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74]

Clinical Pearl

Twin-Star: Adding a new dimension for treatment

of Class II noncompliant patients

Sonali Malay Mahadevia, Abstract

Neha Parshotam Assudani,
Krishnamurthy Gowda,
Aatman Jagdish Joshipura
Department of Orthodontics
and Dentofacial Orthopaedics,
Ahmedabad Dental College, District
Bhadaj, Ahmedabad, Gujarat, India
The orthodontist of today faces the herculian task in getting kids to wear myofunctional
appliances. Even the Twin-Block, which is claimed to be one of the most patient
friendly appliances, is not so easily accepted by the growing child of the 21st century.
An innovative modification of the Twin-Block called Twin-Star is hereby presented.
Compared with the traditionally constructed Twin-Block, the Twin-Star proves to be
esthetically superior, with a higher level of comfort and is less bulky (as it is palate free)
and hence easily accepted by the patient. It is a boon to the orthodontist too as it can
be made in a single sitting by the orthodontist himself.
Key words: Chairside, innovative, invisible, myofunctional appliance, Twin-Block

INTRODUCTION with the help of a Biostar unit (Biostar® VI with Scan

Twin-Block is a versatile and effective appliance
introduced by Clark in 1982[1] used for the correction of
Class II malocclusion.[2-5] It has stood the test of time
and has remained popular over the last two decades.[6]
However, over the years, the hallmarks of comfort and
acceptance have changed and in the present scenario,
the emphasis is more on patient’s aesthetics and comfort
rather than only on mechanical or biological superiority.
It has been widely seen that aesthetics and comfort play
a major role in increasing the patient compliance, which
is of ultimate concern to the orthodontist to achieve
optimum results. We orthodontists find young patients
reluctant to wear a Twin-Block because of either social
or psychological reasons.
An innovative method has been devised in which a
Twin-Block can be fabricated chair side in a single sitting
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DOI:
10.4103/2321-1407.125746
Technology, Great Lakes Tonawanda, NY) or any other
pressure molding unit. This unique Twin-Block, which
we have called “Twin-Star,” is made using a Biocryl sheet
(Clear Splint Biocryl 1 mm round, Great Lakes Tonawanda,
NY). It is patient friendly, as it has a perfect fit, is less bulky
(palate free), has no wire components and above all it can
be easily fabricated by the orthodontist himself.
MATERIALS AND METHODS
Materials required
• A pressure molding machine (e.g., Biostar).
• Biocryl sheet of 1 mm thickness.
• Cold cure clear acrylic.
• Preformed upper and lower acrylic blocks (3-5 mm
height).
• Carbide bur and steel disc.
• Pumice.
Step-by-step procedure
• Make excellent alginate impressions of both the arches.
• Immediately pour the impressions in orthodontic stone
Type III used for orthodontic models.
• When separated, trim maxillary and mandibular models
to a horseshoe shape with the help of a palatal router
and allow to dry.

Address for correspondence:

Dr. Neha Parshotam Assudani, 1, Sadbhav Bunglows, Nr. Civil Hospital, Shahibaug, Ahmedabad - 380 004, Gujarat, India.
E-mail: assudani.neha@gmail.com

