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Design and management of Twin Blocks: Reflections after 30 years of clinical

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Article  in  Journal of Orthodontics · September 2010

DOI: 10.1179/14653121043110 · Source: PubMed

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CLINICAL Design and management of Twin
SECTION
Blocks: reflections after 30 years of
clinical use
; William Clark
The objective of this article is to correct some misconceptions that have arisen since the introduction of Twin Blocks, to
identify factors leading to reduced efficiency and increased failure rate, and to improve the clinical application of Twin Block
technique.
Key words: Aesthetic, comfortable, ‘patient friendly’ Twin Blocks
Received 22nd May 2009; accepted 14th March 2010
Introduction
Journal of Orthodontics jor37.3_Clinical I132.3d 13/7/10 22:26:28
Rev 7.51n/W (Jan 20 2003)
Since the Twin Block appliance was developed in 1977
many authors and clinicians have advocated modifications
to their design and management. These modifications may
lead to a high failure rate and instability in the occlusion
following Twin Block therapy. This article is intended to
The Charlesworth Group, Wakefield +44(0)1924 369598 -
look back at the original design and re-evaluate the
modifications that have occurred over time, with a view to
improving patient acceptance and the stability of the end
result. In the author’s original description of the technique,
the first principle of appliance design is simplicity. The
patient’s appearance is noticeably improved when Twin
Blocks are fitted. Twin Blocks are designed to be
comfortable, aesthetic and efficient. By addressing these
requirements Twin Blocks satisfy both the patient and the
operator as one of the most ‘patient friendly’ of all the
functional appliances. The principles governing basic
design and management have been lost in the passage of
time, with a resulting loss of control and a significant
reduction in efficiency and success in using the technique.
Success rates
One multi-centre randomized controlled trial, which
compared the effectiveness of the Twin Block with the
Herbst appliance in the treatment of class II malocclusion
had a reported failure to complete rate for the functional
phase of treatment of 12.9% for Herbst and 33.6% for
Twin Blocks.1 In the discussion of the results the authors
< reported that provision of treatment at no cost to the
child and parents, and poor socio-economic background
may be factors in poor cooperation and failure to
< Address for correspondence: William Clark.
Email: twinblocks@mac.com
# 2010 British Orthodontic Society
Journal of Orthodontics, Vol. 37, 2010, 204–211
complete treatment. However, appliance design may also
be a factor in patient acceptance: they concluded that
Twin Blocks, perhaps because of the bulky acrylic blocks,
caused more problems than did the Herbst appliance in
eating and speaking. Arguably, because Twin Blocks can
be removed and Herbst appliances are cemented in the
mouth, compliance with wear might also influence the
success of treatment. Clearly a failure rate of 33.6% is
undesirable in orthodontic practice.
In two other studies, the failure to complete rate was
reported as 9 (Ref. 2) and 15% (Ref. 3). An audit of 83
consecutively patients treated by the Twin Block Traction
Technique in the author’s practice during the period May
1979 to May 1982 found an 8.4% failure to complete
treatment.4 After further investigation the author
included 148 patients treated between 1979 and 1990.
Ten patients were identified from practice records, who
did not complete treatment during this 11 year period.
This represents a failure to complete treatment of 6.7%.5
Height of occlusal blocks
Originally the Twin Block appliance was designed for
full time wear, including during eating. An edge-to-edge
bite with a small interincisal space, typically 2 mm,
encourages the patient to close the lips naturally. This
posture is reinforced as the patient eats and drinks with
the appliances in the mouth and patients consistently
develop competent lips and normal lip posture at an
early stage in treatment. This lip posture and behaviour
continues throughout treatment and is well established
by the end of the Twin Block phase, by which time the
incisors and molars should be in occlusion.
DOI 10.1179/14653121043110
 JO Month 2010 Clinical Section Twin Block design and management 205

