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Quantifying Positional Plagiocephaly
Abstract
The treatment of positional plagiocephaly is controversial. A confounding factor is the lack of a proven clinically viable measure to quantify severity and change in plagiocephaly. The use of anthropometric measurements is one proposed method. In this study, the reliability and validity for this method of measurement were investigated. Two clinicians independently recorded caliper measurements of cranial vault asymmetry (CVA) for infants referred for plagiocephaly or torticollis, and an unbiased observer recorded visual analysis scores during the same visit. CVA scores were assigned into three predetermined severity categories (normal CVA < 3 mm, mild/moderate CVA <or= 12 mm, moderate/severe CVA > 12 mm). CVA measurements and visual analysis scores were recorded for 71 and 54 infants, respectively. Intrarater reliability was established (kappa = 0.98, kappa = 0.99), but inter-rater reliability was not (kappa = 0.42). In addition, the inter-rater reliability for the severity categories based upon these measures was poor (kappa = 0.28) and failed to correlate to the visual analysis (kappa = 0.31). Development of a stable and meaningful measurement system for the extent of plagiocephaly is needed to allow scientific studies of the natural history of plagiocephaly and effectiveness of interventions.
... In 2004, Argenta et al. introduced a clinical classification to help quantify the degree of deformity and guide the selection of the appropriate treatment [15]. However, it is still difficult to determine whether a patient requires orthotic helmet treatment, physiotherapy, positional treatment, or no treatment at all due to inaccurate cranial deformity measurements and the lack of clear guidelines for a standardized diagnostic method [4,[19][20][21]. ...
... Although reasonably precise regarding intra-rater reliability, Mortenson et al. discovered insufficient inter-rater reliability in caliper measurements. Subsequently, they recommended further development in this area of diagnosis to measure the degree of plagiocephaly more accurately [20]. Additionally, manual caliper measurements rely on the cooperation of the infants, which is sometimes low. ...
... Additionally, manual caliper measurements rely on the cooperation of the infants, which is sometimes low. Constant moving compromises the measurement and makes it challenging and cumbersome to locate the bony landmarks complex, ultimately leading to imprecise values [19,20,23,24]. ...
This study compared manual and digital measurements of plagiocephaly and brachycephaly in infants and evaluated whether three-dimensional (3D) digital photography measurements can be used as a superior alternative in everyday clinical practice. A total of 111 infants (103 with plagiocephalus and 8 with brachycephalus) were included in this study. Head circumference, length and width, bilateral diagonal head length, and bilateral distance from the glabella to the tragus were assessed by manual assessment (tape measure and anthropometric head calipers) and 3D photographs. Subsequently, the cranial index (CI) and cranial vault asymmetry index (CVAI) were calculated. Measured cranial parameters and CVAI were significantly more precise using 3D digital photography. Manually acquired cranial vault symmetry parameters were at least 5 mm lower than digital measurements. Differences in CI between the two measuring methods did not reach significance, whereas the calculated CVAI showed a 0.74-fold decrease using 3D digital photography and was highly significant (p < 0.001). Using the manual method, CVAI calculations overestimated asymmetry, and cranial vault symmetry parameters were measured too low, contributing to a misrepresentation of the actual anatomical situation. Considering consequential errors in therapy choices, we suggest implementing 3D photography as the primary tool for diagnosing deformational plagiocephaly and positional head deformations.
... The cross-section with the maximum head circumference is used for the measurement plane [2,3], such as the maximum posterior curved plane of the occiput [4], the plane passing through the contralateral lambda suture from the frontal junction point [5], and the plane at the inferior cranial level (superior orbital rim level) [6]. Some reports indicated that 2D evaluations have low measurement variability, but high interobserver variability [7,8]. Another report highlighted a potential error in 2D plane selection [9]. ...
... The severity of the 3D evaluation was defined as follows: mild if ASR ≥ 80.5%, or severe if ASR < 80.5%; mild if PSR ≥ 80.5%, or severe if PSR < 80.5%; and mild if both ASR and PSR were ≥80.5 %, or severe if ASR or PSR was <80.5% [11] (Supplementary Table S1). The severity of the CA-based 2D evaluation was defined as mild (CA = 0-12 mm), or severe (CA > 12 mm) [7,12,20,21]. ...
... To conduct the current study, we searched the literature for a definition of severity used in 3D evaluations, but those we found were inconsistent [7,11,12,20,21]. Although there was no firm professional consensus for the severity threshold in 3D evaluations, a certain criterion was needed to analyze the difference between the 2D and 3D evaluation methods in the current study. ...
This study aimed to assess the measurement precision of a three-dimensional (3D) scanner that detects the geometric shape as surface data and to investigate the differences between two-dimensional (2D) and 3D evaluations in infants with deformational plagiocephaly. Using the 3D scanner that can perform both 2D and 3D evaluations, we calculated cranial asymmetry (CA) for the 2D evaluation, and the anterior symmetry ratio (ASR) and posterior symmetry ratio (PSR) for the 3D evaluation. Intra- and inter-examiner precision analyses revealed that the coefficients of the variation measurements were extremely low (<1%) for all variables, except CA (5%). In 530 infants, the coincidence rate of CA severity by the 2D evaluation and the 3D evaluation was 83.4%. A disagreement on severity was found between 2D and 3D evaluations in 88 infants (16.6%): 68 infants (12.8%) were assessed as severe by 2D evaluation and mild by the 3D evaluation, while 20 infants (3.8%) were evaluated as mild by 2D and severe by 3D evaluation. Overall, the 2D evaluation identified more infants as severe than the 3D evaluation. The 3D evaluation proved more precise than the 2D evaluation. We found that approximately one in six infants differed in severity between 2D and 3D evaluations.
... Anthropometric measurements with calipers have been used frequently to assess head shape but there is controversy regarding the reliability of the data [17] and lack of homogeneity regarding the anthropometric references used [18][19][20][21][22]. Craniometry with caliper is safe, fast, and low cost, which makes it an efficient method for clinical settings. ...
... The inclusion criterion was to show a difference of at least 5 mm between cranial diagonal diameters [17]. Subjects with craniosynostosis, genetic, infectious, metabolic, or neurological diseases were excluded. ...
... Median CVA was 8.19 mm. According to Mortenson and Steinbok, who classify CVA into the following categories: normal CVA < 3 mm, mild/moderate CVA ≥ 3 mm and CVA ≤ 12 mm, moderate/severe CVA > 12 mm [17], the sample had a moderate PP. Plot referring to left cranial diagonal ( Figure 5) shows an excellent degree of agreement, since mean difference is 0.0 cm. ...
(1) Background: anthropometric measurements with calipers are used to objectify cranial asymmetry in positional plagiocephaly but there is controversy regarding the reliability of different methodologies. Purpose: to analyze the interrater and intrarater reliability of direct anthropometric measurements with caliper on defined craniofacial references in infants with positional plagiocephaly. (2) Methods: 62 subjects (<28 weeks), with a difference of at least 5 mm between cranial diagonal diameters. Maximal cranial circumference, length and width and diagonal cranial diameters were measured. Intrarater (2 measurements) and interrater (2 raters) reliability was analyzed. (3) Results: intra- and interrater reliability of the maximal cranial length and width and right cranial diagonal was excellent: intraclass correlation coefficient (ICC) > 0.9. Intrarater and interrater reliability for the left cranial diagonal was excellent: ICC > 0.9 and difference in agreement in the Bland-Altman plot 0.0 mm, respectively. Intrarater and interrater reliability for the maximal cranial circumference was good: differences in agreement in Bland-Altman plots: intra: −0.03 cm; inter: −0.12 cm. (4) Conclusions: anthropometric measurements in a sample of infants with moderate positional plagiocephaly have shown excellent intra- and interrater reliability for maximal cranial length, maximal cranial width, and right and left cranial diagonals, and good intra- and interrater reliability in maximal cranial circumference measurement.
... In 1997, Moss introduced the "Cranial Vault Asymmetry" (CVA), which is defined as the difference between the longest and shortest diagonal of the head [15]. Although the CVA is commonly used and can be easily assessed with a caliper, the disadvantage of this method is that it reduces a threedimensional asymmetry to a simple two-dimensional measurement [16,17]. The application of non-invasive 3D stereophotogrammetry allows for capturing a threedimensional image of an infant's head as well as possible asymmetries. ...
... The comparison of the subjective perception of right-sided and left-sided posterior cranial asymmetries was analyzed using t tests for paired samples. As patient #1 and patient #2 demonstrated a 30°CVA of less than 3 mm and therefore did not fulfill the criteria for DP according to Moss or Mortenson et al. [15,16], the comparison of the subjective perception of a right-sided and a leftsided posterior cranial asymmetry was not suitable. Consequently, we excluded these two patients from this analysis. ...
