in Class I occlusion at the end of the Twin Block stage; (B) In the support phase an anterior inclined plane is fitted
to support the corrected overjet and overbite as the lower premolars and canines erupt into occlusion.
VERTICAL CONTROL OF night is effective in reducing anterior open bite. It also

ANTERIOR OPEN BITE accelerates correction of distal occlusion for patients who
make slow progress due to weak musculature. Clasps
Vertical control is equally important in treatment of on lower molars are placed to prevent their eruption in
anterior open bite and vertical growth patterns. The treatment of vertical growth and anterior open bite. This
occlusal blocks remain in contact with the opposing teeth approach is also appropriate with Fixed Twin Blocks in
throughout treatment. The addition of vertical elastics at treatment of anterior open bite (Figs. 29.8A to E).
B C
D E
Figs. 29.8A to E: (A to C) Vertical intraoral elastics are effective in reducing anterior open bite; (D and E) Appliances may include a tongue
guard or spinner to control tongue thrust. High pull extra oral traction was formerly used to intrude upper molars, but vertical intraoral
elastics worn at night have proved to be equally effective and more patient-friendly.
THE ART OF ORTHODONTICS confines of a genetic paradigm? Is there scope for sig
nificant improvements in existing orthodontic techniques
Orthodontics is not an exact science. Artistry and aes or have we almost exhausted this aspect of orthodontic
thetic appreciation are important factors in successful development? Modern orthodontic techniques with con
orthodontic practice. In clinical practice it is important ventional fixed appliances are frequently delegated to
to place the emphasis on treatment of the individual auxiliaries under supervision. If we confine our treatment
patient by respecting facial form, aiming to produce objectives to orthodontics will we continue to need spe
results that combine facial balance and harmony with cialists?
a balanced functional occlusion and an attractive smile. A broader description of “Orthodontics and dentofa
Few professions offer such a challenging combination of cial orthopedics” conveys the concept that treatment
scientific and artistic values in the pursuit of excellence aims to improve not only dental relationships, but also
in functional and aesthetic objectives as they relate to facial balance.
the human face. The adoption of a wider definition extends the hori
This book is an account of the evolution of Twin Block zons of the profession as well as educating the public to
technique since the author treated the first patient in 1977. appreciate the holistic benefits of functional orthopedic
Clinical experience in using many techniques allowed the therapy.
author to develop new appliances for orthodontic and In our enthusiasm to adopt scientific methodology
orthopedic correction. in research we must not lose sight of the artistic values
This serves as a timely reminder that alternative app that represent a vitally important facet of clinical ortho
roaches to treatment present a challenge to the skill dontics. Indeed the artistic aims of orthodontics relating
and artistry of the orthodontist at a stage when ortho to beauty, balance, and facial aesthetics represent the
dontic treatment is tending to become standardized in most satisfying aspect of our speciality.
variants of the Straight Wire Technique. It is appropriate The new challenge for today’s highly trained ortho
at this time to consider the objectives of treatment, and dontist is to combine orthodontic and orthopedic tech
our vision of the speciality of orthodontics in a changing niques in the treatment of skeletal and functional dis
environment of biological research at cellular, molecular crepancies, and to relate treatment to holistic functional
and genomic level. Advancing technology improves our treatment objectives. It is essential that we recognize the
potential in diagnosis and technique. importance of orthopedic techniques to achieve facial
What are the ambitions of our speciality in the future? balance and harmony and extend our aesthetic and func
As implied in the definition of “orthodontics”, are we sat tional objectives beyond a balanced functional occlusion
isfied simply to produce “straight teeth” within the strict and an attractive smile.
ORTHODONTICS OR ORTHOPEDICS?
Two Typical Patients
The most important decision we make in treatment When we first examine the patient we must decide
planning is based on our initial assessment of the whether the problem is to fix the teeth or to fix the face.
problem. Does this patient require orthodontics or In Dental Chess if we make a mistake in the first move
dentofacial orthopedics? we lose the game! (Figs. 29.9 A and B).
Fig. 29.9A: Fixed appliances fix the teeth. Fig. 29.9B: Functional appliances fix the face.
This is definitely an orthodontic case. There is no way we This is an unusual face. The teeth are no big deal,
can fit all of these teeth in this mouth. What this patient but to treat this patient we must treat the face. This is an
needs is four extractions, followed by braces and that will orthopedic case. This is the most important decision we
fix his teeth. As you can see, the face is otherwise perfectly make in treatment planning. If we make a mistake in the
normal. first move, we lose the game.
Mask modified by William Clark, 2012. Original painting by Alastair Clark, 1983.
Face the Facts
• Functional • Fixed
• Appliances • Appliances
• Create • Correct
• Esthetic faces • Teeth
When we treat the face we should choose a functional appliance.

