Maternal and fetal outcomes in an Italian multicentric cohort of women with multiple sclerosis exposed to dimethyl fumarate during pregnancy.

BACKGROUND: Evidence on the impact of dimethyl fumarate (DMF) during pregnancy in women with multiple sclerosis (MS) is limited. OBJECTIVES: To investigate disease activity and pregnancy outcomes in a retrospective cohort of women exposed to DMF in early pregnancy. METHODS: Women discontinuing DMF after pregnancy confirmation were identified from 29 Italian MS Centers. Disease activity 12 months before conception, during pregnancy, and 12 months postpartum were recorded, exploring reactivation predictors. Pregnancy and fetal outcomes were assessed. RESULTS: The study analyzed 137 pregnancies (12 pregnancy losses, 125 live births) from 137 women (mean age 32.9 ± 4.7 years), discontinuing DMF within a median (interquartile range (IQR)) interval of 4.9 (3.7-5.7) weeks from conception. In live birth pregnancies, annualized relapse rate (ARR) significantly decreased during pregnancy (ARR = 0.07, 95% confidence interval (CI): 0.03-0.14, p = 0.021) compared to pre-conception (ARR = 0.21 (95% CI: 0.14-0.30)) and increased postpartum ((ARR = 0.22 (95% CI: 0.15-0.32), p = 0.006). Median time to first relapse (TTFR) was 3.16 (IQR: 1:87-5.42) months. Higher pre-conception relapse number (hazard ratio (HR) = 2.33, 95% CI: 1.08-5.02) and Expanded Disability Status Scale (EDSS; HR = 1.81, 95% CI: 1.17-2.74) were associated with shorter TTFR, while treatment resumption with longer TTFR (HR = 0.29, 95% CI: 0.11-0.74). Fetal outcomes were unaffected by DMF exposure. CONCLUSION: DMF discontinuation does not increase relapse risk during pregnancy. Early therapy restart prevents postpartum relapses. Early DMF exposure shows no adverse fetal outcomes.

1,25(OH)2D3 Differently Modulates the Secretory Activity of IFN-DC and IL4-DC: A Study in Cells from Healthy Donors and MS Patients.

Immune mechanisms play an essential role in driving multiple sclerosis (MS) and altered trafficking and/or activation of dendritic cells (DC) were observed in the central nervous system and cerebrospinal fluid of MS patients. Interferon ß (IFNß) has been used as a first-line therapy in MS for almost three decades and vitamin D deficiency is a recognized environmental risk factor for MS. Both IFNß and vitamin D modulate DC functions. Here, we studied the response to 1,25-dihydoxyvitamin D3 (1,25(OH)2D3) of DC obtained with IFNß/GM-CSF (IFN-DC) compared to classically derived IL4-DC, in three donor groups: MS patients free of therapy, MS patients undergoing IFNß therapy, and healthy donors. Except for a decreased CCL2 secretion by IL4-DC from the MS group, no major defects were observed in the 1,25(OH)2D3 response of either IFN-DC or IL4-DC from MS donors compared to healthy donors. However, the two cell models strongly differed for vitamin D receptor level of expression as well as for basal and 1,25(OH)2D3-induced cytokine/chemokine secretion. 1,25(OH)2D3 up-modulated IL6, its soluble receptor sIL6R, and CCL5 in IL4-DC, and down-modulated IL10 in IFN-DC. IFN-DC, but not IL4-DC, constitutively secreted high levels of IL8 and of matrix-metalloproteinase-9, both down-modulated by 1,25(OH)2D3. DC may contribute to MS pathogenesis, but also provide an avenue for therapeutic intervention. 1,25(OH)2D3-induced tolerogenic DC are in clinical trial for MS. We show that the protocol of in vitro DC differentiation qualitatively and quantitatively affects secretion of cytokines and chemokines deeply involved in MS pathogenesis.

New Minimally Invasive Intraoral Procedure for Condylar Fractures: Clinical Presentation and Considerations on Current Techniques.

