[Cranial Facial 3D Biometry: Statistical analysis of Class II disharmonies]. / Biométrie cranio-faciale 3D: analyse statistique des dysmorphies de classe II.

We could study Cone Beam documents of patients consulting in ORL with standard Angle Class I occlusion (45 ND), patients consulting in orthodontics with an orthodontic Class II (51 APNS) and patients with a surgical Class II (83 APS). The used 3D biometry calculates systematically a 164 set of parameters able to take into account all kinds of disharmonies; among which 38 parameters are specifically devoted to anterior-posterior "off asymmetry" pathologies. Then the specific Artificial Intelligence (AI) programs treat morphological data and give textual diagnoses. Analysis of the global sample aims to control the efficiency, separating different sub-samples one each other: t test appreciates efficiency of each parameter to recognize clinical sub-sample. The correlation coefficient, r, between each parameter and pseudo Angle molars Class II (GMMy-Gmmy) give the importance of its tie with Class II pathology. Presentation of parameters medium values in each sub-group gives the medium profiles. By direct comparison of patient's parameters values with medium profile, it is possible to locate patient's pathology. So we can take in account new parameters like arches upper/lower gap, anterior bases upper/lower gap, compensatingparameters... It is then possible to make more secure the clinical decision.

[Cranio-Facial 3D Biometry: Complete analysis of a case of class II "limit surgery"]. / Biométrie cranio-faciale 3D: analyse complète d'un cas de classe II « limite chirurgicale ¼.

With the conventional 2D exam of clinical cases, the diagnosis is penalized by the lack of data, not only for vertical or transverse or asymmetrical problems, but for classical cases of anteroposterior dysharmonies. In these cases, the effectively used parameter, ANB angle, seems insufficient. So the authors elaborated a 3D biometry tool. The program of morphological analysis is able to deliver a complete description of dysharmony, supported by Cone Beam data capture. In the first part of this article the authors present the foundation of the model: anatomical reference, skeletal landmarks, teeth location by inertia matrix calculus, parameters, diagnosis and aid to treatment plan. The second part is the presentation, step by step, of the program in function, analyzing a great case of Class II hyperdivergent, border line surgery. All along the diagnosis way, the authors make the assistant discover all the documents given by the computer about complete 3D diagnosis and aid to treatment plan.

AF Ablation Guided by Spatiotemporal Electrogram Dispersion Without Pulmonary Vein Isolation: A Wholly Patient-Tailored Approach.

BACKGROUND: The use of intracardiac electrograms to guide atrial fibrillation (AF) ablation has yielded conflicting results. OBJECTIVES: The authors evaluated the usefulness of spatiotemporal dispersion, a visually recognizable electric footprint of AF drivers, for the ablation of all forms of AF. METHODS: The authors prospectively enrolled 105 patients admitted for AF ablation. AF was sequentially mapped in both atria with a 20-pole PentaRay catheter. The authors tagged and ablated only regions displaying electrogram dispersion during AF. Results were compared to a validation set in which a conventional ablation approach was used (pulmonary vein isolation/stepwise approach). To establish the mechanism underlying spatiotemporal dispersion of AF electrograms, the authors conducted realistic numerical simulations of AF drivers in a 2-dimensional model and optical mapping of ovine atrial scar-related AF. RESULTS: Ablation at dispersion areas terminated AF in 95% of the 105 patients. After ablation of 17 ± 10% of the left atrial surface and 18 months of follow-up, the atrial arrhythmia recurrence rate was 15% after 1.4 ± 0.5 procedures per patient versus 41% in the validation set after 1.5 ± 0.5 procedures per patient (arrhythmia free-survival: 85% vs. 59%; log-rank p < 0.001). Compared with the validation set, radiofrequency times (49 ± 21 min vs. 85 ± 34.5 min; p = 0.001) and procedure times (168 ± 42 min vs. 230 ± 67 min; p < 0.0001) were shorter. In simulations and optical mapping experiments, virtual PentaRay recordings demonstrated that electrogram dispersion is mostly recorded in the vicinity of a driver. CONCLUSIONS: The clustering of intracardiac electrograms exhibiting spatiotemporal dispersion is indicative of AF drivers. Their ablation allows for a nonextensive and patient-tailored approach to AF ablation. (Substrate Ablation Guided by High Density Mapping in Atrial Fibrillation [SUBSTRATE HD]; NCT02093949).

