International Journal Dental and Medical Sciences Research

Volume 4, Issue 2, Mar-Apr 2022 pp 307-312 www.ijdmsrjournal.com ISSN: 2582-6018

Occlusal Bite Force Analysis in Developing Skeletal Class Ii

Malocclusion and Its Changes Following Treatment with Twin
Block Appliance – A T-Scan Study. (Original Research)
Andrea S Lyngdoh1, Rajkumar S Alle2, Bharathi VS3, Kiran H4
1.PostGraduate, Department of Orthodontics and Dentofacial Orthopedics, Raja Rajeswari Dental College and
Hospital, Bangalore, India.
2.Professor, Department of Orthodontics and Dentofacial Orthopedics, Raja Rajeswari Dental College and
Hospital, Bangalore, India.
3.Reader, Department of Orthodontics and Dentofacial Orthopedics, Raja Rajeswari Dental College and
Hospital, Bangalore, India.
4.Professor, Department of Orthodontics and Dentofacial Orthopedics, Raja Rajeswari Dental College and
Hospital, Bangalore, India.

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Submitted: 15-03-2022 Accepted: 28-03-2022
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ABSTRACT:AIM: To analyse the occlusal bite different removable (Activator, Monoblock,
forces in developing Class II skeletal malocclusion Bionator, Twin Block etc.) or fixed (Herbst, Jasper
and its changes following treatment with Twin Jumper, Forsus, Twin Force etc.) functional
Block Appliance by using an Occlusal Analysis appliances have been utilised to encourage or
System – T-Scan (T-Scan III, Tekscan). redirect mandibular growth to correct skeletal
METHODOLOGY: Total of 15 patients of aged discrepancies.2 In Skeletal Class II correction, the
between 10-15 years were selected for this study Twin Block appliance is one of the most commonly
based on the inclusion and exclusion criteria. used functional appliances today. It was designed
Subjects were explained about the procedure in by Dr.William J. Clark in 1977 for full time wear.
detailand an informed consent was obtained from This appliance achieves rapid functional correction
the patients, parents/guardians prior toobtaining the of malocclusion by directing favourable occlusal
T-Scans pre and post twin block therapy. RESULT: forces to occlusal inclined planes that cover the
The results of this study showed that there was posterior teeth.3 The T-Scan III Computerized
statistically significant difference in the occlusal Occlusal Analysis System (Tekscan Inc., South
bite force distribution between the Pre and Post Boston, MA USA) is a dental device used to
Twin Block appliance therapy and there was a analyze relative occlusal force that is recorded
significant equilibrium in the occlusal bite force intra-orally by a pressure-mapping sensor.4 It
which can be attributable to the treatment provided quantifies and displays relative occlusal force
to the patients. CONCLUSION: It can be information, so the clinician can minimize repeated
concluded that Functional Jaw Orthopedics with errors of incorrect occlusal contact selection that
Twin Block can bring about favourable skeletal often occur from relying solely on the combination
changes which enhances patient’s profile by of dental articulating paper and patient feel.21 The
improving the occlusal force distribution. T-Scan T-Scan III determines the contact time-sequencing,
analysis was used as an adjunct to Twin Block and the percentage of relative occlusal
appliance as it reduced the treatment time and forcebetween numerous occlusal contacts, and then
improved the occlusal force distribution post Twin displays them all for dynamic analysis. This
Block therapy. enablesthe clinician to better identify many
KEYWORDS:-Occlusal bite force , Twin block interfering contacts that are not readily identified
appliance, T-Scan analysis. by articulationpaper markings.

