American Journal of ORTHODONTICS
and DENTOFACIAL ORTHOPEDICS
Founded in 1915
The twin block technique
A functional orthopedic appliance system
W. J. Clark, B.D.S., D.D.O.
Kirkcaldy, Scotland
THE OCCLUSAL INCLINED PLANE
The occlusal inclined plane is the fundamental func-
tional mechanism of the natural dentition. Cuspal in-
clined planes play an important part in determining the
relationship of the teeth as they erupt into occlusion.
Occlusal forces transmitted through the dentition
provide a constant proprioceptive stimulus to influence
the rate of growth and the trabecular structure of the
supporting bone.
Fixed occlusal inclined planes have been used to
alter the distribution of occlusal forces in animal ex-
periments investigating the effects of functional man-
dibular displacement on mandibular growth and on
adaptive changes in the temporomandibular joint.‘,’
TWIN BLOCKS
Twin blocks are bite-blocks that effectively modify
the occlusal inclined plane to induce favorably directed
occlusal forces by causing a functional mandibular dis-
placement (Fig. 1, A and B).
Upper and lower bite-blocks interlock at a 45” angle
and are designed for full-time wear to take advantage
of all functional forces applied to the dentition including
the forces of mastication.
Wearing bite-blocks is rather like wearing dentures
and patients can eat comfortably with the appliances in
place.
In comparison to other functional appliances, oc-
clusal inclined planes give greater freedom of move-
ment in anterior and lateral excursion and cause less
interference with normal function. The functional
mechanism is very similar to the natural dentition. An
Volume 93 Number 1 January 1900
Copyright 0 1988 by The C. V. Mosby Company
ORIGINAL ARTICLES
additional motivating factor is that the appearance is
noticeably improved when twin blocks are fitted and
the absence of lip, cheek, or tongue pads places no
restriction on normal function.
With twin blocks full functional correction of oc-
clusal relationships can be achieved in many cases with-
out the addition of any orthopedic or traction forces.
ORTHOPEDIC TRACTION
In cases in which the skeletal discrepancy is severe,
the addition of an orthopedic traction system to support
the action of occlusal inclined planes provides a ver-
satile appliance technique that is effective in the treat-
ment of a wide range of malocclusions.
The indications for treatment include maxillary pro-
trusion, mandibular retrusion, and vertical growth dis-
crepancies .
A functional orthopedic approach eliminates the un-
certainty of treatment response that is sometimes as-
sociated with purely functional techniques. The tech-
nique achieves rapid correction of malocclusion even
in cases with severe malocclusions that are unfavorable
for conventional fixed or functional appliance therapy.
THE CONCORDE FACE-BOW
The twin block technique uses a new method of
applying inter-maxillary traction. The Concorde face-
bow (Fig. 1, C) combines intermaxillary and extraoral
traction by the addition of a recurved labial hook to a
conventional face-bow. Intermaxillary traction is ap-
plied as a horizontal force from the labial hook to the
lower appliance, eliminating the unfavorable upward
1
2 Clark Am. J. Orthod. Dentofac. Orthop.
Januaty 1988

Fig. 1. Twin blocks appliance design. A, Anterior and lateral views show the following components.
Upper appliance: (1) labial bow (0.8 mm) from mesial 6&, (2) clasps (0.8 mm) incorporating coils to
accommodate the Concorde face-bow, and (3) occlusal inclined planes occlude at a 45” angle in @
region. Lower appliance: (1) ball-ended interdental clasps (1 .O mm) in 21112 region, (2) delta clasps
(0.8 mm) on q (the delta clasp, designed by the author, gives excellent retention on lower premolars
and requires minimal adjustment), and (3) inclined planes in @ region. 8, Occlusal views. The upper
appliance has a midline screw for compensatory lateral expansion. Where necessary, a midline screw
or recurved lingual bow (as in a Jackson appliance) can be included in the lower appliance.

component of force associated with conventional in-
termaxillary traction.
The traction components are worn only at night to
reinforce the action of the occlusal inclined plane. If
the patient fails to posture the mandible to the corrected
occlusal position during the night, the intermaxillary
traction force is automatically increased to compensate
so that favorable intermaxillary forces are applied con-
tinuously (Fig. 1, D).
Extraoral traction is added when or&opedic force
to the maxilla is indicated-for example, in correction
of maxillary protrusion.
Unfavorable vertical growth patterns require direc-
tional control of orthopedic force. A vertical component
of extraoral traction applies an intrusive force to the
upper posterior teeth and the palate via the upper ap-
pliance to limit downward maxillary growth. This fa-
cilitates correction of Class II arch relationships in ver-
tical growth discrepancies.
For correction of mandibular retrusion, twin blocks
may be used without traction or alternatively with con-
ventional intermaxillary traction, extending from the
labial hooks on the upper appliance to the distal hooks
on the lower appliance.
The combination of traction and inclined planes is
very effective and is readily accepted by patients who
Volume 93 Twin block technique 3
Number I

