{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,29]],"date-time":"2026-05-29T14:02:37Z","timestamp":1780063357808,"version":"3.54.0"},"reference-count":58,"publisher":"The Angle Orthodontist (EH Angle Education & Research Foundation)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2020,3]]},"abstract":"ABSTRACT<\/jats:title>\n \n Objective:<\/jats:title>\n To compare Phase 1 treatment, using the Frankel 2 (FR2) or the modified Twin Block (MTB), for Class II division 1 malocclusion in children and adolescents with respect to: treatment duration, number of appliance breakages, occlusal outcome, and patient and parent perspectives.<\/jats:p>\n <\/jats:sec>\n \n Materials and Methods:<\/jats:title>\n Sixty participants with a Class II division 1 malocclusion were randomly assigned to either the FR2 or MTB appliance in a two-armed parallel randomized clinical trial with an allocation ratio of 1 to 1. Time to achieve a Class I incisor relationship was the primary outcome. The number of appliance breakages was recorded. The Peer Assessment Rating (PAR) index was used to evaluate pre- and post-treatment occlusal outcome on study models. Participants completed the child OHRQoL (oral health-related quality of life), Piers-Harris, Standard Continuum of Aesthetic Need (SCAN), and Oral Aesthetic Subjective Impact Score (OASIS) questionnaires pre- and post-treatment; parents completed a SCAN questionnaire.<\/jats:p>\n <\/jats:sec>\n \n Results:<\/jats:title>\n \n Forty-two participants completed treatment (FR2: 20; MTB: 22). Multiple imputation was used to impute missing data for noncompleters. Mean treatment duration was similar for the two appliances (FR2: 376 days [SD 101]; MTB: 340 days [SD 102];\n P<\/jats:italic>\n = .41). There were no significant differences in mean number of appliance breakages (FR2: 0.3 SD 0.7; MTB: 0.4 SD 0.8;\n P<\/jats:italic>\n = .67 or mean PAR score\n P<\/jats:italic>\n = .48). Patient and parent perspectives did not differ between appliances (\n P<\/jats:italic>\n > .05).\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions:<\/jats:title>\n Phase 1 treatment duration, number of appliance breakages, occlusal outcome, and patient and parent perspectives were similar in 11\u201314 year olds with Class II division 1 malocclusion treated using the FR2 or MTB appliance.<\/jats:p>\n <\/jats:sec>","DOI":"10.2319\/042419-290.1","type":"journal-article","created":{"date-parts":[[2019,10,15]],"date-time":"2019-10-15T08:48:03Z","timestamp":1571129283000},"page":"202-208","source":"Crossref","is-referenced-by-count":25,"title":["Frankel 2 appliance versus the Modified Twin Block appliance for Phase 1 treatment of Class II division 1 malocclusion in children and adolescents: A randomized clinical trial"],"prefix":"10.2319","volume":"90","author":[{"given":"Ciara","family":"Campbell","sequence":"first","affiliation":[{"name":"Consultant Orthodontist, Altnagelvin Area Hospital, Derry, Northern Ireland."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Declan","family":"Millett","sequence":"additional","affiliation":[{"name":"Professor of Orthodontics, Dental School, University College Cork, Ireland."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Niamh","family":"Kelly","sequence":"additional","affiliation":[{"name":"3D Imaging Technical Assistant, Dental School, University College Cork, Ireland."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marie","family":"Cooke","sequence":"additional","affiliation":[{"name":"Consultant Orthodontist, Department of Orthodontics, St. Finbarr's Hospital, HSE Cork Kerry Community Healthcare Area, Cork, Ireland."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Cronin","sequence":"additional","affiliation":[{"name":"Lecturer, School of Mathematical Sciences, Western Gateway Building, University College Cork, Cork, Ireland."