Rare syndromes in dentistry Part 1: The Pierre Robin sequence: a focus on a rare congenital anomaly.

AIM: The aim of this paper was to enlighten the peculiar findings of the Pierre Robin sequence, a rare congenital anomaly with important afterbirth comorbidities. The management of this pathology requires highly specialised centers and highly qualified specialists in order to offer the best therapeutic strategy to the affected child. Early diagnosis and parental counseling play a key role in the managing of PRS: an earlier activation of the treatment path helps to yield better outcomes and to prevent complications. A case of a newborn affected by PRS is presented, showing the steps of the treatment strategy and the final outcome.

Palatal fistula resulting from cocaine abuse: a case report.

Cocaine blocks the reuptake of norepinephrine and dopamine of the sympathetic nervous system. It has a psychomotor stimulating effect that provokes euphoria, motor activity and an amplification of a well being sensation similar to the effect of amphetamines. Well known are the systemic effects of cocaine abuse (acute myocardial infarction, cardiac arrhythmias, aortic ruptures, cerebrovascular accidents). Several local effects are also documented involving above all palatal mucosa and central midface structures. The most common palatal lesions are fistulae resulting from ischemia caused by the constricting effect of cocaine on small vessels, mucosal breakdown, loss of palatal bone, and loss of nasal mucosa. IF cocaine use becomes chronic and compulsive, wider lesions may cause extensive destruction of the osteocartilagineous structures of the nose, sinus and palate, a syndrome called CIMDL (cocaine-induced midline destructive lesion). Many techniques have been described to treat these defects depending on the size and the involved structures of the face. These techniques range from local flaps to complex free flaps. The authors describe a case of a median hard and soft palatal fistula resulting from cocaine abuse treated with local bilateral palatal flaps, and analyze the most common therapeutic options described in literature.

Trigeminal and facial schwannoma: a case load and review of the literature.

Schwannoma or neurilemmoma are benign tumours originating from Schwann cells of the nerve sheath. They can arise from any peripheral, cranial, or autonomic nerve The treatment of extracranial head and neck schwannomas is surgical and the approach depends on the location and extent of the tumor and the nerve involved. The Authors report the case load of surgical managements of three different extracranial nerve schwannomas involved facial and trigeminal nerves, and a review of the literature.

Neonatal molding in deformational auricolar anomalies.

INTRODUCTION: Congenital auricular anomalies can be categorized either as malformational or deformational. The first are characterized by a partial absence of the skin or cartilage resulting in a constricted or underdeveloped pinna and require surgical correction. Deformations are characterized by a misshaped but fully developed pinna and are best treated by auricular molding. AIM: Authors want to present their case load in treatment of infants affected by deformational auricolar anomalies and describe their techniques using early splinting for congenital auricular deformities, like prominent ear, lop ear, constricted ear, Stahl's ear. PATIENTS AND METHODS: Between 2009 to 2011, in Maxillo and Oral Surgery Unit, a nonsurgical technique was used to treat 22 ears affected by deformational anomalies in 12 patients soon after birth. Four patients were female. This kind of nonsurgical correction of the deformed auricle was performed on lop ears (n=6), constricted ears (n=8), prominent ears (n= 4), Stahl's ear (n=4). Children more than two months old were also excluded. The mean of treatment time was 5.5 weeks. RESULTS: according to the Authors and the parents 100% of treated auricles improved. Improving at the end of the molding treatment was observed in 18% of the auricles, but recurrence to one year of stopping treatment. There were not complications caused by this procedure. CONCLUSIONS: The nonsurgical molding has the advantage to correct at a very early age a cosmetic abnormality, giving a natural and in the most of the time a satisfactory results, with a prevalence rate of complications of much less than surgical corrections.

New parameter for the evaluation of disgnathic patient's surgical planning: a preliminary report.

BACKGROUND: Indications for treatment of patients with maxillo-mandibular malformations have to be researched both in the severity of anatomical alteration affecting the face and psychological outcomes. Indeed, it has been underlined that patients decide to undergo orthodontic and orthognathic procedure mainly for aesthetical issues. Moreover the early combined functional and surgical treatment improves relationship skills in young adults. Dealing with these "aesthetic" features pre surgical planning presents some additional challenges. Even if orthognatic surgery aims to the correct repositioning of skeletal bases but we must achieve complete patient satisfaction. AIM: The Authors present a new parameter to be considered in the planning of patients who undergo orthognatic procedure being the restitution of the face the patient would have had without any pathologic mechanism with respect of the aesthetic features of the family. MATERIALS AND METHODS: Authors identified a series of parameters discussed by Arnett et al and performed a clinical and photographic evaluation of these parameters, in latero-lateral view, directly on the relatives of the patients. A cephalometric analysis, was performed and a series of parameters has been taken into account. CONCLUSIONS: It is very difficult to standardize universal parameters acceptable and applicable for every single case, considering that patient's awareness of the anatomical defect and post-surgical satisfaction don't relate to the correct cephalometric evaluation and the real aesthetic outcomes.