... Of all these 3D datasets, we used a PAM cluster analysis to select ten patients who represented all degrees of severity of deformational cranial asymmetries with respect to all of the four symmetry-related variables. Referring to the classifications made by Moss and Mortenson et al., this final sample contained 3D datasets of all degrees of severity of deformational head asymmetries, ranging from almost-perfect symmetry to severe deformational skull asymmetries [15,16]. ...
Objectives
The present investigation aimed to evaluate the subjective perception of deformational cranial asymmetries by different observer groups and to compare these subjective perceptions with objective parameters.Materials and methodsThe 3D datasets of ten infants with different severities of deformational plagiocephaly (DP) were presented to 203 observers, who had been subdivided into five different groups (specialists, pediatricians, medical doctors (not pediatricians), parents of infants with DP, and laypersons). The observers rated their subjective perception of the infants’ cranial asymmetries using a 4-point Likert-type scale. The ratings from the observer groups were compared with one another using a multilevel modelling linear regression analysis and were correlated with four commonly used parameters to objectively quantify the cranial asymmetries.ResultsNo significant differences were found between the ratings of the specialists and those of the parents of infants with DP, but both groups provided significantly more asymmetric ratings than did pediatricians, medical doctors, or laypersons. Moreover, the subjective perception of cranial asymmetries correlated significantly with commonly used parameters for objectively quantifying cranial asymmetries.Conclusions
Our results demonstrate that different observer groups perceive the severity of cranial asymmetries differently. Pediatricians’ more moderate perception of cranial asymmetries may reduce the likelihood of parents to seek therapeutic interventions for their infants. Moreover, we identified some objective symmetry-related parameters that correlated strongly with the observers’ subjective perceptions.Clinical relevanceKnowledge about these findings is important for clinicians when educating parents of infants with DP about the deformity.
... The skull deformity is measured with an anthropometric caliper. The CVAI is the ratio between the long and short cranial diagonal diameter [25,26]. It is calculated by dividing the difference between the two diagonals divided by the value of the greater diagonal. ...
... It has been shown that infants sleeping on their back reach motor developmental milestones later than prone-sleeping and side-sleeping infants [23][24][25][26][27][28][29][30][31][32][33][34] although they catch up by the age of 18 months [34]. It is also possible that some of the exercises proposed in this test are no longer appropriate for the current pediatric population (tying shoelaces, stacking blocks, stringing beads). ...
Objective: To screen the psychomotor development at 24 months of age in children in whom a positional head deformity (PHD), plagiocephaly or brachycephaly, was detected at birth or in the first months of life. Methods: This retrospective study included children with a PHD detected during a specialist consultation in a tertiary centre. In clinical practice, the standardized Ages and Stages Questionnaire at 24 months (ASQ-24) was filled in by the parents at home and sent back to the hospital. The questionnaire results and the children's perinatal characteristics were studied to determine whether PHD influenced their psychomotor development and identify confounding factors that could affect psychomotor development. Results: Based on the ASQ-24 scores, psychomotor development in at least two ASQ domains was delayed in 13 of the 158 included children (8.23%), a rate not different from what found in the general population at 24 months (5-8%). Among the perinatal characteristics, only intra-uterine growth restriction was associated significantly with psychomotor delay. Conclusion: PHD presence does not associate at the risk of psychomotor delay at 24 months according to the ASQ24 test used in the general population of the same age.
... Initial tests yielded highly significant distinctions between the patient group and the control group, thereby allowing for a clear differentiation based on the specific chosen parameters. To ensure comparability to the existing literature, we performed our analyses and created a classification system based on no, moderate, and severe PP, which is in line with Moss and Mortenson et al. 6,11 . Due to the widespread usage of the 30° diagonal difference described by Loveday et al. 10 , our measurements also originated from this gold standard. ...
... In differentiating between no PP and moderate + severe PP, these measurements even reached an AUC of 0.991. This finding highlights the strong results of this measurement method when used by experienced examiners, as has been reported in other studies 11,25 . ...
Positional plagiocephaly (PP) is the most common skull deformity in infants. Different classification systems exist for graduating the degree of PP, but all of these systems are based on two-dimensional (2D) parameters. This limitation leads to several problems stemming from the fact that 2D parameters are used to classify the three-dimensional (3D) shape of the head. We therefore evaluate existing measurement parameters and validate a newly developed 3D parameter for quantifying PP. Additionally, we present a new classification of PP based on a 3D parameter. 210 patients with PP and 50 patients without PP were included in this study. Existing parameters (2D and 3D) and newly developed volume parameters based on a 3D stereophotogrammetry scan were validated using ROC curves. Additionally, thresholds for the new 3D parameter of a 3D asymmetry index were assessed. The volume parameter 3D asymmetry index quantifies PP equally as well as the gold standard of 30° diagonal difference . Moreover, a 3D asymmetry index allows for a 3D-based classification of PP. The 3D asymmetry index can be used to define the degree of PP. It is easily applicable in stereophotogrammetric datasets and allows for comparability both intra- and inter-individually as well as for scientific analysis.
... The inclusion criteria were: babies under 32 weeks old [4] and infants with at least moderate PP (at least 5 mm of difference between cranial diagonal diameters [23]). Subjects with craniosynostosis and with genetic, infectious, metabolic, or neurological diseases were excluded. ...
... The sample of this study consisted of 74 children with PP, with a difference of at least 5 mm between diagonal cranial diameters, that is, children with at least moderate deformity [23]. The GLM outcomes showed that the severity of PP was related to the left active cervical rotation ROM and with transport type independently of the active cervical rotation ROM. ...
Positional plagiocephaly (PP) is a general term describing cranial distortion from pre- or postnatal forces on the infant head. Abnormal intrauterine forces, multiple births, primiparous mothers, obstetric interventions, prematurity, male sex, excessive time lying in the supine position, and mobility restrictions of the cervical spine have been considered as the main predisposing factors. The objective was to investigate the association between the severity of PP and the active cervical rotation and to analyze the influence of predisposing factors in babies with PP. An analytical cross-sectional study was performed on 74 babies with moderate PP. Clinical and demographic data, cranial vault asymmetry, and active cervical rotation range of motion (ROM) were measured. Associations were analyzed with generalized linear models. The mean age was 16.8 ± 5.0 weeks, and 56.8% were male. A restriction in the ROM of active cervical rotation, especially to the left side, was observed. Our models showed that cranial asymmetry was related with left active cervical rotation ROM (p = 0.034) and with being transported in a pushchair (p < 0.001). Conclusions: An increased severity of PP was related with being transported in a baby pushchair and with a reduced active cervical rotation ROM toward the most restricted side.
... Pediatricians in Section III of the Aragon Health Services referred 34 subjects aged less than 28 weeks having signs of PP. The inclusion criterion was infants with a difference of at least 5 mm between cranial diagonal diameters [40], that is, infants with moderate or severe PP [41]. We excluded infants who had received orthotic treatment, physiotherapy or presented genetic, communicable, metabolic or neurological illness or craniosynostosis. ...
... The CVA was calculated with the formula: "Long diagonal cranial diameter (mm) -Short diagonal cranial diameter (mm)" [46]. According to Mortenson & Steinbok, the CVA can be classified into the following categories: normal CVA < 3 mm, mild / moderate CVA ≤ 12 mm, moderate / severe CVA > 12 mm [41]. ...
Background
Positional plagiocephaly frequently affects healthy babies. It is hypothesized that manual therapy tailored to pediatrics is more effective in improving plagiocephalic cranial asymmetry than just repositioning and sensory and motor stimulation.
Methods
Thirty-four neurologically healthy subjects aged less than 28 weeks old with a difference of at least 5 mm between cranial diagonal diameters were randomly distributed into 2 groups. For 10 weeks, the pediatric integrative manual therapy (PIMT) group received manual therapy plus a caregiver education program, while the controls received the same education program exclusively. Cranial shape was evaluated using anthropometry; cranial index (CI) and cranial vault asymmetry index (CVAI) were calculated. Parental perception of change was assessed using a visual analogue scale (− 10 cm to + 10 cm).
Results
CVAI presented a greater decrease in PIMT group: 3.72 ± 1.40% compared with 0.34 ± 1.72% in the control group ( p = 0.000). CI did not present significant differences between groups. Manual therapy led to a more positive parental perception of cranial changes (manual therapy: 6.66 ± 2.07 cm; control: 4.25 ± 2.31 cm; p = 0.004).