ABSTRACT: Mandibular fractures are the third most prevalent maxillofacial traumatic events. Surgical approaches to the condyle are a debated topic. This study describes a mini-invasive technique for condylar fracture reduction. The patient of this study suffered multiple traumatic injuries including a carotid artery dissecting aneurysm, which contraindicated the standard open reduction and internal fixation technique. The novel minimally invasive technique involves intraoral access and fracture fragment realignment using a periosteal elevator, a molar occlusal splint, and intermaxillary fixation after intraoperative radiologic imaging confirmation of condyle reposition.The approach avoids skin incisions and tissue dissection, with good aesthetic outcomes and facial nerve preservation. This technique proved to be safe and simple to be less demanding for the patient, with a shorter recovery time than experienced with other techniques.The results suggest this technique is a good option for the surgical treatment of condylar neck fractures showing favorable rim morphology with primary stability after reduction.

Condylar Fractures: Multistep Surgical Planning by Mini-Invasive Approach, Patient Series.

PURPOSE: Surgical treatment for condylar fractures is a challenging procedure most debated in scientific literature without a broad consensus on the selection of surgical techniques to be used and relative indications.The goal of this work is to propose a multistep surgical planning for condylar fractures based on an effective mini-invasive approach and safe procedure aimed to avoid as much as possible skin incision in the aesthetic areas of the face and neck, to decrease the risk of facial nerve injury. METHODS: Ten patients with dislocated condylar neck fractures and sub-condylar fractures were included in this study.All the patients were studied with radiological images, computed tomography scans with three-dimensional reconstructions preoperatively and immediate postoperatively.Patients were evaluated pre- and post-operatively for dental occlusion, bone fragment alignment after reduction and after fixation, facial nerve functionality, skin scarring, temporomandibular joint functionality, temporomandibular joint symptomatology, and patient satisfaction. RESULTS: Results were satisfactory for different parameters evaluated. No significant complications resulted in follow-up, particularly for facial nerve injury. By using this multistep procedure with each stage functional to the following one, the authors achieved satisfactory results following treatment of dislocated condylar fractures.

Operationalization of a frailty index in patients with multiple sclerosis: A cross-sectional investigation.

BACKGROUND: Frailty is an age-related status of increased vulnerability to stressors caused by the accumulation of multiple health deficits. This construct may allow to capture the clinical complexity of patients with multiple sclerosis (MS). OBJECTIVE: To investigate the relationship between frailty and the clinical manifestations of MS. METHODS: Patients with MS were consecutively enrolled at five tertiary dedicated services. Disability and fatigue were assessed. The phenotypes of MS were also identified. Frailty was measured using a frailty index (FI), computed by cumulatively considering 42 age-related multidimensional health deficits. RESULTS: Overall, 745 MS patients (mean age = 48.2 years, standard deviation = 11.7 years; women 68%) were considered. The median FI value was 0.12 (interquartile range = 0.05-0.19) and the 99th percentile was 0.40. FI scores were associated with MS disease duration, disability, fatigue, as well as with the number of previous disease-modifying treatments and current symptomatic therapies. A logistic regression analysis model showed that FI score was independently associated with the secondary progressive phenotype. CONCLUSION: Frailty is significantly associated with major characteristics of MS. The findings of the present cross-sectional investigation should be explored in future longitudinal studies.

Deep grey matter involvement and altered sensory gating in multiple sclerosis.