Electrogram Fractionation-Guided Ablation in the Left Atrium Decreases the Frequency of Activation in the Pulmonary Veins and Leads to Atrial Fibrillation Termination: Pulmonary Vein Modulation Rather Than Isolation.

OBJECTIVES: This study sought to evaluate the impact of a complex fractionated atrial electrogram (CFAE)-guided ablation strategy on atrial fibrillation (AF) dynamics in patients with persistent AF. BACKGROUND: It is still unclear whether complete pulmonary vein isolation (PVI) is required or if the ablation of well-delineated pulmonary vein (PV) subregions could achieve similar outcomes in persistent AF. METHODS: CFAE-guided ablations were performed in 76 patients (65.2 ± 10 years of age) with persistent AF. In 47 patients, we measured mean PVs and left atrial appendage (LAA) cycle length (CL) values (PV-CL and LAA-CL), before ablation and before AF termination. We defined "active" PVs as PV-CL ≤ LAA-CL, "rapid fires" as PV-CL ≤80% of LAA-CL, and "PV-LAA CL gradient" as a significant CL difference between the 2 regions. RESULTS: AF termination (sinus rhythm [SR] or atrial tachycardia [AT] conversion) occurred in 92% and SR conversion in 75%. The radiofrequency time for AF termination and total radiofrequency time were 26 ± 25 min and 61.1 ± 21.6 min, respectively. Thirty of 47 patients had active PV (with 19 PV "rapid fires"). Ablation significantly increased median CL, both at PVs and LAA from 188 ms (interquartile range [IQR]: 161 to 210 ms) to 227.5 ms (IQR: 200 to 256 ms) (p < 0.0001) and from 197 ms (IQR: 168 to 220 ms) to 224 ms (IQR: 193 to 250 ms) (p < 0001), respectively. After ablation, PV-LAA CL gradients were withdrawn and all PV "rapid fires" were extinguished (without PVI). After 17.2 ± 10 months of follow-up and 1.61 ± 0.75 procedures, 86.3% and 73% of the patients were free from AF and from any arrhythmia (AF/AT), respectively. CONCLUSIONS: CFAE-guided ablation leads to a large decrease in PV frequency of activation, preceding AF termination. A PV modulation approach, rather than complete PVI, may be preferable for persistent AF.

[Beauty judgment: review of the literature]. / L'appréciation de la beauté : revue de littérature.

Esthetic judgments are surely subjective, but as surely, that does not preclude them being studied objectively through rigorous scientific methods. The factual basis of a science of esthetics is not to settle whether some person or image is "objectively beautiful" but rather to determine whether some representative set or sets of individuals judge or experience him/her/it as beautiful or unattractive. The aim of this paper is to review the definitional, theoretical and methodological aspects pertaining to the perception of facial/dental attractiveness by a group of representative individuals. The first part lays down the basic principles of the perception of facial/dental attractiveness: the perception involves a jury, a field of investigation and a test providing quantitative data; the following general determinants of beauty perception are reviewed: the average morphology, the judge's cultural background, the numerology, the judge's ethnical origin. Indirect determinants are the dentition, the osseous architecture and the muscular envelope. Some disruptive factors might alter the judges' facial perception. They might be qualified as either peripheral to the face or psycho-social factors. Peripheral factors include hair style and color, skin hue, wrinkles, lips color... Psycho-social factors cover the personality of the subject being evaluated, his/her intelligence or behavior. The second part deals specifically with the methodology used to determine facial attractiveness and to correlate this latter with a specific morphology. Typically such a study aims to determine average esthetic preferences for some set of visual displays among a particular jury, given a specific task to judge esthetic quality or qualities. The sample being studied, the displays, the jury or jurys, the rating procedure must all be specified prior to collecting data. A specific emphasis will be given to the rating process and the associated morphometrics, the ultimate goal being to discriminate morphologies judged as attractive among our patients.

[Contribution of three dimensional cephalometry in the study of determining morphological parameters for facial esthetics]. / Apport de l'analyse céphalométrique tridimensionnelle dans l'étude des déterminants morphologiques de l'esthétique faciale.

