April 01, 2019

Why don’t patients wear their Twin Blocks?

We do not really know why some of our patients wear their Twin Blocks and why some do not manage to co-operate. This new paper gives us useful information. A few weeks ago I posted about a great study that used timers to measure co-operation with the Twin Block appliance.  The authors also did additional research to find out what influenced the patients to co-operate with treatment.  I thought that this was really interesting as it provided us with a lot of clinically relevant information. A team from Barts and the London Dental School, in the beautiful South of England, did this study. The AJO-DDO published it.

Understanding factors influencing compliance with removable functional appliances: A qualitative study Anas El-Huni et al. AJO-DDO  2019;155:173-81 https://doi.org/10.1016/j.ajodo.2018.06.011

They wrote an excellent introduction on factors that influence compliance with removable orthodontic appliances.  The noncompliance rates with Twin Blocks are between 10-49%.  But, we all think that our own patients are better than the average!  It is also clear that patients tend to overestimate their individual compliance rates. In this respect, their study using timers can provide us with great information, and they decided to carry out this further study on their sample.

What did they ask?

They asked:

What are the factors associated with different levels of compliance with the Twin Block appliance? Can we obtain information that may be used to increase compliance?

What did they do?

They did a research project using qualitative methods.  This is a relatively new technique for orthodontic research, but it is becoming more popular. In effect, qualitative research involves interviewing people and then analysing the results in a standardised way. Its main advantage is that this method gathers opinions and feelings about treatment or its outcome.  As a result, the findings are very relevant to our patients. They took a sample of 22 patients who were taking part in the trial of full or part-time wear of Twin Blocks. They monitored the time that the appliances were being worn with the Theramon device.  The sample included a mixture of good and poor compliers. In the first stage of the study, they developed a topic guide that they used to structure the interviews.  They then carried out semi-structured interviews of the sample of patients. Each meeting lasted about 45 minutes. Finally, they transcribed the interviews, and the team analysed them using something called Framework methodology. I have been involved with this in some of our research, and this is a lengthy process of discussion and retesting that eventually identifies themes.

What did they find?

For most orthodontists, qualitative research is challenging to read and follow. I think that this is because we are used to numbers etc.  The results are presented as descriptives, and we also struggle with this.  I have tried to make this as simple as possible because of space constraints.  I feel that these are the relevant findings. They identified five main themes, these were:

  • Self-motivation
  • Social influence
  • Quality of life impairment and adaptability
  • Perceived treatment progress
  • Pragmatic and recall issues.

They also divided these into enablers (influences positively) and barriers (influences negatively) and some could be both of these. I will look at some of these in more detail. Self-motivation clearly influenced the patients. They wanted to improve their appearance.  They also did not want to be different from other people their age.  However, the lack of self-motivation was a barrier to co-operation.

Social influences.

These included their parents, peers and the orthodontist. One crucial key to co-operation is the relationship between the patient and the orthodontist. The orthodontist needed to be supportive and informative.  This also relied on positive reinforcement from the operator.  Similar factors were reported for the influence of their parents. My interpretation of this was that being supportive was more important than taking a threatening stance when co-operation was not good.  Finally, the influence of their peers was very important. Their co-operation was influenced by positive and negative influences in the somewhat harsh life of the school and playground.

Quality of life impairment and adaptability.

This was crucial to co-operation and was concerned with how the patients overcame the hassle of wearing the Twin Block.  These included pain and teasing. These quotes are very relevant.

“I stopped wearing it because of the pain and the way that I spoke with it.” “No one could understand me, I just stayed quiet, and after a while, I just took it off”. “I got teased at first about my talking, but it stopped after a while”.

Perceived treatment progress.

They found that a positive attitude towards treatment progress was fundamental. The orthodontists pointed out the changes and the patients notice their appearance improving.

Pragmatic and recall issues

These were concerned with prescribed wear time, interference with daily activities and reminders.  These were all rather complex interactions and reflected the problems with the patients having an active life and having to adapt to wearing the appliance.

