Guide Dr.

Chandralekha B
Prof & HOD Dept. Of Orthodontics Vydehi Institute Of Dental Sciences

By Dr. Nilofer
PG Student Dept. Of Orthodontics

Contents

Introduction Twin Block Principles Development of Twin Block Stages Of Treatment Mode Of Action Appliance design Various modifications Case selection Clinical management Effects of Twin Block References

Introduction
Twin blocks are designed on aesthetic principles to free the patient of the restriction imposed by a one-piece appliance made to fit the teeth in both jaws without overly restricting normal movements of the tongue, lips and mandible.

 Twin block appliances are simple bite blocks which achieve rapid functional correction of malocclusion by the transmission of favorable occlusal forces to occlusal inclined planes that cover the posterior teeth.
The forces of occlusion are used as the functional mechanism to correct the malocclusion.

TWIN BLOCK PRINCIPLES

The occlusal incline plane is the fundamental functional mechanism of the natural dentition. It plays an important role in determining the relationship of the teeth as they erupt into occlusion.
A functional equilibrium is established under neurological control in response to repetitive tactile stimuli.

When mandible occludes in a distal relationship to the maxilla, occlusal forces have a distal component of force that is unfavorable to normal forward mandibular development. Inclined planes - represent a servo mechanism that locks the mandible in a distally occluding functional position.

Occlusal forces Constant proprioceptive stimulus BONE Rate of growth Trabecular structure

Twin Blocks are constructed to a protrusive bite that effectively modifies the occlusal inclined plane by means of acrylic inclined planes on occlusal bite blocks. The occlusal inclined plane acts as a guiding mechanism causing the mandible to be displaced downward and forward with the appliance in the mouth The patient cannot occlude comfortably in the former distal position, and the mandible is encouraged to adopt a protrusive bite with the inclined planes engaged in occlusion.

The upper and lower bite blocks interlock at a 70 degree angle. Full time wear takes advantage of all functional forces applied to the dentition including the forces of mastication. Muscle behaviour is immediately influenced through the placement of inclined planes. The muscles of mastication must adapt to the altered balance of occlusal forces by guiding the mandible into protrusive function. This guidance results in rapid soft tissue adaptation to achieve a new position in equilibrium in muscle behaviour. Rapid improvement in facial appearance occurs during the first few weeks and months of treatment

Development of Twin block

The twin block appliance evolved in response to a clinical problem that presented when a young patient fell and completely luxated an upper central incisor
Lip trap was causing root resorption and mortality Upper and lower acrylic plates with bite blocks were fabricated - advance mandible - reduce overjet and eliminate lip trap

Hence, the first twin block was fitted on 7th of September 1977. Although the root resorption was severe, this treatment worked and helped save the tooth.

Goal of the twin block appliance

To produce a technique that could maximize the growth response to functional mandibular

protrusion by using an appliance system that is simple, comfortable and aesthetically acceptable to the patient

TWIN BLOCK STAGES

1.

The Twin Block Technique has 2 stages :

Active phase : Posterior inclined planes adjust the vertical dimension and correct the malocclusion by functional mandibular protrusion.

1.

Support phase : An anterior inclined plane is used to retain the corrected incisor relationship until the buccal segment occlusion is fully established.
Occlusal cover is maintained over the posterior teeth to prevent eruption in treatment of anterior open bite. Orthopedic traction : Where necessary retractive forces may be applied by the addition of headgear tubes to upper first molars.

MODE OF ACTION
Effects on the condyle:
Rapid adaptive changes in the tissues surrounding the condyle when a full-time functional appliance is fitted. Intense cellular activity Proliferating connective tissue and capillary blood vessels Harvold (1983)

Effects on the muscles: Aggarwal et al AJO 1999 Electromyographic study on the adaptive changes during treatment. Bilateral electromyographic activity of the elevator muscles of the mandible i.e. anterior temporalis and masseter) was monitored over 6 months.

