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CASE REPORT
Early class III management in deciduous
dentition using reverse twin block
Abstract
Class III malocclusion poses a challenging dilemma for the
clinician because these children have of growth patterns
that differ from that of children with class I malocclusion. The
mandible grows more rapidly than the maxilla, exacerbating
the class III malocclusion as the child go through adolescence.
Ever since Clark described a version of the twin block, it has
steadily gained popularity in the management of early class
III malocclusion in children. However, not many cases are
reported in the literature on its use in deciduous dentition. This
article tries to provide an insight into the reverse twin block
appliance and reports two cases of early class III malocclusion
treated using reverse twin block..
Key words
Class III malocclusion, deciduous dentition, reverse twin block
Introduction
Class III malocclusions may be limited to dentoalveolar
discrepancies but are more frequently skeletal in
nature.[1] The characteristic features of a class III
malocclusion are present at an early age, usually
between 3 and 5 years of age.[2–4] The skeletal and
dental features in class III malocclusion are established
early in childhood and do not self-correct during child
development.[5]
The maxilla is reported to grow less anteriorly in
class III subjects than in class I normal controls. In
addition, the vertical growth pattern of the craniofacial
structures of class III subjects differ when compared
to that of class I subjects.[6]
A developing class III malocclusion presents with
maxillary skeletal retrusion, mandibular skeletal
protrusion, or a combination of the two. In addition
to these sagittal problems there may be posterior
56 JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Jan - Mar 2013 | Issue 1 | Vol 31 |
Sargod SS, Shetty N1, Shabbir A
Departments of Pedodontics, 1Orthodontics, Yenepoya Dental
College, Derlakatte, Mangalore, Karnataka, India
Correspondence:
Dr. Sharan S Sargod, Department of Pedodontics, Yenepoya
Dental College, Derlakatte, Mangalore, India.
E-mail: sharansargod@yahoo.co.in
Access this article online
Quick Response Code: Website:
www.jisppd.com
DOI:
10.4103/0970-4388.112418
PMID:
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and anterior crossbites also present. Other factors
determining a class III malocclusion are vertical in
nature and may have their origin in either deficient
vertical skeletal growth (brachycephalic) or excessive
vertical growth (dolicocephalic). If left untreated, the
class III malocclusion or severe anterior crossbite may
worsen, with the majority of these patients ultimately
requiring orthognathic surgery as adults.
The timing of treatment of class III malocclusion is
critical for optimum outcomes. Delaying appropriate
treatment beyond the mixed dentition stage (10 years of
age) will limit the effectiveness of orthopedic correction.
required to treat most of the class III malocclusions.
More importantly, treating a class III malocclusion in
the late deciduous and early mixed dentition stages has
been shown to be more beneficial to the child because
there is improved maxillary orthopedic correction
combined with controlled mandibular growth than
when treatment is undertaken in the later childhood
growth stages.[7] Treatment strategies directed at
the cause of the class III malocclusion may consist
of corrective orthodontics, dentofacial orthopedics,
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Sargod, et al.: Early class III management in deciduous dentition
and orthognathic surgery, or a combination of these,
depending on the type of class III malocclusion and
the age of the patient.
Orthopedic correction of class III malocclusion has
been described utilizing a Petit- or Delaire-style face
mask or reverse headgear for maxillary deficiency.
A chin-cup type headgear may also be used for the
treatment of mandibular prognathism. The most
commonly used is the functional regulator III (FR III)
described by Frankel.
The twin block appliance is widely used for the
treatment of class II malocclusions. However, Clark has
described a version of the twin block that may be used
for class III malocclusions, known as the class III twin
block appliance or the reverse twin block.
Reverse twin block: Appliance design[8]
Functional correction of class III malocclusion is
achieved in the twin block technique by reversing
the angulation of the inclined planes and harnessing
occlusal forces as the functional mechanism to correct
arch relationships by maxillary advancement, while
using the lower arch as the means of anchorage. The
position of the bite blocks is reversed compared to twin
blocks for class II treatment. The occlusal blocks are
placed over the upper deciduous molars and the lower
first molars.