Pleomorphic adenoma of the lacrimal gland: two clinical cases.

INTRODUCTION: Pleomorphic adenoma of the lacrimal gland is uncommon but it is the most common benign epithelial tumor of this gland. In the literature few cases have been reported in patients aged between 6 years and 80 years with a mean age of 39 years. A correct diagnosis and treatment is fundamental in order to avoid a relapse and sometimes their malignant transformation. An incisional biopsy is better to be avoided because it could injure the capsule, leading to dissemination of tumoral cells in the orbital tissues with a recurrence rate of 30% over 5 years. AIM: This papers want to support the use of mini-invasive surgery for the treatment of orbital lesions when it is possible. MATERIALS AND METHODS: We report two clinical cases of pleomorphic adenoma affecting the lacrimal gland treated with two different surgery approaches. The radiographic and photographic documentation of the patients was collected in the pre-and post-operatively. All patients underwent a CT scan and MRI. CONCLUSIONS: This lesions requires a well-grounded clinical and therapeutic protocol to avoid the risk of malignant transformation or disease recurrence, very dangerous at this site. CT scan and MRI scan are very important to recognize different types of lesions involving the lacrimal gland and fossa. A mini-invasive surgery reduces hospitalization, risk of complications, surgical times and bleedings and guarantees an excellent functional and esthetic result when performed by a skilled surgeon.

Le Fort III osteotomic variants.

INTRODUCTION: Midface hypoplasia is a skeletal defect involving all three space planes, hence needing a three-dimensional repositioning. This research study shows two cases of cranio-facial dysostosis, on which two Le Fort III variants were performed. CASE REPORT: In the first case we report the performing the two types of osteotomy simultaneously. Le Fort I, however, has been performed without any pterygomaxillary disjunctions, thus accomplishing a complete midface mobilization without any variation of the occlusal ratios. In the second case a modified Le Fort III osteotomy has been performed with median disjunction; reduction of the transverse interdacryal diameters and of the pyriform opening. DISCUSSION: Among all osteotomic variants we would like to mention the one introduced by Obwegeser in 1969 where, in patients with acceptable dental occlusal ratios, Le Fort III and Le Fort I have been performed in conjunction. This technique allows a different midface and dental occlusion repositioning. CONCLUSIONS: In adult patients with permanent dentition and normal occlusal ratios this technique may be chosen for a midface advancement without compromising the dento-skeletal relations, in order to achieve the best functional and aesthetical results.

Do lower third molars increase the risk of complications during mandibular sagittal split osteotomy? Systematic review and meta-analysis.

The aim of this systematic review was to investigate whether the presence of third molars (3Ms) during sagittal split osteotomy of the mandible increases the risk of complications. Searches were conducted using MEDLINE via PubMed, LILACS, Cochrane Central, Scopus, DOSS, and SIGLE via OpenGrey up to December 2020. Fifteen articles were included for evaluation and 14 in the meta-analysis, with a total of 3909 patients and 7651 sagittal split osteotomies (670 complications). Inferior alveolar nerve (IAN) exposure in the proximal segment was the most frequent complication (n = 409), followed by bad splits (n = 151). Meta-analysis revealed no significant increase in the incidence of 3M-related IAN exposure (P = 0.45), post-surgical infections (P = 0.15), osteosynthesis material removal (P = 0.37), or bad splits (P = 0.23). The presence of 3Ms was associated with a reduced risk of nerve disorder (P = 0.05) and favoured bad splits in the lingual plate (P = 0.005). The quality of evidence was very low, mainly due to non-randomized study designs, high risk of bias, inconsistency, and imprecision. This systematic review suggests that the removal of 3Ms before sagittal mandibular osteotomy does not reduce the incidence of complications. Thus, we recommend future better-designed studies with rigorous methodologies and adjustments for confounding factors.

