Copy number variation analysis implicates novel pathways in patients with oculo-auriculo-vertebral-spectrum and congenital heart defects.

Oculo-auriculo-vertebral spectrum (OAVS) is a developmental disorder of craniofacial morphogenesis. Its etiology is unclear, but assumed to be complex and heterogeneous, with contribution of both genetic and environmental factors. We assessed the occurrence of copy number variants (CNVs) in a cohort of 19 unrelated OAVS individuals with congenital heart defect. Chromosomal microarray analysis identified pathogenic CNVs in 2/19 (10.5%) individuals, and CNVs classified as variants of uncertain significance in 7/19 (36.9%) individuals. Remarkably, two subjects had small intragenic CNVs involving DACH1 and DACH2, two paralogs coding for key components of the PAX-SIX-EYA-DACH network, a transcriptional regulatory pathway controlling developmental processes relevant to OAVS and causally associated with syndromes characterized by craniofacial involvement. Moreover, a third patient showed a large duplication encompassing DMBX1/OTX3, encoding a transcriptional repressor of OTX2, another transcription factor functionally connected to the DACH-EYA-PAX network. Among the other relevant CNVs, a deletion encompassing HSD17B6, a gene connected with the retinoic acid signaling pathway, whose dysregulation has been implicated in craniofacial malformations, was also identified. Our findings suggest that CNVs affecting gene dosage likely contribute to the genetic heterogeneity of OAVS, and implicate the PAX-SIX-EYA-DACH network as novel pathway involved in the etiology of this developmental trait.

Koolen-de Vries syndrome in the first adulthood patient of Southern India ancestry.

Koolen-de Vries syndrome (KdVS, MIM#610443) is a rare malformation condition mainly characterized by cognitive impairment in association with craniofacial and visceral anomalies. The core phenotype is caused by mutations in the chromatin remodeler KANSL1 (MSL1V1, KIAA1267, KAT8 Regulatory NSL Complex Subunit 1, MIM#612452), which maps to 17q21.31 critical genomic region (Koolen et al., Nature Genetics 2012;44:639-641). Considering its molecular basis, KdVS is included in the group of Developmental Disorders of Chromatin Remodeling (DDCRs), also termed chromatinopathies. We describe the first KdVS patient of Southern India ethnicity, harboring the typical de novo 17q21.31 microdeletion, including KANSL1. Observed facial features and congenital anomalies are in line with the already reported KdVS phenotype, suggesting that phenotypic features are consistent across different ethnicities.

Mandibular Fractures Epidemiology and Treatment Plans in the Center of Italy: A Retrospective Study.

ABSTRACT: The epidemiology of maxillofacial fractures is variable in different geographic regions. Economic and social conditions, laws and types of behavior can be considered the most important factors influencing these differences.Mandibular fractures were first cited in 1650 BC in an Egyptian papyrus. Today, these fractures are one of the most prevalent facial skeletal injuries.A 4-year retrospective study was performed and the trauma - related data were collected from medical and radiological archives. The analysis comprised patients admitted for mandibular fracture at Sapienza University of Rome - Policlinico Umberto I between January 1, 2016 and December 31, 2019. The data include age, sex, etiology, anatomical sites of the fractures, eventual maxillofacial associated fractures and treatment.We collected 172 patients, 138 males (80.2%) and 34 females (19.8%) with 270 mandibular fractures. The average age was 35.4 years. The youngest and oldest patients were aged 6 and 90 years, respectively. The age group 20 to 29 years was the most represented with 52 patients (30.2% of the total sample). Assaults were the most common etiology (n = 53, 30.8%), followed by falls (n = 45, 26.2%). The condyle was the most involved region (n = 86, 32%), followed by parasymphysis region (n = 72, 26.6%) and angle (n = 62, 23%).154 patients (89.5%) reported only mandibular fractures. Eighteen patients (10.5%) had other associated maxillofacial fractures; the most frequently encountered maxillofacial fractures associated with mandibular fractures were the zygomatic complex fractures (n = 9, 5.2%). Open reduction and internal fixation was the most preferred surgical treatment (n = 115, 66.9%).This study showed that mandibular fractures predominate in 20 to 29 years group and in the male sex. Assaults are the most frequent cause. The prevalent fracturing site is condylar process. Orbital - maxillary - zygomatic complex fractures were the most common associated maxillofacial fractures and open reduction and internal fixation was the preferred surgical strategy.The results of this analysis agree to other studies and provide important clinical information that will help in study of these injuries.

