Caring for Infants with Robin Sequence Treated with the Tübingen Palatal Plate: A Review of Personal Practice

The Tübingen Palatal Plate (TPP) is a minimally invasive yet highly effective functional orthodontic treatment for upper airway obstruction in infants with Robin Sequence (RS). It consists of a palatal plate to cover the cleft and a velar extension that shifts the root of the tongue forward. We review our practical experience with this approach. First, upon admission, our local orthodontists perform an (3-D) intraoral scan of the maxilla. Based on the scan data, the TPP is manufactured in a semi-digital workflow. The length and angulation of its extension is checked via awake laryngoscopy and the effectiveness confirmed by a sleep study. Plates are kept in place by adhesive cream. When inserting the TPP, the tip of the tongue must be visible. Next, metal fixation bows should be secured to the forehead using tape and elastic bands. Plates are removed daily for cleaning, and the oral mucosa is then checked for pressure marks. Feeding training (initially only via finger feeding) may even start before plate insertion. Breathing often normalizes immediately once the plate is inserted. For isolated RS, we have never had to perform a tracheostomy. This has largely been possible through our highly dedicated and competent team, particularly the nursing staff, and the early involvement of parents.

Effects of Elastodontic Appliance on the Pharyngeal Airway Space in Class II Malocclusion

BACKGROUND

The present study analyzed the changes obtained on the upper airway and hyoid bone dimensions in a group of patients with skeletal Class II malocclusion treated with functional elastodontic devices compared to an untreated control group.

METHODS

A group of 33 patients (19 females and 14 males) with Class II malocclusion treated with AMCOP^® SC elastodontic device was compared with a control group of 35 subjects (17 females and 18 males) with untreated Class II malocclusion. Lateral cephalograms were available at the start (T0) and end of treatment/period of observation (T1). Cephalometric analysis was performed and linear measurements to evaluate airway space and hyoid bone position were also obtained. A multivariate analysis of variance for repeated measures (MANOVA) was performed to determine the effects of interactions for the groups for time.

RESULTS

Statistically significant differences were found in the study group from T0 and T1 with an improvement of superior upper airway (SPAS p < 0.0001), while in the control group it did not change in a statistically significant way from T0 to T1. The MANOVA test showed statistically significant differences between the two groups for the changes of SPAS (p = 0.003), IAS (p = 0.049), and H-C3 vertical (p = 0.038) values.

CONCLUSIONS

Functional elastodontic therapy produced significant favorable airway changes in skeletal class II subjects.

Evaluation of Local Application of Glucosamine Sulfate and Chondroitin Sulfate on Temporomandibular Joint Response and Alleviation of Pain and Tension During the Functional Treatment of Skeletal Class II Patients: A Randomized Control Clinical Trial

OBJECTIVE

 This study was conducted to assess the effects of applying a gel of combined glucosamine sulfate and chondroitin sulfate on the temporomandibular joint (TMJ) area in patients with skeletal Class II malocclusion treated by removable functional appliances in terms of TMJ internal proportions, levels of pain, and tension.

MATERIALS AND METHODS

The study included 36 patients aged 10-13 years with skeletal Class II malocclusion due to retrusion of the mandible characterized by: 4-8 degrees of the sagittal skeletal discrepancy (ANB) angle, 4-7 mm of overjet, 72-76 degrees of the sagittal mandibular positioning (SNB) angle, and a bone maturity stage located at pubertal growth spurt. Patients were distributed to the experimental group (Twin-Block appliance + Jointance® gel) or the control group (conventional treatment with the Twin-Block appliance). An allocation ratio of 1:1 was employed. Pre- and post-treatment digital lateral cephalometric radiograms were taken, and the TMJ joint spaces were measured using the Viewbox software (dHAL Software, Kifissia, Greece). The pain and discomfort levels were evaluated using a questionnaire with a four-point Likert scale at three assessment times.

RESULTS

 The anterior and posterior glenoid and anterior condylar distances to the pterygoid vertical (PTV) reference plane significantly decreased after treatment (p<.001), and the anterior joint space decreased significantly (p<.001). In contrast, the superior distance of the condyle to the Frankfort horizontal reference plane increased significantly after treatment, and the same results were found for the posterior and superior joint spaces (p<.05). There were no significant differences between the two groups in the evaluated linear variables. No significant differences were found when comparing pain and tension levels between the two groups at each assessment time. A gradual decrease in pain and tension levels was observed between the three evaluation times in both groups.