Fetal MRI as a complement to US in the evaluation of cleft lip and palate.

PURPOSE: The aim of our study was to investigate the role of fetal magnetic resonance imaging (MRI) as a complement to ultrasound (US) in the evaluation of cleft lip and palate (CLP), whether isolated or in association with syndromic conditions. MATERIALS AND METHODS: We enrolled 24 pregnant women (27 fetuses) (mean gestational age 23.7 weeks) with a level-two US diagnosis of cleft lip (CL) or CLP with or without associated central nervous system (CNS) or facial-bone anomalies. All individuals underwent a fetal MRI examination to study the facial skeleton, CNS and fetal body. For each fetus, the main anatomical facial landmarks and biometric parameters [anteroposterior diameter (APD), biparietal diameter (BPD), inferior facial angle (IFA), frontomaxillary angle (FMA), bi-orbital diameter (BOD), intraorbital diameter (IOD)] were measured. RESULTS: Twenty-five of 27 fetuses had a US diagnosis of CL or CLP. MRI confirmed the diagnosis in 16/25 fetuses and added information about the extent of the cleft and the degree of involvement of the anterior and posterior palate in 8/25 fetuses. MRI ruled out the diagnosis in 1/25 fetuses and identified an alteration of the parameters IFA, FMA and IOD in 6/24 fetuses. CONCLUSIONS: In the study of CLP fetal, MRI is able to define the degree of involvement of the posterior palate and the lateral extent of the cleft with higher diagnostic accuracy than US. Furthermore, MRI provides a complete study of the fetal head and biometric development of the facial bones, thus enabling early detection of potential syndromic conditions.

Iatrogenic damage to the mandibular nerves as assessed by the masseter inhibitory reflex.

Iatrogenic injury of the inferior alveolar or lingual nerves frequently leads to legal actions for damage and compensation for personal suffering. The masseter inhibitory reflex (MIR) is the most used neurophysiological tool for the functional assessment of the trigeminal mandibular division. Aiming at measuring the MIR sensitivity and specificity, we recorded this reflex after mental and tongue stimulations in a controlled, blinded study in 160 consecutive patients with sensory disturbances following dental procedures. The MIR latency was longer on the affected than the contralateral side (P < 0.0001). The overall specificity and sensitivity were 99 and 51%. Our findings indicate that MIR testing, showing an almost absolute specificity, reliably demonstrates nerve damage beyond doubt, whereas the relatively low sensitivity makes the finding of a normal MIR by no means sufficient to exclude nerve damage. Probably, the dysfunction of a small number of nerve fibres, insufficient to produce a MIR abnormality, may still engender important sensory disturbances. We propose that MIR testing, when used for legal purposes, be considered reliable in one direction only, i.e. abnormality does prove nerve damage, normality does not disprove it.

Impact of COVID-19 on maxillofacial surgery practice: a worldwide survey.

The outbreak of coronavirus disease 2019 (COVID-19) is rapidly changing our habits. To date, April 12, 2020, the virus has reached 209 nations, affecting 1.8 million people and causing more than 110,000 deaths. Maxillofacial surgery represents an example of a specialty that has had to adapt to this outbreak, because of the subspecialties of oncology and traumatology. The aim of this study was to examine the effect of this outbreak on the specialty of maxillofacial surgery and how the current situation is being managed on a worldwide scale. To achieve this goal, the authors developed an anonymous questionnaire which was posted on the internet and also sent to maxillofacial surgeons around the globe using membership lists from various subspecialty associations. The questionnaire asked for information about the COVID-19 situation in the respondent's country and in their workplace, and what changes they were facing in their practices in light of the outbreak. The objective was not only to collect and analyse data, but also to highlight what the specialty is facing and how it is handling the situation, in the hope that this information will be useful as a reference in the future, not only for this specialty, but also for others, should COVID-19 or a similar global threat arise again.

Impact of COVID-19 epidemic on maxillofacial surgery in Italy.

