Exploring the toxicity profile of coriander (C. sativum L.) essential oil: implications for translational toxicological research.

The plant species C. sativum L. is a staple in cuisine and holds significant ethnopharmacological value. Its essential oil (EO) is of particular interest, yet its toxicity profile remains a subject of inquiry. This study aimed to elucidate the chemical constituents of C. sativum L. EO and evaluate its toxicity through various parameters, including cytotoxicity assays on HaCaT keratinocytes, in vivo toxicity tests on Galleria mellonella larvae, in vivo genotoxicity assessments on mice and cytotoxicity assays on human erythrocytes. Notably, major constituents such as 2-decen-1-ol, dec-(2E)-enal, and 1,6-octadien-3-ol were found to remain predominant. The IC50 value for the essential oil on the keratinocyte cell line was determined to be 60.13 ± 2.02 µg/mL. However, in vivo toxicity tests with G. mellonella larvae demonstrated safety at doses below 4.5 g/kg. Additionally, genotoxicity assessment revealed that a single dose of 20 mg/mL (5 mg/kg) did not induce a significant increase in micronuclei formation. EO concentrations above 250 µg/mL led to significant changes in human erythrocytes cell viability (p < 0.0001), resulting in over 60% hemolysis. These findings collectively suggest that the essential oil of C. sativum L. exhibits a suitable toxicity profile for conducting preclinical studies in vertebrate animal models.

Effectiveness of elastodontic appliances in the treatment of malocclusions: a review of the literature.

AIM: This paper aims to verify the effectiveness of using elastodontic devices in the treatment of malocclusions in growing patients. An English-language literature search was conducted. The following electronic databases were selected for searching from 2020 to June 2023: PubMed, Web of Science, and Scopus. Eight articles were included based on the inclusion and exclusion criteria. The articles examined highlight the ability of elastodontic devices to act in cases of malocclusion in a safe, simple and more comfortable way for the young patient. However, there is a lack of knowledge about this technique, so this study aims to review the most recent literature to provide the scientific community with new knowledge.

Parkin is a critical player in the effects of caffeine over mitochondrial quality control pathways during skeletal muscle regeneration in mice.

AIM: This study aimed to investigate the effects of caffeine on pathways associated with mitochondrial quality control and mitochondrial capacity during skeletal muscle regeneration, focusing on the role of Parkin, a key protein involved in mitophagy. METHODS: We used in vitro C2C12 myoblast during differentiation with and without caffeine in the medium, and we evaluated several markers of mitochondrial quality control pathways and myotube growth. In vivo experiments, we used C57BL/6J (WT) and Parkintm 1Shn lineage (Parkin-/- ) mice and injured tibial anterior muscle. The mice regenerated TA muscle for 3, 10, and 21 days with or without caffeine ingestion. TA muscle was used to analyze the protein content of several markers of mitochondrial quality pathways, muscle satellite cell differentiation, and protein synthesis. Furthermore, it analyzed mtDNA, mitochondrial respiration, and myofiber growth. RESULTS: C2C12 differentiation experiments showed that caffeine decreased Parkin content, potentially leading to increased DRP1 and PGC-1α content and altered mitochondrial population, thereby enhancing growth capacity. Using Parkin-/- mice, we found that caffeine intake during the regenerative process induces an increase in AMPKα phosphorylation and PGC-1α and TFAM content, changes that were partly Parkin-dependent. In addition, the absence of Parkin potentiates the ergogenic effect of caffeine by increasing mitochondrial capacity and myotube growth. Those effects are related to increased ATF4 content and activation of protein synthesis pathways, such as increased 4E-BP1 phosphorylation. CONCLUSION: These findings demonstrate that caffeine ingestion changes mitochondrial quality control during skeletal muscle regeneration, and Parkin is a central player in those mechanisms.

Otodental Syndrome.

BACKGROUND: Otodental syndrome is a rare autosomal dominant condition characterised by a dental phenotype known as globodontia often associated with high-frequency hearing loss. Globodontia occurs both in the decidous and permanent dentition and affects canine and molar teeth.

Effects of an Educational Book on Paediatric Oral Health knowledge in a sample of Italian women.

