Journal of Orthodontics, Vol.

37, 2010, 209–216

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 complete treatment. However, appliance design may also

be a factor in patient acceptance: they concluded that
Since the Twin Block appliance was developed in 1977 Twin Blocks, perhaps because of the bulky acrylic blocks,
many authors and clinicians have advocated modifications caused more problems than did the Herbst appliance in
to their design and management. These modifications may eating and speaking. Arguably, because Twin Blocks can
lead to a high failure rate and instability in the occlusion be removed and Herbst appliances are cemented in the
following Twin Block therapy. This article is intended to mouth, compliance with wear might also influence the
look back at the original design and re-evaluate the success of treatment. Clearly a failure rate of 33.6% is
modifications that have occurred over time, with a view to undesirable in orthodontic practice.
improving patient acceptance and the stability of the end In two other studies, the failure to complete rate was
result. In the author’s original description of the technique, reported as 9 (Ref. 2) and 15% (Ref. 3). An audit of 83
the first principle of appliance design is simplicity. The consecutively patients treated by the Twin Block Traction
patient’s appearance is noticeably improved when Twin Technique in the author’s practice during the period May
Blocks are fitted. Twin Blocks are designed to be 1979 to May 1982 found an 8.4% failure to complete
comfortable, aesthetic and efficient. By addressing these treatment.4 After further investigation the author
requirements Twin Blocks satisfy both the patient and the included 148 patients treated between 1979 and 1990.
operator as one of the most ‘patient friendly’ of all the Ten patients were identified from practice records, who
functional appliances. The principles governing basic did not complete treatment during this 11 year period.
design and management have been lost in the passage of This represents a failure to complete treatment of 6.7%.4
time, with a resulting loss of control and a significant
reduction in efficiency and success in using the technique.
Height of occlusal blocks
Success rates Originally the Twin Block appliance was designed for
full time wear, including during eating. An edge-to-edge
One multi-centre randomized controlled trial, which bite with a small interincisal space, typically 2 mm,
compared the effectiveness of the Twin Block with the encourages the patient to close the lips naturally. This
Herbst appliance in the treatment of class II malocclusion posture is reinforced as the patient eats and drinks with
had a reported failure to complete rate for the functional the appliances in the mouth and patients consistently
phase of treatment of 12.9% for Herbst and 33.6% for develop competent lips and normal lip posture at an
Twin Blocks.1 In the discussion of the results the authors early stage in treatment. This lip posture and behaviour
reported that provision of treatment at no cost to the continues throughout treatment and is well established
child and parents, and poor socio-economic background by the end of the Twin Block phase, by which time the
may be factors in poor cooperation and failure to incisors and molars should be in occlusion.

Address for correspondence: William Clark, c/o JOR.

Email: [email protected]
# 2010 British Orthodontic Society DOI 10.1179/14653121043110
 210 Clark Clinical Section JO September 2010

A recent article entitled ‘How to…Take a wax bite for phase, as lower molars are not free to erupt. Large
a Twin Block appliance’5 indicates a change from the blocks are uncomfortable to wear and affect speech by
original design of the Twin Block appliance which, I restricting tongue space. It is impossible to incise food
believe, may explain the problems with patient accep- due to the anterior open bite, and it is difficult to chew
tance. The authors of the article propose that an ideal with bulky blocks. This may encourage patients to
wax bite should be at least 7 to 8 mm thick in the remove the appliances for eating, interfering with the
premolar region. Illustrations of this method of record- continuity of appliance wear. In addition, large blocks
ing a construction bite show a 10 mm vertical inter- increase lower facial height excessively and it is not
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.

Disadvantages of thick occlusal blocks

1. Appliances are uncomfortable and cannot be worn
full time.
2. Patients cannot incise or chew food making it
impossible to eat with the appliances in the mouth.
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.
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 (b)
with increased lower face height may embarrass the
patient and result in poor cooperation. The large blocks
produce a large posterior open bite after the Twin Block

(c)
Figure 2 Projet Bite Gauge: (a) select the appropriate groove for
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 appliances9 with the kind permission
Professor J. Moss) of Elsevier Science Ltd)
 JO September 2010 Clinical Section Twin Block design and management 211