AN ALLEGORY
The Ostrich, The Leopard and The Peacock
Fig. 29.10A: The ostrich is an old practitioner who has practiced for 40
years and still uses the same techniques he learned in school. The ostrich
is not interested in anything new, never attends courses or reads books
or journals and is looking forward to retiring.
Fig. 29.10B: The leopard is middle aged and has practiced for 20 years. He
is experienced, but still attends courses and is interested in new techniques.
The leopard is willing to change his spots.
Fig. 29.10C: The peacock is a young bird, still a student or recently

qualified, who is bright and intelligent and attends many courses. In class
the peacock sits and listens with eyes wide open and is interested in
everything new. The peacock represents the future of the profession.
REVIEW OF FUNCTIONAL After a century of development in functional therapy

TREATMENT OBJECTIVES it is incredible that reluctance still exists in the speciality
of orthodontics to accept the holistic benefits of functional
In research the horizon recedes as we advance … and therapy compared to conventional fixed appliances. It is not
research is always incomplete. enough for our patients to aspire to the Hollywood Smile!
—Mark Pattison, 1813–1884 As members of the health profession we must seek to
combine the benefits of aesthetics and functional therapy
Mark Pattison appropriately placed our present state by interacting with professional colleagues in related fields.
of knowledge in perspective more than a century ago. The formation of the International Functional Society at
New research is providing convincing evidence to the inaugural meeting in Paris in 2007 was a positive step
support the value of functional orthopedic techniques to fulfilling this objective.
using full time appliances to influence the functional
—William J Clark
environment of the developing dentition, and to produce
significant improvements in the pattern of facial growth
and dental arch development.
LIFE BEFORE TWIN BLOCKS
Distraction osteogenesis illustrates the potential for This patient was treated by the author during his ortho
modifying bone growth, and fixed functional techniques dontic training in 1963 by extraction of upper first pre
offer a new opportunity for non-invasive osteogenic molars, followed by treatment to retract the prominent
stimulation. upper incisors, resulting in a damaging malocclusion
The next phase in the evolution of orthopedic with severely retroclined incisors and deep overbite
technique is to resolve any remaining doubts regarding (Figs. 29.11A and B).
the efficacy of an orthopedic approach and improve The post treatment profile confirms that treatment did
techniques in order to combine the benefits of ortho not address the aetiology of mandibular retrusion. This
dontic and orthopedic treatment. The recent formation patient’s inadequate treatment had a profound effect on
of a new society, the International Functional Association the author’s approach to the treatment of Class II Division I
(IFUNA) is a step in the right direction. Interesting new malocclusion.
research is emerging on the holistic effects of functional Camouflage treatment with fixed or removable appli
therapy. ances cannot correct a severe mandibular retrusion.
It is long overdue that we change the name of the spe Functional therapy to enhance mandibular growth is the
ciality to recognize the increasing importance of ortho only valid alternative to major surgery, and is the treat
pedic techniques. We should follow the example of Tom ment of choice for the growing patient.
Graber, who was instrumental in renaming the American This experience provided the motivation for the author
Journal of Orthodontics & Dentofacial Orthopedics. to develop Twin Blocks and to write “Piano Keys”.
A B
Figs. 29.11A and B: (A) Model of a severe Class I division 1 malocclusion treated in 1963 by extraction of upper first premolars; (B) The
patient’s profile after treatment failed to correct the mandibular retrusion.
Piano Keys
I can see him yet! What is our purpose in life:
Marching across the room: To clone the image of a smile?
Straight teeth Can we not grasp the nettle of growth
Like soldiers And organise the features
Standing to attention! In a more attractive mode?
Like a picket fence Take courage, young student!
Guarding the entrance to his mouth. Do not be deterred by yesterday’s values.
But what about his face? Let your patient grow with confidence
What is the problem here? In your hands.
I remember him He is not a statistic!
In the dark ages, He is an individual
He of little chin. And must be treated as such.
I fear I wounded him, Now his teeth stand straight
Bracing his teeth But lacking in character,
Inside his lips, A chinless wonder
Capturing his tongue Who dare not smile.
Back in his throat, Do we really want
So that he could not breathe properly. Just “Piano Keys”?
To extract or not to extract? Heaven Forbid!
That was the question. Pierre Robin taught us with the monobloc
What misguided teacher To help our patients breathe better.
Made this ghastly mistake Function is not dead!
To cause an innocent student A new paradigm is emerging.
To denigrate his face? Functional Treatment Objectives
Edward Angle said a century ago Fix the teeth and mend the face.
Our every move can make or mar a face. That is a greater ambition
It is our most important task! Than Just “Piano Keys”!
We cannot disregard
Facial balance and harmony,
Condemning some unsuspecting adolescent
To mediocrity
REFERENCES Moss ML, (1968). The primacy of functional matrices in profacial