AIM: Parents and caregivers, particularly in Italy, often have limited knowledge about their children's oral health. The primary objective of the study is to evaluate the educational effectiveness of a book on nutrition and prevention of oral diseases entitled "Oral health of mother and child in the first 1000 days of life". MATERIALS: The sample for this study was composed of 103 adult Italian women who were potential caregivers of one or more children (e.g., mothers, grandmothers, babysitters, and educators). The enrolled women completed a preliminary online survey which included questions about their socio-demographic characteristics and their knowledge on oral health in the first 1000 days of life of newborns (30 questions). Following the survey, they received the educational book. After reading it, the participants completed a second online survey with the same 30 questions, to measure any improvement in their knowledge. CONCLUSION: It appears that our educational book about nutrition and prevention of oral diseases was effective in enhancing knowledge among the participants in our study. These findings suggest that this educational resource has the potential to be a valuable tool in preventing oral diseases in paediatric populations. However, further confirmation of these results should be obtained through randomised controlled trials.

Evaluation of the release, stability and antioxidant activity of Brazilian red propolis extract encapsulated by spray-drying, spray-chilling and using the combination of both techniques.

Red propolis, originary from Northeast Brazil, has a unique composition and a great commercial interest. However, due to the presence of ethanol and its remarkable sensory characteristic, its application in food products is challenging. Thus, the aim of this work was to microencapsulate the red propolis extract by spray-drying, spray-chilling, and combining both techniques. The particles loaded with propolis extracts were characterised and evaluated according to the stability of phenolic compounds, flavonoids and formononetin, during 60 days of storage. In addition, the formononetin release was also monitored during the oral, gastric, and intestinal phases in the in vitro digestion process. All produced particles presented matrix-type with size, distribution, shape, hygroscopicity, and dispersibility parameters that varied according to the carrier and encapsulation process applied. The techniques used to fabricate the particles efficiently obtained powdered propolis extract and protected the extract's bioactive compounds, total flavonoids and formononetin throughout the analysed period. The gastrointestinal release study presented distinctive releases in all phases (oral, gastric, and intestinal). The spray-dried particles, for example, released formononetin mainly in the oral stage. While the spray-chilled particles were primarily released in the intestinal phase, and coated particles were released gradually throughout the assay, reaching maximum relief in the intestinal phase. In conclusion, using microencapsulation techniques by spray-drying, spray-chilling, and their combination developed particles with different levels of protection during storage, releases and characteristics, which resulted in a range of possible applications in the food, feed, cosmetic, and pharmaceutical industries.

Prevalence of sealant in an Italian paediatric population: an epidemiological study.

AIM: The use of sealants is an effective measure for the prevention of pit and fissure caries in children and it has been well documented by several studies In order to plan and establish a preventive national programme, it is important to know the epidemiological pattern in an Italian paediatric population, correlated to the risk of caries, DMFT and other sociodemographic factors. METHODS: This study was conducted on 2,442 children aged between 6 and 12 years attending the paediatric dentistry department of the University of L'Aquila, Italy. In addition to the oral examination, a questionnaire was administered on bad habits and the family perception of sealing. For descriptive analysis, the sample was stratified into two groups based on the presence/absence of at least one tooth with sealant. The differences between discrete and nominal variables, reported as absolute and percentage frequencies, were assessed by applying the χ2 test or the Fisher's exact test, as appropriate. Continuous variables were expressed in terms of mean values and their standard deviation(±DS) and the differences between the two groups under consideration were analysed through Student's t-test. The tests used are two-way and a significance level of 5% was applied. The statistical analysis was carried out using the statistical package STATA/IC 15.0 (StataCorp LLC, Texas, USA). CONCLUSION: The application of sealants to healthy occlusal surfaces is the best aid in preventing the development of caries in these areas, and this is especially important in childhood and adolescence, when the incidence of this pathology is particularly high.

Neuroimaging Features of Biotinidase Deficiency.

Biotinidase deficiency is an autosomal recessive condition caused by pathogenic variants in the BTD gene. Resultant deficiency of free biotin leads to impaired activity of the enzyme carboxylase and related neurologic, dermatologic, and ocular symptoms. Many of these are reversible on treatment, but early recognition and commencement of biotin supplementation are critical. This practice is especially important in countries where routine neonatal screening for biotinidase deficiency is not performed. In this report comprising 14 patients from multiple centers, we demonstrate the MR imaging patterns of this disorder at various age groups. Knowledge of these patterns in the appropriate clinical context will help guide early diagnosis of this treatable metabolic disorder.

