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Posterior positional plagiocephaly treated
by cranial remodelling orthosis
Lausanne’s experience with 260 children
S. de Ribaupierrea, O. Verneta, B. Rillieta, B. Cavinb, D. Kalinaa, P.-F. Leyvrazb
aService of Neurosurgery, Centre Hospitalier Universitaire Vaudois, Lausanne-CHUV, Switzerland
bDepartment of Orthopaedic Surgery, Hôpital Orthopédique de la Suisse Romande, Lausanne,
Switzerland
Principles: Since the recommendation that in-
fants sleep in the supine position, there has been
an increase in cases of posterior positional plagio-
cephaly. Even though this condition is a purely
cosmetic problem, if it is severe it may affect the
child psychologically. Positioning may help in mild
or moderate cases, but more active treatment may
be necessary in severe cases.
Methods: A prospective study of 260 children
treated by dynamic orthotic cranioplasty for pos-
terior positional plagiocephaly was conducted in
Lausanne from 1995 to 2001. Construction of
these cranial remodelling helmets is decribed in
detail.
Results: The treatment lasted 3 months on av-
erage, was effective, well tolerated, and had zero
morbidity. The ideal period for initiating this ther-
apy is between the ages of 4 and 6 months.
Conclusion: The remodelling helmet is a con-
vincing option which can be recommended in in-
fants with posterior positional plagiocephaly
whose skull deformity is not satisfactorily cor-
rected by physiotherapy. It should always be used
before surgery is considered for patients with
recognised positional plagiocephaly in the first
year of life.
Key words: positional plagiocephaly; helmet; or-
thotic cranioplasty
In 1992 the American Academy of Pediatrics
(AAP), on the basis of a multinational investiga-
tion, established a direct correlation between
prone sleeping position and the incidence of sud-
den infant death syndrome [1]. In this report the
AAP recommended that infants be henceforth po-
sitioned to sleep either on the back or side. After
this publication and the subsequent “Back to Sleep
Campaign” [2], an increasing number of children
with craniofacial deformities was observed. Fol-
lowing an initial period of diagnostic and surgical
roaming in which surgical management had in-
creased to epidemic proportions [3], it became
obvious that this abnormal skull shape was not the
result of craniosynostosis, which is the premature
fusion of cranial sutures, but rather the conse-
quence of unrelieved pressure on the occiput dur-
ing infant sleep. This cranial deformity was called
posterior positional plagiocephaly (PPP). In about
two thirds of cases it may correct spontaneously
after regular changes in sleeping position or fol-
lowing physiotherapy aimed at correcting neck
muscle imbalance [4, 5]. In severe cases which fail
to improve despite counterpositioning treatment,
the hazards of surgical correction may be avoided
by cranial remodelling orthosis, originally de-
scribed in 1979 [6, 7] and more extensively em-
ployed in the nineties [8, 9]. The purpose of this
paper is to review our experience in treating chil-
dren with posterior positional plagiocephaly by
dynamic orthotic cranioplasty.
Summary
No financial
support declared.
Introduction
368
Original article SWISS MED WKLY 2007;137:368–372 · www.smw.ch
Peer reviewed article
SWISS MED WKLY 2007;137:368–372 · www.smw.ch 369
From March 1995 to November 2001, 260 children
presenting with PPP were consecutively treated by dy-
namic orthotic cranioplasty. They were initially examined
by the senior authors at the Paediatric Neurosurgery
Clinic of Lausanne University Hospital, Switzerland
(CHUV). Only patients with obvious cranial deformation
were proposed for a cranial remodelling helmet. For mild
cases, parents were reassured and instructed to place the
bulging side of their infant’s head toward the crib mattress.