growth, Dental Practitioner and Dental Record. 19:65-73.
Clark W, (2010). Design and management of Twin Blocks: O’Brien K, Wright K, Conboy F, et al, (2003). Effectiveness of
reflections after 30 years of clinical use, Journal of Orthodontics. treatment for Class II malocclusion with the Herbst or Twin
37:209-16. Block appliance: a randomized controlled trial, American
Clark WJ, (2011). New horizons in orthodontics & dentofacial Journal of Orthodontics and Dentofacial Orthopedics.
orthopedics: fixed Twin Blocks & TransForce lingual appli 124:128-37.
ances, International Journal of Orthodontics Milwaukee. Shah AA, Sandler J, (2009). How to …. Take a wax bite for a Twin
22:35-40. Block appliance, Journal of Orthodontics. 36:10-2.
Dyer FM, McKeown HF, Sandler PJ, (2001). The modified
twin block appliance in the treatment of Class II division 2
malocclusion, Journal of Orthodontics. 28:271-80.
FURTHER READING
Harradine NW, Gale D, (2000). The effects of torque control Nakamura S, Himuro T, Fukui K, (2006). Changes in craniofacial
spurs in Twin Block appliances, Clinical Orthodontics and soft tissue surface temperature & brain activity during tapping
Research. 3:202-9. with Twin Block appliance, Orthodontic Waves. 65:112-9.
Illing HM, Morris DO, Lee RT, (1998). A prospective evaluation Moss ML, (1981). Genetics, epigenetics and causation, American
of Bass, Bionator and Twin Block appliances. Part 1—the hard Journal of Orthodontics. 80:366-75; American Journal of
tissues, European Journal of Orthodontics. 20:501-16. Physical Anthropology. 86:415-27.
Index
Note: Page numbers followed by f and t indicate figure and table respectively.
A Bioprogressive philosophy, 52 CPAP therapy, 491