Conclusion
Manual therapy plus a caregiver education program improved CVAI and led to parental satisfaction more effectively than solely a caregiver education program.
Trial registration
Trial registration number: NCT03659032 ; registration date: September 1, 2018. Retrospectively registered.
... These devices require hand measurements, are inexpensive, non-invasive and follow normative guidelines (Farkas, 1994). However, authors differ in the accuracy and reliability of the results of these subjective manual measurements, some of them quantifying an interuser accuracy of 2 mm (Mortenson and Steinbok, 2006;Wilbrand et al., 2011). The disadvantages of the manual measurements are the difficulties for getting valuable results after training and the time required to perform repeated measurements. ...
... The results provide higher accuracy than to those obtained with measuring tape and calliper (Mortenson and Steinbok, 2006), especially for transversal and longitudinal distances. Moreover, the interuser reliability of the photogrammetric 3D models seems to be higher for this tool and the models provide much more complete information, as the whole infant's head is measured. ...
Image-based and range-based solutions can be used for the acquisition of valuable data in medicine. However, most of these methods are not valid for non-static patients. Cranial deformation is a problem with high prevalence among infants and image-based solutions can be used to assess the degree of deformation and monitor the evolution of patients. However, it is required to deal with infants normal movement during the assessment in order to avoid sedation. Some high-end multiple-sensor image-based solutions allow the achievement of accurate 3D data for medical applications under unpredicted dynamic conditions in consultation. In this paper, a novel, single photogrammetric smartphone-based solution for cranial deformation assessment is presented. A coded cap is placed on the infant’s head and a guided smartphone app is used by the user to acquire the information, that is later processed on a server to obtain the 3D model. The smartphone app is designed to guide users with no knowledge of photogrammetry, computer vision or 3D modelling. The processing is fully automatic offline. The photogrammetric tool is also non-invasive, reacting well with quick and sudden infant’s movements. Therefore, it does not require sedation. This paper tackles the accuracy and repeatability analysis tested both for a single user (intrauser) and multiple non-expert user (interuser) on 3D printed head models. The results allow us to confirm an accuracy below 1.5 mm, which makes the system suitable for clinical practice by medical staff. The basic automatically-derived anthropometric linear magnitudes are also tested obtaining a mean variability of 0.6 ± 0.6 mm for the longitudinal and transversal distances and 1.4 ± 1.3 mm for the maximum perimeter.
... Although they are based on well-known anatomical landmarks (e.g., inion, glabella, eurion, inner and outer corner of the eye, nasal pyramid, etc.), these measurements do not offer always the possibility to obtain a reliable diagnosis. This is because of the possible un-cooperativity of the patients, which may prevent a correct measuring and its repeatability, and because of the difficult assessment of the facial changes, which may reduce the reliability in the evaluation of the severity and evolution of PDP (Mortenson and Steinbok 2006;Wilbrand et al. 2011). Moreover, the significant differences among the measurement methods prevent a homogeneous evaluation of the results of the treatment. ...
... Of course, the age-dependent measures are corrected by the age of the patient. The main "traditional" measurements can be summarized as follows (Graham et al. 2005;Kluba et al. 2011;Lee et al. 2008;Loveday and De Chalain 2001;Moss 1997;Mortenson and Steinbok 2006): ...
... The portion of the cranium superior to the reference level 0 plane was divided into 9 equally spaced cross-sectional planes, each parallel to the reference plane. The following anthropometric measurements were obtained at levels 3 and 5 ( Fig. 1) [14,15]: (1) the diagonal difference (mm), which is defined as the difference between the longer cranial diagonal and the shorter cranial diagonal, and (2) the CVAI (%), which is defined as long cranial diagonal (mm)-short cranial diagonal (mm) short cranial diagonal (mm) × 100. ...
... Relatively young infants were included in this study to examine the parents' perspectives and clinical effect of cranial orthotic therapy in young age. There were 26 infants (35%) who had mild asymmetric severity, defined as CVAI less than 7%, who were enrolled in this study to assess how the effect of cranial-molding orthotic therapy differs according to the severity [15]. According to the results of this study, parent's satisfaction and therapeutic efficacy were greater when cranial-molding orthoses were applied earlier in infancy. ...
Objective:
To investigate the clinical effectiveness of and parents' perspectives on cranial-molding orthotic treatment.
Methods:
Medical charts were reviewed for 82 infants treated for plagiocephaly with cranial-molding orthoses in our clinic from April 2012 to July 2016 retrospectively. Infants who were clinically diagnosed with positional plagiocephaly and had a Cranial Vault Asymmetry Index (CVAI) of more than 3.5% were included. Pre- and post-treatment CVAI was obtained by three-dimensional head-surface laser scan. Parents' perceptions of good outcome (satisfaction) were evaluated with the Goal Attainment Scale (GAS). The GAS score assessed how much the parent felt that his or her initial goal for correcting the skull asymmetry was achieved after the treatment.
Results:
The compliance with cranial-molding orthoses was 90.2% (74 of 82 infants). There were 53 infants (65% of the 82 infants) who had adverse events with the cranial-molding orthoses during the study. Heat rash was found in 29 cases (35.4%) and was the most common adverse event. The mean GAS T-score was 51.9±10.2. A GAS T-score of 0 or more was identified for 71.6% of parents. The GAS T-score was significantly related to the age (p<0.001), the initial CVAI, and the difference of CVAI during the treatment (p<0.001).
Conclusion:
Parents' perception of good outcome was correlated with the anthropometric improvement in cranialmolding orthotic treatment in infants with plagiocephaly. A high percentage of parents felt that the treatment met their initial goals in spite of a high occurrence of adverse events.
... 3,4 It should also be pointed out that most of these previous studies used anthropometric calipers to measure head shapes, a technique that introduces a good amount of variability in results. [3][4][5][6][7][8]20 The current study addresses many of these concerns. Patients were divided into three age cohorts, and the severity of the presenting asymmetry was categorized as mild to moderate or moderate to severe. ...
... When compared to standard caliper measurements, this technique offers high intrarater reliability, speed and ease of use, and the ability to obtain three-dimensional Plastic and Reconstructive Surgery • August 2017 measurements of shape that cannot be measured in two dimensions. 20,21 Accordingly, this study is really the first to provide accurate and objective evidence demonstrating the efficacy of helmet therapy. This study's classification into severity subgroups also provides valuable insight into the effect of age and baseline shape on reduction of asymmetry, with more severe presentations clearly experiencing lower rates of treatment success in all age groups. ...
... Traditionally, the diagnosis has been made via clinical assessment, sometimes relying on a set of reference images such as the ones described by Argenta, to determine the type and degree of deformation (Argenta et al., 2004;Robinson and Proctor, 2009;Rogers, 2011). However, these methods reportedly have only moderate inter-rater reliability and repeatability, and may be biased by the clinician's knowledge of the infants' referral status, or whether the assessment is made pre-or post-treatment (Mortenson and Steinbok, 2006;Spermon et al., 2008;Atmosukarto et al., 2010). Therefore, various objective measurements for quantifying cranial asymmetry have been developed. ...
... Therefore, we could not study or produce cut-off values for different degrees of DP, which is a limitation of this study. Furthermore, the inter-and intra-rater agreements were far from perfect, albeit the inter-rater agreement was higher compared to previous studies using visual classification (Mortenson and Steinbok, 2006;Spermon et al., 2008;Atmosukarto et al., 2010). Nevertheless, as many as 46 (11%) of the 407 subjects received discrepant expert ratings, which reflects the difficulty and subjectivity of drawing the line between symmetrical and asymmetrical cranial shape, especially in an unselected population such as ours. ...
Objective
Various measurements are used to quantify cranial asymmetry in deformational plagiocephaly (DP), but studies validating cut-off values and comparing the accuracy of such measurements are lacking. In this study, we compared the accuracy of four different measurements in classifying children with and without DP diagnosed by visual assessment, and sought to determine their optimal cut-off values.
Study Design
Two experts rated 407 3D craniofacial images of children aged between 3 and 36 months old using the Argenta classification. We then measured the following asymmetry-related variables from the images: Oblique Cranial Length Ratio (OCLR), Diagonal Difference (DD), Posterior Cranial Asymmetry Index (PCAI), and weighted Asymmetry Score (wAS). We created receiver operating characteristic curves to evaluate the accuracy of these variables.