}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1164","reference":[{"key":"i0003-3219-90-2-202-b01","series-title":"Br Dent J","first-page":"609","article-title":"The orthodontic condition of children in the United Kingdom in 2003","volume":"200","author":"Chestnutt \n IG,","year":"2006","unstructured":"Chestnutt \n IG, \n \n \n Burden \n DJ, \n \n \n Steele \n JG, \n \n \n Pitts \n NB, \n \n \n Nuttall \n N, \n \n \n Morris \n AJ. \n \n \n The orthodontic condition of children in the United Kingdom in 2003. Br Dent J. 2006;200:609\u2013612."},{"issue":"1","key":"i0003-3219-90-2-202-b02","series-title":"Dent Traumatol","first-page":"1","article-title":"Over two hundred million injuries to anterior teeth attributable to large overjet: a meta-analysis","volume":"31","author":"Petti \n S.","year":"2015","unstructured":"Petti \n S. \n \n \n Over two hundred million injuries to anterior teeth attributable to large overjet: a meta-analysis. Dent Traumatol. 2015;31(1):1\u20138."},{"key":"i0003-3219-90-2-202-b03","series-title":"Dent Update. 2","first-page":"464","article-title":"Malocclusion, orthodontics and bullying","volume":"28","author":"DiBiase \n AT,","unstructured":"DiBiase \n AT, \n \n \n Sandler \n PJ. \n \n \n Malocclusion, orthodontics and bullying. Dent Update. 2001;28:464\u2013466."},{"key":"i0003-3219-90-2-202-b04","series-title":"Br Dent J.","article-title":"The impact of two different malocclusion traits on quality of life","author":"Johal \n A,","year":"2007","unstructured":"Johal \n A, \n \n \n Cheung \n MYH, \n \n \n Marcenes \n W. \n \n \n The impact of two different malocclusion traits on quality of life. Br Dent J.2007;27:202(2):E2."},{"issue":"3","key":"i0003-3219-90-2-202-b05","series-title":"Am J Orthod Dentofacial Orthop","first-page":"234","article-title":"Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 1 Dental and Skeletal effects","volume":"124","author":"O'Brien \n K,","year":"2003","unstructured":"O'Brien \n K, \n \n \n Wright \n J, \n \n \n Conboy \n F, \n \n et al. \n Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 1 Dental and Skeletal effects. Am J Orthod Dentofacial Orthop. 2003;124(3):234\u2013243."},{"issue":"2","key":"i0003-3219-90-2-202-b06","series-title":"Am J Orthod Dentofacial Orthop","first-page":"128","article-title":"Effectiveness of treatment for Class II malocclusion with the Herbst or Twin-block appliances: A randomized, controlled trial","volume":"124","author":"O'Brien \n K,","year":"2003","unstructured":"O'Brien \n K, \n \n \n Wright \n J, \n \n \n Conboy \n F\n \n et al. \n Effectiveness of treatment for Class II malocclusion with the Herbst or Twin-block appliances: A randomized, controlled trial. Am J Orthod Dentofacial Orthop. 2003;124(2):128\u2013137."},{"issue":"7","key":"i0003-3219-90-2-202-b07","series-title":"Dent Update","first-page":"302","article-title":"The use of myofunctional appliances in the UK: a survey of British orthodontists","volume":"25","author":"Chadwick \n SM,","year":"1998","unstructured":"Chadwick \n SM, \n \n \n Banks \n P, \n \n \n Wright \n JL. \n \n \n The use of myofunctional appliances in the UK: a survey of British orthodontists. Dent Update. 1998;25(7):302\u2013308."},{"key":"i0003-3219-90-2-202-b08","series-title":"Orofacial Orthopaedics with the Function Regulator","author":"Frankel \n R,","year":"1989","unstructured":"Frankel \n R, \n \n \n Frankel \n C. \n \n \n Orofacial Orthopaedics with the Function Regulator. Basel: Karger;1989."},{"issue":"3","key":"i0003-3219-90-2-202-b09","series-title":"J Orthod","first-page":"209","article-title":"and management of Twin Blocks: reflections after 30 years of clinical use","volume":"37","author":"Clark W. \n Design","year":"2010","unstructured":"Clark W. \n Design \n \n \n and management of Twin Blocks: reflections after 30 years of clinical use. J Orthod. 2010;37(3):209\u2013216."},{"issue":"2","key":"i0003-3219-90-2-202-b10","series-title":"Angle Orthod","first-page":"363","article-title":"Use of the Clark Twin Block functional appliance with and without an upper labial bow: a randomized controlled trial","volume":"82","author":"Yaqoob \n O,","year":"2012","unstructured":"Yaqoob \n O, \n \n \n DiBiase \n AT, \n \n \n Fleming \n PS, \n \n \n Cobourne \n MT. \n \n \n Use of the Clark Twin Block functional appliance with and without an upper labial bow: a randomized controlled trial. Angle Orthod. 