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An effective means of obtaining maxillary expansion and obturation was presented. By use of split palatal orthopedic prosthesis incorporating a posterior fanscrew with an obturator, two patients showed improved speech, cosmetic appearance, and oral physiology while gaining the desired alignment of the maxillary segments before further surgery.
The use of visible light-cured (VLC) resin was evaluated in contrast to more traditional chemical-cured resins for reconstruction of the spine in experimental rats. Such procedures are used to reconstruct vertebra in humans following corpectomy for neoplastic destruction of the spine. Numerous disadvantages exist in the use of chemical-cured resins, including excessive heat generated during the polymerization, cytotoxic effects of the nonpolymerized monomers on adjacent tissues, increased risk of infection due to impaired immunity, and distortion problems with the polymers. A new visible light-cured resin, Triad, was tested for use in maxillofacial prosthetics and for vertebral body replacement in neuro-orthopedic surgery. This study evaluated the biocompatibility of the VLC resin system as a bone implant material. The results of this study have shown the VLC resins underwent polymerization without substantial exothermic reaction and the biologic testing indicated that they are nontoxic and biocompatible. Some of the advantages noticed by using VLC resin are accuracy of fit and ease of fabrication and manipulation.
This article describes a method for making a palatal expansion device for use in conjunction with orthopedic repositioning of the premaxilla in patients with bilateral cleft palate. The technique of constructing the devices involves the microwave processing of a permanent soft liner and a heat-cured acrylic resin in a single-stage curing cycle. The resultant expansion device has the advantages of a soft liner for retention in the nasal cavity and an oral cavity surface that is smooth and closely adapted to the tissues. A paper cover is used during the flasking process, which allows packing of materials without displacement into undesirable locations.
The net treatment effect of or orthodontic or orthopedic therapy may be considered as the algebraic sum of all dentoalveolar, skeletal, and neuromuscular changes over time. Cumulative effects resulting from growth and adaptation in response to therapeutic biomechanical interference may be manipulated to result in clinically significant morphologic alterations in the growing child's dentition and craniofacial skeleton. All of the currently used functional appliances can be regarded as assemblies of a small number of component parts. This article attempts to identify these salient components and their respective contributions to the total design and probable function of such appliances. The logical consequence of such an analysis is the derivation of principles upon which the design of "hybrid" appliances may be based. Hybrid appliances are specifically and individually tailored to exploit the natural processes of growth and development. Such an approach represents a departure from the practice of adopting a "named" appliance for the treatment of a class of malocclusion. Instead, a detailed analysis of skeletodental and soft-tissue features, together with the patient's growth status and underlying cause of the malocclusion, are used to establish a set of treatment objectives. This in turn determines the selection of the components and their assemblies, resulting in appliance designs that uniquely match the needs of individual patients.
The activator, the Bionator, the Fränkel, and, more recently, the Herbst appliances have enjoyed increasing popularity. Although an increase in mandibular growth has not been shown to be clinically consistent or always significant, the popularity of these appliances continues. Another clinical goal of these functional jaw orthopedic (FJO) appliances is to correct, maintain, or protect the integrity of the TMJ--specifically, to prevent posterior condylar displacement and/or anterior disk displacement. Because all FJO appliances anteriorly reposition the condyle during treatment, it is hoped that internal derangement problems may be resolved during treatment. Even though a single TMJ radiograph is not diagnostic in itself, multiple radiographs are helpful in monitoring the net changes in the condylar position during treatment. The relative (or net) change in the condylar position may provide clues to what occurred during treatment. However, TMJ responses are not always predictable during FJO treatment. Three case histories are presented that illustrate unexpected TMJ responses in which the condyles were still posteriorly displaced in spite of FJO treatment. Only 2% to 3% of the author's practice responds in this manner and no physiologic mechanism is suggested. These findings point out the complexity of the TMJ and its treatment, regardless of the appliance, and emphasize that no one approach to TMJ treatment will always be efficacious.