Reverse twin blocks are designed to encourage
maxillary development by the action of reverse occlusal
inclined planes cut at a 70° angle to drive the upper
teeth forwards by the forces of occlusion and at the
same time to restrict forward mandibular development
[Figure 1]. In cases with maxillary contraction and
distal relationship of the mandible, the maxillary
appliance should include provision for three-way
Figure 1: Appliance design
JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Jan - Mar 2013 | Issue 1 | Vol 31 |
expansion to increase the size of the maxilla in both
the sagittal and the transverse dimensions.
An alternative design uses a three-way expansion screw
to combine transverse and sagittal expansion. This is
also effective in expanding a contracted maxilla and
in correcting lingual occlusion if used in combination
with reverse inclined planes.
Case Reports
Case 1
A child of 5 years and 8 months reported to our private
dental clinic with the chief complaint of multiple decayed
posterior teeth. On examination, most of the molars
were decayed, with pulpal involvement. We also noted
that the anteriors were in crossbite from canine to canine
[Figures 2a and b].
Maxillary growth seemed to be restricted due to the
postural shift of the mandible in a class III position,
which may have been due to the grossly decayed lower
posteriors. The possible outcome of the jaw relationships
was explained to the parent. After completing all the
pulp therapy and restorative procedures, the treatment
was aimed at eliminating the anterior interlock. Since
there was no maxillary growth restriction, we decided
to treat the patient with the reverse twin block appliance.
We expected that this would promote maxillary growth
and position the mandible backwards.
A usual wax bite registration in a maximum retrusive
position of the mandible was made, leaving sufficient
clearance between the posterior teeth for occlusal bite
blocks,. Following this, upper and lower bite blocks were
fabricated using cold-cure acrylic resin, with clasps on
the maxillary and mandibular molars. The bite blocks
were made to cover the upper primary first molar and
the lower second molar, with a reverse direction of the
inclined planes. A lower outer passive labial bow and
a b
Figure 2: (a) Preoperative casts - front view. (b) Preoperative casts
- lateral view.
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Sargod, et al.: Early class III management in deciduous dentition
a b
Figure 3: (a) Fabrication of reverse twin block appliance – front view.
(b) Fabrication of reverse twin block appliance – lateral view.
Figure 5: Post treatment
Figure 7: After treatment with reverse twin block appliance
upper anterior eyelet clasps were incorporated for the
purpose of retention [Figure 3a and b].
The patient was instructed to wear the appliance
continuously for as long as possible, including during
meal times initially [Figure 4].
The patient developed an almost edge-to-edge bite
with mild crossbite in relation to 52 and 62, which was
relieved by trimming 72 and 82. The appliance was
activated every 2 weeks by addition of acrylic resin on
the inclines of the bite blocks. At the end of 4 months,
a significant improvement in the profile and positive
anterior relation was noted [Figure 5].
58 JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Jan - Mar 2013 | Issue 1 | Vol 31 |
Figure 4: Reverse twin block appliance
Figure 6: Pretreatment
Case 2
A 5-year-old child was brought to our private dental
clinic with the chief complaint of inwardly placed
upper front teeth. On examination, the patient had
anterior crossbite from canine to canine [Figure 6].
There was no family history of class III malocclusion.
The maxillary growth seemed to be restricted due to
the postural shift of the mandible in a class III position.
A lateral cephalogram revealed that the point A was
in the range of normal values, whereas the point B
was slightly greater than the normal values. Based
on the above findings, a diagnosis of pseudo–class III
malocclusion was made.
the possible outcome of the jaw relationships was
explained to the parent, and a reverse twin block
appliance was constructed as described earlier.
The patient was instructed to wear the appliance
continuously for as long as possible. Improvement in
the profile on wearing the appliance was noted and
appreciated by the parent immediately. The appliance
was activated every 2–3 weeks by addition of acrylic
resin on the inclines of the bite blocks.
The patient developed a habitual closure of the
mandible in a backward position, and correction of
the anterior crossbite was observed within 6 weeks of
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Sargod, et al.: Early class III management in deciduous dentition
starting to wear the appliance [Figure 7]. The patient
was asked to continue with this appliance for another 6
weeks for retention purpose. At the end of 4–5 months,
a significant improvement in the patient’s profile was
appreciable.