Fig. 1 (Cont’d). C, The Concorde face-bow effectively combines extraoral and intermaxillary traction
in the treatment of severe skeletal discrepancies. A recurved labial hook is added to a conventional
face-bow. Outer bow is 1.5 mm; inner bow is 1.13 mm reinforced with tubing; labial hook is 1.13 mm.

Flg. 1 (Cont’d). D, Intraoral views showing twin blocks in open and closed positions. The Concorde
face-bow is illustrated with detail of the recurred labial hook and intraoral attachment of the intermaxillary
elastic.
4 Clark
Fig. 2. A, Simple twin block appliances
produces rapid correction of arch relationshios
cases with unfavorable growth patterns
recognize that the corrective forces are logical and the
appliance system easily understood. The labial hook
presents no problems and patient acceptance is similar
to that of a conventional face-bow.
TWIN BLOCK APPLIANCES
Twin blocks may be either removable or fixed to
the teeth and integrated with fixed appliance technique.
APPLIANCE DESIGN
Removable twin blocks
The upper appliance is retained by modified arrow-
head clasps. The clasps incorporate a coiled tube for
attachment of a face-bow if traction is to be applied.
Retention may be increased by adding ball-ended clasps
in the labial or buccal segments.
A midline expansion screw provides compensatory
lateral expansion of the upper arch to accommodate a
functional protrusion of the lower arch from its retruded
position. Labial and lingual bows (as needed) are in-
cluded to control upper incisor angulation.
Am. J. Orthod. Dentofac. Orthop.
Januar)r 1988
are shown in conjunction with fixed appliances. This combination
that can counteract a slow response to treatment in
In the lower arch, retention is often obtained by
l-mm interdental ball clasps in the lower incisor region
combined with clasps in the buccal segments. The delta
clasp (Fig. 1, A and B) was specifically designed by
the author to extend the area of contact of the clasp in
the undercut and to improve retention with a closed
triangle to increase resistance to fatigue. This combi-
nation of clasps gives excellent retention and is very
effective in limiting proclination of lower incisors dur-
ing the twin block stage.
In mixed dentition treatment, clasps are placed on
the lower incisors and on deciduous molars or first
permanent molars. The lower appliance may be split
anteriorly with the addition of a screw or helical spring
to expand and develop the lower arch, if desired.
The upper bite-blocks cover the lingual cusps of the
upper posterior teeth, extending to the mesial ridge of
the upper second premolar. This allows the clasp to be
more flexible and improves retention of the appliance.
Full occlusal cover is necessary in the lower pre-
molar region to compensate for the discrepancy in arch
Vdumr 93 Twin block technique 5
Number I

Fig. 2 (Cont’d). 8, Diagram showing details of twin blocks combined with fixed appliances. Occlusal
65 56
inclined planes are outlined in black. Clasps on 5 5 are shown in black. In this example the upper
7
fixed appliance is confined to 3211123 at this stage until arch relationships are corrected, allowing ?A
easy transition into a full fixed appliance. In the lower arch, a utility arch accommodates clasps in the
buccal segments. The fixed appliances are shown in red.

width and to allow the inclined planes to interlock in BITE REGISTRATION

occlusion. The lower bite-block extends to the distal
marginal ridge of the lower second premolar (Fig. 2).
For correction of deep overbite, it is an advantage
to leave the lower molars free of the appliance, allowing
their eruption to be controlled in relation to the overbite.
It is very important to prevent molar eruption in
casesin which there is reduced overbite or anterior open
bite. All erupted posterior teeth must occlude.on the
bite-block to prevent overeruption.
For Class II problems, the proper construction
bite is taken and the models are articulated with
mandibular protrusion. The amount of mandibular
protrusion depends on the ease with which the patient
can posture forward. As a general rule, the initial ac-
tivation should reduce the overjet by 5 to 7 mm leaving
3 to 5 mm interocclusal clearance in the first premolar
region. The interocclusal clearance is increased where
there is increased overbite and the bite-blocks are de-
6 Clark Am. J. Orthod. Dentofac. Orthop.
January 1988