2012;82(2):363\u2013369."},{"key":"i0003-3219-90-2-202-b11","series-title":"Am J Orthod Dentofacial Orthop","first-page":"488","article-title":"Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 2: Psychosocial effects","volume":"124","author":"O'Brien \n K,","year":"2003","unstructured":"O'Brien \n K, \n \n \n Wright \n J, \n \n \n Conboy \n F, \n \n et al. \n Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 2: Psychosocial effects. Am J Orthod Dentofacial Orthop. 2003;124:488\u2013494."},{"issue":"4","key":"i0003-3219-90-2-202-b12","series-title":"PLoS Med","first-page":"e96","article-title":"A systematic review of studies that aim to determine which outcomes to measure in clinical trials in children","volume":"5","author":"Sinha \n I,","year":"2008","unstructured":"Sinha \n I, \n \n \n Jones \n L, \n \n \n Smyth \n RL, \n \n \n Williamson \n PR. \n \n \n A systematic review of studies that aim to determine which outcomes to measure in clinical trials in children. PLoS Med2008; 5(4):e96."},{"issue":"4","key":"i0003-3219-90-2-202-b13","series-title":"A prospective controlled study Eur J Paediatr Dent","first-page":"301","article-title":"Early functional treatment in class II division 1 subjects with mandibular retrognathia using Frankel II appliance","volume":"13","author":"Silvestrini-Biavati \n A,","year":"2012","unstructured":"Silvestrini-Biavati \n A, \n \n \n Alberti \n G, \n \n \n Silvestrini-Biavati \n F, \n \n \n Signori \n A, \n \n \n Castaldo \n A, \n \n \n Migliorati \n M. \n \n \n Early functional treatment in class II division 1 subjects with mandibular retrognathia using Frankel II appliance. A prospective controlled study Eur J Paediatr Dent. 2012; 13(4):301\u2013306."},{"issue":"2","key":"i0003-3219-90-2-202-b14","series-title":"Eur J Orthod","first-page":"125","article-title":"The development of the PAR Index (Peer Assessment Rating): reliability and validity","volume":"14","author":"Richmond \n S,","year":"1992","unstructured":"Richmond \n S, \n \n \n Shaw \n WC, \n \n \n O'Brien \n KD, \n \n et al. \n The development of the PAR Index (Peer Assessment Rating): reliability and validity. Eur J Orthod. 1992;14(2):125\u2013139."},{"issue":"3","key":"i0003-3219-90-2-202-b15","series-title":"Cleft Palate Craniofac J","first-page":"260","article-title":"Health-related quality of life of children aged 11 to 14 years with orofacial conditions","volume":"42","author":"Locker \n D,","year":"2005","unstructured":"Locker \n D, \n \n \n Jokovic \n A, \n \n \n Tompson \n B. \n \n \n Health-related quality of life of children aged 11 to 14 years with orofacial conditions. Cleft Palate Craniofac J. 2005;42(3):260\u2013266."},{"key":"i0003-3219-90-2-202-b16","series-title":"Piers-Harris Children's Self-Concept Scale, 2nd ed","author":"Piers \n EV,","year":"2002","unstructured":"Piers \n EV, \n \n \n Harris \n DB, \n \n \n Herzberg \n DS. \n \n \n Piers-Harris Children's Self-Concept Scale, 2nd ed. Torrance, Calif.: WPS;2002."},{"issue":"4","key":"i0003-3219-90-2-202-b17","series-title":"Eur J Orthod","first-page":"314","article-title":"Preliminary evaluation of an illustrated scale for rating dental attractiveness","volume":"9","author":"Evans \n R,","year":"1987","unstructured":"Evans \n R, \n \n \n Shaw \n W. \n \n \n Preliminary evaluation of an illustrated scale for rating dental attractiveness. Eur J Orthod. 1987;9(4):314\u2013318."},{"issue":"2","key":"i0003-3219-90-2-202-b18","series-title":"Eur J Orthod","first-page":"175","article-title":"Perceived aesthetic impact of malocclusion and oral self-perceptions in 14-15-year-old Asian and Caucasian children in greater Manchester","volume":"22","author":"Mandall \n NA,","year":"2002","unstructured":"Mandall \n NA, \n \n \n McCord \n JF, \n \n \n Blinkhorn \n AS, \n \n \n Worthington \n HV, \n \n \n O'Brien, \n KD. \n \n \n Perceived aesthetic impact of malocclusion and oral self-perceptions in 14-15-year-old Asian and Caucasian children in greater Manchester. Eur J Orthod. 2002;22(2):175\u2013183."