Vespa velutina nigrithorax venom allergy: inhibition studies approach for the choice of specific immunotherapy.

Summary: Vespa velutina nigrithorax (VVN), commonly known as Asian wasp because endemic in Asia, represents an alien species in Europe. VVN can induce allergic reactions similar to those caused by other Hymenoptera and death after VVN stings, presumably due to fatal allergic reactions, has been reported. In the treatment of Hymenoptera venom hypersensitivity, specific immunotherapy (VIT) is highly effective. Currently, there is no specific available VIT for VVN, so it is relevant to assess if patients stung by VVN and showing allergic reactions could be treated with the Hymenoptera commercially available extracts Vespa crabro (VC) and Vespula spp (Vspp) or if they need the specific VIT with VVN venom extract. Methods. Four patients with a clinical history of systemic reactions after VVN sting were evaluated. Serum specific IgE were assayed quantitatively with an automated fluoro-enzyme immunoassay ImmunoCAP™ Specific IgE by Phadia™ 1000 System (Thermo Fisher Scientific, Uppsala, Sweden) for VC, Vspp and VVN. Cap inhibition assays were performed incubating serum samples with 200 µl of each venom at increasing concentrations and subsequently specific IgE against each of the venoms were determined in the samples by Phadia™ 250 System (Thermo Fisher Scientific, Uppsala, Sweden). Results. Our results suggested that both Vspp and VC venoms were able to inhibit the specific IgE for VVN, although the VC compared to the Vspp venom showed a higher inhibition. Conclusions. Our inhibition studies suggested that VIT with VC venom, nowadays when there is not specific available VIT for VVN, may be more effective than Vspp VIT in patients with VVN sting reactions.

The Genetic Complexity of Type-IV Trichome Development Reveals the Steps towards an Insect-Resistant Tomato.

The leaves of the wild tomato Solanumgalapagense harbor type-IV glandular trichomes (GT) that produce high levels of acylsugars (AS), conferring insect resistance. Conversely, domesticated tomatoes (S. lycopersicum) lack type-IV trichomes on the leaves of mature plants, preventing high AS production, thus rendering the plants more vulnerable to insect predation. We hypothesized that cultivated tomatoes engineered to harbor type-IV trichomes on the leaves of adult plants could be insect-resistant. We introgressed the genetic determinants controlling type-IV trichome development from S.galapagense into cv. Micro-Tom (MT) and created a line named "Galapagos-enhanced trichomes" (MT-Get). Mapping-by-sequencing revealed that five chromosomal regions of S. galapagense were present in MT-Get. Further genetic mapping showed that S. galapagense alleles in chromosomes 1, 2, and 3 were sufficient for the presence of type-IV trichomes on adult organs but at lower densities. Metabolic and gene expression analyses demonstrated that type-IV trichome density was not accompanied by the AS production and exudation in MT-Get. Although the plants produce a significant amount of acylsugars, those are still not enough to make them resistant to whiteflies. We demonstrate that type-IV glandular trichome development is insufficient for high AS accumulation. The results from our study provided additional insights into the steps necessary for breeding an insect-resistant tomato.

Prevalence of Early Childhood Caries (ECC) in a paediatric italian population: An epidemiological study.