(a) (b)
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 appliances9 with the kind
permission of Elsevier Science Ltd)

possible for the patient to close the lips comfortably. groove for the upper incisors depending on the ease with
This may also limit the improvement in the profile that which the patient can posture the mandible forwards.
results from advancing the mandible by encouraging The lower incisors then bite down into the single groove
downward and backward rotation of the mandible with to register the bite with 2 mm interincisal space.
increased vertical growth in facial height. An edge to edge construction bite with 2 mm
On the other hand, it is equally incorrect to make the interincisal space is registered in the middle groove to
blocks too thin, for example of 3 to 4 mm thickness in the correct an overjet of up to 10 mm for patients with good
premolar region. This allows the patient to retract the horizontal growth potential. The maximum sagittal
mandible in the rest position and results in failure to close activation is 10 mm and larger overjets may be corrected
the blocks correctly, especially during the night, causing a by an initial activation, followed by reactivation of the
reduction in the efficiency of the functional mechanism inclined planes after the initial correction has been
and possible failure to correct the distal occlusion. 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
Bite registration mandible by measuring the protrusive path of the
I believe that the correct bite registration in deep bite mandible. The overjet is measured with the mandible
cases is typically edge-to-edge with a 2 mm interincisal retruded and in the position of maximum protrusion.
space. This is equivalent to an inter-premolar space of 5 The activation must not exceed 70% of the total
to 6 mm. The resulting blocks are 5 to 6 mm thick in the protrusive path in order to remain within physiological
first premolar region and 1 to 2 mm thick in the molar limits of movement of the mandible.
region. The important factor is to open the bite beyond In the treatment of class II division I malocclusion with
the freeway space, so that the patient cannot retrude the an anterior open bite an alternative Projet Bite Gauge
mandible when in rest position, but to avoid making the (usually white in colour) is selected that registers a 4 mm
blocks too thick so that the patient can eat and speak interincisal clearance. This results in approximately 5 mm
comfortably with the appliances in the mouth. clearance between the cusps of the first premolars or
The Projet Bite GaugeTM (Orthocare, Sheffield, UK, deciduous molars. The objective is to open the bite
available at: www.orthocare.co.uk) is designed to record beyond the freeway space, so as to intrude the posterior
a protrusive bite for construction of Twin Blocks and teeth, without making the blocks too thick. The process
other functional appliances. The blue bite gauge of bite registration is similar in other respects to the
registers 2 mm vertical clearance between the incisal method described for treatment of deep overbite.
edges of the upper and lower incisors, which is suitable It is especially important in vertical growth patterns to
for bite registration in most class II division 1 ensure that the patient can maintain the protrusive
malocclusions with increased overbite (Figure 2). position comfortably by selecting a lesser amount of
The bite gauge has three grooves on one side and a initial activation. Occlusal screws may be placed in the
single groove on the opposing side. The simplest method upper block for progressive mandibular advancement.6,7
to register a protrusive bite is to select the appropriate This is possible in the treatment of anterior open bite,
 212 Clark Clinical Section JO September 2010

(a) (b)

(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 appliances9 with the kind permission of Elsevier Science Ltd)

because trimming of the upper occlusal block is not bite for this type of malocclusion requires minimal
required, as it is desirable to apply an intrusive force to the mandibular advancement to an edge to edge occlusion
posterior teeth. This approach is not ideal for treatment of with the incisors in contact. This provides sufficient
patients with deep overbite who require trimming of the height in the blocks to allow correction of the overbite to
upper block to enable the lower molars to erupt. an edge to edge relationship and with the molars
In the treatment of smaller overjets associated with a remaining in occlusion at the end of the Twin Block
full unit distal occlusion, it may be necessary to register a stage. The upper appliance includes a screw or springs to
reverse overjet in the construction bite, and design the advance retroclined incisors.
appliance to advance the upper incisors. Class II division
2 malocclusion is usually associated with a deep or Appliance design
excessive overbite and vertical control is an important
aspect of treatment. There is normally a low mandibular Twin Block appliances can be designed with many
plane angle and a well developed chin. The construction variations depending on the nature of the malocclusion
 JO September 2010 Clinical Section Twin Block design and management 213

(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.10 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,
bite with a small interincisal space encourages lip closure which are shaped as a closed triangle as opposed to an
within 2 or 3 months of commencing treatment. A labial
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
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. appliances9 with the kind permission of Elsevier Science Ltd)
 214 Clark Clinical Section JO September 2010