Maxillofacial departments in 23 surgical units in Italy have been increasingly involved in facing the COVID-19 emergency. Elective surgeries have been progressively postponed to free up beds and offer human and material resources to those infected. We compiled an inventory of 32 questions to evaluate the impact of the SARS-COV2 epidemic on maxillofacial surgery in 23 selected Italian maxillofacial departments. The questionnaire focused on three different aspects: the variation of the workload, showing both a reduction of the number of team members (-16% among specialists, -11% among residents) due to reallocation or contamination and a consistent reduction of elective activities (the number of outpatient visits cancelled during the first month of the COVID-19 epidemic was about 10 000 all over Italy), while only tumour surgery and trauma surgery has been widely guaranteed; the screening procedures on patients and physicians (22% of maxillofacial units found infected surgeons, which is 4% of all maxillofacial surgeons); and the availability of Personal Protective Equipment, is only considered to be partial in 48% of Maxillofacial departments. This emergency has forced those of us in the Italian health system to change the way we work, but only time will prove if these changes have been effective.

Sequences and structures required for recombination between virus-associated RNAs.

RNA recombination has been described for a number of viruses in the plant and animal kingdoms, but the mechanisms of selection of recombination sites are poorly understood. The nonrandom recombination between two subviral RNAs associated with turnip crinkle virus was used to study the requirement for specific sequences and structures in the generation of recombinant molecules. Single-base mutations that disrupted either the stem or the loop of one of the two computer-predicted stem-loop structures eliminated detectable recombinant molecules. However, recombinants were detected if compensatory mutations were generated that re-formed a stable hairpin structure. These results provide evidence for the necessity of specific structures in the formation of recombinant molecules in this system.

Morphometric evaluation of the temporomandibular joint and the masticatory spaces: the role of high-definition MRI.

AIM: The aim of this work was to describe the anatomy of the temporomandibular joint (TMJ), the masticator spaces and their possible variance by means of magnetic resonance imaging MRI. METHODS: We evaluated one TMJ in each of 28 volunteers (14 males and 14 females) without temporomandibular disorders. The TMJ with mouth closed was evaluated on axial, coronal and sagittal planes obtained with a 1.5 Tesla magnetic resonance scanner. MRI scans of the anatomic patterns of the temporomandibular region were analyzed and compared with the classical anatomy notions reported in the literature. Morphometric evaluation of the temporomandibular region and the medial and lateral pterygoid muscles was carried out. RESULTS: MRI anatomy of the TMJ, the masticator spaces and their possible variance were accurately described. In addition, morphometric evaluation of the TMJ and the masticator spaces was performed. Statistical analysis of the measurements showed that the length of the structures related to the glenoid fossa were usually longer in the female than in the males, whereas the condyle and masticator muscles were usually greater in the males than in the females. T-tests showed no significant differences (P > 0.05) between the measurements of the right and left TMJ. CONCLUSIONS: In preoperative maxillofacial surgery assessment, MRI is a useful tool to reduce operating time, avert surgical complications and improve patient outcome.

Current Strategies and Future Outlook for Managing the Neotropical Tomato Pest Tuta absoluta (Meyrick) in the Mediterranean Basin.

The invasion of new regions by exotic pests has been more than ever a critical issue that warrants coordinated international actions to manage established populations and prevent further spreading. Invasive insects can undermine the ecological equilibrium of both natural and agricultural ecosystems. Moreover, increasing temperatures due to climatic change exacerbate this problem by allowing pests to further reach regions previously considered unsuitable. The tomato pinworm Tuta absoluta (Meyrick) (Lepidoptera) is an exotic pest native to Peru that has spread beyond Neotropical America. In Europe, its occurrence was reported in Spain in 2006, and thereafter, it has spread throughout the Mediterranean Basin and further into Africa and part of Asia. While T. absoluta can cause losses to tomato production all over the globe, the differences in each invaded region (e.g., climate, vegetation) may affect its population dynamics and, consequently, management protocols. Therefore, the main intent of this forum paper is to explore how European growers and researchers are dealing with T. absoluta in the Mediterranean area. As for many other invasive pests, the best approach has been the adoption of integrated pest management (IPM). Specifically, the integration of biological control agents (e.g., mirid predators and egg parasitoids), microbial insecticides (i.e., Bacillus thuringiensis), selective chemical insecticides, and sex pheromone-based control has proven adequate, especially in tomato greenhouses. Nonetheless, some of the challenges ahead include the development of resistant tomato cultivars, the management of wild vegetation and companion plants to optimize the conservation of natural enemies and their effectiveness at the crop level, the management of insecticide resistance, and the improvement of sex pheromone-based tactics.

Anatomic relationship between trigeminal nerve and temporomandibular joint.