Genome-Wide DNA Methylation Analysis of a Cohort of 41 Patients Affected by Oculo-Auriculo-Vertebral Spectrum (OAVS).

Oculo-auriculo-vertebral-spectrum (OAVS; OMIM 164210) is a rare disorder originating from abnormal development of the first and second branchial arch. The clinical phenotype is extremely heterogeneous with ear anomalies, hemifacial microsomia, ocular defects, and vertebral malformations being the main features. MYT1, AMIGO2, and ZYG11B gene variants were reported in a few OAVS patients, but the etiology remains largely unknown. A multifactorial origin has been proposed, including the involvement of environmental and epigenetic mechanisms. To identify the epigenetic mechanisms contributing to OAVS, we evaluated the DNA-methylation profiles of 41 OAVS unrelated affected individuals by using a genome-wide microarray-based methylation approach. The analysis was first carried out comparing OAVS patients with controls at the group level. It revealed a moderate epigenetic variation in a large number of genes implicated in basic chromatin dynamics such as DNA packaging and protein-DNA organization. The alternative analysis in individual profiles based on the searching for Stochastic Epigenetic Variants (SEV) identified an increased number of SEVs in OAVS patients compared to controls. Although no recurrent deregulated enriched regions were found, isolated patients harboring suggestive epigenetic deregulations were identified. The recognition of a different DNA methylation pattern in the OAVS cohort and the identification of isolated patients with suggestive epigenetic variations provide consistent evidence for the contribution of epigenetic mechanisms to the etiology of this complex and heterogeneous disorder.

Genetically driven CD39 expression shapes human tumor-infiltrating CD8+ T-cell functions.

In our study, we investigated the role of CD39 on tumor-infiltrating CD8+ T lymphocytes (CD8+ TILs) in colorectal, head and neck and pancreatic cancers. Partially confirming recent observations correlating the CD39 expression with T-cell exhaustion, we demonstrated a divergent functional activity in CD39+ CD8+ TILs. On the one hand, CD39+ CD8+ TILs (as compared to their CD39- counterparts) produced significantly lower IFN-γ and IL-2 amounts, expressed higher PD-1, and inversely correlated with perforin and granzyme B expression. On the other, they displayed a significantly higher proliferative capacity ex vivo that was inversely correlated with the PD-1 expression. Therefore, CD39+ CD8+ TILs, including those co-expressing the CD103 (a marker of T resident memory [TRM] cells), were defined as partially dysfunctional T cells that correlate with tumor patients with initial progression stages. Interestingly, our results identified for the first time a single nucleotide polymorphism (SNP rs10748643 A>G), as a genetic factor associated with CD39 expression in CD8+ TILs. Finally, we demonstrated that compounds inhibiting CD39-related ATPases improved CD39+ CD8+ T-cell effector function ex vivo, and that CD39+ CD8+ TILs displayed effective suppression function in vitro. Overall these data suggest that the SNP analysis may represent a suitable predictor of CD39+ CD8+ T-cell expression in cancer patients, and propose the modulation of CD39 as a new strategy to restore partially exhausted CD8+ TILs.

Maxillo-Mandibular Reconstruction in Pediatric Patients: How To Do It?

Maxillo-mandibular reconstruction in pediatric patients involves particular functional and cosmetic implications. Attention is required for the craniofacial growth over time, involvement of the permanent dentition, facial symmetry, and donor site morbidity. Our aim is to identify the best reconstructive options for maxilla-mandibular defects in children (<18 years) based on our experience with 25 pediatric patients. We believe that reconstruction has to be performed at the same time as resection in pediatric patients. Local flaps should be reserved for cases of maxillary defects because of malignant neoplasms, which ultimately have poor prognosis. In cases of large mandibular defects, radiotherapy is eventually required. When the condition of the soft tissues is poor (because of previous surgery, etc), free flaps potentially represent the best options. Nevertheless, in patients younger than 5 years old (with no damaged tissues), reconstruction with rib grafts should be performed, and the use of titanium plates should be reserved for very select cases (such as temporary reconstruction in toddlers).

