Alessandro Silvestri

Functional therapy in hemifacial microsomia: therapeutic protocol for growing children.

PURPOSE This study evaluates the skeletal response to functional orthodontic therapy in growing children with hemifacial microsomia (HM). A method of classification for mandibular growth subsequent to treatment is also suggested. MATERIALS AND METHODS Sixteen growing children with unilateral HM were treated. Each patient was graded according to the skeletal, auricular, tissue (SAT) classification. Patients graded S4-S5 were excluded because the severity of the malformation made them unsuitable for functional orthodontic treatment. All patients initially underwent a period of treatment with an asymmetrical functional activator (AFA). RESULTS In 7 of 16 cases (43.7%) classified as S1-S2/T1, regardless of the value of A, functional therapy brought about mandibular growth greater on the side of the malformation (G3-G4), re-establishing structural and functional harmony of the entire stomatognathic apparatus. Of the five cases (31.2%) classified as S2/T2, four required surgical intervention at about 10 years of age after an initial period of functional therapy that produced mandibular growth classified G1-G2. In the other case, functional treatment was sufficient to correct the malformation. In four patients (25%) classified as S3/T3 or S3/T2, it was necessary to combine surgical treatment with functional therapy. CONCLUSION Use of the AFA in growing children with HM makes it possible to induce harmonious maxillomandibular growth. Statistically, in S1-S2/T2 cases, functional therapy brings about an overall resolution of the malformation whereas in more severe cases (S2/T2), it needs to be combined with orthodontics using fixed appliances and surgical intervention.

Fast and early mandibular osteodistraction (FEMOD) in severe Pierre Robin Sequence

Pierre Robin Sequence (PRS) is a congenital abnormality characterized by mandibular hypoplasia, glossoptosis and often secondary palate cleft. It may be an isolated or part of a most complicated syndrome. The genetic syndrome that most frequently co-occurs is Stickler syndrome characterized by skeletal abnormalities, joint pain, congenital myopia and retinal detachment. The authors describe their fast and early mandibular osteodistraction (FEMOD) protocol in severe cases of PRS airway obstruction.

Myofunctional and speech rehabilitation after orthodontic-surgical treatment of dento-maxillofacial dysgnathia

OBJECTIVES The lingual dysfunctions play a considerable role in the pathogenesis of dentoskeletal dysmorphisms. The treatment of dento-maxillofacial dysgnathia implies a functional rehabilitation to re-harmonize the stomatognathic system. This study aims to demonstrate the importance of a rehabilitation protocol of functional orofacial parameters at the end of a surgical-orthodontic treatment in order to achieve long-term success. MATERIALS AND METHODS After orthognathic surgery, facial expression exercises and jaw exercises are prescribed to promote the recovery of neuromuscular function. At the end of treatment, a sample of 30 dysgnathic patients underwent a functional evaluation of the orofacial district to identify any lingual or articulatory dysfunctions. The information gathered led to an individual re-education program that consisted of an active myofunctional-logopedic approach integrated with appliances used as retention. RESULTS 19 patients needed myofunctional therapy to re-educate deglutition and tongue posture. Articulatory disorders were found in 7 patients originally suffering from Class III and/or open-bite skeletal disharmony; 5 of these completed rehabilitation with speech therapy. After rehabilitation the functional parameters were completely normalized in 12 patients; in 5 cases, partial improvements were obtained, while in 2 cases the therapy was ineffective. CONCLUSIONS In a patient undergoing post-surgical reconsolidation of his/her functional equilibrium even an uncontrolled speech defect may lead to an instable result. Only through an interdisciplinary approach it is possible to intercept and re-educate all the functions that are not compliant with the structural changes and to eliminate a tendency to relapse of the dysgnathia.

True hemifacial microsomia and hemimandibular hypoplasia with condylar-coronoid collapse: Diagnostic and prognostic differences

