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Belhassen S, Mat Q, Ferret C, Clavel R, Renaud B, Cabaraux P. Post-Traumatic Craniocervical Disorders From a Postural Control Perspective: A Narrative Review. BRAIN & NEUROREHABILITATION 2023; 16:e15. [PMID: 37554255 PMCID: PMC10404808 DOI: 10.12786/bn.2023.16.e15] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 08/10/2023] Open
Abstract
Mild traumatic brain injury (mTBI) and whiplash injury (WI) may lead to long-term disabling consequences known as post-concussive syndrome (PCS) and whiplash-associated disorders (WADs). PCS and WAD patients commonly complain of conditions encompassing dizziness, vertigo, headache, neck pain, visual complaints, anxiety, and neurocognitive dysfunctions. A proper medical work-up is a priority in order to rule out any acute treatable consequences. However investigations may remain poorly conclusive. Gathered in the head and neck structures, the ocular sensorimotor, the vestibular, and the cervical proprioceptive systems, all involved in postural control, may be damaged by mTBI or WI. Their dysfunctions are associated with a wide range of functional disorders including symptoms reported by PCS and WAD patients. In addition, the stomatognathic system needs to be specifically assessed particularly when associated to WI. Evidence for considering the post-traumatic impairment of these systems in PCS and WAD-related symptoms is still lacking but seems promising. Furthermore, few studies have considered the assessment and/or treatment of these widely interconnected systems from a comprehensive perspective. We argue that further research focusing on consequences of mTBI and WI on the systems involved in the postural control are necessary in order to bring new perspective of treatment.
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Affiliation(s)
- Serge Belhassen
- Groupe d'Etudes, de Recherche, d'Information et de Formation sur les Activités Posturo-Cinétiques (Gerifap), Juvignac, France
| | - Quentin Mat
- Department of Otorhinolaryngology, Centre Hospitalier Universitaire (CHU) Charleroi, Charleroi, Belgium
| | - Claude Ferret
- Departments of Oral Health Sciences and Otorhinolaryngology, Centre Hospitalier Universitaire (CHU) de Montpellier, Montpellier, France
| | - Robert Clavel
- Groupe d'Etudes, de Recherche, d'Information et de Formation sur les Activités Posturo-Cinétiques (Gerifap), Juvignac, France
| | - Bernard Renaud
- Groupe d'Etudes, de Recherche, d'Information et de Formation sur les Activités Posturo-Cinétiques (Gerifap), Juvignac, France
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Nota A, Pittari L, Gamba L, Monticciolo FM, Lannes A, Carta C, Beraldi A, Baldini A, Marzo G, Tecco S. Cervical Range of Motion Analysis Performed with an Accelerometer: A Study of Intersession Reliability for Dental Practice. Healthcare (Basel) 2023; 11:healthcare11101428. [PMID: 37239714 DOI: 10.3390/healthcare11101428] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/09/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
During the clinical examination of subjects with temporomandibular disorders (TMDs), the dentist sometimes must evaluate the cervical spine, due to the anatomical and functional connections between the cervical portion of the spine and the stomatognathic apparatus. The accelerometer is a device that evaluates the Range of Motion (ROM) of the main movements of the head on the neck. To date, only a few studies have investigated the repeatability of the use of the accelerometer in the assessment of cervical ROM. Therefore, the present longitudinal observational study analyzed the repeatability of acquired cervical movements on a sample of volunteer subjects who underwent accelerometer testing. A sample of 32 subjects was tested twice within 14 days to assess cervical ROM using a standardized protocol based on a review of existing literature. The results show that the examination is reliable for all the positions of the jaw, except for the parameters regarding the asymmetries of rotation and bending. In conclusion, the accelerometer can be considered a reliable tool for evaluating the active cervical ROM. However, further studies will be necessary to make better evaluations.