BACKGROUND: Somatosensory temporal discrimination threshold (STDT) is altered in multiple sclerosis (MS). In healthy subjects (HS), voluntary movement modulates the STDT through mechanisms of subcortical sensory gating. OBJECTIVE: With neurophysiological and magnetic resonance imaging (MRI) techniques, we investigated sensory gating and sensorimotor integration in MS. METHODS: We recruited 38 relapsing-remitting multiple sclerosis (RR-MS) patients with no-to-mild disability and 33 HS. We tested STDT at rest and during index finger abductions and recorded the movement kinematics. Participants underwent a 3T MRI protocol. RESULTS: Patients exhibited higher STDT values and performed slower finger movements than HS. During voluntary movement, STDT values increased in both groups, albeit to a lesser extent in patients, while the mean angular velocity of finger movements decreased in patients alone. Patients had a smaller volume of the thalamus, pallidum and caudate nucleus, and displayed higher mean diffusivity in the putamen, pallidum and thalamus. STDT correlated with thalamic volume while mean angular velocity correlated with putaminal volume. Changes in mean angular velocity during sensorimotor integration inversely correlated with mean diffusivity in the thalamus and pallidum. Changes in STDT and velocity were associated with fatigue score. CONCLUSION: Altered STDT and sensorimotor integration are related to structural damage in the thalamus and basal ganglia in MS and likely to affect motor performance.

A Modified Novel Technique for Condylar Positioning in Mandibular Bilateral Sagittal Split Osteotomy Using Computer-Assisted Designed and Computer-Assisted Manufactured Surgical Guides.

Current techniques for orthognathic surgery after Le Fort I osteotomy and bilateral sagittal split osteotomy (BSSO) rely on intermediate and final occlusal splints for proper positioning of the dental arches without any control in positioning the condyle and ramus segments. Setting the 2 condyles in centric relation in the glenoid fossae at fixation is paramount for condylar function and the accuracy and stability of postoperative occlusion. Usually the 2 ramus segments are manually positioned and fixated in the final position according to the surgeon's experience. This report describes a novel technique to position the condyle and ramus segments in centric relation using skeletal guides designed by computer-assisted designed and computer-assisted manufactured (CAD-CAM) technology. The skeletal guides have a double-U shape designed to be tooth borne on the distal segment and bone borne on the proximal segment. The guides fit on the last molar crown and the anterior border of the ramus; using these reference points will position the mandibular arch and 2 ramus segments in ideal centric occlusion and centric relation. The condyle position in the sagittal, horizontal, and transverse planes was analyzed by computed tomography and differences in measurements were calculated. This technique confirms precise control of the condylar segment in centric relation with stable centric occlusion using CAD-CAM guides during BSSO.

Abortion induces reactivation of inflammation in relapsing-remitting multiple sclerosis.

OBJECTIVE: To investigate clinical and radiological outcomes of women with relapsing-remitting multiple sclerosis (RRMS) undergoing abortion. METHODS: An independent, multicentre retrospective study was conducted collecting data from eight Italian MS centres. We compared the preconception and postabortion annualised relapse rate (ARR) and number of Gadolinium enhancing (Gd+) lesions, by analyses of covariance. Variables associated with postabortion clinical and MRI activity were investigated using Poisson regression models; each abortion was considered as a statistical unit. RESULTS: From 1995 to 2017, we observed 188 abortions (17 elective) in 153 women with RRMS. Abortions occurred after a mean time of 9.5 (4.4) weeks from estimated conception date. In 86 events out of 188, conception happened during treatment with disease modifying drugs. The mean postabortion ARR (0.63±0.74) was significantly increased (p=0.037) compared with the preconception year (0.50±0.71) as well as the postabortion mean number of new Gd+ lesions (0.77±1.40 vs 0.39±1.04; p=0.004). Higher likelihood of relapses was predicted by higher preconception ARR, discontinuation of preconception treatment and elective abortion; the occurrence of new Gd+ lesions was associated with higher preconception number of active lesions, discontinuation of preconception treatment, shorter length of pregnancy maintenance and elective abortion. CONCLUSIONS: Abortion was associated with clinical and radiological inflammatory rebound remarkably in the first 12 months postevent. Deregulated proinflammatory processes arising at the early stages of pregnancy might play a role both in MS reactivation and abortion. Women with MS should be counselled about these risks of abortion and followed up accordingly.

The Prevalence of Multiple Sclerosis in the Metropolitan Area of Rome: A Capture-Recapture Analysis.

