Orthopedic Correction Research Articles

Quality of life related to type 1 Gaucher disease: Spanish experience

The impact of type 1 Gaucher disease and its therapy on health-related quality of life (QOL) was investigated and the results were compared with a Spanish adult normative group. Between January 1998 and December 2002, a prospective clinical QOL trial was conducted by application of a Spanish version of the Health Survey SF-36 questionnaire. Patients receiving ERT (69 cases) filled in the questionnaire two times, prior to starting ERT and after two years under ERT. The patients were stratified by gender and age group. Clinical and X-ray data to assess bone disease were obtained from the Spanish Gaucher Register. Demographic, clinical, genotype and analytical data and the response to therapy were evaluated. Four grades of severity were established according to bone disease (no symptoms = 0, moderate bone pain = 1, severe bone crisis = 2, fracture/necrosis = 3). Correlation analysis was made between QOL score and grade of bone disease. Mean age+/-SD 33.6+/-11.7 (range 18-66), M/F,ratio 33/36; bone disease: 0 in 27 patients (47.3%), 1 in 11 (19.3%), 2 in 5 (8.8%) and 3 in 14 (24.5%). Physical activity: 11 patients (19.3%) showed severe restriction and 41 patients (71.9%) were only limited for strenuous activities. The mean score for QOL questionnaire was 11.9+/-10.4 (range 2-46). Correlation between score and bone disease was significant only for 1 and 3 grades (p = 0.02). Improvement in self perception of global health was observed ranging from 34.3% before ERT to 91.4% after ERT (p = 0.001). Nevertheless physical activity remained unsatisfactory in 24.5% of patients due mainly to bone sequelae. Physical activities and bone disease grade 1 and 3 are negatively related to QOL. Nevertheless no correlation was found with bone pain crisis, possibly due to the transitory character of this event. In spite of the improvement induced by ERT, a quarter of patients remained with physical limitations related to bone disease as well as in need of orthopaedic correction of bone sequelae. In order to improve the QOL an accurate evaluation of bone disease to define therapeutic approaches must be considered.

Réhabilitation post-orthodontique des séquelles de fente alvéolaire : implantation ou chirurgie plastique parodontale ?

Just as they do for many cranio-facial deformities, the treatment team begins the care of cleft palate patients early and continues treatment over a long period. Throughout the growth period, they perform well-timed interventions and re-evaluations according to the individual plan they have prepared. When growth is completed and the orthopedic and orthodontic corrections have contributed as much as possible to an esthetic and functional equilibrium, a final prosthetic replacement will frequently be required. When the correct edentulous space between the teeth on each side of the defect has been created, or maintained, practitioners can choose between two alternatives: implants or traditional fixed bridges. They should analyze any secondary anatomic discrepancies, severe or superficial, that may have developed, and prepare the best therapeutic pathway for a reconstruction of crestal gingival morphology by means of periodontal surgery.

Long-term effects of Class III treatment with rapid maxillary expansion and facemask therapy followed by fixed appliances

In this cephalometric investigation, we compared the long-term effects of an initial phase of rapid maxillary expansion and facemask (RME/FM) therapy followed by comprehensive edgewise therapy with the effects of growth in untreated, matched controls. The treated sample consisted of 34 patients who underwent RME/FM treatment before the pubertal growth spurt (average age, 8 years 3 months at the beginning of treatment). At the final observation period (average age, 14 years 10 months), all patients were in decelerative growth phases as determined by the cervical vertebral maturation (CVM) method. After the first 10 months of active treatment, significant favorable changes in both the maxillary and the mandibular skeletal components were noted. The forward movement of the maxilla was 1.8 mm greater than in the controls, mandibular projection was reduced by almost 3 mm, and the relative sagittal intermaxillary discrepancy improved by 4.3 mm, as measured by the Wits appraisal. During the posttreatment period, the treated and untreated Class III subjects generally grew similarly, although the skeletal relationship of the maxilla to the mandible remained unchanged in the RME/FM group, whereas the controls had an increased skeletal discrepancy of 3.0 mm. Over the long term, there was a slightly greater increase in midfacial length (1.6 mm) in the treatment group than in the controls. Similarly, the distance from Point A to nasion perpendicular decreased by 1.2 mm in the treated group. The overall increase in mandibular length was 2.4 mm less in the RME/FM group than in the controls, and mandibular projection relative to nasion perpendicular was 3.0 mm less in the treated group. The change in the Wits appraisal was substantial between groups (6.1 mm), with an improvement in the intermaxillary relationship in the treated group (3.4 mm); the Wits appraisal worsened (−2.7 mm) in the untreated controls. No clinically significant differences were observed between the groups in the vertical dimension. Overjet increased significantly in the treated group relative to the controls (4.4 mm), whereas the molar relationship decreased significantly (−3.9 mm). It appears that the favorable skeletal change observed over the long term is due almost entirely to the orthopedic correction achieved during the RME/FM protocol. During the posttreatment period that includes the pubertal growth spurt, craniofacial growth in RME/FM patients is similar to that of untreated Class III controls. Aggressive over-correction of the Class III skeletal malocclusion, even toward a Class II occlusal relationship, appears to be advisable, with the establishment of positive overbite and overjet relationships essential to the long-term stability of the treatment outcome. (Am J Orthod Dentofacial Orthop 2003;123:306-20)