I. INTRODUCTION: II. METHODOLOGY:

Class II malocclusion can be caused by a Ten patients aged between 10-15 years
vertical dysplasia of the maxilla, mandible or both with developing Skeletal Class II malocclusion
and can be impacted by a spatial and sagittal were taken as the Study group and, five patients
abnormalities of the maxilla, mandible, or both.1In aged between 10-15 years with skeletal and dental
the treatment of patients with Skeletal Class II Class I malocclusion as Control group were
malocclusion with mandibular retrognathia selected from the Department. Subjects were

DOI: 10.35629/5252-0402307312 |Impact Factorvalue 6.18| ISO 9001: 2008 Certified Journal Page 307
 International Journal Dental and Medical Sciences Research
Volume 4, Issue 2, Mar-Apr 2022 pp 307-312 www.ijdmsrjournal.com ISSN: 2582-6018

explained about the procedure in detail and an in an Excel sheet which was be correlated with the
informed consent was obtained from the patients, readings obtained from the analysis. Subjects were
parents/guardians prior to obtaining the images pre instructed to occlude onto the recording sensor
and post twin block therapy. Lateral cephalograms three times in succession using their maximum bite
of all 15 subjects were recorded. Angle SNA, SNB force at maximum intercuspation. A single closure
and ANB along with Wits analysis was done to that contained the maximum recorded occlusal
assess the antero-posterior relation of the jaw force was selected for analysis.All measurements
bases.All the subjects had undergone a T-Scan (T- were carried out by the same investigator and OBF
Scan III, Software version 10.0.1, Tekscan, Inc., was recorded at the following time intervals:
Boston, MA, USA) occlusal analysis before the i. Just prior to insertion of Twin Block
commencement of the treatment and after the appliance (T1)
completion of treatment with Twin Block ii. After removal of Twin Block appliance
appliance. An intra-oral examination followed by a (T2)
multi bite closure T-Scan recording that gathers the
occlusal parameters for analysis was done. Prior to Methods Of Statistical Analysis:
recording, each subject had his/her dental arch Statistical Package for Social Sciences
dimensions and tooth distribution entered into T- [SPSS] for Windows, Version 22.0 Released 2013
scan's tooth chart. All multi bite T-Scan recordings Armonk, NY: IBM Corp., was used to perform
were made with the subject sitting upright in dental statistical analyses. Descriptive analysis included
chair. Subjects were instructed to occlude into the expression of bite force in terms of mean and
recording sensor three times in succession using standard deviation (SD). Student Paired t Test was
their maximum bite force. Then the single closure used to compare the mean bite force between pre
that contained the maximum recorded occlusal and post treatment periods in Class II Subjects.
force were selected for analysis. A T-ScanIII Independent Student t Test was used to compare
device was used to analyze occlusal bite the mean bite force between Class I occlusion and
forces.Data analysis was accomplished by playing Class II malocclusion subjects during post
and observing the occlusal force changes, timing treatment periods. The level of significance was set
sequence, and force percentages recorded from at P<0.05.
each subject. The percentage of force was tabulated

Graph 1: Difference between two dependent means using T test

The sample size was estimated using the GPower

software v. 3.1.9.4 [(Franz Faul, Universität III. RESULTS:
Kiel, Germany). Considering the effect size that Total size taken was 15 patients, 10 subjects were
was measured (dz) at 80% at One-Tailed in the study group and 5 subjects were in the
Hypothesis, power of the study at 85% and the control group, out of which the mean age group
margin of the error at 10%, the total sample size were 12.14 ± 1.07 in the study group and
needed was 10. 11.40±0.89 in the control group. In each patient, T-
The overall sample size was inflated to 15 with Scan analysis was done before insertion of Twin
adding 5 samples of Control to compare the Pre-op Block appliance and Post removal of Twin Block
measurements of study parameters with the Study appliance.
group. Final Sample Size comprises of 10 samples
in Study Group & 5 samples in Control Group.

DOI: 10.35629/5252-0402307312 |Impact Factorvalue 6.18| ISO 9001: 2008 Certified Journal Page 308
 International Journal Dental and Medical Sciences Research
Volume 4, Issue 2, Mar-Apr 2022 pp 307-312 www.ijdmsrjournal.com ISSN: 2582-6018

Table 1: MEAN AGE DISTRIBUTION OF THE SUBJECTS

CATEGORY N MEAN STANDARD
DEVIATION
STUDY 10 12.14 1.017
CONTROL 5 11.40 0.89

Table 1 shows the Mean age of the subjects for Study group was 12.14 ± 1.017 and for Control group was 11.40
± 0.89.