BACKGROUND: Limited data are available on the prevalence of multiple sclerosis (MS) in central Italy. The objective of this study is to estimate MS prevalence in the metropolitan area of Rome. METHODS: We used the capture-recapture method to calculate prevalence estimates in the study area. The selected prevalence day was December 31, 2015. A total of 1,007 patients, with a definite diagnosis of MS according to the revised McDonald's criteria, were considered for crude, age- and sex-specific prevalence estimation. RESULTS: The overall crude prevalence rate was 146.2 cases per 100,000 (95% CI 119.9-172.5). A higher prevalence rate was recorded in females (194.1, 95% CI 149.6-238.6) than in males (93.0, 95% CI 67.2-118.8) with a female to male ratio of 1.8. Age-specific prevalence peaked in the 25-34 , 35-44 and 45-54 years class; moreover, it was found to increase up to the 45-54 years age group in females and the 35-44 years age group in males, decreasing thereafter. CONCLUSION: The results confirm that the metropolitan area of Rome is a high-risk area for MS.

Necrotizing odontogenic fasciitis of head and neck extending to anterior mediastinum in elderly patients: innovative treatment with a review of the literature.

BACKGROUND: Necrotizing fasciitis (NF) of odontogenic origin affecting the head and neck region is a rare but serious clinical condition, which, if diagnosed late, can lead to a fatal outcome. The early diagnosis of necrotizing fasciitis can be difficult. Delay in diagnosis leads to increase in the area of necrosis with a resulting increase in cosmetic deformity and life-threatening complication. In this study, we present two cases of elderly patients with aggressive NF affecting the neck and anterior mediastinum, which were of odontogenic origin. METHODS: In the two patients selected necrotic skin and soft tissue were removed and wide exposure was achieved with debridement of the neck at the level of the affected layer of superficial cervical fascia. Saline solution was used as irrigation to treat the patients with acute necrotizing fasciitis. Difficulties in managing this condition with NF extent to deep anterior mediastinum is related to clavicle osteotomy or thoracotomy need with high surgical risks. In our technique, by gentle suction in anterior mediastinum, necrotic tissue resection was possible without any osteotomy need. CONCLUSIONS: Suctioning resection technique associated with hyperbaric, metabolic rebalance, and amino acid support in association with three types antibiotic therapy are fundamental points for correct therapy strategy, leading to full recovery and healing of NF patients even if in very unfavorable conditions. Multidisciplinary approach is paramount for proper treatment of this disease.

Attention-related changes in short-term cortical plasticity help to explain fatigue in multiple sclerosis.

BACKGROUND: In multiple sclerosis (MS), pathophysiology of fatigue is only partially known. OBJECTIVE: The aim of this study was to investigate whether the attention-induced modulation on short- and long-term cortical plasticity mechanisms in primary motor area (M1) is abnormal in patients with MS-related fatigue. METHODS: All participants underwent 5-Hz repetitive transcranial magnetic stimulation (rTMS), reflecting short-term plasticity, and paired associative stimulation (PAS), reflecting long-term plasticity, and were asked to focus their attention on the hand contralateral to the M1 stimulated. A group of age-matched healthy subjects acted as control. RESULTS: In patients with MS, 5-Hz rTMS and PAS failed to induce the normal increase in motor-evoked potential (MEP). During the attention-demanding condition, 5-Hz rTMS- and PAS-induced responses differed in patients with MS with and without fatigue. Whereas in patients with fatigue neither technique induced the attention-induced MEP increase, in patients without fatigue they both increased the MEP response, although they did so less efficiently than in healthy subjects. Attention-induced changes in short-term cortical plasticity inversely correlated with fatigue severity. CONCLUSION: Short-term and long-term plasticity mechanisms are abnormal in MS possibly owing to widespread changes in ion-channel expression. Fatigue in MS reflects disrupted cortical attentional networks related to movement control.

Ridge Expansion by Flapless Split Crest and Immediate Implant Placement: Evolution of the Technique.