open V-shaped loop in the Adams clasp. Alternatively the inhibit eruption of maxillary buccal segments. In the
arrowhead may be circular or ovoid in shape if preferred. Twin Block design the position of the inclined plane is
The Delta clasp does not open with repeated insertion important for vertical control. It is placed mesial to the
and removal, and therefore maintains better retention, lower molars, at the mid point of the second premolar.
and requires less adjustment. A further crucial advan- Vertical control is achieved by trimming the occlusal
tage is that the clasp gives excellent retention on lower surface of the upper block to allow the lower molars to
premolars, and can be used on most posterior teeth. The erupt. Placing the inclined plane mesial to the molars
author has undertaken a study involving 141 patients allows the inclined plane to remain intact when the
who were consecutively treated with Twin Block upper block is trimmed over the lower molars
appliances in his practice between 1979 and 1993 and (Figure 6). At the start of treatment the upper bite
found that 10% of Twin blocks made with Adams clasps block is trimmed leaving a small vertical clearance of 1
(N572) had at least one breakage compared to 1% of or 2 mm to allow the molars to erupt and this process is
Twin Blocks made with Delta clasps (N569).8,9 repeated progressively at each visit as the molars erupt

Clinical management
For many years, the author has taught that Twin Blocks
may be fixed in the mouth for the first two weeks of
treatment. This enables the patient to adapt to full time
use without any interruption in appliance wear. After
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 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).10 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 Figure 7 Support phase: (a) an upper appliance with an anterior
inclined plane supports the corrected incisor and molar relationship
described previously by Woodside11 with regard to the
as the premolars and canines erupt into occlusion; (b) occlusal view
design and management of the activator. To control a of support appliance with anterior inclined plane (Reproduced from
deep overbite the occlusal table is trimmed to permit Clark WJ, Design & construction of Twin Block appliances9 with
vertical eruption of the mandibular buccal segments and the kind permission of Elsevier Science Ltd)
 JO September 2010 Clinical Section Twin Block design and management 215

into occlusion. This sequence of adjustment does not Support and retention
allow the tongue to spread laterally between the teeth to
prevent eruption of lower molars, and results in more Twin Blocks may be left out when the overjet and
rapid development of the vertical dimension (Figure 6). overbite are corrected and the molars have erupted fully
It is important to support the mandible in a protruded into a class I occlusion. A fixed appliance may be used to
position throughout the sequence of trimming the level the lower arch and complete treatment if required,
blocks. The leading edge of the inclined plane on the or alternatively an appliance with an anterior inclined
upper bite block remains intact. plane may be fitted for support and retention (Figure 7).

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

(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 appliances9 with the kind
permission of Elsevier Science Ltd)
 216 Clark Clinical Section JO September 2010

Functional retention is recommended following func- improve efficiency in the application of Twin Block
tional therapy. A simple retainer with an anterior technique. Facial appearance improves immediately
inclined plane may be used to support the corrected when Twin Blocks are inserted. Aesthetic Twin Block
incisor and molar relationship while the premolars and design encourages patients to wear the appliances full
canines erupt into occlusion. This is worn full time until time. These are important factors in patient motivation
the buccal segment occlusion is fully established and and cooperation.
may then continue as a night time retainer. In mixed The author’s web site is www.twinblocks.com and
dentition treatment, Twin Blocks may continue to be contains further information on recent developments,
worn at night to retain the corrected occlusion. Vertical including Fixed Twin Blocks.
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 References
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treatment for Class II malocclusion with the Herbst or Twin
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Orthod Dentofacial Orthop 2003; 124: 128–37.
For several years after developing Twin Blocks, the author 2. Illing HM, Morris DO, Lee RT. A prospective evaluation of
continued to use a labial bow on the upper appliance. In Bass, Bionator and Twin Block appliances. Part 1 – the
the author’s Twin Block study commencing in 1995,4 it hard tissues. Eur J Orthod 1998; 20: 501–16.
was observed that the upper incisors were over corrected, 3. Harradine NWT, Gale D. The effects of torque control
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overbite. In most cases, a labial bow is not necessary. The 202–09.
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naturally and a lip seal develops as the appliance is worn Orthopaedics. Thesis for DDSc Degree at University of
24 h a day, including for eating. Lip pressure acts to retract Dundee, 2010.
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illustrated with clasps on lower molars, an upper labial 6. Geserick M, Olsburg SR, Petermann D. The bite jumping
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dentition a more comfortable and aesthetic design places
8. Clark WJ, Stirrups D. The Delta Clasp. Design and
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construction in aspects of Twin Block functional therapy in
principles Twin Blocks can be almost invisible and well
orthodontics & dentofacial orthopaedics. Unpublished
tolerated appliances with a low rate of failure to
material in thesis presented to Dundee University, 1995.
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method described is shown in Figure 8. Science, 2002.
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This article identifies common errors in Twin Block 11. Woodside DG. The activator. In Graber TM, Neumann B
design and management, which influence the rate of (eds.). Removable orthodontic appliances. Philadelphia, PA:
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