Table 2: GENDER-WISE DISTRIBUTION OF THE SUBJECTS

CATEGORY N STUDY CONTROL

N % N %

MALES 10 7 57.1% 3 60.0%

FEMALES 5 3 42.9% 2 40.0%

Table 2 shows the gender distribution of the subjects, out of which the Study group consists of57.1% are males
and 42.9% are females and in the Control group consisting of 60.0% males and 40.0% females.

Table 3:COMPARISON OF MEAN OCCLUSAL BITE FORCE IN RIGHT AND LEFT SIDES B/W 2
GROUPS DURING T1 PERIOD USING INDEPENDENT STUDENT T TEST
SIDE GROUPS N MEAN STANDARD MEAN P-
DEVIATION DIFFERENCE VALUE
RIGHT STUDY 10 46.89 8.01 -5.77 0.21
CONTROL 5 52.66 6.37
LEFT STUDY 10 53.11 8.01 5.77 0.21
CONTROL 5 47.34 6.37

Mean Occlusal Bite Force in Right &

Left sides b/w 2 groups during T1
60.00 52.66 53.11
46.89 Period 47.34
Mean Occlusal Bit Force

50.00
40.00
30.00
20.00
10.00
0.00
Right Left
Study
Graph 2: Mean occlusal bite force in Right and Left sides between 2 groups during T1 period

For the Study group: The mean occlusal bite force was not statistically significant [P=0.21]. Similarly,
on the right side was 46.89 and on the left side was the mean Occlusal bite force on left side during T1
53.11. For the Control group: The mean occlusal period in study group was 53.11 ± 8.01 and in
bite force on the right side was 53.11 and on the Control group was 47.34 ± 6.37 and the mean
left side was 47.37.The mean Occlusal bite force on difference was 5.77. However, this mean difference
right side during T1 period in study group was on the left side between 2 groups was not
46.89 ± 8.01 and in Control group was 52.66 ± 6.37 statistically significant [P=0.21].
and the mean difference was -5.77. However, this
mean difference on the right side between 2 groups

DOI: 10.35629/5252-0402307312 |Impact Factorvalue 6.18| ISO 9001: 2008 Certified Journal Page 309
 International Journal Dental and Medical Sciences Research
Volume 4, Issue 2, Mar-Apr 2022 pp 307-312 www.ijdmsrjournal.com ISSN: 2582-6018

Table 4:COMPARISON OF MEAN OCCLUSAL BITE FORCE IN RIGHT AND LEFT SIDES B/W T1
AND T2 PERIOD IN STUDY GROUP USING STUDENT PAIRED T TEST
SIDE TIME N MEAN STANDARD MEAN P-
DEVIATION DIFFERENCE VALUE
RIGHT T1 10 46.89 8.01 -5.14 0.04
T2 5 52.03 3.48
LEFT T1 10 53.11 8.01 5.14 0.04
T2 5 47.97 3.48

Mean Occlusal Bite Force in Right & Left

sides b/w T1 & T2 period in Study Group
60.00 52.03 53.11
46.89 47.97
Mean Occlusal Bit Force

50.00
40.00
30.00
20.00
10.00
0.00
Right T1 T2 Left
Graph 3: Mean occlusal bite force in Right and Left sides between T1 and T2 period in Study Group