APOS Trends in Orthodontics | January 2014 | Vol 4 | Issue 1 21

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Mahadevia, et al.: Twin-Star: Adding a new dimension for treatment of Class II noncompliant paƟents
• Paint a separating medium (Great Lakes separator,
Great Lakes Tonawanda, NY) on the models, which
will prevent plaster from sticking to the thermoplastic
material.
• Place the Biocryl sheet in the pressure molding
machine[7] and turn on the heat source. As the material
gets hot it will begin to sag. The secret to uniform
adaptation is getting the material evenly heated. It
should sag (1/4th) one quarter before being vacuum
formed over the model [Figure 1a].
• When the material is ready, pull it down over the model
and turn the suction on.
• The thermoplastic material will retain heat for a while.
To ensure complete cooling run the model under water
or let it set for at least 5 min. Now these well-fitting
trays are ready for trimming [Figure 1b and c].
• They can be trimmed with a steel disc and removed
from the models.
• Wax bite is recorded in the traditional manner
[Figure 2a-c].
b c
Figure 1: (a) Heating process in pressure molding unit (b) upper splint
(c) lower splint
b c
Figure 3: (a) Upper block prepared on upper splint (b) lower block
prepared on lower splint (c) upper and lower splints with block in place
22
• The acrylic upper and lower blocks can either be
constructed now or prefabricated beforehand and
kept ready.
• The upper block covers the second premolar, first
molar and the second molar [Figure 3a].
• The lower block extends from distal half of the canine
to the mesial half of the second premolar [Figure 3b].
• Adjust the blocks in the patient’s mouth so that lower
block interlocks with the upper at an angle of 70°,[2]
having at least 5-6 mm of thickness to help maintain
the forward position of the mandible.
• After the adjustment is done, mark this position and
with cold cure fix them in the upper and lower splints
[Figure 4].
• Upper and lower splints with block in place
[Figure 3c].
• The appliance can be polished using pumice in the
usual way and is now ready to be fitted in the patient’s
mouth [Figure 5].
• Patient is instructed to wear it for 24 h.[8,9]
a b
c
Figure 2: Bite recorded (a) right lateral view (b) left lateral view
(c) frontal view
b c
Figure 4: Upper and lower blocks in place (a) frontal view (b) right
lateral view (c) left lateral view
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Mahadevia, et al.: Twin-Star: Adding a new dimension for treatment of Class II noncompliant paƟents
CASE REPORT
• A 12-year-old male patient reported to the Department
of Orthodontics, Ahmedabad Dental College,
Ahmedabad, India with a chief complaint of forwardly
placed upper front teeth.
• On extraoral clinical examination, it was found that
he had a convex profile, retruded chin position,
posterior facial divergence, decreased clinical FMA,
deep mentolabial sulcus and hypotonic lips [Figure 6a].
• A clinical VTO was performed which was found to be
positive.
• On intraoral clinical examination, the overjet was 8 mm
and overbite was 7 mm, molar relationship was Class II
on the right and left sides and the canine relationship
on the right side was Class II [Figures 7a and 8a].
• Lateral cephalogram showed retrognathic mandible,
reduced Frankfurt’s mandibular plane angle (FMA),
average to horizontal growth pattern. [Figure 9a].
Orthopantogram showed presence of all teeth,
symmetrical dental development on both sides and
adequate alveolar support to the teeth [Figure 10a].
• The patient was diagnosed as having Angle’s Class
II malocclusion on skeletal Class II bases with
c
b d e
Figure 5: The finished appliance in the mouth (a) maxilla (b) mandible
(c) frontal view (d) right lateral view (e) left lateral view
b
Figure 7: Intraoral photographs (a) pre-treatment (b) post-treatment
APOS Trends in Orthodontics | January 2014 | Vol 4 | Issue 1
orthognathic maxilla and retrognathic mandible.
The growth pattern was average to horizontal, upper
and lower incisors were proclined and crowded. An
increased overjet and overbite was also present [Table 1].
• The ideal treatment plan was non-extraction two phase
treatment. First phase consisted of myofunctional
appliance therapy using Twin-Star, followed by fixed
appliance in the second phase.
• The skeletal correction was achieved after wearing
the appliance for 10 months, which was followed by a
retention phase of 3 months [Table 1].
• Post-treatment extraoral clinical examination showed
that, there was pleasing improvement in facial
appearance, a straight profile, average chin position,
and lip competency was achieved [Figure 6b].
• Post-treatment intraoral clinical examination showed
that, overjet was corrected and overbite was reduced,
molar and canine relationships were Class I bilaterally.
[Figure 7b and 8b].
• Orthopantogram showed eruption of premolars
[Figure 10b].
b
Figure 6: Extraoral photographs (a) pre-treatment (b) post-treatment
a b
Figure 8: Maxillary arch and mandibular arch (a) pre-treatment
(b) post-treatment
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Mahadevia, et al.: Twin-Star: Adding a new dimension for treatment of Class II noncompliant paƟents

Table 1: Cephalometric readings pre-treatment and post-treatment

Skeletal measurement Mean value Pre-treatment Inference Post-treatment (Phase I)
SNA 82° 82° Average position of maxilla 81°
SNB 80° 76° Posterior position of mandible 79°
ANB 2° 6° Class II skeletal pattern 2°
SND 76° 72° Retrusive chin position 74°
FMA 25° 24° Horizontal growth pattern 25°
N perpendicular to point A 0±2 mm −2 mm Orthognathic maxilla 2 mm
N perpendicular to Pog 0-4 mm −7.5 mm Retrognathic mandible −3.5 mm
Witt’s appraisal AO is 2 mm ahead of BO Class II skeletal pattern AO and BO coinciding

• Post-treatment lateral cephalogram showed positive

growth response during treatment with significant
increase in mandibular length and a resultant
improvement in mandibular retrusion [Figure 9b].
• Sella nasion line was used as reference line for
Superimpositions of pretreatment and posttreatment
cephalograms which showed forward movement of
point B by 3 mm and achievement of class I molar
relationship. [Figure 11].
a b
Figure 9: Lateral cephalogram (a) pre-treatment (b) post-treatment Advantages
• This appliance can be fabricated chair side in a single
sitting.
• The appliance is esthetically appealing to the patient.
• It offers optimum patient comfort hence patient
compliance is good.
• The speech is better as palate remains free and there
are no wire components present.
a
• Retention and fit is excellent.
• Incisal capping is present; hence proclination of lower
incisors[10] is prevented.
CONCLUSION
An attempt has been made to modify a myofunctional
b
appliance in a way that is beneficial to the patient, as it
Figure 10: Orthopantogram (a) pre-treatment (b) post-treatment
proves to be comfortable, esthetic and well-fitting and can be
fabricated in a single sitting at the chairside. The construction
of other functional appliances also in this manner will
make it simple for us to treat a greater number of patients
who require growth modulation therapy. As we embark on
“orthodontics next generation” we owe it to our patients to
make treatment more pleasant in the years to come.

REFERENCES
1. Clark WJ. The Twin Block traction technique. Eur J Orthod
1982;4:129-38.
2. Clark WJ. Treatment of Class II division 1 malocclusion deep overbite.
In: Clark WJ, editor. Twin Block Functional Therapy Applications in
Dentofacial Orthopaedics. 2nd ed. London: Mosby Wolfe; 2002. p. 89-100.
3. Clark WJ. The Twin Block technique. In: Graber TM, Rakosi T,
Figure 11: Superimposed tracings of pre-treatment and post-treatment Petrovic AG, editors. Dentofacial Orthopedics with Functional
cephalograms Appliances. 2nd ed. St. Louis: Mosby; 1997. p. 268-98.

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Mahadevia, et al.: Twin-Star: Adding a new dimension for treatment of Class II noncompliant paƟents

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[Last cited on 2013 Aug 11].
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How to cite this article: Mahadevia SM, Assudani NP, Gowda K,
Joshipura AJ. Twin-Star: Adding a new dimension for treatment of Class II
noncompliant patients. APOS Trends Orthod 2014;4:21-5.
Source of Support: Nil. Conflict of Interest: None declared.

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