A de novo proximal 3q29 chromosome microduplication in a patient with oculo auriculo vertebral spectrum.

Oculo auriculo vertebral spectrum (OAVS; OMIM 164210) is a clinically and genetically heterogeneous disorder originating from an abnormal development of the first and second branchial arches. Main clinical characteristics include defects of the aural, oral, mandibular, and vertebral development. Anomalies of the cardiac, pulmonary, renal, skeletal, and central nervous systems have also been described. We report on a 25-year-old male showing a spectrum of clinical manifestations fitting the OAVS diagnosis: hemifacial microsomia, asymmetric mandibular hypoplasia, preauricular pits and tags, unilateral absence of the auditory meatus, dysgenesis of the inner ear and unilateral microphthalmia. A SNP-array analysis identified a de novo previously unreported microduplication spanning 723 Kb on chromosome 3q29. This rearrangement was proximal to the 3q29 microdeletion/microduplication syndrome region, and encompassed nine genes including ATP13A3 and XXYLT1, which are involved in the organogenesis and regulation of the Notch pathway, respectively. The present observation further expands the spectrum of genomic rearrangements associated to OAVS, underlying the value of array-based studies in patients manifesting OAVS features.

Juvenile idiopathic/rheumatoid arthritis and orthognatic surgery without mandibular osteotomies in the remittent phase.

BACKGROUND: Orthognathic treatment of patients with juvenile idiopathic/rheumatoid arthritis is still controversial. Mandibular procedures may result in relapse and further condylar resorption and pain. Maxillary osteotomies and genioplasty may be effective for the correction of malocclusion and for aesthetics. PATIENTS AND METHODS: Five patients with juvenile idiopathic/rheumatoid arthritis with severe temporomandibular joint (TMJ) involvement underwent orthognathic surgery with a simultaneous Le Fort I osteotomy and advancement genioplasty. The age of the patients at the time of surgery ranged between 17 and 29 years (mean, 21.75 years). The patients were under follow-up for a minimum of 8 months after surgery, and measurements were performed using Dolphin 3D imaging. RESULTS: All 5 patients have an improved occlusion and improved facial aesthetics. The mean mandible rotation advancement was 5.6 mm (range, 4 to 7 mm). The mean posteroanterior face height ratio (S-Go/N-Me) after surgery was 63.9 (range, 62.9 to 65.8). No exacerbation of the juvenile rheumatoid arthritis was encountered as a result of the surgical procedure. CONCLUSIONS: Le Fort I osteotomy with impaction and advancement genioplasty are effective procedures for occlusal and aesthetic correction of juvenile idiopathic/rheumatoid patients. Mandibular procedures may evoke further condylar resorption with pain and functional impairment of the TMJ.

Surgical management of enophthalmos in Duane syndrome.

Duane syndrome is a congenital disorder of eye movement characterized by partial or absent development of the sixth cranial nerve nucleus and/or the sixth nerve itself. Patients often undergo procedures, both surgical and nonsurgical, to correct ocular misalignment and improve the resulting visual problems. We present a case report of a 49-year-old woman with left-sided Duane syndrome who underwent aesthetic surgical correction of enophthalmos.

FOXI3 pathogenic variants cause one form of craniofacial microsomia.

Craniofacial microsomia (CFM; also known as Goldenhar syndrome), is a craniofacial developmental disorder of variable expressivity and severity with a recognizable set of abnormalities. These birth defects are associated with structures derived from the first and second pharyngeal arches, can occur unilaterally and include ear dysplasia, microtia, preauricular tags and pits, facial asymmetry and other malformations. The inheritance pattern is controversial, and the molecular etiology of this syndrome is largely unknown. A total of 670 patients belonging to unrelated pedigrees with European and Chinese ancestry with CFM, are investigated. We identify 18 likely pathogenic variants in 21 probands (3.1%) in FOXI3. Biochemical experiments on transcriptional activity and subcellular localization of the likely pathogenic FOXI3 variants, and knock-in mouse studies strongly support the involvement of FOXI3 in CFM. Our findings indicate autosomal dominant inheritance with reduced penetrance, and/or autosomal recessive inheritance. The phenotypic expression of the FOXI3 variants is variable. The penetrance of the likely pathogenic variants in the seemingly dominant form is reduced, since a considerable number of such variants in affected individuals were inherited from non-affected parents. Here we provide suggestive evidence that common variation in the FOXI3 allele in trans with the pathogenic variant could modify the phenotypic severity and accounts for the incomplete penetrance.