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Affiliation(s)
- Alessandro Nota
- Dental School, Vita-Salute San Raffaele University and Department of Dentistry, IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Laura Pittari
- Dental School, Vita-Salute San Raffaele University and Department of Dentistry, IRCCS San Raffaele Hospital, 20132 Milan, Italy
- Department of Clinical Medicine, Public Health, Life and Environmental Sciences (MeSVA), University of L'Aquila, 24100 L'Aquila, Italy
| | - Laura Gamba
- Dental School, Vita-Salute San Raffaele University and Department of Dentistry, IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Francesco Manfredi Monticciolo
- Dental School, Vita-Salute San Raffaele University and Department of Dentistry, IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Alessia Lannes
- Dental School, Vita-Salute San Raffaele University and Department of Dentistry, IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Carlotta Carta
- Dental School, Vita-Salute San Raffaele University and Department of Dentistry, IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | | | | | - Giuseppe Marzo
- Department of Clinical Medicine, Public Health, Life and Environmental Sciences (MeSVA), University of L'Aquila, 24100 L'Aquila, Italy
| | - Simona Tecco
- Dental School, Vita-Salute San Raffaele University and Department of Dentistry, IRCCS San Raffaele Hospital, 20132 Milan, Italy
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Diéguez-Pérez M, Fernández-Molina A, Burgueño-Torres L. Influence of occlusion and mandibular position on foot support and head posture in adult patients. Cranio 2022:1-8. [PMID: 36334277 DOI: 10.1080/08869634.2022.2140245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To study postural changes, taking into account different mandibular positions and the cephalic and plantar body segments. METHODS A cross-sectional, descriptive, clinical, and observational study was carried out on 76 patients, (mean age 28.79 years), in whom body posture and plantar support were evaluated in the maximum mandibular intercuspal position and the mandibular rest position without dental contact. RESULTS When the mandibular position was altered, 71.01% of the patients showed changes in the bipupillary line (p = 0.008), while those who did not show such changes did, however, show changes in plantar support. More than 85% of the sample experienced alterations in the plantar plane when the mandibular position was changed, with statistically significant results (p < 0.001). CONCLUSION There is a positive relationship between the different segments in body posture. In the sample, changes in plantar support with respect to the different mandibular positions were noticeable.
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Affiliation(s)
- Montserrat Diéguez-Pérez
- Department of Preclinical Dentistry, Faculty of Biomedical Sciences and Health Sciences, European University of Madrid, Madrid, Spain
- Department of Dental Clinical Specialties, Faculty of Dentistry, Complutense University of Madrid, Madrid, Spain
| | - Aurora Fernández-Molina
- Department of Preclinical Dentistry, Faculty of Biomedical Sciences and Health Sciences, European University of Madrid, Madrid, Spain
| | - Laura Burgueño-Torres
- Department of Preclinical Dentistry, Faculty of Biomedical Sciences and Health Sciences, European University of Madrid, Madrid, Spain
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Alessandria M. Horizontal Heterophoria Modifications by Means of Thin Proprioceptive Stimulations Applied on the Foot Sole: A Randomised Study. J Mot Behav 2022; 54:620-630. [PMID: 35236256 DOI: 10.1080/00222895.2022.2046539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Some authors have demonstrated that proprioceptive stimuli applied on the feet soles can interfere on the ocular muscles. However, these studies do not clarify possible functional differences between the dominant eye and the non-dominant eye. The purpose of this randomised study is to establish if the positioning of an Internal Heel Wedge (IHW) and an External Heel Wedge (EHW) can modify horizontal heterophoria, determine dissimilar behaviours between the dominant eye and the non-dominant eye. Forty-two healthy subjects, with a right dominant eye, were tested. The 1.5 mm-thick proprioceptive stimuli were shaped out of a cork half-moon. The experimental group was divided into two groups: IHW group and EHW group. Both groups performed the "Baseline" (without mechanical stimulation) and "After 15'" (following a fitting period of 15 minutes on a treadmill with mechanical stimulation) trials. The control group performed the same trials without any podalic stimulation. Meaningful changes were observed on the horizontal heterophoria of the non-dominating eye with an IHW. Non-statistically significant variations were observed with an EHW and in the Control group. A thin heel wedge applied on the foot sole was able to generate functional changes in the non-dominant eye and could help health professionals develop increasingly personalised rehabilitation programmes.