Physiotherapy was proposed where appropriate. In every
child anthropometric measurements were taken, includ-
ing head circumference, distance from external auditory
meatus to external canthus (EAM – EC) and fronto-occip-
ital (FO) diagonals (Fig. 1). In unilateral posterior posi-
tional plagiocephaly there is typically an occipito-parietal
flattening, ipsilateral to this flattening the ear is anteriorly
displaced, and frontal bossing is observable. The ipsilat-
eral external auditory meatus to external canthus distance,
as well as the diagonal measured from the occipital flatten-
ing to the contralateral forehead, are therefore shorter
than their contralateral counterparts (Fig 1, lines A and B).
In a vertex view, the head exhibits the shape of a parallel-
ogram.
All cranial remodelling helmets were made in the Ergo-
therapy Service of the Hôpital Orthopédique de la Suisse
Romande, Lausanne, Switzerland. These orthoses are
thermoplastic constructs consisting of a semi-rigid styrene
outer shell thermobonded to a polyurethrane foam inner
lining (Polyform, Smith & Nephew, Germantown, USA).
The first step was to cover the infant’s head with a jersey
sock in order to make a plaster of Paris impression (Fig. 2
– left). This impression is then filled with plaster to create
a positive cast which is afterward corrected by applying a
crescent-shaped silicone module over the occipital flatten-
ing. A cranial remodelling orthosis is then created over this
corrected cast (Fig 2 – centre). A few days later the helmet
is applied to the infant (Fig. 3). Pressure is directed to con-
strain growth at the ipsilateral frontal and contralateral
parieto-occipital bulging, whereas a cavity is created over
the adjacent flattened area to promote remodelling. The
Patients and methods
Results
From March 1995 to November 2001, 260 in-
fants (63 girls and 197 boys) were consecutively
treated with a cranial orthosis for PPP in the Hôpi-
tal Orthopédique de la Suisse Romande, Lau-
sanne, Switzerland. Most of the patients had been
unsuccessfully treated by osteopathy and/or phys-
iotherapy before referral to the CHUV Paediatric
Nuerosurgery Clinic. Mean age at the beginning
of treatment was 6.1 ± 2.0 months (range: 3–18
months). As demonstrated in table 1, there was a
progressive increase in the number of cases treated
during the period of study.
There were 117 children with right-sided pos-
terior plagiocephaly (45%), 100 with left-sided
(38%), and only 43 with a bilateral form, without
lateralisation of the occipital flattening (17%). On
examination there were 36 infants (14%) showing
a contraction of the sternocleidomastoid muscle,
contralateral to the side of posterior plagiocephaly.
Most of the patients, however, even in the absence
Figure 1
Right posterior positional plagiocephaly. Vertex view of the
head. Right occipital flattening (arrow). Short (A) and long
(B) fronto-occipital diagonals.
Figure 2
Plaster of Paris im-
ression from the in-
fant’s head covered
with a jersey sock.
helmet was worn progressively during the first week of
treatment up to 21 hours a day. Every 2–3 weeks, the chil-
dren were followed up in the Ergotherapy Service for ad-
justment of the orthoses where necessary. In addition, the
patients were reevaluated at the end of the treatment by
the senior authors. At every examination anthropometric
measurements were repeated. Data are presented as the
mean ± SD. Statistical comparisons were performed by the
Student paired ttest analysis. Significant differences were
reported when the p value was <0.05.
Positional plagiocephaly, infant, helmet, dynamic orthotic cranioplasty 370
therapy was initiated before 6 months of age its
mean duration was 12 ± 6 weeks, and 13 ± 10 weeks
when patients were aged over 6 months at treat-
ment onset. This difference was not statistically
significant.
The results were subjectively considered good
by the parents and the investigators (Fig. 4). Ob-
jectively, this favourable impression was confirmed
by anthropometric measurements showing sym-
metrisation of the ipsilateral and contralateral
EAM – EC distances as well as FO diagonals.
Therefore, the ratios of these left and right dis-
tances and diagonals rapidly tend toward 1.0. In-
deed these ratios improved to statistically signifi-
cant levels after as little as 1 month of treatment
(figures 1 and 2).