Results
All variables performed well, but OCLR consistently provided the best discrimination in terms of area under the curve values. Subject’s age had no clear effect on the cut-off values for OCLR, PCAI, and wAS; however, the cut-off for DD increased monotonically with age. When subjects with discrepant expert ratings were excluded, the optimal cut-off values for DP (Argenta class ≥ 1) across all age-groups were 104.0% for OCLR (83% sensitivity, 97% specificity), 10.5% for PCAI (90% sensitivity, 90% specificity), and 24.5 for wAS (88% sensitivity, 90% specificity).
Conclusion
We recommend using OCLR as the primary measurement, although PCAI and wAS may also be useful in monitoring cranial asymmetry. The threshold of relative asymmetry required for a deformation to appear clinically significant is not affected by the child’s age, and DD has no additional utility in monitoring DP compared to using only OCLR.
... Another option is to use a caliper, Mortenson and Steinbok found good intra-reliability but poor inter-reliability. They assumed that the identification of landmarks used for the measurements and infant behavior could have affected the results in their study [23]. Infants do not always cooperate to make the measurements easy, quite the opposite the measurements can be a real challenge. ...
... We obtained better inter-reliability than the study by Mortenson and Steinbeck [23] this may partly be due to the fact that a headband with marks was used and the fact that the headband was on during the whole session. Wilbrand et al. found that calipers can provide highly precise information, they had an assistant holding the infants head during assessment [27]. ...
Objective: The aim of the study was to determine the intra-and inter-reliability for measuring infants with plagiocephaly and brachycephaly with a craniometer when using a marked headband as landmarks. Subjects: Six physiotherapists and eight infants participated in the study. Methods: The physiotherapists measured all infants twice; each infant was measured with the same headband and craniometer. The physiotherapists were blinded to measurements carried out by their colleagues. The infants with their parents changed places in the room to minimize the possibility that the physiotherapists would remember their first measurements of any infant. Results: There was a high intra-and inter-reliability, for intra-reliability ICC 0.96 to 0.99 and for inter-reliability ICC 0.98. Conclusion: It is possible to achieve a high intra-and inter-reliability when using a headband and craniometer when measuring cranial vault asymmetry for plagiocephaly and cephalic ratio for brachycephaly.
... The infants with previous history of moderate/severe plagiocephaly were included in the study. 16 All the infants received the same treatment. They were included in a physiotherapy programme, and they used an orthotic helmet. ...
... Infants were discharged when an independent expert pediatric neurologist considered the asymmetry corrected based on the anthropometric measurements (normal CVA < 3 mm). 16 Children were excluded from the study if they had a diagnosis or a previous history of prematurity, cranyosinostosis, developmental dysplasia of the hip, perinatal fracture of the clavicle, torticollis, obstetric brachial plexus palsy, central nervous system disorders, congenital abnormalities or malformations, disorders in sensory systems, acquired musculoskeletal or nonmusculoskeletal asymmetry, idiopathic scoliosis or a respiratory condition such as asthma. These conditions have reported to cause asymmetry 1 or a postural adaptation. ...
AimThe objective of the study was to assess posture, muscle flexibility and balance in children aged 3-5years old with a history of nonsynostotic plagiocephaly. Methods
Fifty-two children with previous history of plagiocephaly were evaluated, along with 52 control subjects matched for age, sex, height, weight and physical activity. The outcome measures included static posture, assessed through the measurement of angles and distances between anatomical landmarks; muscle flexibility, evaluated with the Stibor, Shober and finger-to-floor distance tests and balance, assessed by the Pediatric Balance Scale. ResultsOne-way analysis of variance afforded statistically significant differences (P<0.05) in head position, muscle flexibility (thoracic mobility and trunk and lower limbs muscle shortening) and balance. Conclusion
Children with previous history of non-synostotic plagiocephaly present changes in head position, muscle shortening and a poor balance when compared to control children at 3-5years old.
... Such measurements performed directly on the head, of landmarks anthropometrically established, are reliable, being the difference between the largest and smallest diagonal diameter of the skull. An index CVA <3 mm is considered physiological, a deviation between 3 mm and 12 mm is considered a mild to moderate asymmetry and a deviation over 12 mm is considered a moderate to severe asymmetry (Mortenson & Steinbok, 2006). It does not require additional instruments for measuring and classifying asymmetry and is divided into 5 categories: (Neumann, 1942). ...
... paediatricians or neurosurgeons) using callipers and measuring tape. The manual measurements are standardized, and usually include cranial perimeter, oblique diameters, head width and head length 10,34,35 . The reproducibility of manually extracted heads measurements relies on the standard position of the head 10 and the interuser reliability can be low 36 . ...
Cranial deformation and deformational plagiocephaly (DP) in particular affect an important percentage of infants. The assessment and diagnosis of the deformation are commonly carried by manual measurements that provide low interuser accuracy. Another approach is the use of three-dimensional (3D) models. Nevertheless, in most cases, deformation measurements are carried out manually on the 3D model. It is necessary to develop methodologies for the detection of DP that are automatic, accurate and take profit on the high quantity of information of the 3D models. Spherical harmonics are proposed as a new methodology to identify DP from head 3D models. The ideal fitted ellipsoid for each head is computed and the orthogonal distances between head and ellipsoid are obtained. Finally, the distances are modelled using spherical harmonics. Spherical harmonic coefficients of degree 2 and order − 2 are identified as the correct ones to represent the asymmetry characteristic of DP. The obtained coefficient is compared to other anthropometric deformation indexes, such as Asymmetry Index, Oblique Cranial Length Ratio, Posterior Asymmetry Index and Anterior Asymmetry Index. The coefficient of degree 2 and order − 2 with a maximum degree of 4 is found to provide better results than the commonly computed anthropometric indexes in the detection of DP.
... Firstly, the Argenta classification is used for the establishment of severity of the skull shape; however, this method is a visual assessment and is therefore subjective and not quantitative (Argenta et al., 2004;Feijen et al., 2012). Secondly, caliper measurement is frequently used in the clinical setting; this method is objective, but the interrater reliability of caliper measurements ranges widely between studies (Graham et al., 2005;Mortenson and Steinbok, 2006). ...
Objective
Craniofacial measuring is valuable for diagnosis and evaluation of growth and treatment of positional skull deformities. Plagiocephalometry (PCM) quantifies skull deformities and is proven to be reliable and valid. However, PCM needs direct skin contact with thermoplastic material, is laborious and time-consuming. Therefore, Skully Care (SC) was developed to measure positional skull deformities with a smartphone application.
Design
SC is retrospectively compared to PCM.
Setting
Pediatric physiotherapy centers.
Patients
Age ≤1 year, analyzed or treated for positional skull deformities.
Interventions
A total of 60 skull shape analyses were performed.
Main Outcome Measures
The main outcome measures employed are Pearson correlation coefficient between cranial vault asymmetry index (CVAI; in SC) and oblique diameter difference index (ODDI; in PCM) and between cranial index (CI; in SC) and cranial proportional index (CPI; in PCM). Mann–Whitney U test determined difference of time consumption between PCM and SC.
Results
High correlation was found between CVAI and ODDI ( r = 0.849; P < .01) in positional plagiocephaly and very high correlation between CI and CPI ( r = 0.938; P < .01) in positional brachycephaly. SC is significantly faster than PCM ( P < .001).
Conclusions
SC is valid in analyzing positional skull deformities and strongly correlates to PCM, the gold standard in daily physiotherapy practice. The combination of simplicity, validity, speed, and user and child convenience makes SC a promising craniofacial measuring method in daily practice. SC has potential to be the modern successor for analyzing positional skull deformities.
... In forensic anthropology, conventionally, a direct measurement is performed on the bone using calipers to measure the length and width [3]. However, this conventional method has lower validity and reliability [5], as well as a limitation on the visualization of human skeletal morphology [6]. Contrarily, the geometric morphometric approach provides more information on the shape and shows better reliability, accuracy, and validity with great reproductivity [7]. ...
