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The Twin Block Appliance

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This presentation gives an overview of Twin Block Appliance therapy and some of the relevant contemporary research.

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The Twin Block Appliance

  1. 1. The Twin Block Appliance Nalaka Jayaratne BDS, PhD Resident in Orthodontics, University of Connecticut School of Dental Medicine USA
  2. 2. History • First used on Sept 7th, 1977 by William Clark Clark W.J. Twin Block Functional Therapy: Applications in Dentofacial Orthopedics (3rd Edition)
  3. 3. History • First used on Sept 7th, 1977 by William Clark • “Necessity is the mother of invention” Clark W.J. Twin Block Functional Therapy: Applications in Dentofacial Orthopedics (3rd Edition)
  4. 4. History • First used on Sept 7th, 1977 by William Clark • “Necessity is the mother of invention” • Used for a son of a dental colleague with CII D1 who luxated Upper Cent. Incisor to Clark W.J. Twin Block Functional Therapy: Applications in Dentofacial Orthopedics (3rd Edition)
  5. 5. History • First used on Sept 7th, 1977 by William Clark • “Necessity is the mother of invention” • Used for a son of a dental colleague with CII D1 who luxated Upper Cent. Incisor to Clark W.J. Twin Block Functional Therapy: Applications in Dentofacial Orthopedics (3rd Edition)
  6. 6. History • First used on Sept 7th, 1977 by William Clark • “Necessity is the mother of invention” • Used for a son of a dental colleague with CII D1 who luxated Upper Cent. Incisor to ▫ Prevent lip trap posture mandible forward ▫ Prevent direct pressure on upper incisor Clark W.J. Twin Block Functional Therapy: Applications in Dentofacial Orthopedics (3rd Edition)
  7. 7. History • First used on Sept 7th, 1977 by William Clark • “Necessity is the mother of invention” • Used for a son of a dental colleague with CII D1 who luxated Upper Cent. Incisor to ▫ Prevent lip trap posture mandible forward ▫ Prevent direct pressure on upper incisor Clark W.J. Twin Block Functional Therapy: Applications in Dentofacial Orthopedics (3rd Edition)
  8. 8. Concept • Maximize growth response to functional mandibular proturusion Clark W.J. Twin Block Functional Therapy: Applications in Dentofacial Orthopedics (3rd Edition)
  9. 9. Concept • Maximize growth response to functional mandibular proturusion Occlusal inclined plane Displaces mandible downward and forward Unfavorable cuspal contacts of distal occlusion replaced by favorable proprioceptive contacts Frees mandible from locked distal functional position Clark W.J. Twin Block Functional Therapy: Applications in Dentofacial Orthopedics (3rd Edition)
  10. 10. 4
  11. 11. 4 • Protrusive function Sensory receptors in muscles of mastication, teeth, tissues  Functional response in underlying bone  Adaptation to new favorable maxillomandibular relation
  12. 12. 4 • Protrusive function Sensory receptors in muscles of mastication, teeth, tissues  Functional response in underlying bone  Adaptation to new favorable maxillomandibular relation • Rapid soft-tissue changes  Muscles adapt
  13. 13. 4 • Protrusive function Sensory receptors in muscles of mastication, teeth, tissues  Functional response in underlying bone  Adaptation to new favorable maxillomandibular relation • Rapid soft-tissue changes  Muscles adapt • Bony changes gradual
  14. 14. Design • Posterior bite-blocks with an inclined plane • Clasps • Labial bow • Screws – midline or saggital
  15. 15. What is the angle of the inclined plane of a twin block?
  16. 16. What is the angle of the inclined plane of a twin block?
  17. 17. Why is this angle selected instead of 45 degree inclined plane?
  18. 18. Answer • 450 Inclined plane Apply equal downward and forward component of force to the lower dentition Both downward and forward stimulus to growth Clark W.J. Twin Block Functional Therapy: Applications in Dentofacial Orthopedics (3rd Edition)
  19. 19. Answer • 450 Inclined plane Apply equal downward and forward component of force to the lower dentition Both downward and forward stimulus to growth • 700 Inclined plane More horizontal component of forces More forward mandibular growth Clark W.J. Twin Block Functional Therapy: Applications in Dentofacial Orthopedics (3rd Edition)
  20. 20. Should you instruct the patient to remove the twin block while eating food?