Temporomandibular joint disorders (TMD) is a collective term used to describe pathologic conditions involving temporomandibular joint (TMJ), masticatory muscles and associated structures. Common related complaints include local pain, limited mouth opening and TMJ noises whereas symptoms often associated to TMD with debated pathogenesis enclose earache, headaches, tinnitus and trigeminal-like symptoms such as atypical orofacial pain. In particular, TMD trigeminal associated symptoms are intricate, difficult to treat and exert a great impact on everyday life of the patients thus invoking a complex multidisciplinary treatment. In this paper, the authors analyze the anatomic and topographic relationships between the mandibular branch of the trigeminal nerve and the medial aspect of the TMJ capsule in 8 fresh adult cadavers thus resuming a pathologic relationship between atypical trigeminal symptoms and TMD.

Security "high-tech" individual extra-light device mask 2.0: CAD/CAM evolution.

In 2008, we presented our security "high-tech" individual extra-light device mask (SHIELD), a protective shield based on the face cast of an injured soccer player that can be customised. It allows a shortened convalescent period, is comfortable, fits well, and allows the patient to continue to play at a professional level in their chosen sport or activity in the shortest time possible. It has been used often in both amateur and professional categories of many sports, and we now present an update.

Evaluation of the Adolescent Drug Abuse Diagnosis instrument in a Swiss sample of drug abusers.

OBJECTIVE: The aim of this study was to evaluate a French language version of the Adolescent Drug Abuse Diagnosis (ADAD) instrument in a Swiss sample of adolescent illicit drug and/or alcohol users. PARTICIPANTS AND SETTING: The participants in the study were 102 French-speaking adolescents aged 13-19 years who fitted the criteria of illicit drug or alcohol use (at least one substance--except tobacco--once a week during the last 3 months). They were recruited in hospitals, institutions and leisure places. Procedure. The ADAD was administered individually by trained psychologists. It was integrated into a broader protocol including alcohol and drug abuse DSM-IV diagnoses, the BDI-13 (Beck Depression Inventory), life events and treatment trajectories. RESULTS: The ADAD appears to show good inter-rater reliability; the subscales showed good internal coherence and the correlations between the composite scores and the severity ratings were moderate to high. Finally, the results confirmed good concurrent validity for three out of eight ADAD dimensions. CONCLUSIONS: The French language version of the ADAD appears to be an adequate instrument for assessing drug use and associated problems in adolescents. Despite its complexity, the instrument has acceptable validity, reliability and usefulness criteria, enabling international and transcultural comparisons.

Use of rigid external fixation in fractures of the mandibular condyle.

In this article the use of a rigid external fixation system is proposed for the early treatment of condylar fractures. This method offers the advantage of not damaging the articular structures during reduction and allows early mobilization for a rapid recovery. In our Centre 28 patients have been treated with the rigid external fixation system, with good functional results. Of these 15 men and 13 women, 22 had a monocondylar fracture and 6 had a bicondylar fracture. In all the cases there was complete recovery of the occlusal stituation and of the mouth opening; no patient surgically treated with this method has ever presented problems of a local or general nature. The purpose of this report was to evaluate the use of external fixation for the treatment of extracapsular condylar fractures with luxation of the fragment out of the glenoid cavity.

Debonding of adhesively restored deep Class II MOD restorations after functional loading.

PURPOSE: To assess debonding due to functional loading at the cervical dentin margins of deep Class II MOD restorations prepared with a variety of adhesive restoratives in endodontically-treated teeth. MATERIALS AND METHODS: MOD preparations and endodontic treatment were carried out on extracted sound maxillary premolars. The cavities were restored with seven material combinations: Three different resin-based composites (RBC) (Z100, Herculite XRV or Clearfil RP with their respective bonding systems); two bonded amalgam combinations (Valiant with Superbond D or with Panavia 21) and two sandwich combinations [the RBC Tetric with the polyacid-modified RBC (compomer) Compoglass or Z100 with the resin-modified glass ionomer Fuji II LC]. For each group, half of the samples were exposed to mechanical functional loading and the other half served as control. Imperfect bond formation and debonding due to loading was determined by dye penetration. In addition, the dye penetration scores were correlated with the cusp fracture strengths of similarly prepared restorations of a previous study. RESULTS: After functional loading, the RBC in combination with hybridizing dentin bonding agents showed better preservation of marginal integrity than the sandwich restorations, which in turn performed better than the amalgam restorations (P < 0.05). Debonding correlated with reduction in fracture resistance. Under the conditions of this study, debonding of adhesive MOD restorations by functional loading can best be prevented by using RBC in combination with hybridizing dentin-bonding systems.