A recent article entitled ‘How to…Take a wax bite for
a Twin Block appliance’6 indicates a change from the
original design of the Twin Block appliance which, I
believe, may explain the problems with patient accep-
tance. The authors of the article propose that an ideal
wax bite should be at least 7 to 8 mm thick in the
premolar region. Illustrations of this method of record-
ing a construction bite show a 10 mm vertical inter-
incisal space. Although no facial photographs are
shown, excessive lengthening of the lower face does
not improve the patient’s appearance and may dissuade
the patient from wearing the appliance. The bite
opening appears to be excessive.
phase, as lower molars are not free to erupt. Large
blocks are uncomfortable to wear and affect speech by
restricting tongue space. It is impossible to incise food
due to the anterior open bite, and it is difficult to chew
with bulky blocks. This may encourage patients to
remove the appliances for eating, interfering with the
continuity of appliance wear. In addition, large blocks
increase lower facial height excessively and it is not

Disadvantages of thick occlusal blocks

1. Appliances are uncomfortable and cannot be worn
full time.
2. Patients cannot incise or chew food making it
COLOUR
Journal of Orthodontics jor37.3_Clinical I132.3d 13/7/10 22:26:29

impossible to eat with the appliances in the mouth.

FIGURE
Rev 7.51n/W (Jan 20 2003)

3. Speech is badly affected by large blocks which

obstruct the tongue.
4. Facial height is excessive with large blocks.
5. It is not possible to close the lips comfortably.
(a)
6. Patients are embarrassed when wearing the appli-
ances at school.
The Charlesworth Group, Wakefield +44(0)1924 369598 -

7. Lower molars are not free to erupt.

8. A large posterior open bite develops during
treatment, which may lead to an unsupported
temporomandibular joint after treatment.
An example of a Twin Block appliance with excessive
height of the blocks to accommodate magnets is shown
in Figure 1. Labial wires are obvious and this, combined
with increased lower face height may embarrass the (b)
patient and result in poor cooperation. The large blocks
produce a large posterior open bite after the Twin Block

(c)
COLOUR
Figure 2 Projet Bite Gauge: (a) select the appropriate groove for
FIGURE the upper incisors depending on the size of the overjet and the ease
with which the patient can posture forward; (b) the lower incisors
bite into a single groove to register a protrusive bite; (c) bite
registration for an overjet of up to 10 mm. The blue Projet bite
gauge gives 2 mm interincisal opening and there is 5–6 mm vertical
Figure 1 Twin Blocks with excessive height of the blocks to space between the premolars (Reproduced from Clark WJ, Design
accommodate magnets (Reproduced with the kind permission of & construction of Twin Block appliances10 with the kind
Professor J. Moss) permission of Elsevier Science Ltd)
 JO Month 2010
(a)
Figure 3 Aesthetic Twin Blocks improve patient cooperation: (a) a labial bow is seldom required on Twin Blocks. Ball clasps mesial to
lower canines are virtually invisible in the mouth; (b) composite profile photographs for the same patient before Twin Blocks, after 8 weeks
treatment and 18 months out of retention (Reproduced from Clark WJ, Design & construction of Twin Block appliances10 with the kind
permission of Elsevier Science Ltd)
possible for the patient to close the lips comfortably.
This may also limit the improvement in the profile that
results from advancing the mandible by encouraging
Journal of Orthodontics jor37.3_Clinical I132.3d 13/7/10 22:26:40
downward and backward rotation of the mandible with
increased vertical growth in facial height.
Rev 7.51n/W (Jan 20 2003)
On the other hand, it is equally incorrect to make the
blocks too thin, for example of 3 to 4 mm thickness in the
premolar region. This allows the patient to retract the
mandible in the rest position and results in failure to close
the blocks correctly, especially during the night, causing a
The Charlesworth Group, Wakefield +44(0)1924 369598 -
reduction in the efficiency of the functional mechanism
and possible failure to correct the distal occlusion.
Bite registration
I believe that the correct bite registration in deep bite
cases is typically edge-to-edge with a 2 mm interincisal
space. This is equivalent to an inter-premolar space of 5
to 6 mm. The resulting blocks are 5 to 6 mm thick in the
first premolar region and 1 to 2 mm thick in the molar
region. The important factor is to open the bite beyond
the freeway space, so that the patient cannot retrude the
mandible when in rest position, but to avoid making the
blocks too thick so that the patient can eat and speak
comfortably with the appliances in the mouth.
The Projet Bite GaugeTM (Orthocare, Sheffield, UK,
available at: www.orthocare.co.uk) is designed to record
a protrusive bite for construction of Twin Blocks and
other functional appliances. The blue bite gauge
registers 2 mm vertical clearance between the incisal
edges of the upper and lower incisors, which is suitable
for bite registration in most class II division 1
malocclusions with increased overbite (Figure 2).
The bite gauge has three grooves on one side and a
single groove on the opposing side. The simplest method
to register a protrusive bite is to select the appropriate
Clinical Section Twin Block design and management 206
COLOUR
FIGURE
(b)
groove for the upper incisors depending on the ease with
which the patient can posture the mandible forwards.
The lower incisors then bite down into the single groove
to register the bite with 2 mm interincisal space.
An edge to edge construction bite with 2 mm
interincisal space is registered in the middle groove to
correct an overjet of up to 10 mm for patients with good
horizontal growth potential. The maximum sagittal
activation is 10 mm and larger overjets may be corrected
by an initial activation, followed by reactivation of the
inclined planes after the initial correction has been
achieved. In the treatment of large overjets and patients
with anterior open bite, it is important to relate the
degree of activation to the freedom of movement of the
mandible by measuring the protrusive path of the
mandible. The overjet is measured with the mandible
retruded and in the position of maximum protrusion.
The activation must not exceed 70% of the total
protrusive path in order to remain within physiological
limits of movement of the mandible.
In the treatment of class II division I malocclusion with
an anterior open bite an alternative Projet Bite Gauge
(usually white in colour) is selected that registers a 4 mm
interincisal clearance. This results in approximately 5 mm
clearance between the cusps of the first premolars or
deciduous molars. The objective is to open the bite
beyond the freeway space, so as to intrude the posterior
teeth, without making the blocks too thick. The process
of bite registration is similar in other respects to the
method described for treatment of deep overbite.
It is especially important in vertical growth patterns to
ensure that the patient can maintain the protrusive
position comfortably by selecting a lesser amount of
initial activation. Occlusal screws may be placed in the
upper block for progressive mandibular advancement.7,8
This is possible in the treatment of anterior open bite,
 JO Month 2010 Clinical Section Twin Block design and management 207

