Orthodontic Twin Block Appliance Functional appliances are a variety of appliances designed to correct Class II skeletal malocclusion by positioning

the mandible downward and forward to theoretically enhance mandibular growth. They work on the upper and lower teeth at the same time. They can be tooth borne e.g. The Bionator, The Activator and the Twin Block appliance or tissue borne e.g. Frankels Removable functional regulator. The twin block is a two piece (split activator) using separate maxillary and mandibular appliances with occlusal acrylic portions that serve as guide planes and bite blocks to determine the extent that the mandible is postured downward and forward

Components: 1. Active components Bite ramps They contact when the patient closes down where the mandible can be postured forward. They are made at 70 degrees to the occlusal plane and are placed at the distal third of the cuspids. Midline expansion screw on the upper appliance allows lateral expansion of the maxilla to accept the growing mandible. Other modifications may be: Addition of one anterior screw with torquiring spurs to the upper central incisors. A double cantilever spring behind the upper labial segment

Anterior occlusal cap of acrylic on lower incisors to intrude lower and upper incisors. This opens the deep bite and inhibits proclination of lower incisors

2. Retentive component Adams clasps on maxillary and mandibular first molars and first premolars. Ball ended clasps on the lower labial segment. C clasps around terminal molars on the lower appliance Delta clasps on the lower cuspids and upper permanent molars. Arrow head clasps between the upper bicuspids. Labial bow running from cuspid to cuspid in the upper jaw. 3. Acrylic base plate Can be pigmented. In the lower jaw, the lingual flanges aid in retention and they extend distal to the molars. Deep grooves may be cut into the occlusal surface of the rims to aid in mastication. 4. Anchorage

Indications: I. Angles Class II Division I with proper arch form II. Patient should be in active growth phase III. Lower arch that is uncrowded or decrowded and aligned. IV. Upper arch that is aligned or can be easily aligned V. An overjet of 10 12 mm and a deep overbite.

Phases of Treatment: Active phase: Involves use of the twin block appliance to reposition the mandible until the overjet and overbite are corrected. This takes 7 9 months. Support Phase: An upper removable appliance with a steep incline is used to retain the corrected incisal relationship until posterior relationship is achieved. This takes 4 6 months. I. The Clinical Phase A good diagnosis and treatment planning.

 Complete Maxillary and Mandibular impressions. The clinician must ensure that he captures the palate accurately as well as the area distal to the lower molars. A complete prescription of the components should be given by the clinician. A Protrusive Bite registration The mandible is advanced to an end on end relationship (or 5 8 mm from the centric occlusion). A vertical dimension of 4 5 mm should be established in the bicuspid region. A small opening of 1 2 mm should be left between the incisors. Pour impressions in stone and send the bite and models to the lab

II.

The Laboratory Phase The models are placed into the wax bite presented and articulated in the usual way. The models are prepared by removing any anomalies Undercuts are blocked with wax. Wire work is then fabricated for both upper and lower appliances and the midline screw is secured in place. Upper wire work: Labial bow 3/3 in 0.8mm S.S wire, Adams Clasps 6/6 in 0.7mm S.S wire. Lower wire work: Double Adams Clasp 54/45 in 0.7mm S.S wire, C clasps 21/22 in 0.8mm S.S wire, Ball ended clasps distal 4/4 in 0.8mm S.S. The Models are then returned on the articulator. Wax shuttering is then attached and sealed to the upper model, angling from the mesial of the upper 5s to the mesial of the lower 6s. This enables the technician to sprinkle the acrylic up against the shuttering to create the upper blocks. The anterior and posterior of the model are also blocked out. The model is soaked in water for ten minutes. Monomer and polymer are applied, building the blocks in the desired areas. One should ensure the acrylic flows under the midline screw. Once the blocks are the required height, the upper & lower models are placed back on to the articulator (It is sometimes a good idea to wet the lower model briefly with cold water prior to doing this as it will prevent any acrylic 'sticking' to it) and the upper is gently closed into the lower model, allowing the lower posterior teeth to contact the acrylic blocks.

 The upper model is then again removed from the articulator & placed into a flask and cured according to the manufacturer's instructions. Once cured, the upper model / appliance is removed from the flask and the wax removed by applying boiling water. The upper appliance is then ready for trimming Firstly, the upper part of plastic positioning segment of the mid-line screw is removed (pulled out) using pliers The excess acrylic is trimmed away, gradually shaping the appliance. The mid-line is then marked on the appliance and then cut through using a fine blade saw. The mid-line screw is then opened by a couple of turns to allow polishing of the appliance. A separator of clear adhesive tape is then placed over both blocks as shown to prevent the lower appliance 'sticking' to the upper once the lower acrylic is sprayed and cured. Wax 'shuttering' is again used & attached & sealed to the lower model, angling the wax so it follows the anglulation of the upper interface. The labial and lingual section of the lower model are also blocked out. The lower model is then soaked in cold water for approx 10 mins. The lower appliance is sprayed up is the same way as the upper appliance. Slowly building up both blocks to the required height, then cover the wires in the lingual area between the blocks. Placing both models onto the articulator, gently close the upper appliance into the lower appliance. Once cured, wax on the lower appliance is then removed in the same way as the upper and the cello tape is removed from the upper appliance. The lower appliance is then ready for trimming. Send the finished appliance to clinician.

References: 1. Functional Appliances in Orthodontic Treatment (an atlas of clinical and laboratory construction) Harry S Orton. ISBN 1 85097-012-2. 2. Textbook of orthodontics- Samir E Bishara. 3. Clark WJ (1992). The Twin Block Technique Part 1. Funct Orthod. 1992 NovDec;9(6):45-9.