 Results revealed a significant increase in postural and maximum clenching EMG activity, attributed to enhanced stretch (myotactic) reflex of the elevator muscles, contributing to isometric contractions. The main corrective force for Twin Block treatment appears to be provided through increased active tension in the stretched muscles and not through passive tension.

 The position of the mandible did not change significantly after fatiguing the protrusive muscles. It appeared that lateral pterygoid muscle was not responsible for new position of mandible after treatment with Twin Block. It is possible that TMJ adapted to displacement of mandible by condylar growth and surface modeling of the fossa.

 Lund & Sandler (AJO 1998) compared 36 subjects (mean age 12.4 years) with 27 controls. The subjects showed favourable changes including : 1. forward positioning of mandible 2. increase in mandibular length (Ar-Pog 2.4 mm more than controls) 3. increase in SNB angle 4. increase in lower anterior facial height 5. overjet reduction by 7.5 mm 6. buccal segment correction

 Similar favourable changes reported by

Caldwell & Cook (EJO 1999), Mills & McCulloch (AJO 2000) Toth (AJO 1999) Baccetti, Franchi & McNamara (2000 AJO)

 Kevin OBrien et al (AJO 2003) conducted a Multicenter

trial in U.K. evaluating the effectiveness of early orthodontic treatment with the Twin-Block for Class II Div. 1 malocclusion.

They concluded that early treatment with the Twin-Block is effective in reducing overjet and severity of malocclusion. Most of this correction was due to dento-alveolar change.

Consist of Upper and lower removable acrylic plates with bite blocks Clasps to retain the appliances Expansion screws.

Base plate
Heat or cold cure acrylic Advantages - additional strength of heat cure - speed and convenience of cold cure Preformed bite blocks - manufactured in the correct size and shape for addition to cold cure acrylic

The lower block Covers the occlusal surface of the lower premolars or deciduous molars to occlude with the inclined plane on the upper block

Extends to the distal marginal ridge of 2nd premolar

Flat occlusal bite block - thinner buccolingually in the lower canine region - allows freedom of tongue movement Angulation of blocks in relation to line of arch at right angles advantage is that angulation maintained even after widening the archform along the line of alignment of teeth

Upper bite block

Extends from the mesial surface of the upper second premolar posteriorly to first molar Only the lingual cusps of the upper posterior teeth need to be covered rather than the full occlusal surface allows flexibility of clasp & ease of adjustment

 Wire Components : The clasps used in the standard twin block appliance are
Delta Clasp in the upper 1st molar Delta clasp in the lower 1st

premolar Ball end interdental clasps in anterior region in both arches

 Delta Clasp (0.7 to 6.75 mm SS wire)

The earliest twin blocks had Adams clasps Disadvantage - opens up slightly with repeated insertions and removal, which causes metal fatigue Clark designed Delta clasp in 1985 Retentive loop was designed as closed triangular shaped loop and hence the name

Later the shape became circular for ease of bending (bird beak pliers No. 139)

Advantage The clasp does not open with repeated insertion and removal and therefore maintains better retention and requires less adjustment The apex of the triangle can be directed into mesial or distal interdental area, or The base of the triangle can be adapted against the surface of the tooth to form a line contact In deciduous dentition, C clasps are used for better retention

Labial Bow
Used when severely proclined incisors need uprighting Should not be activated until correction of molar relationship has taken place otherwise the over jet may be reduced thus acting as a barrier, and limiting functional correction by mandiblular advancement

Expansion Screw
Included in the upper appliance for compensatory expansion in the upper arch to accommodate the lower arch as the mandible translates forward Upper and lower midline screws may be used for unequal expansion Must act in horizontal plane not inclined downwards anteriorly

Activation
Twice a week in growing children one quarter turn of each screw at midweek and at the week end Less activation may be required for older children where tooth movements are slower

CONSTRUCTION
1.

2.
3.

Good set of impressions Accurate construction bite Models mounted on an articulator

BITE REGISTRATION
There are two types of bite gauges used to register bite for twin block:
1. 2.