},{"key":"i0003-3219-90-2-202-b19","series-title":"British Standards Glossary of Dental Terms","article-title":"British Standards Institution","year":"1983","unstructured":"British Standards Institution. British Standards Glossary of Dental TermsBS-4492 London: BSI;1983."},{"issue":"5","key":"i0003-3219-90-2-202-b20","series-title":"Am J Orthod Dentofacial Orthop","first-page":"583","article-title":"Incremental versus maximum bite advancement during twin-block therapy: a randomized controlled clinical trial","volume":"126","author":"Banks \n P,","year":"2004","unstructured":"Banks \n P, \n \n \n Wright \n J, \n \n \n O'Brien \n K. \n \n \n Incremental versus maximum bite advancement during twin-block therapy: a randomized controlled clinical trial. Am J Orthod Dentofacial Orthop. 2004;126(5):583\u2013588."},{"issue":"1","key":"i0003-3219-90-2-202-b21","series-title":"J Orthod","first-page":"17","article-title":"A randomized clinical trial of two alternative designs of Twin-block appliance","volume":"39","author":"Trenouth \n MJ,","year":"2012","unstructured":"Trenouth \n MJ, \n \n \n Desmond \n S. \n \n \n A randomized clinical trial of two alternative designs of Twin-block appliance. J Orthod. 2012; 39(1):17\u201324."},{"issue":"2","key":"i0003-3219-90-2-202-b22","series-title":"Am J Orthod Dentofacial Orthop","first-page":"144.e1","article-title":"Comparison of Twin Block and Dynamax appliances for the treatment of Class II malocclusion in adolescents: a randomized controlled trial","volume":"138","author":"Thiruvenkatachari \n B,","year":"2010","unstructured":"Thiruvenkatachari \n B, \n \n \n Sandler \n J, \n \n \n Murray \n A, \n \n \n Walsh \n T, \n \n \n O'Brien, \n K. \n \n \n Comparison of Twin Block and Dynamax appliances for the treatment of Class II malocclusion in adolescents: a randomized controlled trial. 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Am J Orthod Dentofacial Orthop. 1998;113(1):51\u201361."},{"issue":"1","key":"i0003-3219-90-2-202-b25","series-title":"Eur J Orthod","first-page":"84","article-title":"Meta-analysis of skeletal mandibular changes during Fr\u00e4nkel appliance treatment","volume":"33","author":"Perillo \n L,","year":"2011","unstructured":"Perillo \n L, \n \n \n Cannavale \n R, \n \n \n Ferro \n R, \n \n et al. \n Meta-analysis of skeletal mandibular changes during Fr\u00e4nkel appliance treatment. Eur J Orthod. 2011;33(1):84\u201392."},{"issue":"3","key":"i0003-3219-90-2-202-b26","series-title":"Aust Orthod J","first-page":"118","article-title":"Functional appliance treatment assessed using the PAR index","volume":"16","author":"Wijayaratne \n D,","year":"2000","unstructured":"Wijayaratne \n D, \n \n \n Harkness \n M, \n \n \n Herbison \n P. \n \n \n Functional appliance treatment assessed using the PAR index. 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J Orthod. 2017;44(4):241\u2013248."},{"key":"i0003-3219-90-2-202-b01","series-title":"Br Dent J","first-page":"609","article-title":"The orthodontic condition of children in the United Kingdom in 2003","volume":"200","author":"Chestnutt \n IG,","year":"2006","unstructured":"Chestnutt \n IG, \n \n \n Burden \n DJ, \n \n \n Steele \n JG, \n \n \n Pitts \n NB, \n \n \n Nuttall \n N, \n \n \n Morris \n AJ. \n \n \n The orthodontic condition of children in the United Kingdom in 2003. Br Dent J. 2006;200:609\u2013612."},{"issue":"1","key":"i0003-3219-90-2-202-b02","series-title":"Dent Traumatol","first-page":"1","article-title":"Over two hundred million injuries to anterior teeth attributable to large overjet: a meta-analysis","volume":"31","author":"Petti \n S.","year":"2015","unstructured":"Petti \n S. \n \n \n Over two hundred million injuries to anterior teeth attributable to large overjet: a meta-analysis. Dent Traumatol. 2015;31(1):1\u20138."},{"key":"i0003-3219-90-2-202-b03","series-title":"Dent Update. 2","first-page":"464","article-title":"Malocclusion, orthodontics and bullying","volume":"28","author":"DiBiase \n AT,","unstructured":"DiBiase \n AT, \n \n \n Sandler \n PJ. \n \n \n Malocclusion, orthodontics and bullying. Dent Update. 2001;28:464\u2013466."