CONCLUSIONS

 A combination of glucosamine sulfate and chondroitin sulfate did not affect the temporomandibular joint spaces, pain, and tension levels in patients with skeletal Class II malocclusions treated by removable functional appliances.

[Optimization of rehabilitation of elderly and senile patients with primary traumatic dislocation of the shoulder.]

Тhe aim of the study is to improve the treatment outcomes of elderly patients with primary traumatic shoulder dislocation by developing an atraumatic rehabilitation method. The study included 56 patients aged over 60 years with primary traumatic dislocation of the shoulder. The patients of the first group (29 patients) after the dislocation of the shoulder was corrected, functional treatment was performed using orthoses and a developed course of physical therapy. Patients of the second group (27 patients) were treated according to the traditional method with the use of plaster immobilization after the dislocation of the shoulder was corrected. Shoulder joint radiography, MRI, determination of potentials in biologically active points (BAT) during the first 2-3 days after dislocation were used to diagnose shoulder dislocation and assess outcomes. To assess the immediate results, the electrical potential in BAHT was studied after 1,3 and 6 months. In 70,3% of group 1 patients, positive outcomes were obtained after 3-6 months on the ASES scale, while in the second group such results were achieved only in 57,3% of patients, and on the UCLA scale 22,8 and 19,2%, respectively. Thus, the use of the proposed tactics of functional treatment makes it possible to significantly (p<0,05) improve outcomes in patients of the older age group.

Conservative vs. operative treatment for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies

BACKGROUND

This meta-analysis aimed to compare conservative vs. operative treatment for humeral shaft fractures in terms of the nonunion rate, reintervention rate, permanent radial nerve palsy rate, and functional outcomes. Secondarily, effect estimates from observational studies were compared with estimates of randomized clinical trials (RCTs).

METHODS

The PubMed/Medline, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched for both RCTs and observational studies comparing conservative with operative treatment for humeral shaft fractures.

RESULTS

A total of 2 RCTs (150 patients) and 10 observational studies (1262 patients) were included. The pooled nonunion rate of all studies was higher in patients treated conservatively (15.3%) vs. operatively (6.4%) (risk difference, 8%; odds ratio [OR], 2.9; 95% confidence interval [CI], 1.8-4.5; I² = 0%). The reintervention rate was also higher for conservative treatment (14.3%) than for operative treatment (8.9%) (risk difference, 6%; OR, 1.9; 95% CI, 1.1-3.5; I² = 30%). The higher reintervention rate was predominantly attributable to the higher nonunion rate in patients treated conservatively. The permanent radial nerve palsy rate was equal in both groups (OR, 0.6; 95% CI, 0.2-1.9; I² = 18%). There appeared to be no difference in mean time to union and mean Disabilities of the Arm, Shoulder and Hand scores between the treatment groups. No difference was found between effect estimates form observational studies and RCTs.

CONCLUSION

This systematic review shows that satisfactory results can be achieved with both conservative and operative management; however, operative treatment reduces the risk of nonunion compared with conservative treatment, with comparable reintervention rates (for indications other than nonunion). Furthermore, operative treatment results in a similar permanent radial nerve palsy rate, despite its inherent additional surgery-related risks. No difference in mean time-to-union and short-term functional results was detected.

Results of Functional Treatment of Epi-Metaphyseal Fractures of the Base of the Fifth Metatarsal

BACKGROUND

Fractures of the fifth metatarsal base (5th MT) are common foot injuries, but their treatment remains a subject of debate. The aim was to assess the midterm outcome of functionally treated epi-metaphyseal fractures (Lawrence and Botte types I and II) of the 5th MT.

METHODS

This study was a longitudinal retrospective database study with prospective follow-up. Included were all patients with an acute, isolated fracture to the 5th MT base (types I and II). All patients were treated functionally: weightbearing as tolerated without immobilization. Fracture types and fracture characteristics (displacement <2 mm/>2 mm, articular involvement, number of fragments) were assessed retrospectively. Patient-reported outcome measures (PROMs) including the visual analog scale for foot and ankle (VAS FA) and the quality-of-life score (QoL) SF-12 were collected prospectively at 2- and 5-year follow-up. Out of 95 patients, 43 patients (45%) were included with a median follow-up of 5.7 (1.5) years.