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Affiliation(s)
- Marco Alessandria
- Department of Life Sciences and Systems Biology, University of Turin, Torino, Italy
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Nota A, Ehsani S, Pittari L, Gastaldi G, Tecco S. Rare case of skeletal third class in a subject suffering from Solitary Median Maxillary Central Incisor syndrome (SMMCI) associated to panhypopituitarism. Head Face Med 2021; 17:49. [PMID: 34814931 PMCID: PMC8609825 DOI: 10.1186/s13005-021-00300-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background The median solitary maxillary central incisor syndrome (SMMCI) is a rare malformative syndrome consisting of multiple defects, mainly found on the body midline. It can be correlated to the etiopathological and phenotypic pattern of panhypopituitarism. This case-report describes the rare case of a patient suffering from SMMCI and panhypopituitarism, showing an unusual craniofacial morphology. Case presentation From the cephalometric analysis, a skeletal class III was identified (despite the other cases described in literature described as skeletal class II), derived from hypomaxillia and mandibular protrusion. A convex lip profile, with tendency to mandibular hyper-divergency, airway patency, anterior and posterior cross-bite were observed. At the clinical examination, a maxillary cant was evident on the frontal plane that appeared asymmetric, with the prevalence of the third lower part of the face. There were some dysmorphic signs such as: small nose, rectilinear eyelid line and reduced interocular distance. Conclusions The present clinical case shows how, despite the literature, SMMCI can be associated with a III skeletal class, with maxillary hypoplasia and mandibular protrusion. The interdisciplinary collaboration between dentist and pediatrician is therefore important for the early interception of the malocclusions associated with these syndromes.
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Affiliation(s)
- Alessandro Nota
- Dental School and Postgraduate School of Orthodontics, Vita-Salute San Raffaele University and IRCCS San Raffaele Hospital, via Olgettina 58, Milan, Italy
| | - Shideh Ehsani
- Dental School and Postgraduate School of Orthodontics, Vita-Salute San Raffaele University and IRCCS San Raffaele Hospital, via Olgettina 58, Milan, Italy
| | - Laura Pittari
- Dental School and Postgraduate School of Orthodontics, Vita-Salute San Raffaele University and IRCCS San Raffaele Hospital, via Olgettina 58, Milan, Italy.
| | - Giorgio Gastaldi
- Dental School and Postgraduate School of Orthodontics, Vita-Salute San Raffaele University and IRCCS San Raffaele Hospital, via Olgettina 58, Milan, Italy
| | - Simona Tecco
- Dental School and Postgraduate School of Orthodontics, Vita-Salute San Raffaele University and IRCCS San Raffaele Hospital, via Olgettina 58, Milan, Italy
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Siebert L, Kirschneck C, Krey KF, Ratzmann A. Influence of dental occlusion on oculomotory function-A pilot study. Ann Anat 2021; 239:151804. [PMID: 34271107 DOI: 10.1016/j.aanat.2021.151804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 10/20/2022]
Abstract
The aim of this study was to examine the interaction between the oculomotory system and the stomatognathic system based on morphofunctional relationships between the corresponding cranial nerves, their core areas and the reticular formation as a "link" by means of optometric examinations. Test subjects (N = 100) were prospectively recruited and divided into two groups: a young-age (N = 53, age 6-16 years) and old-age group (N = 47, 23-78 years). We determined the horizontal range of convergence and divergence as well as the near convergence point. These optometrically measured parameters were recorded in both groups in the resting position, at maximal mouth opening and with bite-blocking via tin foils (0.5 mm and 1 mm), which were inserted occlusally of the first lower left molar. All oculomotory parameters were significantly altered by bite manipulation and maximal mouth opening. These effects could be observed regardless of age and gender and thus suggest an interaction between eye movement and the orofacial complex. Subjects with asthenopic symptoms showed no different reactions compared to healthy subjects. For a final statement on the correlation between the oculomotory and stomatognathic system, further investigations are necessary. An interdisciplinary cooperation between the different subject areas is recommended for further studies.
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Affiliation(s)
- Lydia Siebert
- University of Greifswald, Department of Orthodontics, Walther-Rathenau-Straße 42a, 17475 Greifswald, Germany.
| | - Christian Kirschneck
- University Medical Hospital Regensburg, Department of Orthodontics, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
| | - Karl-Friedrich Krey
- University of Greifswald, Department of Orthodontics, Walther-Rathenau-Straße 42a, 17475 Greifswald, Germany
| | - Anja Ratzmann
- University of Greifswald, Department of Orthodontics, Walther-Rathenau-Straße 42a, 17475 Greifswald, Germany
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Ozturk T, Ozsaygili C, Topsakal U. Relationship of skeletal malocclusion with eye and hair color in Turkish adolescent patients. APOS TRENDS IN ORTHODONTICS 2021. [DOI: 10.25259/apos_189_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives:
The aim of this study was to establish whether a relationship exists between eye and hair color and orthodontic anomalies; an association has never been evaluated previously.