A new functional appliance (FA) to correct Class II dentoskeletal malocclusions is introduced. The functional orthopedic magnetic appliance (FOMA) II uses upper and lower attracting magnetic means (Nd2Fe14B) to constrain the lower jaw in an advanced sagittal posture. In vitro, a special gauge transducer measured the magnetic attractive path and forces. In vivo, 13 prepubertal female Macaca fascicularis monkeys received facial implants and were treated for 4 months with the following appliances: conventional FA (four subjects), FOMA II (five subjects), a combined FOMA II + FA (two subjects), and sham (control) appliance (two subjects). The in vitro results showed the following: vertico-sagitally displaced upper and lower magnets attracted ultimately along an oblique line with a terminal horizonal slide to become fully superimposed; the functional performance improved when the magnetic interface acted as a magnetic inclined plane; and the magnetic force was able to guide and constrain the mandible toward the constructive protrusive closure position (CPCP) (1.2 mm, F = 570 gm) from levels below the habitual rest position (3 mm, F = 219 gm) and the electromyographic (EMG) relaxed position (8.5 mm, F = 45 gm). The in vivo results demonstrated the following: functional performance increased in FOMA II (22%) and in the combined FOMA II + FA (28%) over the conventional FA; mandibular length increased significantly in the treated animals (means = 2.83 +/- 0.70 mm) over the control animals (means = 0.43 +/- 0.08 mm); incisor proclination was lower in magnetic appliances (means = 4.57 +/- 1.76 degrees) than in the conventional FA (means = 8.75 +/- 1.85 degrees); mandibular elongation and condylar posterior inclination resulted from posterosuperior endochondral growth (increased cell proliferation and/or hyperplasia of functional chondroblasts) and by bony remodeling of the condylar neck (apposition posterior border, resorption anterior border), respectively; virtually no anterior displacement of the postglenoid spine (means = 0.19 +/- 0.68 mm) nor the articular eminence (means = 0.36 +/- 0.69 mm) was found. Increased lower posterior alveolar height (means = 1.71 +/- 0.82 mm) is a major impediment in the correction of excessive lower anterior facial height. The results of the study highly recommend the exploration of the clinical application of the FOMA II.
The bioactivator is an orthopedic appliance that has been used for 20 years in the treatment of Class II, Division 1 cases. The evaluation of its therapeutic effects was performed in this study of 76 9- to 10-year-old patients (at the beginning of treatment). The treated subjects were separated into two groups: group A (bioactivator only) and group B (bioactivator plus headgear). Group C comprised 14 untreated subjects selected as controls. Various statistical assessments were made to separate growth phenomena from treatment effects. It appears that the bioactivator has an effect not only on the dentition but also on the skeletal structures. In both treated groups, the maxillary changes were related to an increased anterior vertical growth and a posterior sagittal growth. The addition of extraoral force helped to achieve a posterior rotation of the upper jaw. When only the bioactivator was worn, the mandibular changes were more vertical than sagittal. The lower jaw appeared more forward, however. When the bioactivator and the headgear force were used simultaneously, the therapeutic effects seemed to be more sagittal than vertical, as if the occipitally directed force vector inhibits or at least exerts a control on the downward growth tendency. Without being significantly different statistically from one to the other, the treated groups showed a marked improvement of the sagittal jaw discrepancy.
An intraoral intermaxillary appliance has been developed for the treatment of Class III malocclusions that exhibit midface sagittal deficiency with or without mandibular excess. The functional orthopedic magnetic appliance (FOMA) III consists of upper and lower acrylic plates with a permanent magnet incorporated into each plate. The upper magnet is linked to a retraction screw. The upper magnet is retracted periodically (e.g., monthly) to stimulate maxillary advancement and mandibular retardation. The attractive mode neodymium magnets used in this study produced a horizontal force of 98 gm and a vertical force of 371 gm. Six female Macaca fascicularis monkeys were treated with FOMA IIIs. An additional three animals were treated with sham appliances. After 4 months of treatment, the following results were found: the growth pattern of the cranial base (saddle angle) was not altered; midfacial protraction did occur along a recumbent hyperbolic curve with a horizontal maxillary displacement and an anterosuperior premaxillary rotation; the cumulative protraction of the maxillary complex was initiated at the pterygomaxillary fissure with an additional contribution provided by other circummaxillary sutures (zygomaticomaxillary s., transverse s., premaxillary s.); and inhibition of mandibular length was minimal, but a tendency toward a vertical condylar growth pattern was observed. The interaction between sutural and condylar growth sites appeared biphasic, characterized by an immediate and rapid excitation of the circummaxillary sutures followed by a delayed and slow suppression of the condylar cartilage. Long-term animal and clinical FOMA III studies are recommended.