RESULTS

For both the VAS FA and SF-12, excellent scores were observed. For 30 patients (77%), longitudinal 2- and 5-year follow-up was available. No significant longitudinal changes could be observed for the VAS FA and SF-12. For both time points, neither fracture type nor characteristics significantly influenced any outcome parameter assessed.

CONCLUSION

Functional treatment by full weightbearing and free range of motion led to excellent 5-year results for both type I and II fractures. Neither fracture location nor characteristics had a significant influence on the 5-year PROMs.

LEVEL OF EVIDENCE

Level III, comparative study.

Evaluation of Profile Changes in Class II Individuals Treated by Means of Herbst Miniscope Appliance

Background: To evaluate the profile changes following orthopedic/orthodontic treatment with the Herbst Miniscope^® appliance in subjects affected with Class II malocclusion with mandibular retrusion. Methods: A total of 44 patients presenting a skeletal Angle Class II malocclusion (ANB > 4°) due to mandibular retrusion and a cervical maturation stage between CS2 and CS3 were included in the study. Of these 44 patients, 22 (mean age 11.9 ± 1.3, HBT group) were treated using the Herbst appliance, while 22 (mean age 10.6 ± 1.3, CTR group) were followed for a 12-month observational period. A cephalometric tracing was performed at the beginning of treatment (T0) and after 12 months (T1). Results: In both groups there was a significant advancement of soft tissue pogonion (HBT = 3.5 ± 3.0 mm, p < 0.001; CTR = 2.2 ± 2.9 mm, p < 0.001), but the difference between the two groups was not significant (p = 0.172). On the contrary, both groups had a significant advancement of the mandibular sulcus (HBT = 3.7 ± 2.8 mm, p < 0.001; CTR = 1.2 ± 2.2 mm, p < 0.001) and a lower lip protrusion (HBT = 3.45 ± 2.51 mm, p < 0.001; CTR = 1.7 ± 2.7 mm, p = 0.008), but in both cases the HBT group showed a statistically significant greater increase in sulcus protrusion (p = 0.002) and lower lip protrusion (p = 0.029) than controls. There were no statistically significant effects on the upper jaw. Conclusions: The Herbst appliance advanced the lower jaw soft tissues.

Effect of a 1-week intense myofunctional training on obstructive sleep apnoea in children with Down syndrome

BACKGROUND

Obstructive sleep apnoea (OSA) is common in children with Down syndrome (DS), yet difficult to treat. As muscular hypotonia of the upper airway may cause OSA and is also common in DS, we tested whether intense myofunctional therapy improves OSA in children with DS.

PATIENTS AND METHODS

Forty-two children underwent cardiorespiratory sleep studies immediately before and after a 1-week intensive training camp consisting of three daily 45 min sessions of myofunctional exercises according to Padovan. Primary outcome was the mixed-obstructive-apnoea/hypopnoea index (MOAHI), secondary outcomes the ≤3% oxygen desaturation index (DI₃), the ≤90% desaturation index (DI₉₀) and the lowest pulse oximeter saturation (SpO_2nadir).

RESULTS

Eighteen recordings had ≥3 hours of artefact-free recording in both the pretreatment and post-treatment sleep study and were therefore included in the analysis. Mean age was 6.3 years (SD 2.5); 83% had OSA prior to intervention. Mean MOAHI was 6.4 (SD 8.6) before and 6.4 (SD 10.8) after the intervention (p>0.05); the DI₃ and SpO_2nadir also did not change. Only the DI₉₀ decreased significantly from 2.7 (SD 4.5) to 2.1 (SD 3.7) (p<0.05).

CONCLUSION

The 1-week intense myofunctional training camp evaluated here in children with DS had only a marginal effect on OSA. Whether a longer follow-up period or duration of intervention would yield stronger effects remains to be determined.