Thin-plate spline analysis of mandibular growth.

The analysis of mandibular growth changes around the pubertal spurt in humans has several important implications for the diagnosis and orthopedic correction of skeletal disharmonies. The purpose of this study was to evaluate mandibular shape and size growth changes around the pubertal spurt in a longitudinal sample of subjects with normal occlusion by means of an appropriate morphometric technique (thin-plate spline analysis). Ten mandibular landmarks were identified on lateral cephalograms of 29 subjects at 6 different developmental phases. The 6 phases corresponded to 6 different maturational stages in cervical vertebrae during accelerative and decelerative phases of the pubertal growth curve of the mandible. Differences in shape between average mandibular configurations at the 6 developmental stages were visualized by means of thin-plate spline analysis and subjected to permutation test. Centroid size was used as the measure of the geometric size of each mandibular specimen. Differences in size at the 6 developmental phases were tested statistically. The results of graphical analysis indicated a statistically significant change in mandibular shape only for the growth interval from stage 3 to stage 4 in cervical vertebral maturation. Significant increases in centroid size were found at all developmental phases, with evidence of a prepubertal minimum and of a pubertal maximum. The existence of a pubertal peak in human mandibular growth, therefore, is confirmed by thin-plate spline analysis. Significant morphological changes in the mandible during the growth interval from stage 3 to stage 4 in cervical vertebral maturation may be described as an upward-forward direction of condylar growth determining an overall "shrinkage" of the mandibular configuration along the measurement of total mandibular length. This biological mechanism is particularly efficient in compensating for major increments in mandibular size at the adolescent spurt.

Realities of Craniofacial Growth Modification

Facial growth modification can be an effective method of resolving skeletal discrepancies. There still is much controversy regarding our understanding of the nature and extent of skeletal orthopedic change possible in individual patients and the most effective appliances and timing of such treatment. In the treatment of class II patients, growth modification can lead to an improvement, if not complete correction of the class II malocclusion. Although two-phase treatment with an early first prepubertal phase can be effective, a later single-phase approach during early puberty seems to be equally effective. Certainly, before surgical correction of the mild to moderate skeletal class II problem in a growing patient is considered, an orthopedic phase of treatment prior to the pubertal growth spurt is an appropriate first step. Skeletal class III patients with a maxillary deficiency stand to gain significant benefits from early orthopedic treatment. However, such therapy may produce more favorable changes for older children and adolescents than previously thought. Nevertheless, orthopedic correction of the mild to moderate skeletal class III should be accompanied by regular progress evaluations to avoid creating significant dental compensations in the face with little skeletal change that ultimately requires surgery anyway. Skeletal class III patients with mandibular excess and/or vertical excess are poor candidates for growth modification. Orthopedic palatal expansion appears to be effective and stable at any time prior to late puberty, a stage of development when ossification of the maxillary sutures is more advanced. Consequently, the timing for expansion may be better determined by the specific needs of each patient. A functional shift resulting from a crossbite is optimally corrected early, so that asymmetric growth of the mandible can be reduced or even prevented. Postpubertal orthopedic expansion is likely to result in bone bending, which will reverse itself over time, potentially leaving periodontal compromise of the maxillary posterior teeth. Therefore, surgically assisted expansion should be considered in such cases. Vertical maxillary excess is challenging to treat with growth modification. The combination of interocclusal acrylic bite blocks combined with a high-pull headgear presently appears to be the best means available. Unfortunately, this treatment has limited success, it must be continued over many years owing to the long-term nature of vertical growth, and it is counterproductive in achieving a balanced sagittal jaw relationship in class I or class III patients with vertical excess. Future research will permit us to have a greater understanding of the nature and extent of facial growth modification possible in individual patients and the optimal appliances and timing of treatment to achieve the best outcome. The development of intraoral osseointegrated attachments such as implants and onplants hold promise for a future means of dissipating orthopedic forces to prevent unwanted dentoalveolar changes that presently occur with our tooth-borne appliances. Analogous attachments presently are undergoing clinical testing for surgically assisted orthopedic movements associated with distraction osteogenesis.