Introduction: Estimation of race plays a significant role in establishing personal identity in forensic anthropology. A cervical vertebra is one of the bones that is least researched in forensic applications. Our study aims to investigate the morphologic variations of the fourth cervical vertebrae (C4) between the different major races in the adult Malaysian population using a three-dimensional (3D) geometric morphometrics method. Methods: Computer tomography images of C4 vertebra, which consist of 386 subjects (169 Malay, 82 Chinese, and 135 Indian) were collected retrospectively from University of Malaya. Twenty-eight landmarks were placed on the images. Procrustes MANOVA, canonical variates analysis(CVA), discriminant function analysis (DFA), and linear measurement were performed using Planmeca Romexis, Checkpoint Stratovan, Morpho J, and Graphpad Prism software respectively to analyze the morphological variations of C4. Results: Procrustes MANOVA showed significant differences in the shape (p <0.0001) and centroid size (p = 0.0003) of the C4 vertebra between races. Canonical variate analysis showed significant differences for Mahalanobis (p <0.0001) and Procrustes (p <0.0001) distances among races. Besides that, a cross-validation value of 66.5% was demonstrated by discriminant function analysis. The use of linear measurements reveals no significant differences between the races, thesemeasurements are the vertebral body height, anterior-posterior length of the vertebral body, length of superior articular facet, and spinous process length. Both intra- and inter-observational reliabilities showed that acceptable human errors for measurement accuracy. Conclusions: Morphologic variations in the shape of C4 can assist in race estimation of the adult Malaysian population using the 3D geometric morphometric approach.
... In forensic anthropology, conventionally, a direct measurement is performed on the bone using calipers to measure the length and width [3]. However, this conventional method has lower validity and reliability [5], as well as a limitation on the visualization of human skeletal morphology [6]. Contrarily, the geometric morphometric approach provides more information on the shape and shows better reliability, accuracy, and validity with great reproductivity [7]. ...
Introduction: Estimation of race plays a significant role in establishing personal identity in
forensic anthropology. A cervical vertebra is one of the bones that is least researched in
forensic applications. Our study aims to investigate the morphologic variations of the fourth
cervical vertebrae (C4) between the different major races in the adult Malaysian population
using a three-dimensional (3D) geometric morphometrics method. Methods: Computer
tomography images of C4 vertebra, which consist of 386 subjects (169 Malay, 82 Chinese,
and 135 Indian) were collected retrospectively from University of Malaya. Twenty-eight
landmarks were placed on the images. Procrustes MANOVA, canonical variates analysis
(CVA), discriminant function analysis (DFA), and linear measurement were performed using
Planmeca Romexis, Checkpoint Stratovan, Morpho J, and Graphpad Prism software
respectively to analyze the morphological variations of C4. Results: Procrustes MANOVA
showed significant differences in the shape (p <0.0001) and centroid size (p = 0.0003) of the
C4 vertebra between races. Canonical variate analysis showed significant differences for
Mahalanobis (p <0.0001) and Procrustes (p <0.0001) distances among races. Besides that, a
cross-validation value of 66.5% was demonstrated by discriminant function analysis. The use
of linear measurements reveals no significant differences between the races, these
measurements are the vertebral body height, anterior-posterior length of the vertebral body,
length of superior articular facet, and spinous process length. Both intra- and inter�
observational reliabilities showed that acceptable human errors for measurement accuracy.
Conclusions: Morphologic variations in the shape of C4 can assist in race estimation of the
adult Malaysian population using the 3D geometric morphometric approach.
... [2,4] In current study, severity of CVA was verified by the caliper cephalometry. Caliper cephalometry is a non-invasive and easily applicable method that provides precise information on major diagnostic features of DP. [20] In previous several studies, Moss [24] et al, and Mortenson [25] et al defined a CVA as normal <3 mm, mild/moderate 12 mm, moderate/severe > 12 mm. Meanwhile, according to the cranial molding therapy protocol, children with DP were treated on the basis of a CVA cutoff value of 10 mm. ...
The purpose of this study was to investigate the prevalence of neurodevelopmental delay among deformational plagiocephaly (DP) children, and to confirm relationship between neurodevelopmental delay and severity of DP.
This study is retrospective study. Five hundred thirteen children who visited for abnormal head shape through outpatient department were recruited. To identify the children with neurodevelopmental delay among the 513 children with DP, Denver Development Screening Test (DDST) was performed in 38 children who suspected of neurodevelopmental delay. Cranial vault asymmetry (CVA) was measured by using caliper, and cranial vault asymmetry index (CVAI) was calculated. Thirty eight children with DP who conducted DDST were divided into 2 groups according to the degree of CVA; group 1 included 21 children with CVA under 10 mm, and group 2 included 17 children with CVA over 10 mm.
There was a significant difference in number of neurodevelopmental delay between group 1 (n = 7) and group 2 (n = 14) (P < .05). Mean grade of DP, CVA, and CVAI (1.76 ± 0.44, 5.90 ± 2.21 mm, 4.20 ± 1.51%) in group 1 was smaller than that in group 2 (3.41 ± 0.8, 12.71 ± 3.22 mm, 8.83 ± 2.18%), respectively (P < .05).
Our results found that the frequency of developmental delay was significantly increased in children with CVA more than 10 mm. Doctors who take care of children with DP had better keep developmental delays in mild.
... Craniofacial measurements are quite important in the diagnosis and evaluation of these patients (22). Previous studies investigated various techniques and skull shape measurements for the diagnosis and follow-up of PSD, however there is no consensus on a practical clinical method to measure the intensity and the change of deformity (23). Radiologic diagnostic techniques are barely helpful in these patients, and although plain radiographs and computerized tomography (CT) scans were performed in the past for these patients, these are not recommended as routine diagnostic tools for patient evaluation. ...
... A total of 239 Caucasian infants (33% female, 67% male) with DP were included in the study. With reference to Moss and Mortenson et al. [28,29], only infants with a cranial vault asymmetry (CVA) of more than 3 mm were included. All the children underwent head orthosis therapy to correct their positional head asymmetry. ...
Objective
Although prematurity is a risk factor for developing deformational plagiocephaly (DP), to our knowledge, there are no studies that have analyzed the impact of a premature birth on the duration of head orthosis therapy and the extent of the reduction in asymmetry during treatment.
Materials and Methods
We examined 239 patients with DP who were undergoing head orthosis therapy. Depending on the gestational age, they were assigned to either a premature (gestational age of < 37 weeks) or a full-term (gestational age of ≥ 37 weeks) group. Head shape was analyzed using 3D-stereophotogrammetry at the start and end of treatment. We performed multiple linear regression analyses to evaluate the impact of prematurity on the duration of therapy and the extent of the reduction in asymmetry, taking age and the initial asymmetry of an infant’s head into account.
Results
Head orthosis therapy led to a significant reduction in asymmetry in both groups. Using multiple linear regression analyses, we demonstrated that age at the start of treatment, the initial asymmetry and prematurity, significantly influenced the duration of therapy. Patients who were born at an earlier gestational age experienced a shorter treatment length. However, prematurity did not affect the extent of the reduction in cranial asymmetry that was achieved.
Conclusions
Along with age at the start of treatment and the initial asymmetry, prematurity is significantly correlated with the duration of head orthosis therapy, but not with the extent of the reduction in asymmetry achieved.
Clinical Relevance
Knowledge of these findings is important for clinicians when planning treatment and discussing the effectiveness of head orthosis therapy with the parents of premature infants with DP.
... Consequently, the evaluation and monitoring of the deformation is a usual practice during paediatric consultations. However, the commonly used techniques, including visual assessment and the use of callipers and measuring tape, are Table 1 Patients' information and distance difference parameters between radiological and photogrammetric models (differences in mm strongly limited and experts do not agree on their reliability and capacity to represent adequately the deformation [16,22]. Specifically designed 3D scanners and setups of 3D cameras have become an alternative for the evaluation of cranial deformation (such as STARscanner and 3dMD) [22,3,8]. ...
Cranial deformation in infants is a common problem in paediatric consultations. The most accurate medical diagnostic imaging methodologies are Computed Tomography (CT) and Magnetic Resonance Image (MRI). However, these radiological imaging technologies involve high costs and are invasive, especially for infants. Therefore, they are only used for severe cases, while milder cases are evaluated using less precise methodologies, such as callipers or measure tapes. The use of smartphone-based photogrammetric 3D models has been presented as a possible alternative to extracting accurate and complete external information in a low-cost, non-invasive manner but its accuracy is still to be tested. In this study, photogrammetric and radiological cranial 3D models have been obtained for a set of 10 patients. In order to compare them, the distances between model surfaces have been calculated. Results show an overestimation of the photogrammetric models up to 3.2 mm due to both hair and usage of caps. However, differences in shape, given by the standard deviation of the distances are below 1.5 mm for every patient. The accuracy of low-cost smartphone-based photogrammetric models has been found to be comparable to medical diagnostic imaging methodologies used for cranial deformation analysis.
... A limitation of all long-term studies investigating the effectiveness of head orthosis therapy is that the data acquisition is based on 2D-anthropometric measurements using callipers or tapes. Nowadays, however, 3D-stereophotogrammetry is the method of choice for analysing skull morphology, as it is no longer based only on 2D anthropometric measurements (16,(34)(35)(36)(37)(38). The present study is the first long-term investigation to exclusively use 3D-stereophotogrammetry to analyse the skull morphology in all severity grades in children with DP treated with head orthosis therapy. ...