  21. 21. Answer • Twin blocks are designed to be worn 24hrs per day to take full advantage of all functional forces applied to the dentition, including forces of mastication Clark W.J. Twin Block Functional Therapy: Applications in Dentofacial Orthopedics (3rd Edition)
  22. 22. Types of Twin Blocks 1. Standard Twin Block 2. Sagittal Twin Block 11
  23. 23. 3. Reverse twin block Clark W.J. Twin Block Functional Therapy: Applications in Dentofacial Orthopedics (3rd Edition)
  24. 24. Selection criteria for simple treatment
  25. 25. Selection criteria for simple treatment 1. Class II division 1 malocclusion (ideal but CII D2 & CIII can also be treated)
  26. 26. Selection criteria for simple treatment 1. Class II division 1 malocclusion (ideal but CII D2 & CIII can also be treated) 2. Uncrowded or decrowded dentition
  27. 27. Selection criteria for simple treatment 1. Class II division 1 malocclusion (ideal but CII D2 & CIII can also be treated) 2. Uncrowded or decrowded dentition 3. Full unit distal occlusion
  28. 28. Selection criteria for simple treatment 1. Class II division 1 malocclusion (ideal but CII D2 & CIII can also be treated) 2. Uncrowded or decrowded dentition 3. Full unit distal occlusion 4. Well-developed arches
  29. 29. Selection criteria for simple treatment 1. Class II division 1 malocclusion (ideal but CII D2 & CIII can also be treated) 2. Uncrowded or decrowded dentition 3. Full unit distal occlusion 4. Well-developed arches 5. OJ < 10mm & deep overbite
  30. 30. Selection criteria for simple treatment 1. Class II division 1 malocclusion (ideal but CII D2 & CIII can also be treated) 2. Uncrowded or decrowded dentition 3. Full unit distal occlusion 4. Well-developed arches 5. OJ < 10mm & deep overbite 6. Profile improve when the mandible is brought forward to correct OJ
  31. 31. Selection criteria for simple treatment 1. Class II division 1 malocclusion (ideal but CII D2 & CIII can also be treated) 2. Uncrowded or decrowded dentition 3. Full unit distal occlusion 4. Well-developed arches 5. OJ < 10mm & deep overbite 6. Profile improve when the mandible is brought forward to correct OJ 7. Active grower
  32. 32. Bite registration
  33. 33. Bite registration • Guide the mandible into planned position before taking the bite
  34. 34. Bite registration • Guide the mandible into planned position before taking the bite • A horseshoe-shaped wax bite rim is prepared
  35. 35. Bite registration • Guide the mandible into planned position before taking the bite • A horseshoe-shaped wax bite rim is prepared • Form the wax bite
  36. 36. Bite registration 1. Vertical opening : • 2 mm interincisal space • .
  37. 37. Bite registration 1. Vertical opening : • 2 mm interincisal space • Equivalent to an inter-premolar space of 5- 6 mm • .
  38. 38. Bite registration 1. Vertical opening : • 2 mm interincisal space • Equivalent to an inter-premolar space of 5- 6 mm 2. AP : • For most patients: edge to edge (if not uncomfortable) • Facial profile should improve • .
  39. 39. Bite registration 1. Vertical opening : • 2 mm interincisal space • Equivalent to an inter-premolar space of 5- 6 mm 2. AP : • For most patients: edge to edge (if not uncomfortable) • Facial profile should improve • Maximum ~ 10mm • .
  40. 40. Bite registration 1. Vertical opening : • 2 mm interincisal space • Equivalent to an inter-premolar space of 5- 6 mm 2. AP : • For most patients: edge to edge (if not uncomfortable) • Facial profile should improve • Maximum ~ 10mm • Must not exceed 70% of the total protrusive path (OJ measured with the mandible retruded and in the position of maximum protrusion) • .