In this series good results were obtained with
a single helmet in 147 patients, whereas 98 and 15
infants required 2 and 3 cranial orthoses respec-
tively. The cranial orthosis did not restrict cranial
growth, since serial head circumference measure-
ments showed that every patient remained on his
usual percentile curve.
Figure 3
Side view of an in-
fant wearing a cranial
remodelling helmet.
1995 1996 1997 1998 1999 2000 2001
N (girls/boys) 15 (3/12) 20 (0/20) 14 (0/14) 38 (8/30) 44 (13/31) 50 (17/33) 79 (22/57)
Mean age at treatment onset (months) 5.8 7.1 5.1 6.2 6.0 6.1 6.0
Mean duration of treatment (weeks) 21 18 17 15 12 12 9
Mean number of helmets used per child 1.4 1.5 1.6 1.8 1.6 1.7 1.2
Table 1
Epidemiology of
patients treated with
cranial remodelling
orthosis in Lausanne
from 1995 to 2001.
Figure 4
A. Pretreatment ver-
tex view of the head
of a 4-month-old in-
fant with right poste-
rior positional plagio-
cephaly. B. Results
after 2 months of
treatment by cranial
orthosis.
AB
Discussion
Etymologically, the term “plagiocephaly” has
Greek roots, “plagios” meaning “oblique” and
“kephale” head. One cause of plagiocephaly is
craniosynostosis, which is premature fusion of the
cranial suture(s). The skull shape can be predicted
from the suture(s) involved. Early fusion of the
lambdoid suture(s), which separate the parietal
from the occipital bones, causes posterior plagio-
cephaly. However, premature lambdoidal fusion is
extremely rare: whereas the overall incidence of
craniosynostosis is 6 per 10,000 live births, plagio-
cephaly secondary to isolated lambdoid premature
of clear-cut torticollis, had a tendency to turn the
head preferentially on one side, as previously de-
scribed [10].
Average duration of treatment was 13 ± 8
weeks (range: 4–31 weeks). There was a tendency
toward shorter treatment over the years. When
SWISS MED WKLY 2007;137:368–372 · www.smw.ch 371
fusion occurs in only 3 cases per 100,000 births
[11–13]. In contrast, over the past decade there has
been an increasing incidence of PPP [14, 15] which
has been reported in up to 48% of live births [11,
16]. It is important to distinguish lambdoid cran-
iosynostosis from PPP, because the course and the
management of these two conditions are clearly
different. True synostosis is habitually present
from birth, and is progressive. It never improves
spontaneously and carries the risk of intracranial
hypertension, although this occurs in less than
10% of cases when only a single suture is involved
[17]. In contrast, PPP is usually absent at birth, de-
velops during the first months of life, and carries
no risk of increased intracranial pressure.
Regarding the pathophysiological mechanism
of PPP, it is accepted that external forces applied
consistently to a specific region of the infant’s head
deform the skull. This explains why the increasing
incidence of babies presenting with occipital flat-
tening has coincided with current advice to posi-
tion infants to sleep in the supine position to pre-
vent sudden infant death syndrome [12, 14, 15].
Other pre- and postnatal factors, though rarer,
may favour the development of PPP by external
constraint. They include multiple births, de-
creased amniotic fluid, macrocephaly, malformed
uterus, congenital torticollis, cervical spine anom-
aly or brain injury with asymmetrical spasticity [7,
11, 15, 16, 18–20]. In these situations the cranial
deformity is usually present from birth and wors-
ens over the following weeks.