This study presents a model for the computation of the forces exerted on the chin and on the forehead by the facial orthopedic mask in skeletal Class III malocclusions. Cephalometric data as well as geometry of the mask are taken into account to simulate in quantitative terms the entire approach. A computer program has been implemented to validate the model on a group of patients. Despite the approximations about the mechanical characteristics of the appliance and of the constraints (rigid body, ideal constraints) and despite the unavoidable errors in the estimation of the geometric parameters (dimensions and angles), it is shown that the computation of the forces (in orientation and in magnitude) at the forehead and at the chin is possible. Some practical applications of the model are presented.
STUDY OBJECTIVE: To determine whether transdermal fentanyl can provide a significant component of postoperative analgesia. DESIGN: Randomized, double-blind study. SETTING: Inpatient surgery in a university hospital. PATIENTS: 40 adult patients scheduled for orthopedic surgery with general anesthesia. INTERVENTIONS: 20 patients in each group had general anesthesia with propofol, isoflurane in nitrous oxide and oxygen (O2), and small boli of alfentanil or sufentanil. Preoperatively, the first group (F) received a transdermal therapeutic system fentanyl patch (75 micrograms/hr) for 72 hours, and the second group (P) received a placebo patch. Morphine was given postoperatively according to clinical necessity. MEASUREMENTS AND MAIN RESULTS: Morphine consumption, pain visual analog scale, and eventual sedation were assessed, as well as respiratory rate and blood pressure. Plasma fentanyl concentrations were determined. Only 11 Group F patients needed morphine compared with 19 Group P patients, and mean morphine dose was significantly lower in Group F. One Group F patient had decreased O2 saturation and intense sedation, necessitating administration of naloxone. The mean maximum plasma fentanyl concentration in Group F was 1.63 ng/ml. CONCLUSION: Efficacy of transdermal fentanyl for postoperative pain relief is shown, but intense respiratory depression is sometimes seen.
Achilles tendon rupture is a relatively uncommon occurrence in a general ED population. The history can be subtle, and physical findings may not be clear-cut. Prompt diagnosis and treatment of these injuries, however, is important to improved clinical outcome. The emergency physician needs to remain vigilant for this diagnosis to avoid this orthopedic pitfall. This review article examines the clinical presentation, diagnostic technique, and management options applicable to the emergency physician in the treatment of Achilles tendon rupture.
BACKGROUND: The objective of this study was to select a model of cephalometric variables to predict future Class III growth patterns based on the results of early orthopedic treatment with a protraction facemask. MATERIAL: Sixty-four patients with Class III malocclusion were treated with a protraction facemask. Cephalometric radiographs were taken before treatment and a minimum of 3 years after treatment. The sample was divided into 2 groups: successful and unsuccessful according to overjet and molar relationships. Eleven linear and 5 angular measurements were made on the pretreatment radiograph. A logistic regression model was used to identify the dentoskeletal variables most responsible for the prediction of successful and unsuccessful outcomes in subjects receiving treatment. RESULTS: Stepwise variable selection generated 4 variables significant in predicting successful treatment outcomes: position of the condyle with reference to the cranial base (Co-GD, P = .02), ramal length (Co-Goi, P = .03), mandibular length (Co-Pg, P = .01), and gonial angle (Ar-Goi-Me, P < .0001). The gonial angle was found to be significantly larger in the unsuccessful group. Controlling for other variables, the probability of successful treatment is an increasing function of Co-GD and Co-Goi, and a decreasing function of Co-Pg and Ar-Goi-Me. A logistic equation was established that is accurate in predicting successfully treated Class III patients 95.5% of the time and unsuccessful ones 70% of the time. CONCLUSIONS: These results suggest that Class III growing patients with forward position of the mandible, small ramal length, large mandibular length, and obtuse gonial angle are highly associated with unsatisfactory treatment outcomes after pubertal growth.
UNLABELLED: This self-directed learning module highlights a clinical vignette of 2 patients: (1) a woman with bilateral, distal, upper-limb pain assessed by differential diagnosis, laboratory work-up, and treatment of rheumatologic disorders frequently seen in the physiatric practice setting and (2) a 57-year-old man with an acute recurring monoarthritis of the knee and addresses clinical presentation, assessment, medical management, and rehabilitation approaches. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on 2 aspects: (1) the differential diagnosis of polyarthralgia, distal upper-limb pain, criteria for classification of rheumatoid arthritis, synovial fluid analysis, and comprehensive treatment of rheumatoid arthritis, both pharmacologic and nonpharmacologic and (2) the differential diagnosis, clinical diagnostic considerations, current pharmacotherapy, invasive procedure options, and orthotic and exercise interventions for a patient with calcium pyrophosphate dehydrate-induced monoarthritis of the knee. OVERALL ARTICLE OBJECTIVES: (a) Clinical evaluation, diagnosis, management, and rehabilitation strategies in persons with initial presentations of inflammatory distal upper-limb pain and (b) clinical evaluation of an individual with crystal-induced monoarthritis and differentiation of the pathophysiology, assessment, and treatment of chondrocalcinosis.