George bite gauge Exactobite gauge

George bite gauge

Has a sliding jig attached to a millimeter scale Designed to measure the protrusion path of the mandible determine accurately the amount of activation registered in the construction bite.

Incisal portion has three incisal grooves to be positioned on the incisal edge of the upper incisor
A single groove on the opposing side that engages the incisal edge of the lower incisor The appropriate groove is selected

 Exactobite or Projet Bite Gauge Incisal portion has three incisal grooves to be positioned on the incisal edge of the upper incisor

A single groove on the opposing side that engages the incisal edge of the lower incisor The appropriate groove is selected

Designed to record a protrusion bite for construction of twin blocks Registers 2 mm vertical clearance between the incisal edges of the upper and the lower incisors

5 or 6 mm of clearance in the first premolar region and 3 mm of clearance distally in the molar region
Ensures that space is available for vertical development of posterior teeth to reduce the overbite.

Guidelines
Horizontal consideration
According to the Roccabado (1992), the position of maximal protrusion is not a physiological position and the range of physiological movement of the mandible is only 70% of the total protrusive path. This is also called freedom of movement.

Total protrusion path is calculated by measuring the overjet in most retruded position and then in the most maximal protrusion and finding the difference between the two.

The initial activation should not exceed 70% of the protrusive path
Average 5 10 mm on initial activation, depending upon the freedom of movement in protrusion function This degree of activation allows an overjet as large as 10 mm to be corrected

Midline consideration
Centre lines should be coincident provided no dental asymmetry is present

Vertical consideration
Two factors determine the amount of vertical clearance Thickness of the bite block

Adequate vertical clearance must be available between the cusps of the upper and lower first premolars or deciduous molars to accommodate blocks of sufficient thickness (5 mm) to activate the appliance

Freeway Space Activation must open the bite beyond the freeway space to ensure that the patient can not drop the mandible into rest position and negate the proprioceptive functional response of the inclined planes

Intergingival height To establish the correct vertical dimension Measured from gingival margin of upper incisor to gingival margin of lower incisor when teeth are in occlusion Comfort zone for intergingival height for patients is generally found to be 17-19 mm Height of upper & lower incisors minus overbite

Horizontal Vs Vertical growth pattern

Horizontal growth pattern - maintain edge to edge incisor relationship more easily (provided the overjet is not excessive)
Vertical growth patterns 1. May not tolerate the same degree of sagittal activation (weak musculature) 2. A smaller initial activation is necessary 3. Gradual mandibular advancement

Angulations of the inclined planes

Earliest appliances articulated at 90 angle Difficult maintain a forward posture blocks occluded on each other - posterior open bite Angle of inclination was changed from 90 to 45.

The 45 inclined plane : Applies downward & forward components of force to the lower dentition which are equal to each other. So, After 8 years, the angulation was finally changed to the steeper angle of 70. It was reasoned that this may encourage more forward mandibular growth.

Three phases
Active phase

Support phase
Retention phase

Active Phase

Twin blocks are worn full time The objective is to correct arch relationships in the anterior-posterior vertical transverse dimensions Normally overjet and overbite are corrected within 6 months and the lower molars have erupted into occlusion into 9 months The average time is 6 9 months

 Clinical management during active phase

Instructions to the patient 1st visit
Ways to insert and remove the appliance Operation of screw The screw is turned for the first time after the appliance has been worn for one week. Twice a week after one week. Once mid-week and again on the weekend Patient should be instructed to eat with the appliance Proper cleaning especially after eating

The clinician should check that the patient bites comfortably in a protrusive bite Overjet is measured for future reference

The lingual acrylic of the appliance must be relieved

The clasps are adjusted If a labial bow is present, it should be out of contact with the upper incisors

2nd visit : after 10 days

Should be comfortable with the appliance If the patient is failing to posture forward consistently, reduce activation by trimming the inclined planes to achieve patient compliance

To correct deep bite

Trimming of upper block occlusodistally by 1mm in case of deep overbite. No trimming should be done in case of reduced overbite or open bite.