Materials and Methods:
The records of 406 adolescent patients to the Erciyes University Faculty of Dentistry for orthodontic treatment were included in this retrospective cohort study. Participants were divided into sagittal (Class I, Class II, and Class III) and vertical (low angle, normal angle, and high angle) skeletal malocclusion classes. Moreover, participants were also divided by their eye (brown, green, or blue) and hair (black, brown, or blonde) color. Collated data were statistically evaluated using the SPSS software by applying the one-way analysis of variance, Kruskal–Wallis, the Pearson Chi-square, and Fisher’s exact tests. Statistical significance was accepted at P < 0.05.
Results:
No statistically significant relationships were identified between sagittal and skeletal malocclusion and eye color (P > 0.05). However, the sella-nasion-b and CoGn parameters of brown-eyed individuals were significantly smaller than individuals with other eye colors (P < 0.05). Moreover, a statistically significant difference was established for the CoA, CoGn, and ANS-Me parameters between the different hair groups (P < 0.05). All three parameters were significantly lower in brown-haired individuals compared to individuals with black haired (P < 0.05).
Conclusion:
This study identified no significant association between the eye and hair color variable, with similarly formed craniofacial structures, and with the sagittal and vertical skeletal malocclusion. Therefore, any malocclusion estimation assumption formed based on either the hair or eye color of an individual will be incorrect.
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Affiliation(s)
- Taner Ozturk
- Department of Orthodontics, Erciyes University, Kayseri, Turkey,
| | - Cemal Ozsaygili
- Department of Ophthalmology, Kayseri City Training and Research Hospital, Kayseri, Turkey,
| | - Ugur Topsakal
- Department of Orthodontics, Erciyes University, Kayseri, Turkey,
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Vompi C, Serritella E, Galluccio G, Pistella S, Segnalini A, Giannelli L, Di Paolo C. Evaluation of Vision in Gnathological and Orthodontic Patients with Temporomandibular Disorders: A Prospective Experimental Observational Cohort Study. J Int Soc Prev Community Dent 2020; 10:481-490. [PMID: 33042891 PMCID: PMC7523923 DOI: 10.4103/jispcd.jispcd_273_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 12/11/2019] [Indexed: 11/24/2022] Open
Abstract
Objectives: Temporomandibular disorders (TMDs), orthodontic diseases, and vision dysfunctions seem to be strictly related. The purpose of this study was to prove the relationship, to evaluate the prevalence and the distribution of vision defects in dysfunctional and orthodontic patients, and to establish the type of the relationship. Materials and Methods: A total of 100 patients with TMDs were selected and studied through epidemiological analyses of the following factors: gnathological parameters (temporomandibular joint pathologies according to Diagnostic Criteria for Temporomandibular Disorders); occlusal and skeletal parameters (overjet, overbite, dental class, transversal discrepancies, and mandibular asymmetry); and orthoptic parameters (refractive defects and oculomotor diseases). A prospective experimental observational cohort study was conducted. A comparison with the average frequency of vision defects of the Italian population was performed. The prevalence of vision defects was evaluated. All gnathological and orthodontic parameters were associated with the orthoptic ones. A descriptive and statistical analysis of the data was carried out with the Statistical Package for the Social Sciences software; z test (P < 0.05), frequency analysis (frequency >50%), chi-square test, and Student’s t test (P < 0.05) were performed. The scientific consistency was evaluated by using the scientific criteria of Bradford Hill. Results: The comparison with the Italian population showed a higher frequency of refractive defects in the study sample (P < 0.001). The most frequent vision defects were phorias (92%) and tropia (3%). The increased frequency of ocular convergence reduction in the presence of disc displacement with reduction was significant (n = 28; 60%; P < 0.05). In the presence of asymmetry, low frequencies of astigmatism (n = 18; 30%) were observed compared to its absence (n = 22; 54%) (P < 0.05) and high frequencies of motor ocular deviations (n = 59; 100%) were observed compared to its absence (n = 36; 88%) (P < 0.05). In the presence of headache, low frequencies of emmetropia (n = 13; 22%) and higher frequencies of hyperopia (n = 18; 30%) were observed (P < 0.05). Two of five scientific criteria of Bradford Hill were met. Conclusion: It seems to emerge a possible positive relationship between TMD and vision defects. In particular, the most interesting associations were found between functional or skeletal orthognathic alterations and oculomotor dysfunctions. However, it was not possible to establish the type of relationship.