COLOUR
FIGURE

(a) (b)
Journal of Orthodontics jor37.3_Clinical I132.3d 13/7/10 22:26:46
Rev 7.51n/W (Jan 20 2003)
The Charlesworth Group, Wakefield +44(0)1924 369598 -

(c) (d)
Figure 4 Twin Block design: (a) the upper Twin Block has a midline screw to expand the upper arch; (b) the lingual flange of the lower
appliance extends to the molar region, but does nor obstruct eruption of the molars in deep bite cases. The lower block tapers in the
canine region to improve speech by increasing space for the tongue; (c) ball clasps mesial to lower canines are virtually invisible in the
mouth; (d) the upper block contacts the lower molars when the appliance is fitted but is trimmed progressively from the second visit
onwards to encourage eruption of lower molars in treatment of deep overbite (Reproduced from Clark WJ, Design & construction of Twin
Block appliances10 with the kind permission of Elsevier Science Ltd)

because trimming of the upper occlusal block is not
required, as it is desirable to apply an intrusive force to the
posterior teeth. This approach is not ideal for treatment of
patients with deep overbite who require trimming of the
upper block to enable the lower molars to erupt.
In the treatment of smaller overjets associated with a
full unit distal occlusion, it may be necessary to register a
reverse overjet in the construction bite, and design the
appliance to advance the upper incisors. Class II division
2 malocclusion is usually associated with a deep or
excessive overbite and vertical control is an important
aspect of treatment. There is normally a low mandibular
plane angle and a well developed chin. The construction
bite for this type of malocclusion requires minimal
mandibular advancement to an edge to edge occlusion
with the incisors in contact. This provides sufficient
height in the blocks to allow correction of the overbite to
an edge to edge relationship and with the molars
remaining in occlusion at the end of the Twin Block
stage. The upper appliance includes a screw or springs to
advance retroclined incisors.
Appliance design
Twin Block appliances can be designed with many
variations depending on the nature of the malocclusion
 JO Month 2010 Clinical Section Twin Block design and management 208