Le Fort III external midface distraction: surgical outcomes and skeletal stability.

A retrospective study on the stability of Le Fort III midface advancement with distraction in craniofacial dysostosis. Twenty-six surgical procedures for midface advancement were performed between 2000 and 2009. Subjects were 14 consecutive patients who underwent Le Fort III osteotomy with midface advancement using a rigid external distraction device (Synthes) in the Dep of Maxillo-Facial Surgery of the University "Sapienza" of Rome. In this study, 8 patients (n = 3 females, n = 5 males) affected by craniofacial dysostosis (Crouzon, n = 5; Apert, n = 3; Pfeiffer syndrome, n = 1; and other, n = 1) were selected on the basis of age and radiologic documentation. The mean age at the time of the procedure was 8.6 years, and all the patients had at least 1 year of follow-up after distraction.The radiologic documentation of each case was composed of posteroanterior and lateral cephalograms preoperatively (T1), at the time of removal of the distractor device (T2), and at follow-up (T3).The average latency period before activation of the distractor was 5 days. The device was activated on an average of 15 mm (range, 7-22 mm) as recorded on the device at a rate of 1 mm/d. Activation period ranged from 7 to 15 days, and the consolidation period was 8 to 12 weeks.Seven anatomic landmarks and 5 cephalometric measurements were identified on the lateral cephalograms at each of the 3 time periods. The cephalograms underwent digital analysis via Dolphin imaging digitalization software by 2 operators independently. The displacement of each identified landmark was recorded and examined in relation to their position at each time point.Cephalometric analysis revealed stability of Le Fort III midface advancement during follow-up. However, bone growth after midface advancement is limited, and as reported in the literature, almost no spontaneous growth is present because of the intrinsic nature of malformations. Patients treated in the growing age benefit from midface advancement, with resolution of exophthalmos, ocular bulb exposure, airway impairment, and good aesthetic outcome.

Three-Dimensional Comparison of the Maxillary Surfaces through ICP-Type Algorithm: Accuracy Evaluation of CAD/CAM Technologies in Orthognathic Surgery.

PURPOSE: This retrospective study aims to compare the accuracy of two different CAD/CAM systems in orthognathic surgery. The novelty of this work lies in the method of evaluating the accuracy, i.e., using an Iterative Closest Point (ICP) algorithm, which matches a pair of 2D or 3D point clouds with unknown dependencies of the transition from scan s(k) to scan s(k+1). METHODS: The study population was composed of ten patients who presented to the Maxillofacial Surgery Department of the University "Sapienza" of Rome for the evaluation and management of skeletal malocclusions. The patients were divided into two groups, depending on the technique used: group 1: splintless group (custom-made cutting guide and plates); group 2: splint group (using a 3D-printed splint). STL files were imported into Geomagic® Control X™ software, which allows for comparison and analysis using an ICP algorithm. The RMSE parameter (3D error) was used to calculate the accuracy. In addition, data were compared in two different patient subgroups. The first subgroup only underwent a monobloc Le Fort I osteotomy (p-value = 0.02), and the second subgroup underwent a Le Fort I osteotomy associated with a segmental osteotomy of the maxilla (p-value = 0.23). RESULTS: Group 1 showed a 3D error of 1.22 mm ± SD 0.456, while group 2 showed a 3D error of 1.63 mm ± SD 0.303. These results have allowed us to compare the accuracy of the two CAD/CAM systems (p-value = 0.09). CONCLUSIONS: The ICP algorithm provided a reproducible method of comparison. The splintless method would seem more accurate (p-value = 0.02) in transferring the surgical programming into the operating room when only a Le Fort I osteotomy is to be performed.