According to Table 4, there was a the Twin Block approach to treatment was to
significant improvement in occlusal bite force produce a technique that could maximize the
between the right and left sides between T1 and T2 growth response to functional mandibular
period.The mean occlusal bite force on the right protrusion by using an appliance system that is
side during T1 was 46.89 and during T2 was 52.03. simple, comfortable and aesthetically acceptable to
The mean occlusal bite force on the left side during the patient.5The main objective of the therapy with
T1 was 53.11 and during T2 was 47.97. The mean Twin-block is to induce supplementary lengthening
Occlusal bite force in study group on right side of the mandible by stimulating increased growth at
during T2 period was significantly increased 52.03 the condylar cartilage and have maximum
± 3.48 as compared to T1 period 46.89 ± 8.01 and therapeutic effects if the mandibular growth spurt is
the mean difference was statistically significant at included.3The T-Scan III analyses contact time-
P=0.04. Contrastingly, the mean Occlusal bite force sequencing and percentages of relative occlusal
in study group on left side during T2 period was force between multiple occlusal contacts, then
significantly decreased 47.97 ± 6.37 as compared to displays them all for dynamic study.15In this study,
T1 period 53.11 ± 8.01 and the mean difference we had assessed the occlusal force distribution
was statistically significant at P=0.04. This infers pattern and the changes in the force distribution
that the T2 period established a significant pattern in developing Class II malocclusion with
equilibrium in the occlusal bite force as compared Twin Block Appliance by using an Occlusal
to T1 period which can be attributable to the Analysis System – T-Scan analysis. We had also
treatment provided to the patients. compared the Pre and Post T-Scan data before
Twin Block insertion and Post Twin Block therapy.
IV. DISCUSSION: Based on the findings of the study and the literature
The goal of orthodontic therapy is to reviewed, it was concluded that the state of
improve the patient's quality of life by aligning functional occlusion should be reviewed during the
their teeth enhancing dentofacial aesthetics and finishing stages of orthodontic treatment to correct
good jaw function. Patients with Class II any occlusal interferences, as 3-dimensional control
malocclusion frequently have a deficiency in of tooth position while the appliance is still in
mandibular size, thus an effective method of place, it is relatively easy to operate without
improving the mandible's forward growth and prolonging treatment time. This study also
development is desirable. The goal in developing confirmed that there was a positive correlation
DOI: 10.35629/5252-0402307312 |Impact Factorvalue 6.18| ISO 9001: 2008 Certified Journal Page 310
 International Journal Dental and Medical Sciences Research
Volume 4, Issue 2, Mar-Apr 2022 pp 307-312 www.ijdmsrjournal.com ISSN: 2582-6018

between occlusal bite forces and changes seen post [3]. Clark WJ. The Twin Block Technique a
removal of Twin Block appliance. Also, the Functional Orthopedic Appliance System.
occlusion's post-debonding settling must be American Journal of Orthodontics and
evaluated, and precise occlusal modifications must Dentofacial Orthopedics. 1988 Jan
be made to achieve a stable and healthy functioning 1;93(1):1-8.
occlusion. [4]. Majithia IP, Arora V, Kumar SA, Saxena V,
V. CONCLUSION: Mittal M. Comparison of articulating paper
The T-Scan system offered Orthodontists markings and T Scan III recordings to
immediate access to patient’s functional occlusion. evaluate occlusal force in normal and
We could see the static anddynamic quality of rehabilitated maxillofacial trauma patients.
inter-arch contactsin real time in a form that was medical journal armed forces India. 2015
preservedin a record for comparison atany future Dec 1;71:S382-8.
date. Thus, by gaining information on the earliest [5]. Clark W, Clark WJ. Twin block functional
occlusal contact, it was adjusted, and simultaneous therapy. JP Medical Ltd; 2014 Sep 30.
occlusal contact was established. The consequence [6]. Baysal A, Uysal T. Dentoskeletal effects of
of this occlusal therapy was that the patient could Twin Block and Herbst appliances in
feel a more widespread contact sensation at the patients with Class II division 1 mandibular
end, the reason being that the establishment of true retrognathy. European journal of
and measurable bilateral simultaneous occlusal orthodontics. 2014 Apr 1;36(2):164-72.
contact was achievable by using the T-Scan. [7]. Mills CM, McCulloch KJ. Posttreatment
Besides good esthetics, form and function, changes after successful correction of Class
achieving a balanced occlusion was an important II malocclusions with the twin block
goal after orthodontic treatment. This study appliance. American Journal of Orthodontics
concludes that there was statistically significant and Dentofacial Orthopedics. 2000 Jul
difference found in overall bite force readings 1;118(1):24-33.
between the pre insertion of Twin Block Appliance [8]. Sarinnaphakorn L, Qadeer S, Chitkraisorn T,
and the post removal of the appliance. In spite of Kerstein R. Force distribution on occlusal
overall bite force varying significantly, bite force splints using T-Scan occlusal analysis.
imbalance was present on left and right sides in Advanced Dental Technologies &
both the groups which indicated a need to balance Techniques. 2020 Jan 16:11730.
the same to achieve the aim of good and stable [9]. Computerized Occlusion – Using T-Scan III
functional occlusion. The bite force imbalance by Dr. J.H. Kim, DDS Pg no 510
improved significantly post removal of Twin Block [10]. Cohen-Lévy J, Cohen N. Computerized
Appliance and suggested that the differences in the occlusal analysis in Dentofacial orthopedics:
occlusal bite force distribution between pre and indications and clinical use the T-scan III
post Twin Block therapy led to a significantly system. Journal of Dentofacial Anomalies
change in the patient’s occlusion which showed and Orthodontics. 2012;15(2).
that the Twin Block appliance helped and improved [11]. Kerstein R. Articulating paper mark
the patient's occlusion, and the T-scan analysis was misconceptions and computerized occlusal
a good diagnostic tool because it helped to assess analysis technology. Dental implantology
the occlusal force distribution. update. 2008 Jun 1;19(6):41-6.
[12]. Lund DI, Sandler PJ. The effects of Twin
REFERENCES: Blocks: a prospective controlled study.
[1]. Coskuner HG, Ciger S. Three-dimensional American Journal of Orthodontics and
assessment of the temporomandibular joint Dentofacial Orthopedics. 1998 Jan
and mandibular dimensions after early 1;113(1):104-10.
correction of the maxillary arch form in [13]. Toth LR, McNamara Jr JA. Treatment
patients with Class II division 1 or division 2 effects produced by the Twin-block
malocclusion. The korean journal of appliance and the FR-2 appliance of Fränkel
orthodontics. 2015 May 1;45(3):121-9. compared with an untreated Class II sample.
[2]. Mills CM, McCulloch KJ. Posttreatment American Journal of Orthodontics and
changes after successful correction of Class Dentofacial Orthopedics. 1999 Dec
II malocclusions with the twin block 1;116(6):597-609.
appliance. American Journal of Orthodontics [14]. Sonnesen L, Bakke M. Molar bite force in
and Dentofacial Orthopedics. 2000 Jul relation to occlusion, craniofacial
1;118(1):24-33. dimensions, and head posture in pre-