AIM: The present work aims to evaluate, through an epidemiological study, the prevalence of Early Childhood Caries in an Italian paediatric population, aged up to 71 months, evaluating some determinants that will be illustrated in this study in order to adopt preventive care and intervene as early as possible to limit the development of this disease. METHODS: The sample consisted of 76 children aged up to 71 months who were examined at the PAediatric Dentistry Clinic of the University of l'Aquila. Parents were informed of the research that was taking place. All read the information sheet explaining the study and signed the informed consent where it was emphasised that the data collected would be treated and stored in a strictly confidential manner, pursuant to the Legislative Decree 196/2003 in force in Italy since June 30, 2003, regarding the protection of individuals with regard to the processing of personal data. At the end of this study, a standardised questionnaire administered. The questionnaire, divided into two parts, made it possible to acquire information regarding the characteristics of the population. First part: General data of the child and the medical history of the mother and father; Second part: The age and gender of the child, the type and duration of breastfeeding, the use of sugary pacifiers, oral hygiene and frequency of consumption of sugars drinks and food, identifying the starting age. RESULTS: Evaluating the dmft of each child, 40.79% of our sample population is affected by ECC; 57.89% of the children used the pacifier and 13,16% of them have or have used it with honey with a p value of 0.001, therefore this parameter was statistically significant, together with the intake of candies, chocolates and sugar drinks. The data was collected for a period of about 12 months, consequently a descriptive statistical analysis was conducted in which the characteristics of the population under consideration were outlined. Discrete and nominal variables have been described with frequencies and percentages. The percentage differences were evaluated using the chi-square test and the Fisher test. Quantitative variables were expressed in terms of mean and standard deviation and significance was assessed by the Mann-Whitney test. The level of significance was established as p <0.05. A Logistic Regression was conducted to evaluate the risk factors associated with a dmft>0 setting, dmft=0/dmft>0 as the dependent variable and the variables investigated as explanatory variables. The evaluation of the association was reported as the Odds Ratio with the 95% confidence interval. The statistical analysis was carried out using the Stata 12/1C statistical package. CONCLUSION: ECC is a multifactorial disease in which eating habits play a very important role. A diet that from childhood is characterised by a high consumption of sugar-rich food and drinks is highly associated with the incidence of ECC in later years.

Essential Oils Extracted from Organic Propolis Residues: An Exploratory Analysis of Their Antibacterial and Antioxidant Properties and Volatile Profile.

The industrial processing of crude propolis generates residues. Essential oils (EOs) from propolis residues could be a potential source of natural bioactive compounds to replace antibiotics and synthetic antioxidants in pig production. In this study, we determined the antibacterial/antioxidant activity of EOs from crude organic propolis (EOP) and from propolis residues, moist residue (EOMR), and dried residue (EODR), and further elucidated their chemical composition. The EOs were extracted by hydrodistillation, and their volatile profile was tentatively identified by GC-MS. All EOs had an antibacterial effect on Escherichia coli and Lactobacillus plantarum as they caused disturbances on the growth kinetics of both bacteria. However, EODR had more selective antibacterial activity, as it caused a higher reduction in the maximal culture density (D) of E. coli (86.7%) than L. plantarum (46.9%). EODR exhibited mild antioxidant activity, whereas EOMR showed the highest antioxidant activity (ABTS = 0.90 µmol TE/mg, FRAP = 463.97 µmol Fe2+/mg) and phenolic content (58.41 mg GAE/g). Each EO had a different chemical composition, but α-pinene and ß-pinene were the major compounds detected in the samples. Interestingly, specific minor compounds were detected in a higher relative amount in EOMR and EODR as compared to EOP. Therefore, these minor compounds are most likely responsible for the biological properties of EODR and EOMR. Collectively, our findings suggest that the EOs from propolis residues could be resourcefully used as natural antibacterial/antioxidant additives in pig production.

Introgression of the sesquiterpene biosynthesis from Solanum habrochaites to cultivated tomato offers insights into trichome morphology and arthropod resistance.

MAIN CONCLUSION: Cultivated tomatoes harboring the plastid-derived sesquiterpenes from S. habrochaites have altered type-VI trichome morphology and unveil additional genetic components necessary for piercing-sucking pest resistance. Arthropod resistance in the tomato wild relative Solanum habrochaites LA1777 is linked to specific sesquiterpene biosynthesis. The Sesquiterpene synthase 2 (SsT2) gene cluster on LA1777 chromosome 8 controls plastid-derived sesquiterpene synthesis. The main genes at SsT2 are Z-prenyltransferase (zFPS) and Santalene and Bergamotene Synthase (SBS), which produce α-santalene, ß-bergamotene, and α-bergamotene in LA1777 round-shaped type-VI glandular trichomes. Cultivated tomatoes have mushroom-shaped type-VI trichomes with much smaller glands that contain low levels of monoterpenes and cytosolic-derived sesquiterpenes, not presenting the same pest resistance as in LA1777. We successfully transferred zFPS and SBS from LA1777 to cultivated tomato (cv. Micro-Tom, MT) by a backcrossing approach. The trichomes of the MT-Sst2 introgressed line produced high levels of the plastid-derived sesquiterpenes. The type-VI trichome internal storage-cavity size increased in MT-Sst2, probably as an effect of the increased amount of sesquiterpenes, although it was not enough to mimic the round-shaped LA1777 trichomes. The presence of high amounts of plastid-derived sesquiterpenes was also not sufficient to confer resistance to various tomato piercing-sucking pests, indicating that the effect of the sesquiterpenes found in the wild S. habrochaites can be insect specific. Our results provide for a better understanding of the morphology of S. habrochaites type-VI trichomes and paves the way to obtain insect-resistant tomatoes.