Fig. 3. Patient with a Class II, Division 1 malocclusion, treated with the twin block appliances and
Concorde face-bow combination. This combines functional therapy with extraoral traction and intraoral
intermaxillary elastic force. The combined appliances were worn 10 months. The extraoral distal and
high-pull headgear vector applied intrusive forces to the maxillary posterior teeth (8 to 10 hours per
night extraoral force wear). A guide plane was used to support the corrected position and treatment
during the retention period of 14 months. No fixed appliances were used. A, Beginning facial views at
10 years 7 months. B, Age 11 years 5 months, at end of active correction phase. C, At end of retention,
age 13 years 9 months.

signed to allow the free eruption of the lower molars
to reduce the overbite by increasing the lower facial
height.
The registration bite should allow for correction of
midlines in cases in which they are displaced by func-
tional occlusal interference or guidance into habitual
occlusion. Twin blocks may be activated unilaterally to
correct postural mandibular displacement with center
line displacement and asymmetric buccal segment re-
lationships. The occlusal inclined plane is particularly
well suited to the correction of functional abnormalities
associated with asymmetric mandibular development.
For correction of asymmetry, the lower appliance re-
quires maximum retention in the lower arch to minimize
dental movement and to encourage asymmetric com-
pensatory growth.
Volume 93 Twin block technique 7
Number I

\
\

Fig. 3 (Cont’d). F and G, Cephalometric tracings. F, Age 10 years 5 months. G, Age 10 years 11
months.

FIXED TWIN BLOCKS
Twin block appliances may be designed for direct
fixation to the teeth by bonding. The appliances resem-
ble the Herbst appliance, substituting occlusal inclined
planes for telescopic tubes to provide the functional
component to guide the mandible into a protrusive PO-
sition.3.4
Preformed wedge attachments are being designed
at present for direct fixation to molar bands to allow
simpler application in fixed appliance technique.
8 Clark Am. J. Orrhod. Denmfac. Orthop.
Januay 1988

Fig. 3 (Cont’d). H through J. Cephalometric tracings. H, Age 11 years 6 months. I, Age 13 years
9 months. J, Superimposed tracings, ages 10 years 5 months and 11 years 6 months.

CLINICAL MANAGEMENT STAGE 1 -ACTIVE PHASE

This report refers to the treatment of an uncrowded
Class II, Division 1 malocclusion primarily, using re-
movable twin blocks. The patient had a combination
of maxillary protrusion and mandibular retrusion. The
technique is described in two stages, an ,active phase
with twin blocks and traction attachments, and a support
phase with a guide plane after correction of arch rela-
tionships.
Twin blocks are combined with intermaxillary and
extraoral traction for rapid correction of arch relation-
ships (Fig. 1, D).
The initial activation is checked when twin blocks
are fitted to confirm that the patient can comfortably
maintain the altered postural position.
Twin blocks are removed for eating for the first
3 days until the initial discomfort from appliance wear
Volume 93
Twin block technique 9
Number 1

Fig. 4. The major skeletal correction was completed in this case with twin blocks and Concorde face-
bow. A severe Class II, Division 1 malocclusion presented a 16-mm overjet with maxillary protrusion
and mandibular retrusion with E absent. The overjet was reduced to 2 mm after 6 months treatment
with twin blocks and Concorde face-bow. The position was then retained. Treatment was completed
with fixed appliances. A, Facial views, age 11 years 4 months. B, Age 11 years 6 months. C, Age 12
years 3 months.

has been resolved. Thereafter, the appliances are worn
continuously. It is important for the patient to under-
stand that wearing twin blocks for eating increases the
orthopedic forces and improves the response to treat-
ment; this makes it a true functional appliance.
It may be necessary to trim or relieve the flange of
the lower appliance, lingual to the lower incisors, to
avoid soft-tissue irritation. The upper midline screw is
turned a one-quarter turn every week to 10 days until
the arch width is adequate to accommodate the lower
arch in its corrected position. It is important to check
the expansion of the upper arch at each visit to avoid
excessive expansion (Fig. 1, B).
The Concorde face-bow is adjusted so that it lies
10 Clark Am. J. Orthod. Denrofac. Onhop.
January 1988

Fig. 4 (Cont’d). D, Intraorr.! views, age 11 years 4 months.