Improving compliance

Finally, the authors made some suggestions to improve compliance. These were:

  • Effective communication between the orthodontist, their team and the patient.
  • Modifying the appliance, by making the blocks smaller (but this may influence their effectiveness)
  • Using reminders, for example, apps or text reminders.

They also produced this nice graphic that outlines the influences.

What did I think?

I thought that this was a great piece of research that provided us with useful clinical information. While some of the findings reinforced my clinical impressions of the influences of co-operation, it also reminded me of the importance of explaining the treatment to the patient and parent.  I was also encouraged to see that they suggested using reminders and timers to improve co-operation.  I think that all those who treat patients with functional appliances should read this paper because it is full of exciting and relevant information. Some will feel that the findings are obvious, however, having positive reinforcement of our current practice is always useful.  We all like to know if we are doing the right thing.

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Have your say!

  1. yes – as we know from ‘the coal face’ if you can get patient on-board, you have success : Our internal audits based on success of Twin Block OJ reduction (to less than 4mm) after 6mths wear is 84% success
    you have believe in them and ‘sell’ them to patient and parent
    To quote John Sandler – “if you don’t have a personality… don’t use twin blocks”

  2. We needed a study to tell us this?

  3. Users of Twin Blocks, Congratulations. I’ve used them also.

    For me, just too much hassle. I’m too tired to constantly deal with them. 😉

    Thanks for all your work Kevin!

  4. I love twin blocks but I don’t have patients wear them at school
    16 hours a day wear on week days and 24/7 on weekends.

  5. I think it would be better to ask why orthodontists want to torture their patients with twin block.

    • ??? I am curious what your go-to Class 2 correction is?

      I think all of those are torture, not only for how you may or may not be compromising the airway and TMJ (research is still not complete) but for quality of life. Have you ever had a Herbst or a Mara in YOUR mouth? I have. It’s awful. I would never, ever put that in a patient.

      My first choice is always the healthiest with the least risks and side effects.

  6. The factors of success, begins with patient selection- especially evaluation of the motivation and adaptability of the child. Secondly, parental attitude( ‘We would go for surgery’ are not the right ones!), of support, and understanding.
    Once selected, different motivational methods, namely, first degree, second degree or third degree may be employed, depending on the case/attitude. In first degree,we appreciate the child, congratulate on the achievement of progress, to further encourage wear. In the second degree, we may use the demerits of alternatives like major surgery, prolonged fixed appliance treatment(with extraction of four sound teeth?), increased expenses and delay, (so in short, a sugarcoated blackmail?) etc. In the third degree, it is recommended to cement/bond the twin block, so the patient volunteered option of wearing is converted into a ‘punitive’ method.(Like Herbst,Jumper, Forsus, Carriere etc)
    The study, probably, documents the impressions more scientifically.
    In the Indian Context, there are four degrees of getting compliance: Saama, Daana, Bhedha and Danda, in Sanskrit, with almost similar meanings, as explained above.

  7. ??? I am curious what your go-to Class 2 correction is?

    I think all of those are torture, not only for how you may or may not be compromising the airway and TMJ (research is still not complete) but for quality of life. Have you ever had a Herbst or a Mara in YOUR mouth? I have. It’s awful. I would never, ever put that in a patient.

    My first choice is always the healthiest with the least risks and side effects.

    • I like Forsus appliances. As a 40 yr old orthodontist in treatmen now with them, i woukd have no problems recommending them. Better than rubber bands for me.

  8. Twin Block, Bionator, MARA, Herbst, Rick-o-nator, Forsus, Carriere Motion, etc all in desperate search for the Golden Grail of Sunday bite Cl II correction. Are there any Cl II patient’s that don’t need their mandibles postured forward? Can you imagine anyone not wanting or needing this?

  9. Whilst working with Dina Slater at Sunderland Royal Hospital, we made a Twin Block for DINA to wear to demonstrate to the patients that ‘it’s not too bad’ once ‘settled in’ and this worked really well to help get the patients on board with the process and increase compliance – so a draw full of self fitting appliances for Orthodontists is the way forward 😂😂

  10. I use to routinely use a Herbst. Now I give them a choice of the Herbst or aligners and class II elastics. The aligners work surprisingly well.

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