There have been numerous studies of facial esthetics, but few have benefited from the new techniques provided by 3D imaging. The aim of this study is to determine which are the most crucial cephalometric criteria for facial esthetics by identifying the strongest correlations between the esthetic rating and 3D Cephalometric values, the Cepha 3Dt. A group of 91 subjects (from 10 to 60 years of age) was rated by a jury of 50 randomly selected judges (from 12 to 65 years of age) using an analog scale. We then looked for the most important correlations between the esthetic ratings and the tridimensional cephalometric values by using 3D Cephalometric Analysis on a global sample, and on Class II and Class III sub-samples. Facial esthetics therefore appeared to be especially linked to: anterior-posterior dimension, maxillo-mandibular disharmony, relationships between the anterior areas (alveolar and basal), the alveolar region has a greater impact than the basal area on facial architecture. In the Class II group, sagittal discrepancies and mandibular divergence have an equal impact on the assessment of facial esthetics.

Active or passive pulmonary vein in atrial fibrillation: is pulmonary vein isolation always essential?

BACKGROUND: The role of pulmonary veins (PVs) in persistent atrial fibrillation (AF) perpetuation appears less important than in paroxysmal AF. Electrogram-based substrate ablation is not widely performed as a stand-alone strategy. OBJECTIVE: To evaluate PV activity in AF perpetuation and efficacy of our patient-tailored ablation strategy (electrogram-based substrate ablation with or without pulmonary vein isolation [PVI]). METHODS: One hundred twenty-one patients with paroxysmal (n = 19; 15.7%), persistent (n = 77; 63.6%), or long-standing persistent (n = 25; 20.7%) AF underwent electrogram-based substrate ablation with AF termination end point: sinus rhythm or atrial tachycardia conversion. Before ablation, we classified PVs as "passive" if silent PV or if PV cycle length is greater than left atrial appendage cycle length. No PVI was performed in such cases. RESULTS: Passive PVs were observed in 52 of 121 patients (paroxysmal AF = 0%, persistent AF = 40%, and long-standing persistent AF = 76%; P < .0001]). Substrate ablation terminated AF in 95.6% (sinus rhythm conversion in 80.2%). Compared with patients with active PVs, patients with passive PVs had longer AF sustained duration (19.1 ± 29.7 months vs 4.9 ± 11.1 months; P < .0001), larger left atrial diameter (46.9 ± 7.3 mm vs 41.9 ± 6.0 mm; P = .0014), lower left ventricular ejection fraction (45.4% ± 13.5% vs 55.1% ± 9.4%; P < .0001), and more often structural heart disease (57% vs 33%; P = .02). After a follow-up of 20.39 ± 11.23 months (1.6 procedures per patient), 82% were arrhythmia free with this strategy. CONCLUSIONS: PV activity during AF decreases with AF chronicity, left atrial dilatation, and left ventricular ejection fraction. Our patient-tailored ablation strategy without systematic PVI provides good results.

[Very early treatment, early treatment or just watchful waiting? Thoughts based on the follow-up treatment of class III with vertical excess]. / Traitements très précoces, précoces ou bien expectative armée ? Réflexion à partir du suivi d'un cas de classe III avec excès vertical.

The debate concerning the optimal timing for beginning treatment of maxillo-facial dysmorphia is far from over. The possible choices are very early treatment in the primary dentition, early treatment only during a period of time when the mixed dentition is stable or waiting until complete adult dentition is present, at the end of, or close to the end of, the growth period. Opting for early treatment is problematic because it is difficult to make a very early diagnosis (and sometimes impossible to make when there are no strong developmental signs for dysmorphia present), long-term prognosis can always be inaccurate, patients may not yet be psychologically mature enough, there is insufficient anchorage available, ultimately a two-stage treatment is required and hence a longer process, the feeling that this is "experimental therapy", that, in case of failure, leads to disappointment and a loss of confidence. Opting for later treatment reassures both orthodontist and patient; however, these delayed treatments might represent a lost opportunity for some patients who must a priori undergo more extractions and additional surgical procedures. The presentation of a case of hyperdivergent class III occlusion, where the orthodontist hesitates to treat at various stages of growth, and finally ends up performing a late surgical treatment, illustrates quite well the problem we face in choosing a timeframe for treatment.