3rd visit : after 4 weeks: Positive Progress must be noted Review of progress reduction of OJ and correction of molar relationship. Adjustment of labial bow to keep out of contact (This is because we dont want any retraction which would hamper mandibular growth Check up for screw activation & its effects Trimming of upper block as needed

4th visit : after 6 weeks Similar pattern of adjustment. REACTIVATION OF TWIN BLOCKS:

To increase the forward posture - by the addition of the cold cure acrylic to extend the anterior incline of the upper twin block

No acrylic added to distal of lower block Preformed blocks -reactivation of 2, 3 or 5mm increments maybe cold cured or light cured into place

Reactivation is needed when

Protrusive path of mandible is restricted requiring gradual and progressive activation, as in a) Overjet is greater than 10mm b) In vertical growth pattern when patient cannot tolerate 10mm protrusion c) In adult treatment, when the muscles and ligaments are less responsive to a sudden large displacement of the mandible d) TMJ dysfunction

Support Phase
The aim is to retain the corrected incisor relationship until buccal segment occlusion is fully established

An upper removable appliance with steep anterior inclined guide plane

The lower appliance is left out at this stage and the posterior bite blocks are removed to allow the posterior teeth to erupt into occlusion The upper and lower buccal teeth are usually in occlusion within 3 - 6 months. Full time wear necessary to allow time for internal bony remodeling - important phase, stability is excellent after twin block treatment which can be attributed partly to the supportive phase

Retention phase
A normal period of retention follows treatment after occlusion is fully established During the retention period the appliance wear can be gradually reduced to night time wear Extends for 9 months usually

Average treatment time

Active phase- 6-9 months
Support phase- 3-6 months Retention phase- 9 months

Average treatment time 18 months

Monitoring Condylar Position During Treatment

X-rays to evaluate position of condyle in the glenoid fossa
Before Rx with the teeth in contact Downward and forward position of the condyle when the

appliance is inserted After the overjet has been reduced On completion of Rx

Incorporation of additional screws

Twin block Schwarz appliance

Twin block sagittal appliance

Incorporation of springs Springs can be fitted for individual teeth movement. They can be used to procline retroclined incisors in case of Class II div 2 malocclusion

Twin block Crozat appliance

Magnetic Twin Block

To increase occlusal contact on the bite blocks

Samarium cobalt and Neodynium boron magnets

Attracting magnets Increased activation can be built Increase frequency and force of contact on the inclined planes, thus enhances the adaptive response

Repelling magnets Used with less activation built into the inclined plane Intended to apply additional stimulus to posture the mandible forward

Disadvantages
Amount of activation not clear Reactivation would deactivate the magnet

Moss & Shaw 1990 reported a 50% increased rate of correction of overjet compared to a similar group of patients without the magnets

Twin block with Concorde face bow Indications

Severe maxillary protrusion

To control a vertical growth pattern by the

addition of vertical traction to intrude the upper posterior teeth In adult treatment where mandibular growth cannot assist the correction of a severe malocclusion

The Concorde face bow is a new means of applying intermaxillary and extraoral traction to restrict maxillary growth and at the same time to encourage mandibular growth in combination with functional mandibular protrusion

 A conventional face bow is adapted by soldering a recurved labial hook to extend forward to rest outside the lips as an anchor point to combine intermaxillary and extraoral traction.

 Intermaxillary traction was added to the appliance system to ensure that if the patient postured out of the appliance during the night the intermaxillary traction force would increase. This ensured that the appliance was effective 24 hrs per day.

Fixation of twin block

Prior to fixation, teeth first fissure sealed and treated with topical fluoride : Two methods Zinc oxide or zinc phosphate cement Direct application of composites around clasps

Twin block Transpalatal arch

Twin block Hyrax appliance

Twin block lingual arch

Advantages of fixed Twin block

Patient cooperation not required Works 24 hrs a day No transitional phase between functional phase and the fixed phase so treatment time is reduced

Twin block with fixed appliance

Simultaneous correction of arch relationship and alignment The presence of bite blocks prevents traumatic occlusion on the fixed attachments and avoid breakage as a result of excessive overbite An easy transition may then be made to a full fixed appliance phase to detail the occlusion and complete the treatment.