Flg. 4 (Cont’d). E, Intraoral views, age 12 years 3 months.

just below the level of the upper lip at rest, with the
ends of the outer bow sloping slightly upward above
the level of the inner bow. The resulting extraoral trac-
tion applies an upward component of force that helps
to retain the upper appliance (Fig. 1, C).
The intermaxillary elastic is attached under the ball
clasps in the lower labial segment and passes to the
labial hook on the face-bow (Fig. 1, C). If lower in-
cisors are already proclined, less elastic traction will
be tolerated. Avoid prolonged elastic traction in slow
vertical-growing patterns. The retention of the appli-
antes must be checked after the traction assembly is
fitted. Extraoral traction is applied by a straight pull to
a conventional headcap worn every night for 8 to 10
hours using 200 g distal extraoral force on each side
and approximately 150 g intermaxillary force.
At each monthly visit, the occlusion is checked for
correction of arch relationships.
Clinical response in active phase
The clinical response observed after fitting twin
blocks is closely analogous to the changes observed and
Volume 93
Twin block technique 11
Number 1

Fig. 4 (Cont’d). F through I, Cephalometric tracings. F and H correspond to A and C at the beginning
(F) and end (H) of treatment. I, Superimposition of before and after treatment tracings.

Fig. 4 (Cont’d). J, Fixed appliances used to complete treatment.

 Am. J. Orthod. Dent&c. Orthop.
12 Clark
Januaty 1988

Fig. 5. For legend, see opposite page.

Volume 93 Twin block technique 13
Number 1

reported in animal experiments using fixed inclined Management of overbite

planes.
Within a few days of fitting the appliances, the
position of muscle balance is altered so that it be-
comes painful for the patient to retract the mandible.
This has been described as the “pterygoid response”
(McNamara*) or the formation of a “tension zone” distal
to the condyle (Harvold5). It is rare for such a response
to be observed with functional appliances that are not
worn full-time.
The rapid clinical response confirms the summary
of adaptive responses in functional protrusion experi-
ments with fixed inclined planes by McNamara.’
The placement of appliances results in an immediate change
in the neuromuscular proprioceptive response. Provided all
phasic and tonic muscle activity is affected, the resulting
muscular changes are very rapid, and can be measured in
terms of minutes, hours and days. Structural alterations are
more gradual and are measuredin months, whereby the dento
skeletal structures adapt to restore a functional equilibrium to
support the altered position of muscle balance.’
The patient’s rate of growth should be taken into
account in timing the reactivation of the bite-blocks by
the addition of cold cure acrylic to the mesial inclined
plane of the upper blocks. However, an overjet of up
to 10 mm can be corrected without reactivating the bite-
blocks if the rate and direction of mandibular growth
are favorable.
If the patient’s rate of growth is slow or the direction
of growth is vertical rather than horizontal, it is advis-
able to advance the mandible more gradually over a
longer period of time to allow compensatory mandibular
growth to occur.
Full correction of sagittal arch relationships can be
achieved in as little as 2 to 6 months, giving a normal
incisor relationship with the buccal segments out of
occlusion due to the presence of the bite-blocks. It is
a consistent feature in functional techniques that sagittal
correction of arch relationships is achieved before com-
pensatory vertical development in the buccal segments
is complete (Fig. 3).
Deep overbite is reduced by overcorrecting the in-
cisors to an edge-to-edge relationship before reducing
the height of the bite-blocks. Vertical development of
the lower molars is encouraged from the beginning of
the active phase of treatment by progressively trimming
the upper bite-block occlusodistally to allow the lower
molars to erupt. At the end of the active phase, the
incisors and the molars should be in correct occlusion.
At this stage an open bite is still present in the
premolar region because of the presence of the bite-
blocks. The lower block is trimmed over a period of
2 or 3 months to reduce the open bite in the premolar
region. It is important to maintain adequate interlocking
wedges to maintain anteroposterior correction of arch
relationships.
This methori of reducing overbite by controlled
eruption of posterior teeth supported by occlusal bite-
blocks results in favorable changes in facial balance by
increasing lower facial height.
Conversely, if the overbite is reduced before treat-
ment, it is important to prevent overeruption of posterior
teeth, which would further reduce the overbite. All
erupted teeth must then be in occlusal contact with the
bite-blocks. If second molars erupt during the active
phase, occlusal cover or occlusal rests must be extended
to prevent overeruption of these teeth.
When the overbite is reduced, clasps are placed on
the posterior teeth and the appliances are left clear of
the anterior teeth to encourage eruption of the incisors.
In addition, a vertical-pull headgear may be used to
apply an intrusive force to the upper molars to reduce
the vertical component of growth.
STAGE 2-SUPPORT PHASE
The aim of the second stage of treatment is to retain
the corrected incisor relationship until the buccal seg-
ment occlusion is fully established, using an upper
Hawley-type removable appliance with an inclined
guide plane to retain the sagittal relationship. The upper
and lower buccal teeth are usually in occlusion within