},{"key":"i0003-3219-90-2-202-b04","series-title":"Br Dent J.","article-title":"The impact of two different malocclusion traits on quality of life","author":"Johal \n A,","year":"2007","unstructured":"Johal \n A, \n \n \n Cheung \n MYH, \n \n \n Marcenes \n W. \n \n \n The impact of two different malocclusion traits on quality of life. Br Dent J.2007;27:202(2):E2."},{"issue":"3","key":"i0003-3219-90-2-202-b05","series-title":"Am J Orthod Dentofacial Orthop","first-page":"234","article-title":"Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 1 Dental and Skeletal effects","volume":"124","author":"O'Brien \n K,","year":"2003","unstructured":"O'Brien \n K, \n \n \n Wright \n J, \n \n \n Conboy \n F, \n \n et al. \n Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 1 Dental and Skeletal effects. Am J Orthod Dentofacial Orthop. 2003;124(3):234\u2013243."},{"issue":"2","key":"i0003-3219-90-2-202-b06","series-title":"Am J Orthod Dentofacial Orthop","first-page":"128","article-title":"Effectiveness of treatment for Class II malocclusion with the Herbst or Twin-block appliances: A randomized, controlled trial","volume":"124","author":"O'Brien \n K,","year":"2003","unstructured":"O'Brien \n K, \n \n \n Wright \n J, \n \n \n Conboy \n F\n \n et al. \n Effectiveness of treatment for Class II malocclusion with the Herbst or Twin-block appliances: A randomized, controlled trial. Am J Orthod Dentofacial Orthop. 2003;124(2):128\u2013137."},{"issue":"7","key":"i0003-3219-90-2-202-b07","series-title":"Dent Update","first-page":"302","article-title":"The use of myofunctional appliances in the UK: a survey of British orthodontists","volume":"25","author":"Chadwick \n SM,","year":"1998","unstructured":"Chadwick \n SM, \n \n \n Banks \n P, \n \n \n Wright \n JL. \n \n \n The use of myofunctional appliances in the UK: a survey of British orthodontists. Dent Update. 1998;25(7):302\u2013308."},{"key":"i0003-3219-90-2-202-b08","series-title":"Orofacial Orthopaedics with the Function Regulator","author":"Frankel \n R,","year":"1989","unstructured":"Frankel \n R, \n \n \n Frankel \n C. \n \n \n Orofacial Orthopaedics with the Function Regulator. Basel: Karger;1989."},{"issue":"3","key":"i0003-3219-90-2-202-b09","series-title":"J Orthod","first-page":"209","article-title":"and management of Twin Blocks: reflections after 30 years of clinical use","volume":"37","author":"Clark W. \n Design","year":"2010","unstructured":"Clark W. \n Design \n \n \n and management of Twin Blocks: reflections after 30 years of clinical use. J Orthod. 2010;37(3):209\u2013216."},{"issue":"2","key":"i0003-3219-90-2-202-b10","series-title":"Angle Orthod","first-page":"363","article-title":"Use of the Clark Twin Block functional appliance with and without an upper labial bow: a randomized controlled trial","volume":"82","author":"Yaqoob \n O,","year":"2012","unstructured":"Yaqoob \n O, \n \n \n DiBiase \n AT, \n \n \n Fleming \n PS, \n \n \n Cobourne \n MT. \n \n \n Use of the Clark Twin Block functional appliance with and without an upper labial bow: a randomized controlled trial. Angle Orthod. 2012;82(2):363\u2013369."},{"key":"i0003-3219-90-2-202-b11","series-title":"Am J Orthod Dentofacial Orthop","first-page":"488","article-title":"Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 2: Psychosocial effects","volume":"124","author":"O'Brien \n K,","year":"2003","unstructured":"O'Brien \n K, \n \n \n Wright \n J, \n \n \n Conboy \n F, \n \n et al. \n Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 2: Psychosocial effects. Am J Orthod Dentofacial Orthop. 2003;124:488\u2013494."},{"issue":"4","key":"i0003-3219-90-2-202-b12","series-title":"PLoS Med","first-page":"e96","article-title":"A systematic review of studies that aim to determine which outcomes to measure in clinical trials in children","volume":"5","author":"Sinha \n I,","year":"2008","unstructured":"Sinha \n I, \n \n \n Jones \n L, \n \n \n Smyth \n RL, \n \n \n Williamson \n PR. \n \n \n A systematic review of studies that aim to determine which outcomes to measure in clinical trials in children. 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