Bite gauge, 15, 15f Crowded dentition, 54
Acrylic blocks, 343 Bite guide, 98 Crowding, 275
Adaptive response, 38 Bite ramp appliances, 98f intermaxillary traction, 284
bone growth, 38 Bite registration, 29, 101, 179–180, management of, 280
neuromuscular adaptations, 38 205–206, 502, 547 Customized fixed twin blocks, 410
skeletal adaptations, 38 correct, 548
Adenoidal facies, 109 errors in, 547f
Adjustment splint, 497f incorrect, 547f
D
Adult ferrets, 36 Bone growth, adaptation, 38 Deciduous molars and canines, 88f
Adult therapy, 391 Brachyfacial, 68 Deep overbite
Adult treatment, 324 growth pattern, 463, 463f management of, 104–105
Aesthetic appliance design, 548 skeletal pattern, 446, 446f vertical control of, 550, 550f
Aesthetic factors, statistical evaluation of, Breathe easy twin blocks, 505 Delta clasp, 88, 88f
516 Buccal segment occlusion, 443f adjustment of, 89
Affine transformation grids, 521 Dental chess, 543, 543f
Airway obstruction, 177 Dental orthopedics, 2
Airway anatomical evaluation, 494f C Dentition
ANB angle, 117 Case selection two-phase treatment, 128–137
Andrews straight wire technique, 489 orthodontic correction, 401 Dentoalveolar factors, 261
Anterior open bite, 94, 179, 192, 294 orthopedic correction, 401 Dentofacial
vertical control of, 551, 551f Cephalometric analysis, 56, 68, 527 development, 60
Anterior repositioning devices, 496 films and tracings, 462f orthopedics, 2, 552
Appliance design, 119, 230f Development fixed twin blocks, 415
image, 514
case report, 338f–339f Disfiguring malocclusion, 138
radiographs, 513
clinical management, 336–337 Distal extraoral traction, 166
records, 462
evolution of, 85 Distal occlusion, increased overjet, 487f
studies, 531t
round tripping, 337 Dolichofacial, 68
Cephalometry, 519
temporomandibular joint pattern, 81
Cephalostat, 513
dysfunction, 340 Dysfunction syndrome, 331
Chairside kits, 202
traction, 337 Combination therapy, 145, 227
Appliance fitting, 114 Combined fixed/functional therapy, 423f E
Appliance therapy, 203 Combining fixed and functional therapy,
Arch development, 362 462, 462f Edge-to-edge occlusion, 227
and initial alignment, 420 Combining fixed twin blocks, 460 Elastic bands, 178f
Arch length discrepancy (ALD), 53, 376 Concorde facebow, 165–166, 173 Elastic chain, 396
Avoiding extraction of premolars, 288 Condylar cartilage growth rate, 36, 36f EMG
Condyle axis, 61f representative sections of, 41f
EMT appliance, 498f
B Cone beam CT scans, 494, 495f
Construction bite, 438 Essix positioning trays, 451, 451f, 457f
Balance, 60 Continuous positive airway pressure Esssix twin blocks, invisible, 100f
Balanced facial proportions, 63–64 (CPAP), 491–492 Euclidean distance matrix analysis
Base plate, 89 Contracted archform, 298 (EDMA), 519
Bimaxillary dental protrusion, 346, 346f CPAP device, 491, 496 Exactobite project, 101, 499
Extraction therapy, 25, 52, 301–309, 432, Frankfort horizontal, 63 K
489 Full-time appliance wear, 103
case report, 301–303, 302f–303f Functional appliance therapy, 38–39 Kendall’s spherical blackboard, 519
combination therapy, 307 Functional orthopedic therapy, 109,
mandibular retrusion, 307 419–420, 419f
maxillary protrusion, 307
L
Extraoral traction, 166
Extreme mandibular retrusion, 424f
G Lateral pterygoid muscle, 493–494