Background:
As there are very few long-term studies on the effects of head orthosis on deformational plagiocephaly (DP), we investigated the outcomes of patients, including facial symmetry and dental occlusion.
Methods:
Forty-five infants with DP [cranial vault asymmetry index (CVAI) > 3.5 per cent] were divided into two groups: one treated with head orthosis (32 infants) and another without (13 infants). Another group without head asymmetry (CVAI ≤ 3.5 per cent) served as control. Using 3D-stereophotogrammetry, cranial asymmetry was analysed using symmetry-related variables [CVAI, posterior cranial asymmetry index (PCAI), and ear offset]. Data acquisition was performed before (T1) and at the end of treatment (T2), and at the age of 4 years (T3) for the treated group and at T1 and T3 for the remaining groups. Parameters of facial symmetry and dental occlusion were assessed at T3 for infants with DP.
Results:
Symmetry-related variables (∆T1-T3) improved significantly more in the treated than the control group, whereas these parameters did not differ significantly between the untreated and control group. Comparing the treated and untreated groups between T1 and T3, the reduction in the asymmetry at the treated group was significantly higher for the CVAI and PCAI. In follow-up, the untreated group showed higher incidences of facial asymmetries than the treated group. Seventy-five per cent of all lateral crossbites found in patients with DP were contralateral to the posterior flattening.
Limitations:
Due to ethical reasons, the investigation is a non-randomized study. Parameters of facial symmetry were only assed for the treated and untreated groups.
Conclusion:
Head orthosis therapy in patients with DP leads to significantly better long-term outcomes. Facial asymmetries are more frequent in patients with DP who do not receive this treatment.
... Correction of the anterioredorsal axis and the two oblique manual anthropometric measurements are more critical in very severe ear-shift cases. In clinical practice, we observe an increasing inter-observer variability with aggravation of the ear-shift (Mortenson and Steinbok, 2006;Schaaf et al., 2010). An objective measurement of plagiocephaly as demonstrated with our technique, allows analysis of the cranial base and facial asymmetry. ...
Purpose:
The recommendation issued by the American Academy of Pediatrics in the early 1990s to position infants on their back during sleep to prevent sudden infant death syndrome (SIDS) has dramatically reduced the number of deaths due to SIDS but has also markedly increased the prevalence of positional skull deformation in infants. Deformation of the base of the skull occurs predominantly in very severe deformational plagiocephaly and is accompanied by facial asymmetry, as well as an altered ear position, called ear shift. Moulded helmet therapy has become an accepted treatment strategy for infants with deformational plagiocephaly. The aim of this study was to determine whether facial asymmetry could be corrected by moulded helmet therapy.
Materials and methods:
In this retrospective, single-centre study, we analysed facial asymmetry of 71 infants with severe deformational plagiocephaly with or without deformational brachycephaly who were undergoing moulded helmet therapy between 2009 and 2013. Computer-assisted, three-dimensional, soft-tissue photographic scanning was used to record the head shape before and after moulded helmet therapy. The distance between two landmarks in the midline of the face (i.e., root of the nose and nasal septum) and the right and left tragus were measured on computer-generated indirect and objective 3D photogrammetry images. A quotient was calculated between the two right- and left-sided distances to the midline. Quotients were compared before and after moulded helmet therapy. Infants without any therapy served as a control group.
Results:
The median age of the infants before onset of moulded helmet therapy was 5 months (range 3-16 months). The median duration of moulded helmet therapy was 5 months (range 1-16 months). Comparison of the pre- and post-treatment quotients of the left vs. right distances measured between the tragus and root of the nose (n = 71) and nasal septum (n = 71) revealed a significant reduction of the asymmetry (Tragus-Nasion-Line Quotient: 0.045-0.022; p < 0.0001; Tragus-Subnasale-Line Quotient: 0.045-0.021; p < 0.0001). The control group without treatment showed no significant change in the quotient (Tragus-Nasion-Line Quotient no helmet: 0.049-0.055/Tragus-Subnasale-Line Quotient no helmet: 0.039-0.055).
Conclusion:
Moulded helmet therapy can correct facial symmetry in infants with deformational plagiocephaly and associated facial and basal skull asymmetry.
... Wilbrand et al. argued that calliper measurements provide highly precise information as long as a strictly standardized protocol is followed; the patient should be in a standard position, the examiner should be trained, and the patient should be cooperative 18 . Because of these conditions, exact measurements and documentation are challenging 16,19 . In addition, these measurements are two-dimensional, and therefore do not provide an adequate description of the 3D cranial shape. ...
Craniosynostosis is a congenital defect which can result in abnormal cranial morphology. Three dimensional (3D) stereophotogrammetry is potentially an ideal technique for the evaluation of cranial morphology and diagnosis of craniosynostosis because it is fast and harmless. This study presents a new method for objective characterization of the morphological abnormalities of scaphocephaly and trigonocephaly patients using 3D photographs of patients and healthy controls. Sixty 3D photographs of healthy controls in the age range of 3-6 months were superimposed and scaled. Principal component analysis (PCA) was applied to find the mean cranial shape and the cranial shape variation in this normal population. 3D photographs of 20 scaphocephaly and 20 trigonocephaly patients were analysed by this PCA model to test whether cranial deformities of scaphocephaly and trigonocephaly patients could be objectively identified. PCA was used to find the mean cranial shape and the cranial shape variation in the normal population. The PCA model was able to significantly distinguish scaphocephaly and trigonocephaly patients from the normal population. 3D stereophotogrammetry in combination with the presented method can be used to objectively identify and classify the cranial shape of healthy newborns, scaphocephaly and trigonocephaly patients.
... Other types of craniofacial deformity, including positional plagiocephaly and brachycephaly, could also benefit from objective parameters of evaluation. 12 Definition of a large series of developmentally normal, full-term infants with high-resolution 3D reconstructed head CT scans allowed exploration of normative ranges for common anthropometric cranial indices and the development of 2 new indices (metopic index and towering index) that are potentially useful in the clinical setting. The same series of imaging was used to assess timing of metopic suture closure among infants. ...
OBJECTIVE
Subjective evaluations typically guide craniosynostosis repair. This study provides normative values of anthropometric cranial indices that are clinically useful for the evaluation of multiple types of craniosynostosis and introduces 2 new indices that are useful in the evaluation and management of metopic and bicoronal synostosis. The authors hypothesize that normative values of the new indices as well as for established measures like the cephalic index can be drawn from the evaluation of CT scans of normal individuals.
METHODS
High-resolution 3D CT scans obtained in normal infants (age 0–24 months) were retrospectively reviewed. Calvarial measurements obtained from advanced imaging visualization software were used to compute cranial indices. Additionally, metopic sutures were evaluated for patency or closure.
RESULTS
A total of 312 participants were included in the study. Each monthly age group (total 24) included 12–18 patients, yielding 324 head CT scans studied. The mean cephalic index decreased from 0.85 at age 0–3 months to 0.81 at 19–24 months, the mean frontoparietal index decreased from 0.68 to 0.65, the metopic index from 0.59 to 0.55, and the towering index remained comparatively uniform at 0.64 and 0.65. Trends were statistically significant for all measured indices. There were no significant differences found in mean cranial indices between sexes in any age group. Metopic suture closure frequency for ages 3, 6, and 9 months were 38.5%, 69.2%, and 100.0%, respectively.
CONCLUSIONS
Radiographically acquired normative values for anthropometric cranial indices during infancy can be used as standards for guiding preoperative decision making, surgical correction, and postoperative helmeting in various forms of craniosynostosis. Metopic and towering indices represent new cranial indices that are potentially useful for the clinical evaluation of metopic and bicoronal synostoses, respectively. The present study additionally shows that metopic suture closure appears ubiquitous after 9 months of age.
... A transcranial difference of <3 mm was considered mild, between 3.1 and 11.9 mm moderate, and 12 mm or greater. 15 The side of occipital flattening (posterior plagiocephaly) was noted as right or left. ...