Discussion
A class III malocclusion is not a single diagnostic
entity but rather a spectrum of clinical manifestations,
with varying clinical and cephalometric features that
predict differing biologic potential. Most importantly,
identification of a specific class III malocclusion
in the young child allows both early treatment of
the malocclusion and correction of the underlying
etiology.[8]
Early treatment is often indicated to counter the
unfavorable developmental pattern. There are not many
reports in the literature about the use of reverse twin
block in the deciduous dentition. However, its use in
the mixed dentition stage is well documented in the
literature. After taking into account the compliance of
the child, intervention as early as in deciduous dentition
is advisable for better results in children. With good
motivation and periodic reinforcement, most patients
cooperate with the treatment since opening and closing
of the mouth is not restricted.
In treatment with reverse twin block, the occlusal
force exerted on the mandible is directed downwards
and backwards by the reverse inclined planes. No
damaging force is exerted on the condyles because the
bite is hinged open with the condyles down and forward
in the fossae, and the inclined planes are directed
downwards and backwards on the mandibular teeth.
The force vector in the mandible passes from the lower
molar towards the gonial angle. This is the area of the
mandible best able to absorb occlusal forces.[9]
The degree of skeletal discrepancy is an important
factor in case selection. There should be minimal
maxillary skeletal deficiency and the mandibular plane
angle should not be very steep. In some cases class III
occlusion may respond to treatment in the deciduous
and mixed dentition, but relapse may occur during the
pubertal growth spurt and the position may need to
be reviewed.
Clinically, the important question is whether or not the
patient can occlude squarely edge to edge on the upper
and lower incisors. The ease with which the patient can
JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Jan - Mar 2013 | Issue 1 | Vol 31 |
achieve this position is an indication of the prognosis
for correction. The most favorable cases for correction
present a postural class III, where the incisors can meet
comfortably edge to edge but the patient is forced to
move the mandible forward in order to occlude on the
posterior teeth. If an edge-to-edge occlusion is achieved
only with difficulty, the prognosis for orthodontic
correction is poor.[9]
Once the appliance is delivered, the maxilla starts to
advance anteriorly within 4 weeks. This will be evident
with the patient’s edge-to-edge bite anteriorly. Addition
of acrylic to the inclined planes may be necessary
to increase the forces over the maxilla and mandible
to establish a positive overjet. Kidner et al., in their
evaluation of the reverse twin block appliance on 14
subjects of <12 years of age, found that the changes
were mainly dentoalveolar, with the skeletal changes
limited to slight downward and backward rotation
of the mandible. The average treatment time in their
patients was only 6.6 months.[10]
Twin blocks are designed to be worn 24 hours per day
to take full advantage of all functional forces applied to
the dentition, including the forces of mastication. The
appliance is well tolerated and changes are observed
within 6 weeks of starting to wear the appliance. The
first principle of appliance design is simplicity. The
patient’s appearance is noticeably improved when the
twin blocks are fitted.
Reverse twin blocks are designed to be comfortable,
esthetic, and efficient. By addressing these requirements,
reverse twin blocks satisfy both the patient and the
operator as it one of the most patient friendly of all
the functional appliances.[9]
Conclusions
It is important to remove the anterior interlock as
early as possible so as to allow for normal unrestricted
growth of the maxilla and also to guide the mandible
to a normal retrusive position. Reverse twin block or
class III twin blocks can be used successfully for early
treatment of class III malocclusions in deciduous
dentition. The appliance is easy to fabricate and is
well tolerated by children; also, faster correction can
be achieved with these appliances than with other
appliances. However, a prospective study with long-
term evaluation is required to fully evaluate the efficacy
of this appliance.
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Sargod, et al.: Early class III management in deciduous dentition

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9. Kanas RJ, Carapezza L, Kanas SJ. Treatment classification of
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How to cite this article: Sargod SS, Shetty N, Shabbir A. Early
class III management in deciduous dentition using reverse twin
block. J Indian Soc Pedod Prev Dent 2013;31:56-60.
Source of Support: Nil, Conflict of Interest: None declared.

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