  41. 41. Bite registration 1. Vertical opening : • 2 mm interincisal space • Equivalent to an inter-premolar space of 5- 6 mm 2. AP : • For most patients: edge to edge (if not uncomfortable) • Facial profile should improve • Maximum ~ 10mm • Must not exceed 70% of the total protrusive path (OJ measured with the mandible retruded and in the position of maximum protrusion) • . Important to 1. Open the bite beyond the freeway space patient cannot retrude the mandible when in rest position
  42. 42. Bite registration 1. Vertical opening : • 2 mm interincisal space • Equivalent to an inter-premolar space of 5- 6 mm 2. AP : • For most patients: edge to edge (if not uncomfortable) • Facial profile should improve • Maximum ~ 10mm • Must not exceed 70% of the total protrusive path (OJ measured with the mandible retruded and in the position of maximum protrusion) • . Important to 1. Open the bite beyond the freeway space patient cannot retrude the mandible when in rest position 2. Avoid making the blocks too thick  patient should be able to eat and speak comfortably with the appliances in the mouth
  43. 43. Delivering the Appliance – Things to Explain
  44. 44. Delivering the Appliance – Things to Explain 1. Components and the function of the appliance Point out the 70 degree inclined planes.
  45. 45. Delivering the Appliance – Things to Explain 1. Components and the function of the appliance Point out the 70 degree inclined planes. 2. Explained that Twin Blocks achieve correction through the forces of occlusion.  wear the appliances full time  learn how to eat with the appliances in the mouth. The twin block manual - Protec dental laboratory
  46. 46. Delivering the Appliance – Things to Explain 1. Components and the function of the appliance Point out the 70 degree inclined planes. 2. Explained that Twin Blocks achieve correction through the forces of occlusion.  wear the appliances full time  learn how to eat with the appliances in the mouth. 3. How to clean the appliances after each meal The twin block manual - Protec dental laboratory
  47. 47. Delivering the Appliance – Things to Explain 1. Components and the function of the appliance Point out the 70 degree inclined planes. 2. Explained that Twin Blocks achieve correction through the forces of occlusion.  wear the appliances full time  learn how to eat with the appliances in the mouth. 3. How to clean the appliances after each meal 3. Prior to insertion, tell the patient about the improved facial esthetics they'll notice when the appliances are fitted. After fitting, tell the patient that to permanently achieve the facial esthetics, they will need to wear the appliances full-time throughout treatment. It is helpful for the patient to see profile photo prior to and after fitting the appliance. The twin block manual - Protec dental laboratory
  48. 48. Delivering the Appliance – Things to Explain 1. Components and the function of the appliance Point out the 70 degree inclined planes. 2. Explained that Twin Blocks achieve correction through the forces of occlusion.  wear the appliances full time  learn how to eat with the appliances in the mouth. 3. How to clean the appliances after each meal 3. Prior to insertion, tell the patient about the improved facial esthetics they'll notice when the appliances are fitted. After fitting, tell the patient that to permanently achieve the facial esthetics, they will need to wear the appliances full-time throughout treatment. It is helpful for the patient to see profile photo prior to and after fitting the appliance. 4. Although the appliances will feel bulky initially to the patient, they will feel comfortable in a few days. The twin block manual - Protec dental laboratory
  49. 49. Vertical control
  50. 50. Vertical control • Timing:1-2 months after the appliance was inserted
  51. 51. Vertical control • Timing:1-2 months after the appliance was inserted • Method: trimming the upper block to leave 1mm clearance between bite and lower molar
  52. 52. What are the skeletal effects of Twin Block appliance?
  53. 53. Herbst vs. Twin Block: Which is better?
  54. 54. • OJ ≥ 7 mm • second premolars erupted • no craniofacial syndrome
  55. 55. Conclusions
  56. 56. Conclusions • Phase I treatment is more rapid with the Herbst appliance, but overall duration of treatment is similar to that with the Twin-block
  57. 57. Conclusions • Phase I treatment is more rapid with the Herbst appliance, but overall duration of treatment is similar to that with the Twin-block • The Herbst appliance is prone to debonding and component breakage
  58. 58. Conclusions • Phase I treatment is more rapid with the Herbst appliance, but overall duration of treatment is similar to that with the Twin-block • The Herbst appliance is prone to debonding and component breakage • There are no differences in the dental and skeletal effects of treatment between the 2 appliances
  59. 59. Does Twin Block have an effect on the airway?