Various treatment strategies and techniques have been proposed to perform alveolar bone augmentation; most common are guided bone regeneration, split crest, and autologous bone grafting. All of these techniques are reported to possess bone regenerative properties of osteoinduction and osteoconduction in relation to regenerated bone survival. Split crest resulted to be one of the most reliable bone augmentation techniques. In this study, we describe a new flapless-modified split crest technique on 4 patients to optimize the bone regeneration with bone augmentation implant insertion in 1 single stage. The rationale of this technique is to obtain a proper buccal cortex expansion preserving its vascular supply and avoiding periosteal elevation for better cortical bone preservation. The main advantages of this technique consist in a single surgical stage without donor sites, vascular periosteal preservation of vestibular cortical walls, preservation of alveolar bone height avoiding bone loss after implant kit drilling, and preservation of proper cortical thickness on both sides, thereby saving periosteal nourishment on the vestibular side. Indication for this technique could be extended to almost every implant insertion for alveolar height saving at drilling time for implant insertion, because of the alveolar crest shape.

New Technique for Mandibular Symphyseal Distraction by a Double-Level Anchorage and Fixation System: Advantages and Results.

INTRODUCTION: A surgical technique to widen the mandible is the mandibular midline distraction: the most common indications for mandibular midline distraction are severe mandibular anterior crowding, severe mandibular transverse deficiency, uni- or bilateral crossbite, impacted anterior teeth with inadequate space, and tipped teeth. Commonly used distraction devices can be divided into 2 systems: bone-borne distraction system appliance, dental-borne distraction systems. Each system has peculiar advantages, disadvantages, and different indications. To combine advantages of both systems we developed a new technique adopting an immediate basal bone widening with fixation after osteotomy and a dental borne rigid lingual system for distraction. AIM: The aim of this work is to show a new technique for symphysis mandibular distraction based on a double-level anchorage and fixation system on clinical patients showing final results and advantages. METHODS: Two patients affected by dento-alveolar and basal bone maxillary and mandibular transversal collapse even in association with other skeletal malocclusion were selected. Patients were clinically and radiographically studied and analyzed at different times before and after surgery. Dental and basal bone measurements were performed clinically and radiographically. RESULTS: The results were optimal with perfect dental arches alignment followed by closing of the open bites with multiple-segmented surgery in a second surgical time. No misalignment of the 2 mandibular halves was noticed during the distraction procedure. DISCUSSION: Dental-bone discrepancies correction is mandatory before orthodontic treatment alignment. Transversal jaw expansion can be achieved safely and stably by distraction of both maxillae for the combination of osteogenesis and histogenesis with augmentation of both bone and soft tissue. Bone-borne distraction will result in more stable results; dental-borne devices will result in more simple and aesthetically rewarding procedures. Hybrid techniques usually show mixed results depending on the characteristics of the device. For this reason we developed a combination of both the aforementioned systems which is not a hybrid system but the combination of an immediate expansion of the symphysis and fixation by 1 miniplate with only 2 screws acting like hinges during distraction, combined with a lingual distraction system at the alveolar bone level. CONCLUSIONS: Bone-borne distraction systems result in more efficient basal bone mandibular widening with increased stability for dental results. For dental-borne appliance the advantages consist in no second surgery need for their removal, no transmucosal hardware emergence and better aesthetic, especially when lingual devices were used. Our technique combines advantages of both procedures.

Management of Zygomatic Fractures in Young Patients: Technical Modifications for Aesthetic and Functional Results.