A Comparative Study of Conservative Functional Treatment versus Acute Ligamentous Repair in Simple Dislocation of the Elbow in Adults

BACKGROUND

Elbow dislocation is the second most frequent type of large joint dislocations in adults. Standard treatment of simple elbow dislocation (SED) without manifestation of instability includes closed reduction, short-term immobilization of the elbow followed by functional aftercare. This study evaluates SED treatment, comparing outcomes of conservative functional treatment and surgical therapy.

MATERIALS AND METHODS

54 adult patients with SED without manifest instability treated in tertiary hospital between January 2008 and June 2015 were analyzed in this retrospective study. 28 patients were treated conservatively. Closed elbow reduction was followed by short-term plaster splint and active rehabilitation. Twenty six patients underwent closed elbow reduction and subsequent reconstruction of torn collateral ligaments. Postoperatively, plaster splint was applied followed by rehabilitation.

RESULTS

Patients who were treated conservatively reached statistically significant better scores in Quick Disability Arm Shoulder Hand, Oxford Elbow Score, and Mayo Elbow Performance Score. Functional conservative treatment resulted in a higher range of motion. The complication rate was higher in the group of surgically treated patients.

CONCLUSIONS

Careful examination of elbow stability after closed reduction of SED is crucial for further therapy. Patients with stable SED should be treated with functional conservative therapy. Surgical collateral ligaments revision and reconstruction are indicated only for patients with manifestation of elbow instability.

Functional treatment in rotator cuff tears: is it safe and effective? A retrospective comparison with surgical treatment

BACKGROUND

The aim of this study was to compare rehabilitation protocol and operative treatment in a population of patients with a diagnosis of small to medium rotator cuff tears (≤3 cm), the null hypothesis being that there would been no difference in terms of clinical outcomes and patient's satisfaction between the rehabilitation protocol and the surgical treatment.

METHODS

Patients with small to medium supraspinatus tears were retrospectively enrolled in this study and divided in 2 groups: arthroscopic repair (group A, 20 patients) and reinstated (group B, 18 patients). At a mean follow-up of 18 months, both groups underwent clinical (Constant, QuickDash, VAS), dynamometric and ultrasonographic evaluation.

RESULTS

In both groups a significant clinical improvement was registered compared to baseline. However, surgical treatment yielded better results in Constant (p=0.004), Quick-Dash (p=0.0012), VAS (p=0.048) and strength evaluation (p=0.0014). In group A the re-tear rate was 10%, while in group B only 11% of increased tear size was registered.

CONCLUSION

At a short term follow-up, the surgical treatment of small to medium supraspinatus tears yielded better clinical outcomes compared to the rehabilitation protocol, with better strength outcomes and 10% re-tear rate. Nevertheless, physiotherapy still offers acceptable results and could be a valuable option in patients not undergoing surgery.

LEVEL OF EVIDENCE

III.

A comparative, prospective, and randomized study of two conservative treatment protocols for first-episode lateral ankle ligament injuries

BACKGROUND

The objective of this study was to investigate functional results, the amount of time that patients missed from regular working activities, and the incidence of residual mechanical ankle instability following conservative treatment of a first episode of severe lateral ankle ligament sprain (with articular instability).

METHODS

This prospective and randomized study included 186 patients with severe lateral ankle ligament injuries, who were randomly assigned into 2 conservative treatment groups. In group A, participants were treated with a walking boot with weight-bearing allowed, pain management, ice, and elevation with restricted joint mobilization for 3 weeks. In group B, patients were treated with a functional brace for 3 weeks. After this period, patients from both groups were placed in a short, functional brace for an additional 3 weeks, during which they also started a rehabilitation program.

RESULTS

No statistically significant difference was found in pain intensity score between the 2 groups; however, functional evaluations based on the AOFAS ankle and hindfoot score system showed a statistically significant improvement in the group treated with the functional brace. In addition, the average recovery period necessary for patients of group B to resume their duties was shorter than that for patients in group A. No significant difference was detected in residual mechanical ankle instability between the 2 groups.

CONCLUSION

Patients with severe lateral ankle ligament lesions treated with a functional brace were shown to exhibit somewhat better results than those treated with a walking boot, and both methods presented a very low incidence of residual chronic instability. We found adequate conservative treatment was sufficient to reestablish ankle stability and that functional treatment had a marginally better clinical short-term outcome with a shorter average recovery period.

LEVEL OF EVIDENCE

Level I, prospective randomized study.