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Affiliation(s)
- Chiara Vompi
- Units of Gnathology, Department of Head and Neck, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Emanuela Serritella
- Units of Gnathology, Department of Head and Neck, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Gabriella Galluccio
- Units of Orthodontics, Department of Head and Neck, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Santino Pistella
- Units of Ophthalmology, Department of Head and Neck, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Alessandro Segnalini
- Units of Ophthalmology, Department of Head and Neck, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | | | - Carlo Di Paolo
- Units of Gnathology, Department of Head and Neck, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
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Evaluation of Lower Dental Arch Crowding and Dimension after Treatment with Lip Bumper versus Schwarz Appliance. A Prospective Pilot Study. Dent J (Basel) 2020; 8:dj8020034. [PMID: 32290075 PMCID: PMC7344829 DOI: 10.3390/dj8020034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 03/30/2020] [Accepted: 04/07/2020] [Indexed: 02/05/2023] Open
Abstract
Aim: The treatment of patients with mixed dentition, with inferior moderate dental crowding (the so-called borderline cases, between extraction and expansion) is not yet clear. Two examples of widely used appliances for increasing lower dental arch dimensions are the Schwarz’s appliance and lip bumper. The aim of this prospective study was to compare dental crowding and arch dimensions from pre- to post-treatment with lip bumper versus Schwarz’s appliance. Subjects and Methods: Pre- and post-treatment orthodontic records of twenty subjects (10 males and 10 females) were analyzed in the present study. Inclusion criteria were: first/second molar class malocclusion; crowding of the mandibular arch, from mild to moderate (4–6 mm); mixed dentition; age ≤ 9 years at the beginning of the treatment; stage CS1 or CS2 of maturation of the cervical vertebrae analysis (CVM) at the beginning of the treatment. Ten subjects were treated with a lip bumper, and ten with the removable Schwarz appliance. The primary outcomes were the variations in dental crowding and arch dimensions from pre- to post-treatment. Results: Both the two appliances caused a statistically significant mean improvement/reduction in crowding, of 3.5 mm and 2.9 mm, for the Schwarz appliance and lip bumper, respectively. The Schwarz appliance resulted more effective in increasing arch dimension at the intercanine level, and arch perimeter, while the lip bumper achieves a higher increase in arch length. Conclusions: A lip bumper and Schwarz appliance are both useful in reducing crowding in mixed dentition. This improvement is due to the increase in dental arch dimensions, although the distribution of space resulted slightly differently between the two appliances.
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Marino A, Nota A, Caruso S, Gatto R, Malagola C, Tecco S. Obstructive sleep apnea severity and dental arches dimensions in children with late primary dentition: An observational study. Cranio 2019; 39:225-230. [PMID: 31238802 DOI: 10.1080/08869634.2019.1635296] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objective: The aim of this study was to compare the dimensions of the upper and lower arches in children affected by OSAS with different levels of severity of obstruction.Methods: Twenty-seven Caucasian children (14 males, 13 females; mean age 6, range 5.2-6.1 years) with a diagnosis of OSAS determined by polysomnography were enrolled in this study. The dimensions of both dental arches were measured, and the data were compared among children affected by severe, moderate, and mild OSAS.Results: Statistically significant differences among the three groups revealed that children with severe OSAS had the highest values of upper intercanine and intermolar distances in the sample.Discussion: A severe OSAS grade (AHI > 10) is associated with statistically significantly higher upper intercanine and intermolar distances compared with mild and moderate grades. An early approach to OSAS in children with late primary dentition is auspicated in order to prevent an influence on dental arches growth.
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Affiliation(s)
- Alessandra Marino
- Faculty of Psychology and Medicine, La Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Alessandro Nota
- Dental School, Vita-Salute San Raffaele University and IRCCS San Raffaele, Milan, Italy.,Department MeSVA, University of L'Aquila, L'Aquila, Italy
| | - Silvia Caruso
- Department MeSVA, University of L'Aquila, L'Aquila, Italy
| | - Roberto Gatto
- Department MeSVA, University of L'Aquila, L'Aquila, Italy
| | - Caterina Malagola
- Faculty of Psychology and Medicine, La Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Simona Tecco
- Dental School, Vita-Salute San Raffaele University and IRCCS San Raffaele, Milan, Italy
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