INTRODUCTION: The zygomaticomaxillary complex is very vulnerable to injury because of its intrinsically prominent convexity. There are 2 different surgical approaches for the therapy of these fractures: closed reduction and open reduction. In the open reduction 2 or 3 fixation points with related incisions are usually necessary in dislocated fractures: osteosynthesis must be performed starting from zygomaticofrontal suture when dislocated at this site, followed by zygomatic body fixation on the anterior sinus wall, anterior orbital floor margin fixation, and finally orbital floor reconstruction in case of eye globe dislocation with diplopia. AIM: This study evaluated the combination of the transconjunctival (TC) approach without canthotomy in association with the transoral maxillary approach and lateral rim skin incision (SI) without canthotomy for frontozygomatic dislocated fractures to achieve proper reduction and stabilization without any aesthetic decay in young patients. A less invasive and more aesthetic technique is shown for treating dislocated zygomaticomaxillary complex fractures with 2 or 3 fixation points and platelet-rich fibrin (PRF) use to promote tissue healing. MATERIALS AND METHODS: Ten patients (mean age: 32) were referred for dislocated zygomaticomaxillary complex fracture. Five patients were treated by TC approach without canthotomy in association with the transoral maxillary approach and, when needed, eyebrow SI without canthotomy for frontozygomatic dislocated fractures (group 1). Five more patients were treated by traditional subciliar incision at lower eyelid and vertical lateral incision at lateral margin of the orbit (group 2). Autologous PRF for orbital floor reconstruction was used. The follow-up period was 6 months long. Follow-up radiographs (TC) and photos were routinely used to evaluate the adequacy of reduction and lower eyelid right position or retraction. RESULTS: All cases were successful; there were no problems at surgery and postoperative time. During the 6-month follow-up, all 5 patients of group 1 showed satisfactory facial symmetry, no noticeable scarring, no ectropion or lower eyelid significant droop, and no functional impairment. Mean difference for lower eyelid droop between the 2 groups of patients was 1.4 mm at T1 and 1.2 mm at T2. DISCUSSION: Aesthetic result is a priority in the treatment planning of orbitozygomatic fractures because of the fundamental role of the eye and lid area in the aesthetic of the face. In our experience best aesthetic results were achieved through a latero cantal horizontal SI combined to a vertical periosteal incision at the frontozygomatic rim without canthotomy, thus performing a different double-layer incision. In the patients with large orbital floor dislocation, reconstructive titanium mesh was covered by autologous PRF membranes, which can improve the vascularization of the surgical site, by promoting neoangiogenesis. CONCLUSIONS: In young patients these techniques are indicated because of the need of better aesthetic results that can be achieved by preventing postoperative functional impairment with lower eyelid droop and unnatural aesthetic asymmetry of the 2 lower lids. This more conservative technique resulted in better aesthetic results, avoiding most common complications.

New Techniques in Relation to New Concepts of the Aesthetic of the Face: Technical Considerations and Aesthetic Evaluation.

Aesthetic of the face is greatly changed in relation to common standards of the past. Modern concepts of beauty from popular models of beautiful faces to actors show a biprotrusive asset with high tension for soft tissues. Facial symmetry has been proposed as a marker of developmental stability that may be important in human mate choice. Any deviation from perfect symmetry can be considered a reflection of imperfect development. The goal of maxillofacial surgery should be to give the best results for both aesthetic and functional aspects. Following these new concepts of aesthetic of the face, new surgical procedure by osteodistraction techniques will lead to a very natural final result by harmonizing the face. The aim of this study was to detect aesthetic results on 10 patients operated for skeletal discrepancies by maxillary distraction and jaw repositioning compared with other 10 patients operated by conventional techniques on a 5-point scale by Likert.

Osteodistraction With Dental Implant-Borne Devices for Bone Regeneration in Atrophied Premaxilla.

Aim of this work is to present the evolution of an innovative technique for tooth/implant supported bone distraction, leading to proper oral rehabilitation in patients with atrophic alveolar bone, even when a complete premaxilla expansion is needed, or in patients in whom implants were already present, but inserted in wrong position.Distraction osteogenesis was selected because of its moderate invasiveness, the few surgical steps needed, and the proper cost/benefits balance. This procedure is particularly suited for young patients with remarkable aesthetic demands related to active social and working life, as for elderly patients expecting lower surgical stress and risks.

Chin Wing Osteotomy for Bilateral Goldenhar Syndrome Treated by "Chin Wing Mentoplasty": Aesthetic, Functional, and Histological Considerations.