Scoliosis with cognitive impairment in a girl with 8q11.21q11.23 microdeletion and SNTG1 disruption.

Idiopathic scoliosis (IS) is an abnormality of the vertebral column with a spine curvature of at least 10 degrees. It is the most common spinal deformity in children with a prevalence of 2%-3%, and its aetiology is unknown. Genetic factors are known to play a role and a number of linkage analyses showed associations of various loci. Here we describe a new case of a de novo interstitial deletion 8q11.21q11.2 disrupting SNTG1 gene, identified by array-CGH in a girl with cognitive impairment and a scoliosis that 'appears' like to IS. SNTG1 encodes γ-1 Syntrophin protein that is part of the dystrophin associated protein complex and interacts directly with the C-terminal of dystrophin. Its expression is restricted to neurons and particularly in those areas of the brain that have been suggested to affect postural control. The involvement of SNTG1 gene in IS was already been reported in a family with a breakpoint between exons 10 and 11. Mutational analysis of SNTG1 exons in 152 sporadic IS patients had revealed changes in three patients. In conclusion, our data add a further line of evidence suggesting SNTG1 could represent an interesting candidate for its involvement in scoliosis.

Prenatal diagnosis of rhombencephalosynapsis: neuroimaging features and severity of vermian anomaly.

OBJECTIVES: To describe the prenatal neuroimaging spectrum of rhombencephalosynapsis (RES) and criteria for its classification according to the severity of vermian anomaly. METHODS: In this multicenter retrospective study of fetuses with RES between 2002 and 2020, the medical records and brain ultrasound and magnetic resonance images were evaluated comprehensively to determine the severity of the vermian anomaly and the presence of associated brain findings. RES was classified, according to the pattern of vermian agenesis and the extent of the fusion of the hemispheres, as complete RES (complete absence of the vermis) or partial RES (further classified according to the part of the vermis that was missing and, consequently, the region of hemispheric fusion, as anterior, posterior, severe or mixed RES). Findings were compared between cases with complete and those with partial RES. RESULTS: Included in the study were 62 fetuses with a gestational age ranging between 12 and 37 weeks. Most had complete absence of the vermis (complete RES, 77.4% of cases), a 'round-shaped' cerebellum on axial views (72.6%) and a transverse cerebellar diameter (TCD) < 3rd centile (87.1%). Among the 22.6% of cases with partial RES, 6.5% were classified as severe partial, 6.5% as partial anterior, 8.1% as partial mixed and 1.6% as partial posterior. Half of these cases presented with normal or nearly normal cerebellar morphology and 28.5% had a TCD within the normal limits. Infratentorially, the fourth ventricle was abnormal in 88.7% of cases overall, and anomalies of the midbrain and pons were frequent (93.5% and 77.4%, respectively). Ventriculomegaly was observed in 80.6% of all cases, being more severe in cases with complete RES than in those with partial RES, with high rates of parenchymal and septal disruption. CONCLUSIONS: This study provides prenatal neuroimaging criteria for the diagnosis and classification of RES, and identification of related features, using ultrasound and magnetic resonance imaging. According to our findings, a diagnosis of RES should be considered in fetuses with a small TCD (severe cerebellar hypoplasia) and/or a round-shaped cerebellum on axial views, during the second or third trimester, especially when associated with ventriculomegaly. Partial RES is more common than previously thought, but presents an extreme diagnostic challenge, especially in cases with normal or nearly-normal cerebellar morphobiometric features. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Ganglionic Eminence Anomalies and Coexisting Cerebral Developmental Anomalies on Fetal MR Imaging: Multicenter-Based Review of 60 Cases.