Linear vs. volumetric values, 516
Genetic control paradigm of, 39 Lingual arch development, 369f, 479f
F Genioplasty, 352 Lip contour, 54
Geometric morphometric techniques, Lip pads, 231
Face, volumetric growth of, 516 519 Lower dentition, 67
Facial appearance, 402f, 404f, 412f George bite gauge, 31f, 500f Lower second premolars, 436, 436f
Facial architecture, 60 Glenoid fossa remodeling, 38
Facial asymmetry, 240, 323 Growth changes, interpretation of,
appliance design, 311 535–537 M
case study, 311 Magnetic force, 204, 317
clinical management, 311
Facial axis angle, 56, 61f, 66
H Magnetic resonance imaging (MRI), 41,
538, 538f
Facial balance and harmony, 449f Headgear effect, 521 Magnetic twin blocks, 323f
Facial growth, 514 Heat-cured blocks, 89f introduction, 317
Facial profile, dramatic improvement in, Herbst appliances, 343, 472, 472f, 475f
441f magnetic force, 317
Herbst splint, 497f Magnets
Facial rectangle, 62 Horizontal registration plane, 62
Finite-element scaling analysis (FESA), attracting, 317–318
519 case study, 319–322, 319f–322f
Fixed appliances, 392, 392f, 447f, 460, I repelling, 318
553f Malocclusion, 7, 57, 424
treatment, 456 Imaging technology case report, 13, 13f, 368, 368f
Fixed functional appliances, 471–489 analysis of shape, 520f modification for treatment of, 13f
form and function, 471 analysis of size, 520f positioning trays, 450, 450f
Herbst appliance, 471–472 morphometric analysis, 519 treatment of class III, 10, 10f
Fixed/functional therapy, 276 volumetric analysis of, 517–519
Mandible, peripheral length, 515
Fixed inclined planes, 36f Improved facial balance, 461f
Mandibular advancement, 349, 349f,
Fixed lingual retainer, 482f Inclined planes, 92
408f, 461
Fixed lower lingual retainer, 418f angulation of, 15
appliances for, 489
Fixed therapy, 275 Incorrect bite registration, 547
Incorrect construction bite, 343f growth, 515f
Fixed twin blocks, 404f–405f, 414f, 415, length, 514
421, 421f, 440, 440f, 442, 454, Indirect bonding technique, 438, 440,
440f retrusion, 161, 424
454f, 455, 461, 464, 464f, 466
Intergingival height measurement, 105f Maxillary advancement, 239f
case selection, guidelines for, 401
Intraoral appliances, 493t Maxillary arch development, 386f
concurrent arch development, 414
effectiveness studies of, 493 Maxillary contraction, 362
designs for, 399, 399f
evolution of, 490 Maxillary convexity, 66
dolichofacial pattern, 452, 452f
patient selection for, 493 Maxillary dentition, 8
evolution of, 396
individual, 397, 397f side effects, 493 Maxillary expansion, 453, 453f
mandibular retrusion, 425 Intraoral traction, 191f Maxillary protraction, 249
molar bands, 398, 398f Intraoral vertical elastics, 191f, 192 Maxillary protrusion, 167
occlusal blocks, 396 Intrusive force, 173 Maxillary retraction, 26
protocol, 395 Invisible twin blocks, 100, 100f Maxillary expansion appliance, 480
prototype design, 395f Mesofacial, 68
prototype, 425f J Mixed dentition, 119, 385, 427, 427f
treatment concepts, 395 Moses appliance, 502
Forsus appliance, 488f Jasper jumper, 473, 473f–474f Moses bite, 502, 502f
Forsus fatigue resistant device, 484, 484f Jigsaw puzzle, 59, 61 Moses’ sleep appliance, 502, 502f
Index 559
N Pedodontic practice, 138 Second molars, extraction of, 55