Deformational plagiocephaly (DP) in infants has been associated with developmental delay that can last until adolescence. Despite this association and a 5-fold increase in incidence of DP over the past 2 decades, there are currently no guidelines regarding screening for developmental delay or identification of which infants with DP are at the greatest risk of delay. A prospective, nonrandomized study was performed. Infants diagnosed with DP who had no prior intervention were eligible for enrollment. Cranial deformity was measured by cross-cranial measurements using calipers, and developmental delay was measured using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Correlation between cranial deformity and developmental delay was analyzed using a linear regression. Twenty-seven infants, ages 4.0 to 11.0 months (mean?=?6.61 months) diagnosed with DP were studied. Developmental delay was observed on the composite language (n?=?3 of 27, 11%), and composite motor (n?=?5 of 23, 22%) scales, but not the cognitive scale. Severity of cranial deformity did not correlate with scores on any Bayley-III scales (cognitive R?=?0.058, P?<?0.0001; composite language R?=?0.03, P?<?0.0001; composite motor R?=?0.0195, P?<?0.0001). This study demonstrates that severity of cranial deformity cannot be used to predict presence or degree of developmental delay. Craniofacial surgeons should be aware of this risk and consider developmental screening based on clinical suspicion.
... The inherent asymmetry in these patients may throw off the technician seeking the widest point of the head. 10 Here, photogrammetry has the advantage as it allows for systematic, precise orientation of the head prior to landmark placement. These differences between the modalities may explain the relatively weak correlation between them. ...
The severity of deformational plagiocephaly is frequently measured by cranial vault asymmetry (CVA). Cranial vault asymmetry is a simple linear proxy for the three-dimensional deformity. Different anthropometric landmarks have been suggested as the endpoints of the cross-cranial diagonals that determine CVA. One promising albeit counterintuitive set of digital landmarks is the frontozygomaticus and contralateral eurion. The validity of nondigital caliper measures associated with the diagonals defined by the frontozygomaticus and contralateral eurions has not been tested. In this study, the authors compare caliper measures against stereophotogrammetric measures that have been documented to correlate strongly with overall skull asymmetry. Cranial vault asymmetry was assessed by direct anthropometry with 2 different measures on 36 patients. Frontozygomaticus and contralateral eurion (fz-eu) and 30 degrees off the anteroposterior diameter (30offAP). Three-dimensional photographs were obtained and also used to quantify CVA in these subjects; digital measures of fz-eu and an overall measure of plagiocephaly (Global) were calculated. Global and 30offAP obtained at 31 patient visits in 2011 were also included. The measure best-correlated with overall Global asymmetry was digital fz-eu (R2 = 0.80). Caliper fz-eu was not strongly correlated with Global asymmetry (R2 = 0.27) or with digital fz-eu (R2 = 0.34). Differences between the digital and caliper fz-eu measures were 5 +/- 4 mm (mean +/- st. dev.). Differences between the caliper fz-eu and 30offAP measures were 6 +/- 4 mm. Digital fz-eu shows an excellent correlation to Global asymmetry. However, attempts to replicate this result in the clinical setting by measuring fz-eu with calipers were unsuccessful.
... While visual assessment of head shape asymmetry is essential and has been regarded as the best diagnostic test [14], taking anthropometric measurements using metal sliding callipers is an inexpensive and practical way of obtaining absolute indicators of cranial vault asymmetry. Additionally, researchers have established the validity and reliability of this technique [15,16]. Calliper measurements in our clinics were taken with the child sitting on the parent's lap with an assistant holding the child's head in a fixed position. ...
Positional plagiocephaly is the most common type of cranial asymmetry affecting infants. We aimed to investigate the effectiveness of helmet therapy compared to no helmet therapy in treating positional plagiocephaly in infants under the age of 1 year. This retrospective review was conducted in an Australian paediatric hospital and included 171 patients recruited from outpatient clinics. Only 30 patients had positional plagiocephaly scores recorded at first and final consultations while 39 patients had diagonal measurements recorded at both visits. The mean age was 7.38 months at initial consultation with a mean follow-up duration of 5.85 months. Those who had helmet therapy had a significantly greater reduction in diagonal difference than those who did not use helmets (p = 0.011). Therefore, there may be a role for helmet therapy in the treatment of severe positional plagiocephaly.
... 12 The outcomes of cranial molding helmet therapy for deformational plagiocephaly have been measured by crude scales based on the visible deformity, caliper cephalometry, imaging studies, including sonography and computed tomography (CT), and a laser-based measurement system. [12][13][14][15] Cephalometry is an inexpensive and noninvasive technique for measuring skull asymmetry, 16 but this measurement has not been regularly reproduced. Serial CT scans are much more accurate and can measure the direction of the sutures and quantify deformities around the suture line. ...
Objectives:
The purpose of this study was to investigate the changes in skull shape on sonography after cranial molding helmet therapy in infants with deformational plagiocephaly.
Methods:
Twenty-six infants who were treated with cranial molding helmet therapy were recruited. Caliper and sonographic measurements were performed. The lateral length of the affected and unaffected sides of the skull and cranial vault asymmetry index were measured with calipers. The occipital angle, defined as the angle between lines projected along the lambdoid sutures of the skull, was calculated by sonography. The occipital angle difference and occipital angle ratio were also measured. All caliper and sonographic measurements were performed in each infant twice before and twice after treatment.
Results:
The study group included 12 male and 14 female infants with a mean age ± SD of 6.2 ± 3.5 months. The mean treatment duration was 6.0 ± 2.5 months. The difference in lateral length before and after helmet therapy was significantly greater on the affected skull than the unaffected skull (16.7 ± 12.7 versus 9.0 ± 13.4 mm; P< .01). The difference in the occipital angle before and after helmet therapy was significantly greater on the affected skull than the unaffected skull (-5.7° ± 7.3° versus 4.2° ± 7.9°; P < .01). The cranial vault asymmetry index and occipital angle ratio were significantly reduced after helmet therapy (cranial vault asymmetry index, 9.3% ± 2.3% versus 3.5% ± 3.0%; occipital angle ratio, 1.07 ± 0.05 versus 1.01 ± 0.01; P < .05).
Conclusions:
These results suggest that occipital angle measurements using sonography, combined with cephalometry, could provide a better understanding of the therapeutic effects of cranial molding helmet therapy in infants with deformational plagiocephaly.
Background
The differentiation of unilateral lambdoid synostosis (ULS) and deformational plagiocephaly (DP) is vital to provide appropriate treatment intervention. Three-dimensional (3D) photo grammetry provides rapid, reproducible image capture without radiation exposure. Advanced analytical methods can help identify distinctive features to differentiate the two craniofacial conditions. This study uses 3D photogrammetry of ULS and DP patients to analyze the global cranial morphology for diagnostic differentiation.
Methods
A retrospective review of 3D photogrammetry of 19 ULS and 25 DP patients were analyzed. Cranial vault asymmetry index, oblique cranial length ratio, and diagonal difference were measured. 3D photogrammetry-based composites were created and overlaid on age and gender-matched controls to generate heat maps representing morphologic differences in contour.
Results
Cranial vault asymmetry index and oblique cranial length ratio were significantly different between ULS and DP (0.019; 0.022). 3D photogrammetry ULS composite showed retrusion in the ipsilateral occipitoparietal area, contralateral posterior parietal projection, contralateral frontal projection, relative ipsilateral mastoid bulge, and facial projection. DP composite showed unilateral occipital projection and contralateral anterior projection. The contralateral occipital regions in the occipital and anterior areas remained equivocal to control patients.
Conclusions
Diagnostic differentiation of ULS and DP has previously relied on observation and linear measurements of cranial asymmetry in a single plane. 3D photogrammetry composites provide a global contour evaluation for diagnosis and longitudinal outcome analysis.
Shape analysis of infant's heads is crucial to diagnose cranial deformities and evaluate head growth. Currently available 3D imaging systems can be used to create 3D head models, promoting the clinical practice for head evaluation. However, manual analysis of 3D shapes is difficult and operator-dependent, causing inaccuracies in the analysis. This study aims to validate an automatic landmark detection method for head shape analysis. The detection results were compared with manual analysis in three levels: (1) distance error of landmarks; (2) accuracy of standard cranial measurements, namely cephalic ratio (CR), cranial vault asymmetry index (CVAI), and overall symmetry ratio (OSR); and (3) accuracy of the final diagnosis of cranial deformities. For each level, the intra- and interobserver variability was also studied by comparing manual landmark settings. High landmark detection accuracy was achieved by the method in 166 head models. A very strong agreement with manual analysis for the cranial measurements was also obtained, with intraclass correlation coefficients of 0.997, 0.961, and 0.771 for the CR, CVAI, and OSR. 91% agreement with manual analysis was achieved in the diagnosis of cranial deformities. Considering its high accuracy and reliability in different evaluation levels, the method showed to be feasible for use in clinical practice for head shape analysis.