Simple clinical examination is usually suffi-
cient to diagnose postural posterior plagiocephaly
[11]. In vertex view, patients presenting with PPP
exhibit a parallelogram-shaped head: there is a flat-
tening of one side of the posterior cranium, along
with contralateral parieto-occipital and ipsilateral
frontal bossing, and the ipsilateral ear is displaced
anteriorly. In contrast, in unilateral lambdoid syn-
ostosis, the vertex view reveals a trapezium-shaped
head: there is unilateral occipitoparietal flattening
associated with contralateral frontal bossing. In
addition, the area of the fused lambdoid suture
presents as a bony ridge, with a bony prominence
in the mastoid region behind the ear, which is dis-
placed posteriorly and inferiorly [21]. Normally
there is no need for complementary radiological
investigations. In this study, neither CT scans nor
plain x-rays were done routinely. However, several
patients referred to our clinic had already had skull
x-rays done elsewhere. In this situation skull x-rays
reveal a sclerotic margin parallel to a patent lamb-
doid suture on the side of the occipital flattening
(Fig. 5). This aspect, sometimes called “lazy lamb-
doid”, must not be confused with a true lambdoid
synostosis where the suture is no longer visible
[22].
This study confirms some characteristic fea-
tures of PPP: three quarters of the patients were
boys, and there were a majority of infants with
right-sided plagiocephaly. A male preponderance
in up to 73% of cases and a right/left preference in
a proportion of 2:1 are also reported in the litera-
ture [4, 9, 10, 14, 16, 19, 22–25].
The natural history of PPP is difficult to es-
tablish in the absence of reliable and reproducible
data which would allow grading of its severity. It
has however been reported that over 70% of cases
improve spontaneously [4]. This improvement
may be encouraged by regular changes in sleeping
position and/or physiotherapy [4, 25, 26]. Severe
positional skull deformations may not always cor-
rect satisfactorily [6, 15, 27]. Even though there is
little information about the true risks of leaving
this condition untreated [11], PPP is probably es-
sentially a cosmetic problem of no significant neu-
rological consequence [4, 15, 27]. The role of the
various therapeutic modalities must therefore be
determined. In the nineties, when this condition
was emerging, surgical management was carried to
epidemic proportions [3, 4] until cranial remodel-
ling helmets were developed [8, 9]. This treatment
by orthotics was inspired by ancestral ethnic prac-
tices once aimed at intentionally deforming chil-
dren’s skulls [28].
This study shows that cranial remodelling or-
thosis is a valuable treatment option for infants
whose PPP is not satisfactorily corrected by phys-
iotherapy. The earlier the helmet is applied, the
more rapid and complete will be the correction [9,
11, 14, 24]. In practice, the ideal period for initiat-
ing this treatment is from 4 to 6 months of age. At
this age, in our series, the treatment duration av-
Figure 5
Skull x-rays of a
5-month-old baby
with left posterior po-
sitional plagio-
cephaly. A. AP view
showing patent radi-
olucent lambdoid su-
tures. Note the scle-
rotic margin (arrows)
parallel to the left
lambdoid suture,
on the side of the
occipital flattening.
B. Lateral view. The
sclerotic margin is
also visible (arrows).
AB
eraged 3 months. Before 4 months of age, experi-
ence has shown that the infants usually do not have
enough cervical muscle strength to tolerate the
helmet. After 1 year of age, because cranial growth
lessens and the skull thickens, correction by ortho-
sis is longer and less impressive. In addition, older
children tend to remove their helmets themselves
as they do not tolerate them as well as younger
ones. In practice, we do not usually propose treat-
ment after 1 year of age except as an ultimate at-
tempt to avoid surgical correction. Convincing re-
sults in such rare cases have however been reported
in a small series [29].
Conclusion
This study shows that treatment by cranial re-
modelling orthosis is effective, well tolerated, and
has zero morbidity. It can be recommended in in-
fants with PPP whose skull deformity is not satis-
factorily corrected by physiotherapy. This thera-
peutic option should always be taken up before sur-
gery is considered for patients with recognised
PPP in the first year of life, bearing in mind that
this type of surgery would be a cosmetic procedure
frequently requiring blood transfusion and not
without risk in view of the proximity of posterior
dural sinuses.
Correspondence:
Dr S. de Ribaupierre
Service of Neurosurgery
Centre Hospitalier Universitaire Vaudois
Rue du Bugnon 46
CH-1011 Lausanne
Switzerland
E-Mail: s_derib@hotmail.com
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