case report, 138–143 Self-ligating brackets, 447
Neuromuscular and skeletal adaptations, Pharyngeal airway, 109 Sella–nasion–A-point (SNA) angle, 525
38 Phonetic bite, 499 Severe tongue thrust, 347
Neuromuscular bite, 501 Pitfalls Simple twin blocks, 118
Nitinol arch wires, 444, 444f design, 343 Skeletal planes, 64
Non-etch technique, 438 functional therapy, 344, 344f Sleep apnea and health, 511
Non-extraction therapy, 52, 55, 476f Planning Sleep apnea-hypopnea syndrome, 490
Nonsurgical class III correction, 245f clinical examination, 47 Snoring, 491
diagnosis and treatment, 47 Soft palate appliance, 496, 496f
photographic records, 47 Soft tissue response, 105
O Polysomnography, 492 SomnoMed MAS, 498f
Positive airway pressure, 492f Splint therapy, 335
Obstructive sleep apnea (OSA), 491
Post treatment stability, 423f Spring loaded appliances, 481f
Occlusal blocks, 32, 32f, 400, 457f
Postpubertal stage, 463 Spring-loaded fixed functional
Occlusal inclined plane, 36, 36f, 90
Posture, 60 appliances, 489
Occlusal screw, 248–249
Pretreatment records, 432f Standard twin blocks, 86–87
Occlusion, 331
occlusal views of, 90f
arch form, 415f Procrustes analysis, 519
Statistical analysis, limitations of, 545
case history, 333 Progressive activation, 31–32
Statistical evidence, relevance of,
case report, 331–332 Project bite gauge, 101, 102f
513–514
diagnosis, 333 Prototype appliances, 403
Straight wire technique, 468, 552
importance of, 331 Prototype fixed twin blocks, 425f
Sunday bite, 350, 350f
internal derangement, 334 Protrusive bite registration, 499
Superimposition techniques, 519
reciprocal click, 333
Synthetic crown contours (Truax), 119
relief of pain, 332
the closed lock, 333 R
Occlus-o-Guide appliance, 127–128,
Randomized controlled trial, 545 T
128f, 387, 412, 422, 422f
Rapid palatal expander, 2 50
OPAP devices (oral pressure appliance), Temporomandibular joint (TMJ), 26–27,
Registration bite, 109, 438
496, 497f 34
Removable retainers, 416f
Oral appliances, types of, 496 pain, 331
Retention, 469, 469f
Orthodontics, 2, 552–553 therapy, 335
Retroclined upper incisors, 205
approach, 2 Thin plate spline analysis, 521
Retrognathic, 68
correction, 312 Three-way screw appliance design, 230f
Reverse pull facial mask, 239
dental chess, 1 Thumb sucking, 181
dentofacial, 4 Reverse twin blocks, 96, 96f, 227, 227f,
Tongue guard, 180
force, 4 229, 247f
Tongue-retaining device, 496, 496f
genetic paradigm, 2–3 appliance, 230, 230f
Tooth movements, 324
levels, 251 management, 230
Transcutaneous electrical nerve
new horizons in, 361 Richter scale, 53
stimulation (TENS), 501
philosophical divide, 2 Ricketts triangle, 61
Transfer positioning trays, 439, 439f
records, 49 Robin’s Monobloc, 116, 116f, 503, 503f TransForce appliance, 379, 379f, 382f,
treatment concepts, 3, 437, 437f, 504, Rocky Mountain Data Systems, 52 409f
504f Rocky Mountain Orthodontics, 414 TransForce fixed twin blocks, 457
Orthopedic forces, 4 TransForce sagittal appliance, 374f–375f
Orthopedic traction, 1 65
Orthopnea appliance, 498f
S TransForce sagittal arch development,
378, 378f
OSA patients, polygraphic record, 495f Sagittal appliance, 206, 459 TransForce sagittal expander, 374–375
Overjet, overbite and distal occlusion, Sagittal arch development, 92, 458, 458f TransForce transverse appliance, 383f
115 Sagittal length measurement, 377, 377f TransForce transverse arch development,
Sagittal transForce appliance, 207, 380 385, 385f
P Sagittal twin blocks, 207, 312 Transverse and sagittal development,
Schwarz double plate, 29 93, 93f
Palatal expander, 485f Schwarz twin blocks, 128f Transverse arch development, 382, 390,
Palatal screws, 208 Screw advancement system, 202 390f, 420, 420f
Transverse expander, 383 reactivation of, 113 U
Transverse expansion appliance, 433 response, 40
Transverse maxillary development, 8 retention, 18 Unfavorable dental factors, 304–306,
Transverse transforce appliances, 388 retrospective statistical, 544 304f–306f
Triad temporary crown material, 457 sagittal appliance, 92, 92f, 206, 208 Unfavorable skeletal factors, 304–306
Trimming blocks, sequence of, 208 Schwarz appliances, 90f Upper airway resistance syndrome
Triple screw sagittal appliances, 207, sequence of, 16f (UARS), 494
207f studies, 544
Upper and lower blocks, diagram of,
Twin block, 8, 8f–9f, 101, 109, 275 support phase, 17, 17f
400f
advantages of, 115–116 technique, 28
three-way screw for, 93f
airway, 503 temporary fixation of, 1 03
therapy, 41, 55, 99, 152, 153f, 507f–510f Upper dentition, 67
appliance design, 119
appliance, 85, 105, 504, 504f tool, 99, 99f Upper Essix retainer, 431
arch development, 90 traction technique, 164, 526 Upper fixed appliance, 435f
bite registration in, 30 treatment, 12f, 16, 171, 68–83, 539 Upper Schwarz/Lower Jackson twin
breathe easy, 506, 506f vs. Frankel, 539t blocks, 91f
case report, 22–24, 23f, 124–126 vs. Herbst, 539t Uvula repositioning, 496
class II therapy, 504 Twin block treatment, 525
construction, 86 cephalometric evaluation of, 532
Crozat appliances, 91f cephalometric studies, 531t V
design, 16f, 28-29 discussion, 529
designer, 95, 95f FR-2 and controls, 532 Vertical activation, 30
development of, 11–12 mean growth changes, 528–529 Vertical box elastics, 448
electromyographic study, 40–41 skeletal and dental changes in, 537f Vertical dimension, 32
extraoral traction, 351, 351f vs. fixed appliance, 529–530 control of, 32
in treatment of sleep apnea, 505 Twin block appliance, 532 establishment, 105
life before, 555 dentoalveolar changes, 533–534 Vertical extraoral traction force, 94f, 173f
management of, 343, 546 methods and materials, 533 Vertical growth, treatment of, 187
modified design of, 87f normative growth data, 532 Viscoelastic hypothesis, 43
nonsurgical correction of, 507f–510f post-treatment stability, 534 Vision, 60
occlusal screw for, 201f statistical analysis, 533
phase, 424, 424f treatment effect, 532–533
pitfalls in design, 546, 546f Twin force bite corrector, 477, 477f, W
progressive activation of, 97, 113–114, 479–481
201 Two phase treatment, 432 Wilson lower lingual arch, 356, 417