Orbital lesions, an interdisciplinary pathology. The experience of the maxillo-facial surgeons.

AIM: The main focus of this paper was to describe our experience in the management of primary lesions involving the orbit, analyzing signs and symptoms and illustrating surgical management. MATERIAL OF STUDY: We describe our experience managing 62 consecutive patients diagnosed with orbital tumors confined to the orbital content (not involving skin or bone, with no intracranial invasion) and treated between January 2013 and December 2016. Demographic characteristics, symptoms, clinical findings, histological types and approaches have been recorded. RESULTS: We found that the most common clinical manifestations were exophthalmos/proptosis and ocular movement impairment; the most common histological types were vascular malformation and ocular adnexal lymphomas. DISCUSSION: Primary neoplasms involving orbital contents include a broad spectrum of pathologies difficult to manage without a firm diagnosis, usually histological. Different surgical accesses are described in order to perform incisional biopsy or resection of the mass. CONSCLUSION: In every case, accurate surgical planning is mandatory, in order to prevent functional and/or aesthetic complications. KEY WORDS: Blepharoplasty incision, Intraorbital neoplasia, Lateral orbital tumor, Orbitotomy, Surgical treatment, Transconjunctival approach.

Upper airway volume after Le Fort III advancement in subjects with craniofacial malformation.

AIM: There are no quantitative standards for the volumetric measurements of the airway space after Le Fort III advancement. Computed tomographic (CT) scans have provided the opportunity to compare with the accuracy of real anatomic changes, thus the functional improvements, resulting after a surgical treatment. MATERIALS AND METHODS: Three-dimensional CT scans processed by Digital Imaging and Communications in Medicine files in Dolphin 3D software were used to assess the airway space volume in 4 subjects affected by craniofacial syndromic malformations treated with Le Fort III advancement. The preoperative (T0) and postoperative (T1: 6 mo after surgery) three-dimensional craniofacial CT scans of the subjects were collected and retrospectively analyzed. Image segmentation of the anatomic structures of interest and the three-dimensional graphic rendering were done by using the Dolphin Imaging Plus 11.0 software. RESULTS: The airway space volume was significantly increased after surgery (mean [SD]: from 9166.57 [1861.48] mm to 15,300.45 [5114.09] mm; P < 0.01). The sagittal surfaces had an expansion from 798.92 (74.88) to 1151.45 (218.47) mm. The coronal surfaces grew from 226.75 (62.85) to 390.42 (102.21) mm, and axial surfaces increased 473.32 (62.34) to 676.00 (151.07) mm from T0 to T1. CONCLUSIONS: In conclusion, this study showed an increase in the upper airway space volume in white subjects after Le Fort III advancement.

Head and Neck Cancer Treatment during COVID-19 Pandemic: A Central Experience in Rome. Emergency Management, Infection Prevention and Control.

The COVID-19 pandemic has significantly affected the surgical units, especially those operating on the airways. This study evaluates the series of patients with tumors of the head and neck treated by our unit during Phase-1 of the pandemic and the efficacy of the preventive measures implemented for protecting both the patients and staff. A screening program was administered to all the patients who had to undergo surgery. None of the patients tested and operated during Phase 1, between 10 March and 18 May 2020, were positive for COVID-19. A significant portion of the patients was suffering from tumors in advanced stages (T3 and T4). Two patients developed respiratory symptoms during their stay at the unit, so they were put in precautionary isolation and tested, but resulted negative for COVID-19. All the surgical department staff followed the Italian Ministry of Health's prevention protocol and underwent serological testing. IgG and IgM were negative in everyone, thus confirming that nobody had been exposed to the virus. This study highlights the commitment to efficiently treating patients suffering from tumors of the head and neck region and confirms the effectiveness of the safety measures used to protect our patients and staff's health.

Metastasis from pancreatic adenocarcinoma to the cheekbone.