[Study of asymmetries in the severe antero-posterior disharmonies]. / Etude des asymétries dans les grandes dysmorphies antéro-postérieures.

Using the Treil 14 points cephalometric model orthodontists can prepare a complete cranio-facial anatomic assessment at three analytic levels: the framework or envelope, the basal bone and the alveolo-dental arcade. The assessment of border-line surgical antero-posterior dysmorphosis can elucidate interesting depictions of asymmetries, their relation to other malformities, and their genesis. Asymmetry arises from over-growth of one side of the face in all three dimensions of space even if, clinically, it often appears that one dimension is predominately affected. The ortho-morphic cases of Angle Class I present a little right excess or "natural" asymmetry. The Class III cases present a severe excess on the right side, while the Class II cases present an excess on the left side comparing with reference sample.

Posterior growth and forecasting the development of mandibular third molars.

The inter-dependence of overall orthodontic treatment and the development of the third molars requires the entire dentition to be taken into consideration ab initio and for the patient to be fully informed as to the extractions involved. The anatomical conditions in which the development of the wisdom teeth can occur are studied using comparative samples, with and without third molar retention, followed up to the age of 20 years. Posterior growth observed between the beginning of multiband treatment and adulthood amounted to 11/16mm (girls/boys). The initial difference in forecasting the space between the groups with retained third molars and without was slight (5.5mm). However, this difference was maintained throughout the growth period and was sufficient to guide the final choice whether to extract these teeth or allow them to erupt.

[Three-dimensional 14 point-cephalometric analysis: compensation of maxillofacial dysmorphisms]. / Analyse céphalométrique tridimensionnelle à 14 points: compensations des dysmorphies maxillo-faciales.

The eight points cephalometric Treil model and the alveolodental parameters already allows an initial description of the maxillofacial framework and the teeth. Added six points allows taking into consideration an intermediate level: the maxillary and mandibular skeletal basis. So, the 14 points complete model allows a complete craniofacial anatomy description in three analysis levels: the framework or envelope, the osseous bases, the alveolodental arch. The correlation study between the 3D parameters at different levels defines the compensation notion. It allows understanding how skeletal disharmony may be distributed among the different levels. Only vertical direction compensations are analysed here.

[Three-dimensional cephalometry: applications in clinical practice and research]. / Céphalométrie tridimensionnelle: applications en clinique et en recherche.

A 3D cephalometric analysis method from scanner acquisition has been developed thanks to a long collaboration between Dr Treil and the Department of Orthodontics in Toulouse III University. It allows a perfect knowledge of maxillo-facial architecture using fourteen landmarks related to the neuromatricial axis of facial growth. These landmarks can be identified without ambiguity. The marking of each tooth relative to dental arches (gravity centre coordinates and torque and tipping of each tooth), and the location of arches relative to maxillo-facial frame are given by the analysis. Description and reconstruction of dental and maxillo-facial anatomy are possible with three levels: maxillo-facial frame, maxillar and mandibular bases and dentoalveolar level. The method not only gives more precise information than conventional cephalometrics in anteroposterior and vertical directions, but it allows transversal analysis and asymmetry measurement. Applications are numerous in research as well as in clinical medicine: analyses of cases border line surgery, surgical set-up, facial asymmetry, analysis of dentoalveolar compensations, definition of therapeutic aims, occlusal analysis and set-up, study of evolution in anthropology-primatology, study of growth etc. This method of description using a pattern of landmarks is perfectly adapted to the last developments of modern research techniques: morphometric geometry with Procustes superimpositions, EDMA, TPS, FEM.

[Correlations between the volume of the sinuses and the facial bones and parameters of 3D cephalometry]. / Liaisons entre volumes des cavités aériennes et des bases osseuses maxillaires et paramètres de céphalométrie 3D.

The goal of this work is to study, using a sample of 95 persons, the parameters of the 14 points of the 3D Treil cephalometric analysis and to compare them to the facial volumes of these subjects. The 3D parameters are described on three levels and for all three dimensions of space; they are also defined statistically for each class of occlusion, and indications are given for sagittal two-dimensional variables. The correlations between all these variables and facial bones and air cavity volumes are also analyzed. The antero-posterior and vertical variables showed more statistically significant relationships with volumes than with transverse parameters. It appears that a Class III occlusion is primarily related to the vertical and antero-posterior position of the mandible and its morphology and not to its size, while Class II Division 1 types are associated with increased size of the maxillary sinuses. It also appears that facial hyper-divergence is related to a decrease in the size of the maxilla and the mandible.