Orthodontics as a science: The role of biomechanics

The scientific basis of orthodontics rests on a knowledge of anatomy, physiology and growth, and in particular, biomechanics—the relationship between force systems and dental or orthopedic correction. Yet much of clinical orthodontics is delivered without consideration of forces or force systems. This suggests that many clinicians believe that a fundamental knowledge and application of biomechanics has little relevance on a daily basis in their treatment. Let us consider why biomechanics should be at the core of clinical practice.

Treatment of vertebrogenic-dependent tachycardias and extrasystoles in children

Treatment results of 39 children with sinus tachycardia and extrasystolia are presented. All children simultaneously had various types of locomotor system pathology, mainly in the cervical and thoracic spine. In the majority of patients the orthopaedic correction by the authors technique allowed to restore the cardiac rhythm without the use of antiarhythmic drugs.

Magnetic resonance imaging of the shoulder in children with brachial plexus birth palsy

Five patients suffering from Erb-Duchenne brachial plexus birth palsy were prospectively studied with MRI. A group of 11 healthy children was used as a control to understand the MRI anatomy of the normal growing glenohumeral joint. A hypoplastic and flattened posterior part of the glenoid fossa and a blunt posterior labrum were found in all patients. Four patients had a blunt anterior labrum and a flattened humeral head. Three patients presented with a posterior subluxation of the humeral head. These results suggest that MRI provides a non-ionising and non-invasive method of demonstrating the early abnormalities of the shoulder associated with obstetrical brachial plexus paralysis, which may prompt orthopaedic correction.

Dental and facial asymmetries: a review.

Asymmetry in the face and dentition is a naturally occurring phenomenon. In most cases facial asymmetry can only be detected by comparing homologous parts of the face. The etiology of asymmetry includes: a) Genetic or congenital malformations e.g. hemifacial microsomia and unilateral clefts of the lip and palate; b) Environmental factors, e.g. habits and trauma; c) Functional deviations, e.g. mandibular shifts as a result of tooth interferences. Dental asymmetries and a variety of functional deviations can be treated orthodontically. On the other hand, significant structural facial asymmetries are not easily amenable to orthodontic treatment. These problems may require orthopedic correction during the growth period and/or surgical management at a later point. Patient complaints and desires need to be addressed since they may vary from unrealistic expectations to a lack of concern even in the presence of large deviations. With mild dental, skeletal and soft tissue deviations the advisability of treatment should be carefully considered.

Dentofacial Orthopaedic Correction of Maxillary Retrusion with the Protraction Facemask - a literature review

Abstract The retruded maxilla in the Class III skeletal pattern could be effectively corrected with the protraction facemask in selected cases. A review of the different types of orthopaedic appliances used in Class III treatment, the rationale for facemask therapy, the effect of this treatment and the factors affecting stability is presented.

Analysis of activator treatment changes

Abstract The effects of functional appliance treatment have been reported in numerous studies in the literature with great variability in the findings. It is generally agreed that they can be used successfully to treat Class II malocclusions in growing and cooperative patients. However, there is a lack' of consensus regarding the relative orthodontic and orthopedic correction obtained by functional appliances in Class II correction. Lateral cephalometric radiographs from a sample (n=36) of patients who had undergone a phase of treatment with activator appliances were measured and analysed for changes using a modified version of the method described by Johnston (Hashim and Godfrey 1990). In this method, the treatment changes were broken down into: tooth movement relative to basal bone; and the translatory growth of the jaws, both with respect to the cranial base and to each other. The results show that the treatment effects were mainly dentoalveolar. There was a slight orthopedic effect on the maxilla, but no significant mandibular growth was observed, above that which can be expected from normal growth.