COLOUR
FIGURE

(a) (b)
Figure 5 (a) Excessive height of occlusal blocks and visible anterior wires make the appliance bulky and may influence patient
acceptance; (b) clasps on lower molars combined with thick blocks result in a large posterior open bite and an unstable occlusion in mid
treatment. (Reproduced from Dyer et al.11 with the kind permission of Maney Publishing)

to be corrected. However, common principles may be The Delta clasp retains the basic shape of the Adams
applied to achieve the objectives of making the appliances clasp with interdental tags, retentive loops and buccal
aesthetic and comfortable (Figure 3(a)). An edge to edge bridge. The essential difference is in the retentive loops,
Journal of Orthodontics jor37.3_Clinical I132.3d 13/7/10 22:27:04

bite with a small interincisal space encourages lip closure which are shaped as a closed triangle as opposed to an
Rev 7.51n/W (Jan 20 2003)

within 2 or 3 months of commencing treatment. A labial open V-shaped loop in the Adams clasp. Alternatively
bow is seldom required as the lips retract the upper
incisors. The patient’s profile after 8 weeks treatment
provides a preview of the end result (Figure 3(b)).
If designed correctly I believe the Twin Block to be the
most ‘patient friendly’ of all the functional appliances as
The Charlesworth Group, Wakefield +44(0)1924 369598 -

a result of these features and from my experience of

giving courses around the world for the past 30 years it
is very popular with clinicians. In the treatment of deep
overbite the lower appliance does not cover the lower
molars and no clasps are placed on these teeth
(Figure 4). The lingual flange of the lower appliance
extends to the molar region, but does not prevent
eruption of the molars. This is an essential element to
achieve vertical control during the Twin Block stage.

The Delta clasp

The author designed the Delta clasp in 1985 to improve
the retention of the Twin Blocks appliance (Figure 4). It
is similar to the Adams clasp in principle, but
incorporates new features which improve retention,
minimize adjustment and reduce metal fatigue, thereby
reducing the incidence of breakage. The Adams clasp is
designed to fit individual teeth and incorporates inter-
dental tags, and mesial and distal retentive loops that
are directed gingivally into undercuts, and are joined by
a buccal bridge. The shape and position of the arrow-
heads allows the clasp to open slightly with repeated
Figure 6 Trimming upper blocks for vertical control. The blocks
insertion and removal. The Adams clasp therefore are trimmed progressively to encourage eruption of lower molars
requires routine adjustment to improve retention at (Reproduced from Clark WJ, Design & construction of Twin Block
each visit. This increases the risk of metal fatigue. appliances10 with the kind permission of Elsevier Science Ltd)
 JO Month 2010 Clinical Section Twin Block design and management 209

the arrowhead may be circular or ovoid in shape if
preferred.
The Delta clasp does not open with repeated insertion
and removal, and therefore maintains better retention,
and requires less adjustment. A further crucial advan-
tage is that the clasp gives excellent retention on lower
premolars, and can be used on most posterior teeth. The
author has undertaken a study involving 141 patients
who were consecutively treated with Twin Block
appliances in his practice between 1979 and 1993 and
found that 10% of Twin blocks made with Adams clasps
(N572) had at least one breakage compared to 1% of
Twin Blocks made with Delta clasps (N569).9,10
inhibit eruption of maxillary buccal segments. In the
Twin Block design the position of the inclined plane is
important for vertical control. It is placed mesial to the
lower molars, at the mid point of the second premolar.
Vertical control is achieved by trimming the occlusal
surface of the upper block to allow the lower molars to
erupt. Placing the inclined plane mesial to the molars
allows the inclined plane to remain intact when the
upper block is trimmed over the lower molars
(Figure 6). At the start of treatment the upper bite
block is trimmed leaving a small vertical clearance of 1
or 2 mm to allow the molars to erupt and this process is