Fig. 5. Orthopedic correction of facial asymmetry with twin blocks and Concorde face-bow is followed
by fixed appliances to complete orthodontic correction. Patient demonstrated facial asymmetry, showing
correction of center line by unilateral activation in twin block phase. The facial asymmetry and profile
are significantly improved after 2% months’ treatment with twin blocks. The improvement is maintained
throughout treatment; treatment is completed with fixed appliances after 6 months treatment with twin
blocks. A through D, Facial views. A, Age 10 years 6 months. 6, Age 10 years 8 months. C, Age 11
years 3 months. D, Age 12 years 8 months.
14 Clark Am. J. Orthod. Dentofac. Orthop.
January 1988

Fig. 5 (Cont’d). E through I, Intraoral views. E, Beginning of treatment, age 10 years 6 months. F and
G, Age 11 years (G is without appliance in place). H, Finishing and detailing with fixed appliances,
age 12 years 8 months. I, Completed treatment, age 13 years 5 months.

CASE SELECTION
4 to 6 months and the support phase is continued for a
further 3 to 6 months to ailowfunctional reorientation The technique has a wide application in those cases
of the trabecular system before the position is retained in which anteroposterior correction of arch relationship
(Harvold6). is required. For the neophyte, the technique should be
Volume 93 Twin block technique 15
Number I

Fig. 6. This case illustrates a typical approach to treatment in Class II, Division 2 malocclusion,
combining orthopedic and orthodontic phases of treatment. The facial profile is improved in the initial
twin block phase, which completes correction of the distal occlusion. The twin blocks are activated
mainly in the vertical dimension on bite blocks to encourage eruption of posterior teeth. Brackets were
placed on the upper anterior teeth after 4 months of treatment. The twin block phase was completed
after 6 months at which stage full fixed appliances were fitted to complete the final phase of treatment.
A through C, Facial views. A, Age 12 years 10 months. B, Age 13 years 4 months. C, Age 14 years
6 months.

initially to treat Class II, Division 1 malocclusion before relieving crowding. Fixed appliances are I
with an uncrowded lower arch. to lose spaces and to complete treatment object:ives
I n casesin which crowding necessitates extractions, (Figs. 4 through 6).
arch relationships may be corrected with twin ‘blocks In the treatment of Class II, Division 2 maloc:clu-

Fig. 6 (Cont’d). D through G, Intraoral views. D, Age 12 years
F, Age 14 years 6 months. G, Age 16 years 7 months.
sion, twin blocks are designed to procline upper incisors
and align the labial segments while correcting the sag-
ittal malrelationship. The inclined planes are shaped to
encourage molar eruption and the labial segments are
aligned while correcting the distal mandibular occlusion
(Fig. 6).
An integrated approach with fixed appliances allows
alignment, intrusion, and torque to be carried out for
the maxillary labial segments during the active phase
of treatment when arch relationships and skeletal dis-
crepancies are treated simultaneously. The presence of
Am. J. Orthod. Dentofac. Orthop.
January 1988
10 months. E, Age 13 years 4 months.
bite-blocks prevents traumatic occlusion on the fixed
attachments and avoids breakage as a result of excessive
overbite.
The necessity to combine a functional orthopedic
phase of treatment with a subsequent orthodontic phase
is recognized in cases in which additional dental cor-
rection is required. The addition of fixed attachments
during the twin block phase allows an easy transition
into fixed appliances when the functional orthopedic
phase is complete. Supportive mechanics would be nec-
essary after the transition to fixed appliances when the
 Twin block technique 17