INTRODUCTION Long-term results after orthopedic or surgical treatment of hemifacial microsomia (HFM) have shown a tendency toward recurrence of the facial asymmetry. However, the literature contains a number of successful case reports that show surprising changes in the morphology of the condyles. In addition, patients with similar mandibular asymmetries, treated early with surgery, have excellent long-term follow-ups, especially those who have little or no soft-tissue involvement, but only severe mandibular ramal deformities. The phenotypes of these cases are unexpectedly similar, with a consistent collapse of the condyle against the coronoid and a deep sigmoid notch. The objectives of this article were to help distinguish true HFM from this peculiar type of hemimandibular asymmetry morphologically and to quantify their differences before treatement and in the long term. METHODS Panoramic radiographs taken at pretreatment and the long-term follow-up of 9 patients with hemimandibular hypoplasia, characterized by the collapse of the condyle against the coronoid, were compared with those of 8 patients with severe type I and type II HFM; these records were collected before and at least 10 years after distraction osteogenesis. RESULTS Ratios and angular measurements before and after treatment differed significantly between the 2 groups. CONCLUSIONS Perhaps these patients were misdiagnosed and actually had secondary injuries of the condyle, which have a normal functional matrix. Therefore, with growth and functional stimulation, they would tend to grow toward the original symmetry. To make a differential diagnosis between true HFM and this peculiar type of hemimandibular hypoplasia, the collaboration between not only orthodontists and surgeons, but also geneticists and dysmorphologists, is of great importance because of the different prognoses.

Long-term control of the stability of skeletal structures in Class II dentoskeletal deformities after surgical-orthodontic therapy

This study analyzes long-term findings in a group of 10 patients with Class II dentoskeletal malrelationship and who have undergone orthognathic surgical procedures. Changes in cephalometric values relative to the bony structures of the upper jaw and of the mandible are discussed in detail. Patients were reexamined on average, 5.8 years after surgery to show possible modification of the skeletal regions in patients who underwent surgical-orthodontic treatment for malformation of the facial continuum. For each case we made a cephalometric analysis of the lateral cephalograms, as well as the superimposition of tracings relative to the various stages of treatment: at the end of preoperative orthodontic treatment, after surgery, and at the long-term control. Cephalometric values for all patients who took part in this long-term control were recorded and a structural assessment was made.

TMJ replacement utilizing patient-fitted TMJ TJR devices in a re-ankylosis child

Temporomandibular joint (TMJ) ankylosis is a pathological condition characterized by articular bony or fibrous tissue fusion. TMJ ankylosis developing during childhood can lead to growth complications because of the loss of mandibular function. Hard and soft autogenous tissue grafting has been used for TMJ reconstruction in the growing patient. However, in cases where autogenous tissue grafts fail either due to unpredictable growth or ankylosis, total alloplastic temporomandibular joint replacement (TMJ TJR) can provide a viable option. The case of a 7-year old female suffering from recurrent bilateral TMJ ankylosis resulting from birth trauma, and with concomitant obstructive sleep apnea syndrome (OSAS) is presented. Due to prior surgical and autogenous graft failures, the decision was made to complete her joint reconstructions utilizing patient-fitted TMJ prostheses. Questions have been raised about the longevity of TMJ TJR devices as well as their lack of growth potential, but children with TMJ ankylosis do not have condyle-related growth potential and that replacing failed autogenous tissue graft material with more autogenous tissue will result in the same adverse outcomes. Therefore, in growing patients with recurrent TMJ ankylosis and/or failed autogenous tissue grafts, there may be a role for TMJ TJR.

The use of piezosurgery in cranial surgery in children

AbstractPiezosurgery is an alternative surgical technique, now widely tested, that uses ultrasounds for bone cutting. This device uses ultrasounds to section hard tissues without harming surrounding soft tissues. The authors analyzed their experience in craniomaxillofacial procedures with piezosurgery. A comparison between operation timing and complication rates between piezosurgery and traditional cutting instruments has been performed. A total of 27 patients were examined (15 females and 12 males; average age, of 5.5 months) affected by craniosynostosis. The aim of this study was to analyze the advantages and disadvantages of piezosurgery in pediatric craniofacial procedures. Piezoelectric device in this study has shown being a valid instrument for bone cutting in accurate procedures, because it allows performing a more precise and safer cutting, without the risk of harming surrounding tissues.

Comparative stability study of wire osteosynthesis versus rigid fixation in the treatment of Class III dentoskeletal deformities

The study analyzed two samples of 10 patients with Class III dentoskeletal deformities and maxillary and mandibular involvement. Surgery was performed on both jaws at the same time, using different techniques for the stabilization of bone. In one group, osteosynthesis by wire fixation was performed (WF); and in the other group, bicortical screws were used for the mandible (RIF) and plates for the maxilla. At 20 and 40 days after the operation, radiocephalometric examinations were performed, and the differences in structural stability verified, by comparing the efficiency of the two methods of bone stabilization. Results indicate that in the postoperative period analyzed, dentoskeletal movements in the RIF group were inferior compared with the WF group. On the basis of these results, the advantages and the disadvantages offered by these two techniques of bone stabilization are analyzed.