Clinical management
For many years, the author has taught that Twin Blocks
may be fixed in the mouth for the first two weeks of COLOUR
treatment. This enables the patient to adapt to full time FIGURE
Journal of Orthodontics jor37.3_Clinical I132.3d 13/7/10 22:27:12

use without any interruption in appliance wear. After

Rev 7.51n/W (Jan 20 2003)

two weeks, the patient is eating and speaking with the

appliances and is wearing the Twin Blocks full time.
This approach overcomes any problems of cooperation
during the crucial period of initial adaptation to the new (a)
appliances. This simple step eliminates most problems of
cooperation.
The Charlesworth Group, Wakefield +44(0)1924 369598 -

The author believes that the clinical management of

the vertical dimension is equally as important as the
sagittal correction. In the treatment of a deep overbite in
patients with a horizontal growth pattern, it is a mistake
to place clasps on the lower molars. This does not allow
vertical development of the posterior teeth to reduce the
overbite and may result in a large posterior open bite
when the blocks are removed. To illustrate this
permission has been granted to use the following
published case report (Figure 5).11 This is an example
of treatment of a class II division 2 malocclusion
showing the occlusion in mid treatment with posterior
open bites at the end of the Twin Block phase of
treatment. The patient went on to have fixed appliances;
however, in the interim period the occlusion is unstable,
with only incisor contacts. This may encourage relapse,
especially in the hands of an inexperienced practitioner
or if the patient fails to return to complete treatment.

Management of deep overbite (b)

The principle of guided eruption of lower molars was
described previously by Woodside12 with regard to the
design and management of the activator. To control a
deep overbite the occlusal table is trimmed to permit
vertical eruption of the mandibular buccal segments and
Figure 7 Support phase: (a) an upper appliance with an anterior
inclined plane supports the corrected incisor and molar relationship
as the premolars and canines erupt into occlusion; (b) occlusal view
of support appliance with anterior inclined plane (Reproduced from
Clark WJ, Design & construction of Twin Block appliances10 with
the kind permission of Elsevier Science Ltd)
 JO Month 2010 Clinical Section Twin Block design and management 210

repeated progressively at each visit as the molars erupt
into occlusion. This sequence of adjustment does not
allow the tongue to spread laterally between the teeth to
prevent eruption of lower molars, and results in more
rapid development of the vertical dimension (Figure 6).
It is important to support the mandible in a protruded
position throughout the sequence of trimming the
blocks. The leading edge of the inclined plane on the
upper bite block remains intact.
Support and retention
Twin Blocks may be left out when the overjet and
overbite are corrected and the molars have erupted fully

(a) (b) (c)

Journal of Orthodontics jor37.3_Clinical I132.3d 13/7/10 22:27:18
Rev 7.51n/W (Jan 20 2003)
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(d) (e) (f)

(g) (h) (i)