Criterias :
Angles Class II division I malocclusion with good arch form

Uncrowded or well aligned lower arch

Upper arch that is aligned or can be aligned An overjet of 10 -12 mm and a deep overbite A full unit distal occlusion in the buccal segments Clinically good VTO Patient in active phase of growth

Treatment of deep overbite

Trimming upper twin block occlusodistally to encourage eruption of the lower molars (separators can be placed) 1-2 mm clearance over the lower molars

The inclined plane must remain intact, however to maintain the activation to propel the mandible down and forward

Vertical development slower than sagittal correction

Should therefore be made as early as possible in treatment to allow vertical development to proceed concurrently with sagittal correction

Treatment Of Reduced Overbite

Bite registration Activation should not be more than 70% of the total protrusive path
Yellow Projet or exactobite to register a 4mm interincisal clearance with a 5mm clearance in premolar region Bite should be opened beyond the freeway space

Appliance design
All posterior teeth must be in occlusal contact with the opposite bite blocks to prevent their overeruption In the lower appliance clasps placed on first molars to prevent their eruption Second molar eruption should be controlled by placing occlusal rests or extending the upper twin block distally

Orthopedic traction and Palatal spinner

Application of intrusive orthopedic forces may be used to help control vertical growth

Intraoral elastic first used by Dr Christine Mills Effective especially in vertical growers with weak musculature
Magnetic force - attracting or repelling force on the inclined plane.

Treatment Of Class II Div 2

Bite registration
Incisors in an edge to edge occlusion

 Appliance design

Sagittal screws Sagittal and transverse Three way screw

Springs

Triple Screw
20 80% ratio of posterior to anterior movement Designed to improve archform in anteroposterior and transverse dimensions simultaneously with improvement of vertical dimension due to twin block therapy

Treatment of class III

Reverse Twin Blocks
Have a reverse angulation of inclined planes to advance the maxilla using the lower arch as anchorage Important that the patients condyles are not displaced superiorly and or posteriorly in the glenoid fossae at full occlusion The force vector passes from the lower molar towards the gonial angle which is best able to absorb occlusal forces

Bite registration

Not the same degree of activation because of less scope for distal displacement of the mandible
Downward and backward forces absorbed at the gonial angle Teeth closed to position of maximum retrusion, leaving sufficient clearance between post teeth for bite blocks (2 mm interincisal clearance in fully retruded position)

Appliance design

Three way expansion screw

Distal movement of upper molars resisted by occlusion of lower bite blocks net effect forward driving force on upper arch

Lip pads

Should be attached to the anterior segment of appliance

Reverse pull face mask

Elastic force increased gradually 4-6 months of wear using heavy forces Can be used as a nighttime auxiliary

Treatment during mixed dentition

Appliance modification
Limited retention in deciduous teeth Methods to improve retention: Use of C clasp Bond composite on to the buccal surface of to create an undercut or Bond C clasp directly to deciduous molar

Synthetic crown contours, which are bonded onto the buccal surface to improve retention

Grinding a concavity for a ball clasp

Grinding retention grooves into buccal surface

Treatment Of Asymmetry
Effective in correction of facial and dental asymmetry.

Occlusal inclined plane ideal for unilateral activation

Appliance design
Sagittal screws - more frequent turning of screw on the side that requires more distal movement Use of magnets

Treatment of TMJ
Indicated in-early click when condyle is displaced distal to the disc Following objectives are attained
Immediate relief from pain Retraining of muscles to a healthy pattern &

relief of muscle spasm Recapturing of disc by downward & forward posture of mandible Movement of teeth causing occlusal imbalance

Sagittal twin block relieves compression on the joint Important to maintain posterior occlusal support at all times Full time commitment from patient

Comfort Patient wear twin blocks 24 hr per day and eat comfortably Aesthetics Twin blocks can be designed with no visible anterior wires without losing efficiency in correction of arch relationships. Function There is less interface with normal functions because the mandible can move freely in anterior and lateral excursion without being restricted by a bulky one piece appliance

Patient compliance Twin blocks maybe fixed to the teeth temporarily or permanently Removable twin blocks can be fixed in the mouth for the first week or 10 days of treatment Facial appearance The appearance is noticeably improved when twin blocks are fitted Improvements in the facial balance are seen progressively in the first three months of treatment.