Changes in mandibular length before, during, and after successful orthopedic correction of Class II malocclusions, using a functional appliance

Forty-seven girls were successfully treated with a functional appliance (FA). To be included in this study, the rate of increase in mandibular length during treatment had to be greater than twice the mean rate for a subgroup of 20 of these patients evaluated during a pre-FA observation period. The mean mandibular growth rate was 6 mm per year while the FA was activated. In the ensuing months, cephalograms were taken at intervals coinciding with five post-FA phases, including complete edgewise treatment and retention. During the post-FA phase of initial edgewise treatment, the mandibular growth rate was dramatically reduced when compared with 47 controls matched for age, sex, and initial SN:GoGn angle. Selected individual cases are presented to illustrate the great variability in growth responses that were obtained. This study found highly significant increases in mandibular length still present 2 years after treatment, diminished but still significant gains after 3 years, and no significant difference after 4 years.

Selective neurotomy of the tibial nerve for treatment of the spastic foot.

One of the most frequent neurological sequelae seen by the specialist in rehabilitation is the spastic foot. Spasticity in the foot may be responsible for abnormal posture and painful or trophic disturbances impairing standing and walking. This disability can be corrected by a simple neurosurgical procedure, the selective tibial neurotomy. In this procedure, one sections the tibial nerve branches to the muscles sustaining spasticity, i.e., the soleus and/or the gastrocnemius nerves for equinus and ankle clonus or the posterior tibialis branch for varus and the flexor fascicles for tonic flexion of the toes. After microsurgical dissection of each tibial nerve branch at the lower part of the popliteal region and their identification with bipolar electrostimulation, the selected branches are partially sectioned under the operating microscope. The present series consists of 62 operations performed in 53 patients, 9 bilaterally and 44 unilaterally. Operation obtained complete suppression of the disabling spasticity that had been present for 2 to 17 years (4 on average), total pain relief, and consequently improvement of the residual voluntary movements (by achieving a better balance between agonist and antagonist muscles) in 51 of the 62 spastic feet (i.e., 82% of the cases). For all of these patients, the beneficial effects were long-lasting over the 1- to 10-year follow-up (3 years on average). Selective neurotomy of the tibial nerve should be considered only after failure of intensive prolonged kinestherapy and of all available medical treatment. It must take place, however, before the onset of irreversible articular disturbances and musculotendinous retractions, which require complementary orthopedic corrections.

Fra¨nkel appliance therapy: Orthopedic or orthodontic?

The purpose of this article is to evaluate (1) the difference in mandibular growth response of Class II corrected malocclusions compared to Class I corrected malocclusions treated with Fra¨nkel therapy; (2) the influence of a functional orthopedic appliance (Fra¨nkel) on the growing facial complex compared to an untreated sample; (3) difference in Fra¨nkel therapy and edgewise therapy with extraoral traction; (4) individual variations in growth and response to orthodontic therapy; (5) currently proposed diagnostic criteria in the treatment of Class II malocclusions; (6) the capability of Fra¨nkel therapy to elicit differential growth response according to the skeletal deficiencies of the beginning malocclusion. Nine Class I and eleven Class II patients were treated with the Fra¨nkel appliance. Orthopedic and orthodontic changes were evaluated cephalometrically. Orthopedic and orthodontic changes of the Fra¨nkel samples were then compared to an untreated control sample (30 females and 32 males; mean age, 10 years 2 months; mean time lapse, 2 years 5 months; 50 Class I, 12 Class II) and an edgewise-treated sample (32 females and 18 males; mean age, 12 years 1 month; mean time lapse, 2 years 5 months; 25 Class I, 25 Class II). No subjects in any of the groups had teeth removed. Cephalometric measurements were made on a “diagnostic control patient” (dcp) in which the mandible was postured forward approximately 5 mm. to determine whether this total mandibular orthopedic correction of the Class II malocclusion was achieved with Fra¨nkel therapy. Frequency tables depicting individual variations in growth and response to orthodontic therapy were compared to each other and to their averaged values. Individual growth responses were not predictable. On the average, there was a statistically significant difference in response of the Class I and Class II malocclusions in the Fra¨nkel groups to the therapy. The Class II occlusion was corrected to a Class I occlusion, resulting in comparable Class I occlusions after Fra¨nkel therapy. There were no significant differences in orthopedic changes between the Class II group treated with 3 to 4 mm. hyperpropulsion of the mandible compared to the Class I group treated with minimal hyperpropulsion of the mandible. The significant differences were orthodontic. Compared to the untreated control sample, the combined Fra¨nkel groups had a significant (1) increase in mandibular length of 1.1 mm. as a result of an increased backward direction of condylar growth; (2) increase in lower face height; (3) decrease in forward growth of the maxilla; (4) retraction and elongation of maxillary incisors; (5) retraction of maxillary molars; (6) protraction of mandibular incisors; and (7) increased vertical height of mandibular molars. Significant differences of edgewise therapy compared to Fra¨nkel therapy were (1) edgewise therapy had a greater retractive influence on the maxilla; (2) edgewise therapy also produced a similar backward direction of condylar growth but 1.2 mm. less than the Class II Fra¨nkel group; (3) maxillary incisors were retracted more with no elongation; (4) mandibular incisors were retracted rather than protracted; (5) pogonion came forward 1 mm. less than in the Fra¨nkel group. The Class II Fra¨nkel sample did not approach the diagnostic control goal, and averages do not begin to describe the majority of individual changes. Pretreatment measurements of point A and pogonion to the nasion perpendicular plane were not effective diagnostic criteria for differentiating between the Class I and Class II malocclusions in this sample. Pretreatment anteroposterior position of the maxilla or mandible did not appear to have a bearing on the response to Fra¨nkel therapy. In this sample, the additional hyperpropulsion of the mandible in the Class II cases did not elicit more of a mandibular growth response than the Class I sample. However, on the average, both Fra¨nkel samples had approximately 1 mm. more mandibular growth than the untreated sample. This increase in mandibular growth resulted in a longer face, not a more prognathic mandible.

