PMC5952230_01
Pretreatment photos showing space loss of upper left central incisor
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F1
Class II on the right and a one-half unit Class II on the left [Figure 1]. Canines were Class II on both sides.
Orthopantograph confirms the presence of all permanent teeth except the upper left central
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F2
The upper left central incisor was confirmed as missing [Figure 2].
PMC5952230_02
Pretreatment cephalometric radiograph and its tracing
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F3
The cephalometric radiograph and analysis [Figure 3] showed ANB value of 6 , which suggests that the patient had a Class II skeletal pattern.
PMC5952230_03
PMC5952230_04
Twin Block appliance design
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F4
The design of the appliance was modified by adding two C-clasps; one was mesial to the upper left lateral, and the other was mesial to the upper right central, where each clasp was attached to a different acrylic plate to create space for the missing incisor during expansion [Figure 4]. The design composed of 0.9 mm stainless steel Adam clasps on first molars and premolars, in addition to ball-ended clasps on lower incisors.
PMC5952230_05
PMC5952230_06
End of Phase I
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F5
Canines and molars were over corrected to Class III, and space for the missing upper incisor was increased (by 3 mm) as a result of the expansion; however, the overbite was maintained [Figure 5].
PMC5952230_07
Phase II of treatment. Prosthetic tooth (riding pontic) replacing missing central incisor is seen in frontal picture
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F6
An acrylic tooth with a bonded bracket and extended acrylic phalanges helped to maintain the space and improve patient esthetics [Figure 6].
End of treatment photos showing full incisor space, optimum overjet, and overbite
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F7
The end of treatment photos demonstrates the space created for the missing central incisor [Figure 7].
Finishing stage OPG and PA
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F8
No other pathology or abnormal anatomy were noted [Figure 8].
Posttreatment cephalometric radiograph and tracing
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F9
The posttreatment cephalometric tracing [Figure 9] and analysis [Table 1] showed that ANB value has reduced from 6  to 4 .