Speech
Patients can learn to speak normally with twin blocks. Does not distort speech by restricting movements of the tongue, lips or mandible

Clinical management
Adjustment and activation is simple. The appliances are robust and not prone to breakage. Chairside time is reduced in achieving major orthopedic correction

Arch development
Twin blocks allow independent control of upper and lower arch width Appliance design is easily modified for transverse and sagittal arch development

Mandibular repositioning
Full time appliance wear consistently achieves rapid mandibular repositioning that remains stable out of retention

Vertical control Twin blocks achieve excellent control of the vertical dimension in treatment of deep over bite and anterior open bite Facial asymmetry Asymmetrical activation corrects facial and dental asymmetry in the growing child

Safety
Twin blocks can be worn during sports activities with the exception of swimming and violent contact sports, when they may be removed for safety

Efficiency
Twin blocks achieve more rapid control of malocclusion compared to one piece functional appliances because they are worn full time

Age of treatment
Arch relationships can be corrected from early childhood to adulthood However treatment is slower in adults but the response is less predictable

Integration with fixed appliances

Simultaneous skeletal correction and alignment During the support phase an easy transition can be made to fixed appliances

Effects on hard tissue

McNamara et al 1999 Studied the Rx effects produced by Twin block and FR-II appliance compared with an untreated control group 1)Increase in mandibular length in Twin Block -3.0mm Frankel -1.9mm 2)Increase in lower anterior facial height was more in Twin block group 3)More extensive dentoalveolar adaptation was observed more with the tooth borne Twin block appliance

Effects on soft tissue

Rapid changes in craniofacial musculature due to altered muscle function. As appliance is worn full time, even during eating, rapid soft issue adaptation occurs.

Significant facial changes within 2-3 weeks.

Twin Block appliance increases the intermaxillary space - difficult to form an anterior oral seal by contact between the tongue and the lower lip patients adopt a natural lip seal without instruction.
Good lip seal is a functional necessity to prevent food and liquid escaping from the mouth - so, no need for lip exercises.

Within a few days of fitting the appliances, the position of muscle balance is altered so that it becomes painful for the patient to retract the mandible. This has been described as the Pterygoid Response (McNamara) Formation of a tension zone distal to the condyle (Harvold)

 Evaluation was done to see whether the protrusive

muscles were responsible for mandibular repositioning after Twin Block therapy. It was found that fatiguing these muscles did not alter mandibular position in Twin block group after 6 months of treatment

In the pursuit of ideals in orthodontics, facial balance and harmony are of equal importance to dental and occlusal perfection We cannot afford to ignore the importance of orthopedic techniques in achieving these goals by growth guidance during the formative years of facial and dental development

 Twin Block Functional Therapy - Applications in

Dentofacial Orthopaedics.William J Clark

WJ Clark. The twin block technique. A functional orthopedic appliance system.AJODO1988;93(1):1-18 Illing et al. A prospective evaluation of Bass, Bionator and Twin block appliances. Part I-the hard tissues. EJO1998;20:501-516 Chintakanon et al. Effects of Twin block therapy on protrusive muscle functions.AJODO2000;118:392-6

Baccetti et al. Treatment timing for Twin block therapy.AJODO2000;118:159-70

Mills et al.Post treatment changes after successful correction of class II malocclusion with Twin block appliance. AJODO2000;118:24-33 Parkin et al.comparison of 2 modifications of the Twin block appliance in matched class I samples. AJODO2001;119:572-7 Read et al .The integration of functional and fixed appliance treatment. J of Orthodontics2001;28:1318