DOI: 10.35629/5252-0402307312 |Impact Factorvalue 6.18| ISO 9001: 2008 Certified Journal Page 311
 International Journal Dental and Medical Sciences Research
Volume 4, Issue 2, Mar-Apr 2022 pp 307-312 www.ijdmsrjournal.com ISSN: 2582-6018

orthodontic children. The European Journal

of Orthodontics. 2005 Feb 1;27(1):58-63.
[15]. Qadeer S, Yang L, Sarinnaphakorn L,
Kerstein RB. Comparison of closure
occlusal force parameters in post-
orthodontic and non-orthodontic subjects
using T-Scan® III DMD occlusal analysis.
CRANIO®. 2016 Nov 1;34(6):395-401.
[16]. Agbaje JO, Casteele EV, Salem AS,
Anumendem D, Shaheen E, Sun Y, Politis
C. Assessment of occlusion with the T-Scan
system in patients undergoing orthognathic
surgery. Scientific Reports. 2017 Jul
13;7(1):1-8.
[17]. Qadeer S, Yang L, Sarinnaphakorn L,
Kerstein RB. Comparison of closure
occlusal force parameters in post-
orthodontic and non-orthodontic subjects
using T-Scan® III DMD occlusal analysis.
CRANIO®. 2016 Nov 1;34(6):395-401.
[18]. Kerstein RB. Combining technologies: a
computerized occlusal analysis system
synchronized with a computerized
electromyography system. Cranio®. 2004
Apr 1;22(2):96-109.
[19]. Julia CL, Cohen N. Computerized occlusal
analysis in dentofacial orthopedics:
indications and clinical use of the T-Scan III
system. Journal of Dentofacial Anomalies
and Orthodontics 2012 Jan;15(2) 203.
[20]. Thumati P. Digital analysis of occlusion
using T-Scan III in orthodontics. Journal of
Indian Orthodontic Society. 2016
Jul;50(3):196-201.
[21]. Abrol K, Abrol S. T-Scan–The dental
advisor. International Journal of Applied
Dental Sciences. 2019;5(2):2.

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