Orthodontic considerations for the patient wearing a Milwaukee Brace.

The Milwaukee Brace was developed by Dr Walter Blount of Milwaukee, Wisconsin in the mid 1940's as a removable postoperative immobilization device for the treatment of neuromuscular scoliosis patients. This was quickly adopted as a nonoperative treatment device for idiopathic scoliosis. The first report of its use for this purpose came in 1958 (JBJS 40A:511-525, 1958). The principle of the brace (cervicothoracic-lumbosacral orthosis, CTLSO) was to apply longitudinal correction between the pelvic girdle ( originally made of leather and later thermoplastics) and the neck ring and lateral corrective forces applied to the curve apex via pads attached to a metal superstructure that connected the pelvic girdle to the neck ring. The brace was constructed to flatten the lumbar lordosis and in theory increase the effectiveness of the appropriately place pads. Correction was thought to occur by passive pad pressure on the apex (in the thoracic spine via pressure on the apical ribs) of the curves and actively by the muscles pulling away from the pads. The orthotic was used 23 hours a day and often combined with an exercise program. The main problem with the brace was adherence to treatment. Gradually the Milwaukee brace gave way to underarm braces (TLSO's) which were thought to have better patient acceptance. The question of brace efficacy is currently being addressed by the University of Iowa Department of Orthopaedic Surgery led NIH Trial (Braist http://clinicaltrials.gov/ct2/show/NCT00448448Pterm=braist&rank=1). The initial design of the Milwaukee brace used a mandibular occipital ring. In the 1960's and early 1970's Dr Ignacio Ponseti (Professor Emeritus of Orthopaedics at the University of Iowa) and Dr William Olin (Professor Emeritus of Orthodontics at the University of Iowa) studied the adverse oral and mandibular consequences of the Milwaukee Brace in scoliosis patients at the University of Iowa. This study was never published but provided critical information regarding the problems created by the initial version of the Milwaukee Brace that eventually resulted in a design change to a neck ring to avoid the negative aspects of the original design. Dr William Olin was kind enough to share his original manuscript with the Iowa Orthopaedic Journal for publication so that this valuable piece of collaborative University research would be captured for perpetuity. Case 1 has been omitted due to missing data and the figures from cases 3 through 9 have been omitted for space concerns. For those interested in these original images, they have been electronically captured and returned to Dr. Olin.