BACKGROUND AND PURPOSE: The ganglionic eminences are transient fetal brain structures that produce a range of neuron types. Ganglionic eminence anomalies have been recognized on fetal MR imaging and anecdotally found in association with a number of neurodevelopmental anomalies. The aim of this exploratory study was to describe and analyze the associations between ganglionic eminence anomalies and coexisting neurodevelopmental anomalies. MATERIALS AND METHODS: This retrospective study includes cases of ganglionic eminence anomalies diagnosed on fetal MR imaging during a 20-year period from 7 centers in Italy and England. Inclusion criteria were cavitation or increased volume of ganglionic eminences on fetal MR imaging. The studies were analyzed for associated cerebral developmental anomalies: abnormal head size and ventriculomegaly, reduced opercularization or gyration, and abnormal transient layering of the developing brain mantle. The results were analyzed using χ2 and Fisher exact tests. RESULTS: Sixty fetuses met the inclusion criteria (21 females, 24 males, 15 sex unknown). Thirty-four had ganglionic eminence cavitations (29 bilateral and 5 unilateral), and 26 had increased volume of the ganglionic eminences (19 bilateral, 7 unilateral). Bilateral ganglionic eminence cavitations were associated with microcephaly (P = .01), reduced opercularization, (P < .001), reduced gyration (P < .001), and cerebellar anomalies (P = .01). Unilateral ganglionic eminence cavitations were not significantly associated with any particular feature. Bilateral increased volume of the ganglionic eminences showed an association with macrocephaly (P = .03). Unilateral increased volume was associated with macrocephaly (P = .002), abnormal transient layering (P = .001), unilateral polymicrogyria (P = .001), and hemimegalencephaly (P < .001). CONCLUSIONS: Ganglionic eminence anomalies are associated with specific neurodevelopmental anomalies with ganglionic eminence cavitations and increased ganglionic eminence volume apparently having different associated abnormalities.

Mandibular advancement with clear aligners in the treatment of skeletal Class II. A retrospective controlled study.

AIM: The current study aimed to analyse the dentoskeletal effects of the Invisalign mandibular advancement (MA) device in the treatment of skeletal Class II malocclusions. MATERIALS AND METHODS: Pre-treatment and post-treatment lateral skull radiographs from patients treated with MA versus TB (Twin-Block Appliance) at the Department of Orthodontics of the University of L'Aquila, Italy, were traced. Eligibility criteria included SNB<78; ANB>4; no previous orthodontic treatments; and vertebral maturation stage (CVM) CS3. Radiographs from patients with craniofacial anomalies, or who underwent extraction treatments, were excluded. Totally, 20 patients were examined, 10 of whom treated with MA and 10 treated with TB. All the radiographs were traced by one expert operator, blind to the groups. A preliminary method error study was performed to exclude intra-operator differences. RESULTS: Baseline characteristics of the participants were similar between the groups. Both appliances demonstrated a reduction of SNB and ANB angle, and a decrease in overjet. TB demonstrated a higher efficacy in increasing mandibular dimensions. A significant retroinclination of the upper incisive was observed in the TB group, where a decrease of SNA angles was additionally observed. The resulting differences between the two groups could be attributed to the different design of the appliances. CONCLUSIONS: The present data show the effectiveness of both TB and MA in the management of skeletal Class II malocclusions due to mandibular retrusion. But some differences exist in the dentoalveolar effect of the two appliances. MA seems indicated in Class II cases where a control of the upper frontal teeth position is needed.

Use of a modified vertical holding appliance for open bite interceptive treatment in growing patients.

BACKGROUND: The aim of this paper is to illustrate the use of a modified vertical holding appliance (G-VHA) to obtain the vertical control of maxillary molars and tongue stimulation in order to achieve a transverse activation in growing patients with dental open bite without the patient's compliance. CASE REPORTS: The G-VHA is a modified trans-palatal bar with a resin pad covering the Omega central loop and two adjunctive lateral loops to ensure the bar flexibility. The G-VHA is designed to direct the force of the tongue against the upper molars to generate intrusion and at the same time to stimulate and re-educate the tongue. Two cases of dental open bite in growing patients are illustrated. Both patients were successfully treated, and the open bite was fully corrected thanks to molar intrusion, following counterclockwise rotation of the mandible and tongue correction. Finishing of alignment was performed in phase II of the treatment with conventional appliances. CONCLUSION: The G-VHA proved to be effective in controlling the vertical position of maxillary molars promoting the counter-clockwise rotation of the mandible and stimulating a different tongue posture.