Various treatment strategies have been proposed to perform the aesthetic surgical correction of asymmetric deformities of the mandible. These techniques range from relatively simple to complex procedures including bimaxillary surgery associated with complex mandibular osteotomies. The authors describe a patient with grade III Goldenhar syndrome, treated by a "chin wing" mentoplasty as described by Triaca. These situations are classically treated with a bilateral sagittal splint osteotomy (BSSO) in combination with mentoplasty. However, because of a good occlusion with Angle's class I relation, slight imbalance of the occlusal plane with good function of the mouth opening, the patient refused to be treated with a BSSO, hence, a chin wing mentoplasty was performed. Size and stability of bone regeneration were evaluated by histological examination and dynamic-volume computed tomography (CT). Mature bone in the grafted areas was detected by histology and CT scan with stable results and a significant increase of facial aesthetics 1 year after surgery. The authors also demonstrated that the chin wing technique provided a little but significant breathing improvement as detected on CT scans and lateral X-ray cephalograms by measuring the breathing area. Chin wing mentoplasty is a moderately invasive technique that is able to improve the aesthetics of the face and patient breathing.

Intraoral epimucosal fixation for reducible maxillary fractures of the jaws; surgical considerations in comparison to current techniques.

Fractures of the jaw are often treated with rigid and stable internal fixation using plates or miniplates. Early surgery for jaw fractures is the optimal treatment; however, if a late treatment is begun, often the adoption of other protocols is needed. When the jaw fracture has one free bone fragment with 2 full-thickness lesions of mucoperiosteal soft tissues both on the buccal and palatal sides, the risk of resorption or necrosis is very high after elevating a mucoperiosteal flap for rigid fixation. For this reason, we developed an intraoral epimucosal fixation technique using self-locking screws and plates. Substantial advantages of this new technique, in comparison with other commonly used fixation techniques, consisted in the prevention of bone resorption or necrosis by safe and simple screw insertion procedure after manipulation of the fracture for reduction in closed surgery. Major indications for epimucosal fixation in closed surgery are the presence of jaw fractures without dislocation or reducible jaw fractures by manipulation particularly in edentulous patients.

New palatal distraction device by both bone-borne and tooth-borne force application in a paramedian bone anchorage site: surgical and occlusal considerations on clinical cases.

Maxillary constriction is a very common pathology with implications on dental occlusion, temporomandibular joint dysfunction, nasal breathing, and impairment on the smile and face esthetic.New techniques for expansion of the maxillary bones are particularly useful in relation to the new esthetic ideals of smile and face beauty.To achieve a bodily expansion of the maxillary bones, we developed a new rigid palatal distractor device with both tooth-borne and paramedian bone-borne anchorages to achieve a safe and simple anchorage site suitable also for orthodontic appliances.The reported cases show good results, with bodily maxillary expansion and cross-bite correction without any problems or complications. Substantial advantages of this new device and technique, in comparison with other commonly used palatal distractors, consisting of bodily maxillary movements, avoidance of relapse risks, and safe and simple screw insertion site for bone anchorage also suitable for orthodontic movements, are discussed.

A New Method to Design and Manufacture a Low-Cost Custom-Made Template for Mandible Cut and Repositioning Using Standard Plates in BSSO Surgery.

In this study, a new methodology for designing and creating a custom-made template for maxillofacial surgery has been developed. The custom-made template can be used both for cutting and repositioning of the mandible arches for executing a BSSO (bilateral sagittal split osteotomy) treatment. The idea was developed in order to give the possibility of using a custom-made template with standard plates, thus reducing long times, high costs and low availability of custom-made plates; this represents the proof of novelty of the proposed template, based on a well-established methodology. The methodology was completely developed in the CAD virtual environment and, after the surgeons' assessment, an in-vitro experiment by a maxillofacial surgeon was performed in order to check the usability and the versatility of the system, thanks to the use of additive manufacturing technologies. When computer-aided technologies are used for orthognathic surgery, there are significant time and cost savings that can be realised, as well as improved performance. The cost of the whole operation is lower than the standard one, thanks to the use of standard plates. To carry out the procedures, the proposed methodology allows for inexpensive physical mock-ups that enable the BSSO procedure to be performed.