UNLABELLED: This self-directed learning module highlights the pathoanatomy and pathogenesis of lumbar spinal stenosis. The areas covered include assessment and therapeutic options in the rehabilitation of patients with degenerative lumbar spinal stenosis. It is part of the study guide on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. OVERALL ARTICLE OBJECTIVES: (a) To summarize the evaluation and management of lumbar spinal stenosis and (b) to review the pathoanatomy and pathogenesis of lumbar degenerative spinal stenosis.
To assess the benefits of nitric oxide (NO)-releasing sol-gels as potential antibacterial coatings for orthopedic devices, medical-grade stainless steel is coated with a sol-gel film of 40% N-aminohexyl-N-aminopropyltrimethoxysilane and 60% isobutyltrimethoxysilane. Upon converting the diamine groups in these films to diazeniumdiolate NO donors, the NO release from the sol-gel-coated stainless steel is evaluated at both ambient and physiological temperature. Sol-gel films incubated at 25 degrees C have a lower NO flux over the first 24 h compared to those at 37 degrees C, but release more than five times longer. The bacterial adhesion resistance of NO-releasing coatings is evaluated in vitro by exposing bare steel, sol-gel, and NO-releasing sol-gel-coated steel to cell suspensions of Pseudomonas aeruginosa, Staphylococcus aureus, and Staphylococcus epidermidis at 25 degrees C and 37 degrees C. Cell adhesion to bare and sol-gel-coated steel is similar, while NO-releasing surfaces have significantly less bacterial adhesion for all species and temperatures investigated.
The first month of life is a vulnerable time for foals. They must adjust to their environment while they are still compromised immunologically, and their musculoskeletal system is rapidly growing and adjusting to stresses from an increasing amount of exercise. Therefore, if a foal is born with or acquires an abnormality or disease related to the musculoskeletal system, rapid adjustments must be made to allow the foal to grow and respond so that future athletic performance will not be compromised. Problems must be identified early, which requires thorough examinations. This article summarizes treatment options for orthopedic disorders that present or become clinically evident within the first month of life.
An understanding of orthopedic conditions and their medical and surgical treatment is important to help the therapist develop a treatment plan that will help the patient return to function quickly with minimal complications. The therapist must constantly assess the patient for improvement or complications and adjust the therapy plan accordingly. Knowledge of the stages of tissue healing and of the strength of tissues is critical to avoid placing too much stress on the surgical site, yet some challenge to tissues must be provided to optimize the return to function.
Carriers for bone morphogenetic proteins (BMPs) are used to increase retention of these factors at orthopedic treatment sites for a sufficient period of time to allow regenerative tissue forming cells to migrate to the area of injury and to proliferate and differentiate. Carriers can also serve as a matrix for cell infiltration while maintaining the volume in which repair tissue can form. Carriers have to be biocompatible and are often required to be bioresorbable. Carriers also have to be easily, and cost-effectively, manufactured for large-scale production, conveniently sterilized and have appropriate storage requirements and stability. All of these processes have to be approvable by regulatory agencies. The four major categories of BMP carrier materials include natural polymers, inorganic materials, synthetic polymers, composites of these materials. Autograft or allograft carriers have also used. Carrier configurations range from simple depot delivery systems to more complex systems mimicking the extracellular matrix structure and function. Bone regenerative carriers include depot delivery systems for fracture repair, three-dimensional polymer or ceramic composites for segmental repairs and spine fusion and metal or metal/ceramic composites for augmenting implant integration. Tendon/ligament regenerative carriers range from depot delivery systems to three-dimensional carriers that are either randomly oriented or linearly oriented to improve regenerative tissue alignment. Cartilage regenerative systems generally require three-dimensional matrices and often incorporate cells in addition to factors to augment the repair. Alternative BMP delivery systems include viral vectors, genetically altered cells, conjugated factors and small molecules.