Morphologic changes in the sagittal dimension using the Fränkel appliance

Interceptive orthodontic treatment of four patients with the Fränkel appliance is presented. The Fränkel appliance is but one of many appliances available using the principle of functional jaw orthopedics. However, the Fränkel appliance seems to offer a broad range of potential corrections and appears worthy of consideration for early treatment by any orthodontist. The cases presented show various combinations of condylar growth, maxillary retraction, and dentoalveolar changes in the correction of Class II, Division 1 malocclusions with varying degrees of mandibular retrognathia. In all patients facial improvement was noted. Lateral expansion was also noted and offers another possibility in orthodontic treatment. It appears that the Fränkel appliance may be capable of taking advantage of three types of orthopedic correction: condylar growth, maxillary retraction, and lateral expansion. The possibilities of these changes occurring on a routine clinical level are discussed, and further studies of the Fränkel appliance are encouraged. It seems that, regardless of the orthodontist's choice of bands or bonds, the Fränkel appliance could be incorporated into any practice and offer potential orthopedic and/or orthodontic benefits for interceptive orthodontic treatment.

The maxillary orthopedic splint

Craniomaxillary orthopedic correction of the skeletal imbalance of Class II malocclusions is often the desired method of treatment in these cases. The ability to apply a “pure” orthopedic force to the maxillary complex has so far eluded research efforts. However, the use of a maxillary splint with a high-pull extraoral traction assembly has been shown to be most effective in reducing Class II skeletal dysplasias through a combination of dentoalveolar and basal bone changes. Force delivery to the maxillary complex in Class II skeletal jaw disharmonies is through the teeth. The philosophy behind the use of the maxillary splint is that if the force delivered to the upper jaw involved the use of all the upper teeth (and hard palate) rather than only the maxillary first molars, as in conventional extraoral orthodontic therapy, the effect on the jaws would be more orthopedic than orthodontic in nature. The advantages of the use of the maxillary splint in the younger patient with a severe Class II malocclusion are that it reduces the vulnerability of the maxillary incisors to accidental fracture, while concomitantly reducing the Class II dysplasia, thereby effectively shortening the later-stage multiband corrective time and procedures. Further advantages of the maxillary splint described are ease of construction and clinical application, which makes it an attractive appliance for use in dental clinics or institutions in which patient volume, infrequent visits, and ecomomic factors are major considerations. This preliminary report on the philosophy of treatment procedure and description of the appliance design is to be followed by a further cephalometric and clinical evaluation of results achieved with its use.

