Glauco Chisci

Inflammatory Lung Disease in Rett Syndrome

Rett syndrome (RTT) is a pervasive neurodevelopmental disorder mainly linked to mutations in the gene encoding the methyl-CpG-binding protein 2 (MeCP2). Respiratory dysfunction, historically credited to brainstem immaturity, represents a major challenge in RTT. Our aim was to characterize the relationships between pulmonary gas exchange abnormality (GEA), upper airway obstruction, and redox status in patients with typical RTT (n = 228) and to examine lung histology in a Mecp2-null mouse model of the disease. GEA was detectable in ~80% (184/228) of patients versus ~18% of healthy controls, with “high” (39.8%) and “low” (34.8%) patterns dominating over “mixed” (19.6%) and “simple mismatch” (5.9%) types. Increased plasma levels of non-protein-bound iron (NPBI), F2-isoprostanes (F2-IsoPs), intraerythrocyte NPBI (IE-NPBI), and reduced and oxidized glutathione (i.e., GSH and GSSG) were evidenced in RTT with consequently decreased GSH/GSSG ratios. Apnea frequency/severity was positively correlated with IE-NPBI, F2-IsoPs, and GSSG and negatively with GSH/GSSG ratio. A diffuse inflammatory infiltrate of the terminal bronchioles and alveoli was evidenced in half of the examined Mecp2-mutant mice, well fitting with the radiological findings previously observed in RTT patients. Our findings indicate that GEA is a key feature of RTT and that terminal bronchioles are a likely major target of the disease.

Ocular complications after posterior superior alveolar nerve block: a case of trochlear nerve palsy

Many intraoperative complications occurring during third molar surgery are described in the literature. Unilateral trochlear nerve palsy secondary to dental anaesthesia is a rare complication. We report the case of a 36-year-old healthy man, ASA I classification, requiring upper third molar extraction. Articaine 1:200,000 epinephrine for right posterior superior alveolar (PSA) nerve block was administered locally in the mucobuccal fold above the upper third molar. A few minutes after PSA nerve block the patient experienced double-vision. The patient was subsequently visited by an ophthalmologist and the condition was diagnosed as transient unilateral vertical diplopia due to temporary paralysis of the superior oblique muscle as a result of the anaesthetic solution involving the IV cranial nerve. The authors report this unusual case and discuss the possible anatomical pathways that might explain this rare phenomenon.

Magnetic resonance lymphangiography: How to prove it?

We found interest in the article by Mitsumori et al that reported their experience of magnetic resonance lymphangiography (MRL). We congratulate Mitsumori et al on their article on the four consecutive patients studied; however, some critical aspects in the text should be pointed out. For example, Mitsumori et al report a literature review of lymphaticovenular anastomosis (LVA) treatments, but do not report if the four patients affected by lymphedema referred to in that article were operated on with LVA, and the data regarding the postoperative outcomes are not present. MRL has been previously studied for lymphedema diagnosis and staging: Recently at the Lymphoedema Mondial Congress in Rome, 2013, and the International Lymphoedema Congress in Genova, 2014, many criticisms were raised against the use of MRL and the possible discrimination between lymphatic and venous vessels. Lohrmann et al reported the visualization of venous vessels, as contrast may be captured by both lymphatic and venous capillaries: venous vessels resulted in contrast enhancement faster than lymphatic vessels, which were slower. In a lymphedematous limb the diffusion of the contrast in the venous system may be modified due to the previous surgery. Further resonance imaging of lymphatic vessels may be even more doubtful on nonedematous limbs. Another aspect that evoked our attention in the Mitsumori et al article is their criticism of indocyanine green (ICG) lymphography: this minimally invasive imaging technique is more accepted by patients than a 2-hour MRL, it is easy to repeat, and the costs are reduced compared to MRL: further, no pain is usually referred by the patients, while Mitsumori et al report mild to moderate pain in the four patients who received the gadobenate (Gd) contrast injections. Mitsumori et al refer only to the Chang et al and Ogata et al studies regarding ICG lymphography, while recent articles reported even more advantages from the use of this technique. The main doubtful aspect of this article is their difficulty in proving that the identified vessels are really lymphatic vessels: the absence of an MRL performed on healthy limbs reduces the proof of the results of this article. In comparing ICG lymphography to MRL in a limb of healthy patients, we may observe numerous lymphatic vessels in the ICG lymphography that are not reported in the MRL (Fig. 1). To prove this theory, our multidisciplinary study group is performing a study of MRL performed on lymphedema patients enrolled for LVA and histological examination of biopsy specimens of the vessels identified at the MRL. We will soon submit this article.