Twin Block Functional Therapy Applications in Dentofacial Orthopedics 3

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Twin Block Functional Therapy—Applications in Dentofacial Orthopedics

Third Edition: 2015

Contributors to the Second Edition

Gary G Baker DDM GD Singh DDSc PhD BDS

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

Mel Taskey BSc DDS MSc

• Twin Blocks for Arch Development 124

• Combination Fixed/Functional Therapy 276

• Individual Fixed Blocks 397

27. The Flat Earth Concept of Facial Growth 513

The Art of Orthodontics

INTRODUCTION DENTAL CHESS

THE PHILOSOPHICAL DIVIDE In the development of orthodontic technique the concept

Introduction to Twin Blocks

THE OCCLUSAL INCLINED PLANE

Treatment of Class II Division 2 Malocclusion

Treatment of Class III Malocclusion

AK Age 11.1 13.1 16.8

sequence it is important not to reduce the leading edge

Stage 2: Support Phase

RETENTION RESPONSE TO TREATMENT

Case Report: CH Aged 14 Years 1 Month Clinical Management

CH Age 14.1 15.2 19.7

CASE SELECTION FOR Case Report: JMcL Aged 12 Years

Case Report: JMcL

Case Report: JMcL

JMcL Age 12.0 15.2

Form and Function

DEVELOPMENT OF in a high proportion of crowded dentitions treated by

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

Comfort and aesthetics are crucial in appliance OBJECTIVES OF FUNCTIONAL TREATMENT

HISTOLOGICAL RESPONSE TO orthopedic treatment is similar to authors perception of

Diagnosis and Treatment Planning

Orthodontic Records correct archform before the mandible can be advanced

Case Records: GD Aged 14 Years

GD Age 13.10 15.2

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

Figs. 5.8A and B: Profile and tracing before

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

The Clark Cephalometric Analysis

applies in the analysis of facial form and the planning of

Frankfort Plane—Porion to Orbitale

Basion vertical: A perpendicular through basion defines

Craniomandibular angle: Lower incisor angle:

The Upper and Lower Incisors are Soft-Tissue Analysis

Position of the Lower Dentition

KH Age 9.5 11.3 14.7

ME Age 13.0 13.8 17.1

Case Report: PMcL

Case Report: PMcL

PMcL Age 11.6 13.0 17.1

EF Age 12.3 15.2

Case Report: WL Aged 10 Years 3 Months

WL Age 10.3 11.6 16.1

AF Age 11.0 14.3 17.5

LC Age 9.0 10.0 15.4

However, the author investigated the reliability of

INTRODUCTION • Springs to move individual teeth and to improve the

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

FUNCTIONAL ORTHOPEDIC THERAPY Conventional fixed appliances with brackets cannot

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