Concorde face-bow would continue to have a useful The following angular and linear growth changes
application. were highly significant in comparison to normal growth
Reverse twin blocks may be used to correct sagittal change in the control series. The probability value was
arch relationships in Class III malocclusion. The upper less than 1: 1000, on applying Student’s t test to these
twin block is designed to procline upper incisors and changes during the active phase of treatment.
Class III intermaxillary or extraoral traction may also 1. Reduction in the anteroposterior apical base dis-
be applied. crepancy on angular assessment of ANB angle
The technique is effective in the mixed or permanent 2. Increase in effective mandibular length (articu-
dentition and may also be successful in adult treatment lare to gnathion)
except that only dentoalveolar correction occurs as op- 3. Increase in length of the facial axis (cc to gna-
posed to skeletal adaptation in the growing child. The thion)
response to treatment is always related to the patient’s 4. Increase in facial height (nasion to menton). The
growth pattern.7 majority of patients in the control sample had
deep overbite and the aims of treatment were
DISCUSSION consistent with increasing facial height.
In many respects the occlusal inclined plane is a 5. Reduction in facial convexity (A point to facial
significant improvement on existing appliance mecha- plane)
nisms in the functional guidance of facial growth and 6. Reduction in the distance from the distal out-
development. Significant changes in facial appearances line of the upper first molar to the pterygoid
are seen within 2 or 3 months of starting treatment with vertical
twin blocks as a result of altered muscle balance and
continuous wear, even during eating. Rapid soft-tissue LOWER INCISOR ANGULATION
adaptation occurs in response to an improved occlusal In the study of 70 consecutively treated cases, the
relationship. lower incisor was shown to procline in the active phase
Soft-tissue compensation occurs to assist the pri- of treatment and to upright in the support phase. After
mary functions of mastication and swallowing, which treatment the angulation of the lower incisor to the
require an effective anterior oral seal. mandibular plane had decreased slightly by a mean
The twin block appliance positions the mandible value of less than 1”. This had no statistical significance,
downward and forward, increasing the intermaxillary but is important in evaluating the stability of the lower
space. As a result it is difficult to form an anterior oral anterior segment after treatment.
seal by contact between the tongue and the lower lip, A follow-up study was carried out on 60 subjects
and patients spontaneously adopt a natural lip seal for of the same series of treated cases, averaging 18 months
deglutition without exercises when twin blocks are out of retention, which confirmed that the growth
fitted. ,changes that were recorded during the active stage of
The lip seal is maintained throughout treatment and treatment were maintained and that the results were
improved facial balance is evident within a few months stable.
of starting treatment.
Twin blocks have been described by patients as the REFERENCES
1. Charlier JP, Petrovic A, Herman-Stutzman J. Effects of man-
most comfortable of all the functional appliances. Al-
dibular hyperpropulsion on the prechondroblastic zone of young
though the appliances are removable, they produce rat condyle. AM J ORTHOD 1969;55:71-4.
rapid improvements in facial appearance that encourage 2. McNamara JA Jr. Functional determinants of crania-facial size
good patient motivation. For the less cooperative pa- and shape. Eur J Orthod 1980;2:131-59.
tient, upper and lower appliance components may be 3. Howe RP. The bonded Herbst appliance. J Clin Orthod
1982;10:663-7.
bonded.
4. Howe RP, McNamara JA Jr. Clinical management of the bonded
Herbst appliance. J Clin Orthod 1983;7:456-63.
CEPHALOMETRIC ANALYSIS
5. Harvold EP. Bone remodelling and orthodontics. Eur J Orthod
Cephalometric analysis of 70 consecutively treated 1985;7:217-30.
patients showed highly significant growth changes dur- 6. Harvold EP. Primate experiments on oral sensation and mor-
phogenesis. Transactions of 3rd International Congress of the
ing the active phase of treatment, confirming obser-
European Orthodontic Society. 1973;43 1:4.
vations by hlcNamara.8 Comparison was made with 7. Clark WJ. The twin block traction technique. Eur J Orthod
two separate control series of data that recorded growth 1982;4: 129-38.
changes related to age in untreated patients. 8. McNamara JA, Bookstein FL, Shaughnessy TG. Skeletal
18 Clark

and dental changes following functional regulator therapy on longitudinal interdisciplinary study of growth and development.
Class II patients. AM J ORT~IOD1985;88:91-110. University of Nijmegen. San Francisco: Academic Press, 1979.
9. Riolo ML, Moyers RE, McNamara JA Jr, Stuart Hunter W. An
Reprint requests to.
atlas of craniofacial growth. Cephalometric standards from the
Dr. William J. Clark
University School Growth Study, the University of Michigan.
22 Hill Street
Ann Arbor: 1974. Center for Human Growth and Development,
Kirkcaldy KY I 1HX
University of Michigan.
Fife, Scotland. U.K.
10. Prahl Andersen B, Kowalski CJ, Heydendael PHJM. Mixed

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