Temporomandibular synovial chondromatosis with numerous nodules.

Synovial chondromatosis of the temporomandibular joint is an uncommon disorder with an indolent clinical course and a slow progression. We report a rare case of unilateral early synovial chondromatosis of the temporomandibular joint with numerous nodules and discuss possible etiologies for the entity of loose bodies and the evolution of this disease.

Complications of Orbital Floor Repair With Silastic Sheet: the Skin Fistula

AbstractTreatment of orbital floor fracture is a subject of great interest in maxillofacial surgery. Many materials have been described for its reconstruction.In this article, the authors report a case of a patient who, 7 years from a previous orbital floor fracture and treatment with silastic sheet, presented herself to their clinic for the failure of the material used for its reconstruction and a skin fistula.Orbital floor repair with silastic sheet is an old method that no one uses anymore, but we still observe cases of late complications with this material. So a fine knowledge of silastic sheet complications is needed for young surgeons.The authors report the case and perform a literature review about the use of more modern biomaterials for orbital floor reconstruction.

Inferior alveolar nerve lateralization: A dual technique

Dear Editor We read the article ‘Rehabilitation of edentulous posterior atrophic mandible: inferior alveolar nerve lateralization by piezotome and immediate implant placement’ by Fernández Dı́az & Naval Gı́as with great interest, and we congratulate the authors for their review of inferior alveolar nerve lateralization (IANL) and for describing the challenges in re-using an updated technique. The use of piezosurgery is an appealing concept in maxillofacial surgery due to the frequent proximity of the bone surgical site to the nerve and/or vascular tissues; many studies have suggested this application in implant surgery, and have reported satisfactory in vivo and in vitro results compared with the bur technique. In the discussion section, Fernández Dı́az and Naval Gı́as refer to the common habit of the surgeon to choose techniques based on their own experience. We partially agree with this concept, as young surgeons and researchers often introduce new techniques or use validated theories from other medical disciplines to find better postoperative outcomes; hence this appears to be a related condition, more due to the specific personal characteristics of some surgeons than to a common habit. Fernández Dı́az and Naval Gı́as discuss mandibular atrophy, a common case in prosthetic dentistry, and refer to the occurrence of vertical bone resorption and postoperative infections due to wound dehiscence as complications in mandibular bone grafts that could suggest the use of IANL to obtain the needed vertical bone instead. They also relate the use of a sandwich technique as a key factor in decreasing the occurrence

F2-Isoprostanes in soft oral tissues and degree of oral disability after mandibular third molar surgery

OBJECTIVE The aim of this study was to test the value of F(2)-isoprostane (F(2)-IsoP) levels in the pericoronal gingiva as a potential predictor of oral disability after mandibular third molar (M3M) surgery. STUDY DESIGN Thirteen patients (5 male, 8 female) with partially impacted M3M were enrolled. Pericoronal soft tissues histology was obtained, gingival F(2)-IsoPs were measured by gas chromatography/negative-ion chemical ionization tandem mass spectrometry, and health-related quality of life (HRQOL) scores were assessed. RESULTS A variable degree of pericoronitis was evident before the M3M surgery, with a mean level of pericoronal F(2)-IsoPs of 634.8 ± 193.5 pg/mg of tissue. A significant positive correlation between pericoronal F(2)-IsoPs and HRQOL was observed in male (r(s) = 0.440; P = .0011), but not female (r(s) = -0.062; P = .5124) patients. CONCLUSIONS Levels of F(2)-IsoPs in the pericoronal soft tissues are correlated with the degree of oral disability after M3Ms surgery in male, but not female, patients.

Local Versus Systemic Antibiotics Effectiveness: A Comparative Study of Postoperative Oral Disability in Lower Third Molar Surgery