  60. 60. Methods • Pre and post-treatment CBCT scans of 30 growing patients with TB treatment
  61. 61. Methods • Pre and post-treatment CBCT scans of 30 growing patients with TB treatment • 30 age-gender matched untreated controls with the same diagnosis
  62. 62. Methods • Pre and post-treatment CBCT scans of 30 growing patients with TB treatment • 30 age-gender matched untreated controls with the same diagnosis • CBCT’s analyzed with MIMICS software
  63. 63. The pre- (T1) and post-treatment (T2) data of TB patients was registered.
  64. 64. The pharyngeal morphology and the hyoid bone were measured.
  65. 65. Findings • During the TB treatment, the mandible moved advanced by 3.52±2.14 mm in the horizontal direction and 3.77±2.10 mm in the vertical direction. • The upper airway showed a significant enlargement in nasopharynx, oropharynx and hypopharynx. • Hyoid bone moved to a more anterior
  66. 66. • 46 children (aged 9.7±1.5 years, BMI: 18.1±1.04 kg/m2 )
  67. 67. • 46 children (aged 9.7±1.5 years, BMI: 18.1±1.04 kg/m2 ) • Diagnosed with mandibular retrognathia and OSA by polysomnography (PSG) but with no obesity or adenotonsillar hypertrophy
  68. 68. • 46 children (aged 9.7±1.5 years, BMI: 18.1±1.04 kg/m2 ) • Diagnosed with mandibular retrognathia and OSA by polysomnography (PSG) but with no obesity or adenotonsillar hypertrophy • PSG and cephalometric changes before and after appliance removal
  69. 69. • 46 children (aged 9.7±1.5 years, BMI: 18.1±1.04 kg/m2 ) • Diagnosed with mandibular retrognathia and OSA by polysomnography (PSG) but with no obesity or adenotonsillar hypertrophy • PSG and cephalometric changes before and after appliance removal • AHI decreased from 14.08 ± 4.25 to 3.39 ± 1.86 (p < 0.01), and the lowest SaO2increased from 77.78 ± 3.38 to 93.63 ± 2.66 (p < 0.01)
  70. 70. • 46 children (aged 9.7±1.5 years, BMI: 18.1±1.04 kg/m2 ) • Diagnosed with mandibular retrognathia and OSA by polysomnography (PSG) but with no obesity or adenotonsillar hypertrophy • PSG and cephalometric changes before and after appliance removal • AHI decreased from 14.08 ± 4.25 to 3.39 ± 1.86 (p < 0.01), and the lowest SaO2increased from 77.78 ± 3.38 to 93.63 ± 2.66 (p < 0.01) • Twin block appliance may improve the patient's facial profile and OSA symptoms in a group of carefully selected children presented with both OSA and mandibular retrognathia symptoms
  71. 71. • 46 children (aged 9.7±1.5 years, BMI: 18.1±1.04 kg/m2 ) • Diagnosed with mandibular retrognathia and OSA by polysomnography (PSG) but with no obesity or adenotonsillar hypertrophy • PSG and cephalometric changes before and after appliance removal • AHI decreased from 14.08 ± 4.25 to 3.39 ± 1.86 (p < 0.01), and the lowest SaO2increased from 77.78 ± 3.38 to 93.63 ± 2.66 (p < 0.01) • Twin block appliance may improve the patient's facial profile and OSA symptoms in a group of carefully selected children presented with both OSA and mandibular retrognathia symptoms
  72. 72. Take-home messages
  73. 73. Take-home messages • Carful selection and an accurate bite registration is important when using the Twin Block appliance
  74. 74. Take-home messages • Carful selection and an accurate bite registration is important when using the Twin Block appliance • Patients should be encouraged to eat with the appliance
  75. 75. Take-home messages • Carful selection and an accurate bite registration is important when using the Twin Block appliance • Patients should be encouraged to eat with the appliance • Twin Block appliances can improve the airway in addition to the facial profile
  76. 76. Thank You

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