[Three-dimensional imaging and cephalometry of cranio-facial asymmetry]. / Imagerie et céphalométrie tridimensionnelles des asymétries cranio-faciales.

The 75th meeting of the French Orthodontics Society will be held in Biarritz May 8-9-10-11 2002. The main topic for discussion will be: "facial asymmetry". During the meeting, authors will present study of facial asymmetries using a new innovative three-dimensional cephalometry. The method combines CT scans data, anatomical landmarks and mathematical tools to create, using the "Cepha" software, a 3D model of the human face. Balance and symmetry of the model are stable enough to define normality for each individual even with different ethnic and cultural origins. Unbalance and asymmetry characterize pathologies. Follow up shape and size of models allows growth prediction and modeling. The model is in the process of becoming the indispensable reference for all those who are interested in studying the human face: Orthodontics, Surgery, Anatomy, Anthropology, Plastic surgery, Forensic Medicine.

[Orthodontic approach to asymmetry]. / Approche orthodontique des asymétries.

From an orthodontic point of view, asymmetries can be gathered in three great clinical entities: mandibular lateral deviations, dental asymmetries without skeletal involvement, skeletal asymmetries. Once the therapeutic aims and the principles of the orthodontic approach of these dysmorphoses have been recalled, the authors present the various orthodontic means implemented in this type of treatment. Four cases treated illustrate those types of treatment. Vertical non-surgical asymmetry may have an obvious local origin, for instance, a unilateral damage to a nerve. but usually, there is no evident origin. Frequently the occlusal slippage of a severe sagittal or a vertical malformation, which may evolve as a borderline surgery case, is suspected to be the real cause. In these cases, the diagnosis is always late, with the ending growth. The treatment needs peculiar strong asymmetric mechanics and, sometimes, unilateral mixed extractions. The post-treatment occlusion can be unstable; for this reason, the finishing steps must be carefully conducted. Four clinical case reports develop these points ov view. Multidisciplinary treatments prove very useful to solve three types of clinical situations. In the adult patient, facial esthetics are indicated in severe dentofacial asymmetries. Esthetic improvements of dental nature are still required in deviated smiles, or frontal tippings of the occlusal plane. In addition, asymmetrical intermaxillary relationships will lead to functional anomalies: TMJ disorders, dental wear or lingual dysfunctions. Finally, multidisciplinary treatments in the adult concern the occlusal transverse anomalies, the lateral crossbites, the Class II subdivisions, the deviations of the inter-incisor midlines or unilateral edentulousness. The various plans of treatment, as well as the orthodontic mechanics used, are illustrated in the following development by clinical cases.

[3-dimensional cephalometry in orthodontics. The current possibilities of Cepha 3DT software]. / Céphalométrie tridimensionnelle en orthopédie dento-faciale. Les possibilités actuelles du logiciel Cépha 3DT.

A 3D cephalometric analysis method from a scanner acquisition, has been developed thanks to a long collaboration between the CIRAD modeling Laboratory and Jacques Treil. The model of skeletal description is based on eight landmarks related to the neuromatrical axis of facial growth (heads of the mallei, supraorbital, suborbital, submental points); it has been abundantly described. The purpose of this work consists in presenting the dentoalveolar level of the analysis. The description and the marking of the arches and the teeth mainly rest on the systematic use of a mathematical tool, the calculation of the central matrix of inertia, and on three fundamental choices: the identification of the dental arches from their constituting teeth leaving aside any alveolar marking, the marking of each tooth relative to the arch, as it can be observed by the orthodontist's eye, and not relative to the craniofacial architecture, the definition of the position of each tooth by the orientation of its coronoradicular axis and not its sole buccal side, Their uses in orthodontics are numerous: diagnosis, choice of the mechanics, therapeutic simulation, therapeutic follow up, analysis of the findings... Clinical applications illustrate the theoretical presentation.