To the Editor: Impacted mandibular third molar (M3M) removal is a common intervention in oral and maxillofacial surgery. The occurrence of postoperative complications may seriously compromise the recovery and quality of life of patients: health-related quality of life (HRQOL) parameters suggested a worse healing time in patients with postoperative complications occurrence, which may be caused by preoperative inflammation or individual risk factors. There is a controversy in the literature about the use of antibiotics in third molar surgery: some authors suggest the prophylaxis use of antibiotics to reduce the occurrence of postoperative infection complications, whereas others support the idea that, in most cases, antibiotic prophylaxis is not necessary. Very few articles considered the use of local antibiotics in third molar surgery and their effectiveness in reducing postoperative complications and bacteria growth rate. We intended to report the results of our double-blind randomized controlled clinical trial on the effectiveness of local antibiotic administration, systemic antibiotic administration, and their association, compared with a control group, in preventing postoperative infection complications of M3M surgery. A total of 40 patients (16 males, 24 females; mean [SD] age, 31.5 [9.51]; range, 16Y50 y) with impactedM3Mswere enrolled and treated from January 1, 2012 to January 1, 2013 at the Tuscan School ofDental Medicine, University of Siena. We excluded patients with pathologies that could influence results regarding bacterial growth rate. Each patient was randomly assigned in groups in the study and the surgeon received antibiotics instructions, whereas the laboratory received no such information. Group 0 did not receive any antibiotic therapy (control group); group 1 was prescribed with a systemic antibiotic prophylaxis (amoxicillin and clavulanic acid); group 2 received local antibiotic administration (chloramphenicol sodium succinate), mixed with patient blood inside the surgical cavity, during the operative procedure; and group 3 received systemic prophylaxis and local antibiotic administration during the operative procedure. The patients of group 1 and group 3 were instructed to consume 2000 mg/h before surgery and keep 1000 mg as prophylaxis every 12 hours 5 days after the surgery. Local anesthesia and surgical protocol were standardized, except for antibiotic administration. We used a standardized technique to collect the specimen: reference points were the pocket between the secondmolar and the third molar and the former vertex of papilla. A paper cone was left in place for a time of 10 seconds, which was removed afterward and immediately placed in a sterile tube containing 1 mL of sterile saline solution (phosphate buffered saline) and delivered to the analytical laboratory for seeding in culture media (Fig. 1). We performed 3 collections: immediately before anesthesia (T0), 48 hours after intervention (T1), and 7 days after intervention (T2). The patients were visited also 14 days after the surgery with the delivery of the HRQOL diary. None of the examined participants exhibited severe complications. Milder complications at 2 days included swelling on the control group (n = 3), whereas no evidence of soft tissue infection, dry socket, or bone resorption was observed: groups 1, 2, and 3 presented no such complications at day 2. Milder complications at 7 days were swelling on the control group (n = 1), whereas no patients had soft tissue infection, dry socket, or bone resorption: groups 1, 2 and 3 presented no such complications at day 7. The HRQOL parameters revealed no statistically significant difference between the 4 groups in terms of time taken to reach the minimum value (time taken to reach complete remission of symptoms, P = 0.76) both in terms of change rate (the amount of recovery, P = 0.51) (Fig. 2). Regarding aerobic and anaerobic bacterial growth, by comparing the mean differences recorded at the time (T0, T1, T2) in the groups, there was no evidence of statistically significant difference. At T2, the anaerobes count is higher with respect to T0, with the exception of group 2. It should be noted that, in group 0 and group 2 at time T1, the mean value is increased, whereas, in group 1, this value is decreased and, in group 3, is controlled (Fig. 3). Regarding antibiotic administration, some authors suggested a prophylaxis administration (single presurgical dose of 2 tablets of amoxicillin/clavulanic acid, 1000/62.5 mg) in cases of third molar surgery performed without ostectomy, whereas considered an indication to postsurgical preemptive treatment (2 tablets of amoxicillin/ clavulanate daily, for 5 days) the M3M removal with ostectomy. One of the most recent studies provided no statistically significant results in the prophylactic routine use of systemic antibiotics. A recent metaanalysis observed that the most effective dosing strategy was with the first dose started 1 hour before surgery and continuing for 3 to 5 days after the surgery and that a preoperative single dose was nearly as effective as the multiday dosing strategy. The use of routine antibiotic prophylaxis in third molar surgery is a reliable way to reduce the appearance of alveolar osteitis, but the risks for potential antimicrobial FIGURE 1. The paper cone inside the site before the third molar surgery (T0). FIGURE 2. Health-related quality of life parameters significantly decrease with time, but no statistically difference is present among the different groups; however, a greater variance is present in group 0 (control group) compared with other groups, meaning a less controllable and predictable condition. CORRESPONDENCE

LEOPARD syndrome: maxillofacial care.

This article reports a case of a boy with LEOPARD syndrome with unusual mandibular osteolytic osteoclastic-like lesions and eruption disorder. The patient was referred to our department for bilateral facial swelling: systemic examinations, diagnosis, and dental and maxillofacial care are reported.

Giant palatal schwannoma.

Schwannoma is a benign tumor that arises from nerves that contain Schwann cells. We report a case of giant schwannoma of the hard palate, which originated from the greater palatine nerve and is interesting for its large dimensions.