COLOUR
FIGURE

(j)
Figure 8 Treatment of Class II Division I malocclusion with deep overbite: (a–c) occlusion before treatment; (d) bite registration; (e) the
overjet corrects first as the upper block is trimmed to allow molar eruption; (f) the molars are in occlusion, the open bite in the premolar
region is reducing and the occlusion settling during the support phase; (g–i) occlusion 5 years out of retention; (j) composite profiles before
and after treatment and out of retention (Reproduced from Clark WJ, Design & construction of Twin Block appliances10 with the kind
permission of Elsevier Science Ltd)
 JO Month 2010 Clinical Section
into a class I occlusion. A fixed appliance may be used to
level the lower arch and complete treatment if required,
or alternatively an appliance with an anterior inclined
plane may be fitted for support and retention (Figure 7).
Functional retention is recommended following func-
tional therapy. A simple retainer with an anterior
inclined plane may be used to support the corrected
incisor and molar relationship while the premolars and
canines erupt into occlusion. This is worn full time until
the buccal segment occlusion is fully established and
may then continue as a night time retainer. In mixed
dentition treatment, Twin Blocks may continue to be
worn at night to retain the corrected occlusion. Vertical
adjustment by trimming the blocks is seldom required in
mixed dentition treatment. This allows clasps to be
placed on lower molars to improve fixation of the
appliance in mixed dentition.
Aesthetic appliances
Journal of Orthodontics jor37.3_Clinical I132.3d 13/7/10 22:27:40
For several years after developing Twin Blocks, the
Rev 7.51n/W (Jan 20 2003)
author continued to use a labial bow on the upper
appliance. In the author’s Twin Block study in 1995,4 it
was observed that the upper incisors were over corrected,
resulting in an increased interincisal angle and increased
overbite. In most cases, a labial bow is not necessary. The
The Charlesworth Group, Wakefield +44(0)1924 369598 -
edge to edge construction bite encourages the lips to close
naturally and a lip seal develops as the appliance is worn
24 h a day, including for eating. Lip pressure acts to
retract the upper incisors without adding a labial bow.
A frequent error in Twin Block design (Figure 5(a)) is
illustrated with clasps on lower molars, an upper labial
bow and 3 ball clasps in the lower incisor region. In
most cases the labial bow is redundant and can be
removed. The ball clasps may be required in mixed
dentition for additional retention but in permanent
dentition a more comfortable and aesthetic design places
ball clasps mesial to lower canines. Following these
principles Twin Blocks can be almost invisible and well
tolerated appliances with a low rate of failure to
complete treatment. An example of treatment of a class
II division I malocclusion with deep overbite using the
method described is shown in Figure 8.
Conclusion
This article identifies common errors in Twin Block
design and management, which influence the rate of
failure to complete treatment. A protocol is described to
View publication stats
Twin Block design and management 211
improve efficiency in the application of Twin Block
technique. Facial appearance improves immediately
when Twin Blocks are inserted. Aesthetic Twin Block
design encourages patients to wear the appliances full
time. These are important factors in patient motivation
and cooperation.
The author’s web site is www.twinblocks.com and
contains further information on recent developments,
including Fixed Twin Blocks.
References
1. O’Brien KD, Wright K, Conboy F, et al. Effectiveness of
treatment for Class II malocclusion with the Herbst or Twin
Block appliance: a randomized controlled trial. Am J
Orthod Dentofacial Orthop 2003; 124: 128–37.
2. Illing HM, Morris DO, Lee RT. A prospective evaluation of
Bass, Bionator and Twin Block appliances. Part 1 – the
hard tissues. Eur J Orthod 1998; 20: 501–16.
3. Harradine NWT, Gale D. The effects of torque control
spurs in Twin Block appliances. Clin Orthod Res 2000; 3:
202–09.
4. Clark WJ. Aspects of Twin Block functional therapy in
orthodontics & dentofacial orthopaedics. Dissertation
submitted for the degree of DDSc to Dundee University,
1995.
5. Clark WJ. New horizons in orthodontics & dentofacial
orthopaedics. Thesis submitted for the degree of DDSc to
Dundee University, 2010.
6. Shah A, Sandler J. ‘How to…Take a wax bite for a Twin
Block appliance’, J Orthod 2009; 36: 10–12.
7. Geserick M, Olsburg SR, Petermann D. The bite jumping
screw for modified twin block treatment. J Clin Orthod
2006; 40: 432–35.
8. Carmichael GJ, Banks PA, Chadwick SM. A modification
to enable controlled advancement of the Twin Block
appliance. Br J Orthodont 1999; 26: 9–14.
9. Clark WJ, Stirrups D. The Delta Clasp. Design and
construction in aspects of Twin Block functional therapy in
orthodontics & dentofacial orthopaedics. Unpublished
material in thesis presented to Dundee University, 1995.
10. Clark WJ. Twin Block Functional Therapy – Applications in
Dentofacial Orthopaedics, 2nd Edn. Oxford: Mosby/Elsevier
Science, 2002.
11. Dyer FMV, McKeown HF, Sandler PJ. The modified Twin
Block appliance in the treatment of class II division 2
malocclusions. J Orthod 2001; 28: 271–80.
12. Woodside DG. The activator. In Graber TM, Neumann B
(eds.). Removable orthodontic appliances. Philadelphia, PA:
W.B. Saunders, 1977, Chapter 12, 288–89.