Interferon free antiviral treatment of chronic hepatitis C in patients affected by β-thalassemia major

Dear Editor, Chronic hepatitis C (CHC) significantly affects the prognosis of liver disease [1] and health related quality of life (HRQOL) in patients with β-thalassemia major [2, 3]. CHC cure is a crucial event in the prognosis of the disease, since prevents fibrosis progression, decreases the risk of hepatocellular carcinoma (HCC), and improves survival. Standard antiviral therapy with Pegylated Interferon (PEG-IFN) and Ribavirin (RBV) has long been the standard of care, despite its limited efficacy and increased ribavirin induced hematological adverse events in thalassemic patients [4]. Recently, several novel highly effective direct antiviral agents (DAAs) have been approved for HCV treatment, with impressive cure rates, higher than 90%, after 8–12 weeks of therapy and mild adverse events [5], but there are no published reports documenting the efficacy, safety and impact on QOL of available interferon-free antiviral regimens in patients with βthalassemia major. We describe four cases of young patients with βthalassemia major and advanced fibrosis treated with DAAs for CHC (Table 1). HCV genotype was 1b in all p a t i e n t s e x c e p t o n e , wh i c h h a d g en o t y p e 4 . Cryoglobulins were positive in two patients (cryocrit 1.6 and 3.2%) with no organ involvement. All patients were previously non-responders to PEG-IFN ± RBV treatment. Iron chelation drugs included subcutaneous desferrioxamine and/or oral deferasirox. Antiviral therapy with sofosbuvir (SOF) and ledipasvir (LDV) was started for 12 weeks. All patients achieved sustained virologic response (SVR). Treatment was safe and well tolerated, kidney function remained stable, and the only adverse events were mild asthenia and headache. Iron chelation concomitant medications remained unmodified during treatment, as well as the frequency of blood transfusions. Ferritin levels decreased during therapy in three patients, but in two of them returned to baseline levels at FU3. A reduction of liver stiffness, assessed by transient elastography, occurred from baseline to FU3 in all subjects. All SF36 scales related to mental health and to physical health significantly improved at FU6 compared to baseline (Table 2). The present case series suggests that 12-week-combination therapy of SOF/LDV is effective and safe in transfusiondependentβ-thalassemia patients with advanced liver fibrosis. Remarkably, no impact of SOF on kidney function was observed as e-GFR values remained stable during therapy and FU. To our knowledge, no data exist on the interactions between DAAs and iron chelation drugs. We employed SOF and LDV in these patients because this drug combination is associated with limited interactions [6]. Remarkably, in none of the cases, it was necessary to modify iron chelation therapy, and no changes in transfusion requests occurred. Moreover, serum ferritin values, an indirect marker of iron chelation efficacy, showed an improvement during antiviral therapy in all patients but one who reported poor compliance to iron chelation therapy during DAA treatment. A marked improvement of liver stiffness, which correlates with fibrosis stage assessed by liver biopsy [7], was observed in all patients. This result may be partly due to a reduction and control of liver inflammation [8]; however, an initial regression of liver fibrosis might also have occurred, which is an * Elisa Biliotti elisabiliotti@yahoo.it

Unilateral hemimandibular hyperactivity: Clinical features of a population of 128 patients

PURPOSE Facial asymmetries due to unilateral condylar hyperactivity are often a challenge both for maxillo-facial surgeons and for orthodontists; the current literature shows different opinions about aetiology, classification, treatment approach and timing. We made a retrospective study on patients suffering from unilateral condylar hyperactivity between 1997 and 2015 in our Department; clinical features and treatment options were grouped and compared with literature. METHODS The descriptive analysis investigated variables like sex, age, side and direction of the asymmetry, condylar activity and type of intervention. RESULTS The population was composed of 128 patients. The hemimandibular hyperactivity occurs equally in both sexes around the second decade, although the range of the first consultation goes from 7 to 49 y.o. The vertical hyperdevelopment group is almost equal to the horizontal. All the patients with horizontal hyperactivity showed negative scintigraphy and were treated with pre-surgical orthodontics and orthognathic surgery; patients with vertical hyperactivity and positive scintigraphy were treated with condylectomy and post-surgical orthodontics. CONCLUSION In our group of patients, direction of the hyperactivity and results of the scintigraphy lead to treatment choice and timing. Further studies are necessary to explain why, in our group, all the patients with horizontal involvement are negative to scintigraphy.