Bioprogressive therapy as an answer to orthodontic needs Part II

From the foregoing discussions, it may be recognized that a new, lighter, and sequential order of force applications is recommended. Accordingly, in order for the clinician to apply the new technique with the intelligence, he must realize that many biologic factors form the fundamental criteria of its application. We have attempted to examine these factors and place them in their appropriate hierarchy of significance.While edgewise was the background, sufficient departure from traditional edgewise therapy has been made to warrant a new label, “bioprogressive therapy.” It was so named because of the practice of progressive banding and a planned progression of events in sequential order. Eight steps usually form the frame of reference. Ironically, it can be applied in the very young and in the very old.It is difficult to appreciate these views and practices in the beginning because the method may be difficult to envision on the typodont or as simply a laboratory mechanical exercise due to the fact that cortical bone, growth, and muscle are not present in an artificial medium. In order to fully apply the recommendations of the proponents of this method, mechanical forecasting, physiologic forecasting, and growth forecasting principles are all employed. Even as a simple mechanical regime, however, it rates with or better than any other current multibanded method as a practical and efficient clinical procedure.Size 0.016 by 0.016 inch blue Elgiloy wire is commonly but not exclusively used. Loops or forms are bent in the wire for lighter and more continuous pressures on teeth to be moved. Soldering of auxiliaries has been eliminated, as well as the heat treating of wires. The 0.016 by 0.016 inch to 0.016 by 0.022 inch yellow Elgiloy is used for detailing near the end of treatment. The 0.018 by 0.022 inch is the largest wire employed, and it is used for spanning distances between teeth in the progressive debanding phases.Anchor teeth are stabilized against cortical bone; hence, cortical anchorage. In order to position and control the teeth behind or away from cortical bone or against or away from muscle or to intrude into or extrude away from the bony alveolus, three-plane control is utilized. A limited use of round wire is employed with this technique except for specific isolated conditions in which there is a place for tipping or simple alignment and rotation of teeth. We try to avoid leveling with round wires, for reasons that have been explained. Used as a triple-control technique, the bioprogressive method excels in proper overtreatment and for delivery of anchorage.A continuous arch is broken up into segments or sections so that movements in desired planes of space are not complicated and anchorage can be shifted in favor of the desired move.The technique usually involves orthopedic correction, particularly in the maxilla, when such corrections are needed. When this technique is combined with the activator or mandibular posturing devices, an application can be made to provide an anchorage approach to include growth and maxillary and mandibular orthopedics.57Muscle anchorage definitely is considered in anchorage planning and utilized in its fullest application, even to posttreatment rebound.The leveling of the arch by the extrusion of the premolars is considered to be contraindicated. Thus, intrusion of anterior teeth, either upper or lower, is a practiced art with a bioprogressive technique.With this approach, a tremendously wide range of flexibility is possible, and overtreatment is the byword. This flexibility permits the clinician to overcome tooth-size discrepancies, as overtreatment of a part of the arch can easily be attained.The light square wire allows the clinician a wide range of intraoral adjustments. This procedure reduces the clinician's chair time, is much less painful and trying to the patient, and at the same time provides even greater control in the strictest sense of the word. This is an art to be learned by the individual clinician.Another virtue of the “progressive” approach to treatment is particularly thought provoking: absolute standardization is not appealing and is not the aim. Rather, a body of principles has been developed. In depth diagnosis, prognosis, and designing are advocated for the patient, depending upon his particular individual needs. The orthodontist is still in command because anchorage preparation, differences in extraction and nonextraction, and various arch-form differences make absolute straight wire misleading.Visual objective “designing” with cephalometrics as a reference for planning is strongly recommended, although “intuitive planning” is practiced with this method as well as others. In applying specific progressive therapy to its greatest potential, however, the biologic and mechanical principles are put together cephalometrically for each individual patient only after his unique personal requirements are determined. In this manner, the philosophy and science of orthodontics can be practiced with the spirit of the artist.

SPINAL LESIONS IN TETANUS IN CHILDREN

Of 17 tetanus patients exhaustively studied from the clinical and roentgenographic point of view, 15 presented spinal lesions. The lesions were observed at the level of the fourth, fifth, and sixth thoracic vertebrae, though the grossest damage was suffered by the fifth thoracic vertebra. In six patients one vertebra was affected; in three, two vertebrae; in three, three vertebrae; and in two, four vertebrae. The severity of the lesions varied from slight damage undiagnosed by the clinician and revealed only by roentgenography, to serious alterations requiring orthopedic correction. Due to the frequency of spinal lesions, every tetanus patient should have a thorough roentgenographic examination before discharge in order to eliminate any possibility of spinal sequellae. Obligatory immunization of the total child population is the only effective prophylactic measure for the control of spinal lesions in tetanus.