Skeletal metastasis by pancreatic adenocarcinoma are infrequent, and those located in the craniofacial region are very rare. We report the case of a 63-year-old Caucasian woman with a metastatic adenocarcinoma of the pancreatic head previously treated with surgery and chemotherapy presenting a skeletal metastasis in the left cheekbone 5 years after primary treatment. No other similar cases have been previously described. The therapeutic decision was not simple because of the uncommon site of pancreatic metastasis. Surgical resection was the only possibility after the radiotherapy failure. KEY WORDS: Cheekbone mass, Cheekbone metastasis, Pancreatic adenocarcinoma, Pancreatic adenocarcinoma metastasis.

Retrospective review of 78 rehabilitated head and neck postoncological patients: a new classification method.

BACKGROUND: Numerous studies have been published about the prosthetic rehabilitation of the postoncological maxillo-facial patient, but the guidelines that emerge lack a correlation between the anatomical classification of the treated site, which generally is preparatory upon surgery, and the type of prosthetic rehabilitation appropriate to the new anatomical and functional condition. With this correlation, it would be possible to obtain a multidisciplinary and predictable therapeutic process, able to identify from the beginning the best type of prosthetic rehabilitation. METHODS: The authors analyzed a sample of 78 patients treated in the Maxillofacial Surgery Unit of "Sapienza" University of Rome for a tumor of the head and neck area, and at a later stage prosthetically rehabilitated in the years from 2010 to 2013 in the Prosthetic Rehabilitation Unit of the same University because of the consequences of the ablative surgery. After having analyzed data concerning the treatment of the maxillofacial tumor, Authors classified the kind of prosthetic rehabilitation. Removable prosthesis was chosen in 18 cases, while implant (or teeth)-supported rehabilitation was performed in 60 cases. RESULTS: Authors correlated the kind of surgical reconstruction to the prosthetic rehabilitation performed. In the maxilla removable prosthesis was chosen in 8 cases, while implant supported rehabilitation was performed in 18 cases. In the mandible 10 cases were rehabilitated through a removable prosthesis and 42 through a teeth or implant supported prosthesis. CONCLUSIONS: It is evident the need to perform a careful evaluation of the patient, in order to identify the best possible prosthetic rehabilitation.

Adalimumab: Another Medication Related to Osteonecrosis of the Jaws?

Objective. The acronym MRONJ has been created in order to identify "Medication-Related Osteonecrosis of the Jaw," observed after the use of Bisphosphonates, RANK ligand inhibitor, and antiangiogenic medications. Only a case of osteonecrosis of the jaw in a Chron's disease patient following a course of Bisphosphonate and Adalimumab therapy has been recently described, so that it has been supposed that also this medication could promote manifestation of osteonecrosis. Clinical Case. On August, 2014, a 63-year-old female with a history of idiopathic arthritis treated with medical treatment with Adalimumab from 2010 to 2013 presented referring pain in the right mandible. Results. This patient presented with nonexposed osteonecrosis of the jaw after placement, on September, 2010, of four titanium fixtures in the mandible. Conclusions. The authors suggest that the biologic therapy with an anti-TNF-α antibody might promote the manifestation of osteonecrosis and compromise oral healing capacity of the bone.

Treatment timing and multidisciplinary approach in Apert syndrome.

Apert syndrome is a rare congenital disorder characterized by craniosynostosis, midface hypoplasia and symmetric syndactyly of hands and feet. Abnormalities associated with Apert syndrome include premature fusion of coronal sutures system (coronal sutures and less frequently lambdoid suture) resulting in brachiturricephalic dismorphism and impaired skull base growth. After this brief explanation it is clear that these anatomical abnormalities may have a negative impact on the ability to perform essential functions. Due to the complexity of the syndrome a multidisciplinary (respiratory, cerebral, maxillo-mandibular, dental, ophthalmic and orthopaedic) approach is necessary in treating the psychological, aesthetic and functional issues. The aim of this paper is to analyse the different functional issues and surgical methods trying to enhance results through a treatment plan which includes different specialities involved in Apert syndrome treatment. Reduced intellectual capacity is associated to the high number of general anaesthesia the small patients are subject to. Therefore the diagnostic and therapeutic treatment plan in these patients has established integrated and tailored surgical procedures based on the patients' age in order to reduce the number of general anaesthesia, thus simplifying therapy for both Apert patients and their family members.