Speichel ist ein Sekret, welches aus den Kopfspeicheldrüsen (Glandulae parotideae, Glandulae submandibulares und sublinguales) und mehreren kleinen Glandulae der Mundschleimhaut sezerniert wird. Bislang sind zahlreiche Biomarker bei unterschiedlichen Patientengruppen aus Speichel analysiert worden. In der vorliegenden Studie sollte eine non-invasive Methode entwickelt werden, um knöcherne Stoffwechselvorgänge longitudinal bei Säuglingen darstellen zu können. Die Bestimmung der Aktivität der alkalischen Phosphatase im Speichel eines wachsenden Säuglings könnte eine solche Methode darstellen. Bei Säuglingen ist bislang keine Speichelanalyse mit diesem Ziel beschreiben worden. Zusätzlich sollte die Aktivität des spezifischen Biomarkers der morphologischen Veränderung des Säuglingskopfes im ersten Lebensjahr gegenübergestellt werden. Es wurden 40 Säuglinge (19 männlich, 21 weiblich) ohne auffällige Kopfdeformitäten zu vier Zeitpunkten untersucht (T1: 4 Monate ± 14 Tage; T2: 6 Monate ± 14 Tage; T3: 8 Monate ± 14 Tage; T4: 10 Monate 14 Tage). An jedem Messtermin wurde ein 3D-Scan des Kopfes angefertigt und zeitgleich eine Speichelprobe entnommen. Die virtuellen Datensätze konnten mit Hilfe der Software Cranioform Analytics 4,0 ® der Firma Cranioform (Alpnach, Schweiz) analysiert werden. Die Aufarbeitung der Speichelproben erfolgte photometrisch mittels des VersaMax® Elisa Microplate Reader der Firma Molecular Devices GmbH. Durch dieses zusätzliche non-invasive Testverfahren sollte die alkalische Phosphatase (AP) als ein Biomarker des Knochenstoffwechsels im Speichel untersucht werden und so einen zusätzlichen Parameter generieren, anhand dessen auch Rückschlüsse auf knöcherne Wachstumsprozesse von Säuglingen gezogen werden können. In vorangegangenen Untersuchungen konnte anhand der 3D-Oberflächendaten die physiologische Kopfform und Entwicklung von Säuglingen einer Kontrollgruppe sowie von Säuglingen mit lagebedingtem Plagio-/Brachyzephalus analysiert werden. Die 3D-Datenbank sollte durch diese Studie vergrößert und durch die Verringerung der Messabstände präzisiert werden. Zusätzlich sollte während des Beobachtungszeitraumes ein Biomarker zur Wachstumsanalyse generiert werden. Es konnte die Aktivität der AP im Speichel nachgewiesen werden. Eine Korrelation der Aktivität mit den wachstumsbezogenen Parametern der Kontrollgruppe ergab keine Signifikanz. Die Erweiterung der 3D-Datenbank und der Nachweis der Aktivität der AP im Speichel der Probanden sollte einen weiteren Beitrag dazu leisten, die non-invasive Bildgebung in der Diagnostik sowie Langzeitkontrolle des Kopfwachstums bei Säuglingen zu etablieren und es sollte versucht werden, einen auf non-invasivem Weg gewonnen Biomarker als diagnostischen Parameter heranzuziehen. Weitere Untersuchungen sind hierfür notwendig, um zukünftig, ggf. über Speichelanalysen, Aussagen über Wachstumsaktivität und -dynamik im Säuglingsalter treffen zu können.
Background:
This study aimed to evaluate the correlation and consistency between traditional head measurement and structured light three-dimensional (3D) scanning parameters when measuring infant skull shape.
Methods:
A total of 76 infants aged 3 months to 2.5 years old were included in the study. Head circumference (HC) was measured with a tape measure. The transverse, anteroposterior, and oblique diameters were measured using a spreading caliper, and the cranial vault asymmetry index (CVAI) and a cranial index (CI) of symmetry were calculated; 76 cases were measured successfully. The above indexes were measured using a structured light 3D scanning system (71 cases were measured with success). Thus, in the end, the valid data of 71 cases were analyzed, and the measurements of the two approaches were compared.
Results:
The 95% confidence interval of traditional head measurement and structured light 3D scanning was between 0.633 and 0.988. Pearson's correlation coefficient indicated a high correlation between the two methods (r=0.793-0.980). The correlation coefficients of the transverse diameter, anteroposterior diameter, and HC, and the CI of symmetry were higher than 0.9. The lowest correlation coefficient for the CVAI was 0.793. The P values of the above measurement data were all <0.001, which indicated that they were closely related. A Bland-Altman plot indicated reasonable consistency between the two methods.
Conclusions:
Both traditional head measurement and structured light 3D scanning are suitable for the measurement of infant head shape. However, while traditional head measurement using a spreading caliper is economical and simple, making it suitable for general screening at a basic level, structured light 3D scanning can deliver additional parameters, which is useful for infants with an abnormal head shape. The latter is also convenient for designing a customized helmet for skull correction when needed.
Der lagerungsbedingte Plagiozephalus (LP) stellt die häufigste Schädeldeformation bei Kleinkindern dar. Ursachen, Risikofaktoren und die Wirksamkeit konservativer Therapieverfahren wurden in einer Vielzahl von Veröffentlichungen dargestellt. Untersuchungen zur Langzeitstabilität des Helmtherapieerfolges und die Auswirkungen eines LP auf das stomatognathe System bei Kleinkindern sind hingegen selten. Die vorliegende kontrollierte, prospektive Längsschnittstudie stellt die erste 3D- Untersuchung dar, die belegt, dass die Kopforthesentherapie bei Patienten mit LP zu besseren Langzeitergebnissen im Vergleich zu anderen Therapieoptionen führt. Auch nach Abschluss der Kopforthesentherapie ist eine weitere Verbesserung der Kopfform zu beobachten. Bei Patienten mit LP besteht zudem grundsätzlich ein höheres Risiko für laterale Kreuzbisse, die bevorzugt auf der kontralateralen Seite in Relation zur abgeflachten Hinterhauptseite auftreten. Gesichtsasymmetrien treten häufiger bei Patienten mit LP auf, bei denen keine Kopforthesentherapie durchgeführt wurde. Folglich stellt die Kopforthesentherapie eine geeignete Therapieoption für Säuglinge mit LP dar, um sowohl die Schädelasymmetrie als auch das Auftreten dentofazialer Asymmetrien zu reduzieren.
Introduction. Posterior Positional plagiocephaly (PPP) is a cranial deformation seen in infants. The case number increased since 1992, following the supine sleeping advice. Most of the time several factors are combining together, leading to a multi-level lack of mobility of the infant, thus leading to the cranial deformation. Studies show this deformation to be linked with perturbations in various fields. Objective. This study aims to assess the efficacy of osteopathic care on the severity of the PPP. Materials and methods. 100 infants were recruited in an osteopathic practice in Lyon (France). All the infants followed the same study protocol; however, the treatment was individualized. Three consultations occurred with a 15 days′ interval over 30 days′ period. Craniometric measurements were realized with Mimos® craniometer on each consultation. Results. The mean severity of the PPP was 10,1 mm at Day 0. At day 30, this average was down to 6 mm. It is a significant (p<0,001) clinical and statistical decrease. Out of the 100 infants, 98 had a decreased deformation while two stagnated. Conclusions. As every infant is unique, every plagiocephaly is different, thus the treatment was not standardised. This study suggest some effectiveness for osteopathic care in the cranial asymmetry of infants with PPP. Other studies should be done, some with a control group, in order to compare our results with spontaneous evolution of plagiocaphaly.
In the last two decades, pediatricians observe an immense increase in the incidence of skull deformities with patent sutures, also known as positional plagiocephaly or positional brachycephaly. This chapter introduces the topic with its biological basis, its risk factors, as well as its clinical classification. The possible implications of positional skull deformities are discussed.
PurposeThe aim of this study is to compare the symmetry of the facial and dentoalveolar structures of patients with unilateral impacted maxillary canine teeth with a control group of individuals without impacted teeth using three-dimensional face scans.Methods
The study included 28 patients (10 females, 18 males) with unilateral impacted maxillary canine teeth and 28 patients (15 females, 13 males) without any impacted maxillary canine between 12 and 25 years of age. The 3dMDface™ (3dMD Inc., Atlanta, GA, USA) imaging system was used to obtain 3D face images. 3dMD Vultus® (3dMD Inc., Atlanta, GA, USA) software was used for the measurements.ResultsAccording to the study findings, there were differences in linear measurements and volume measurements between the right and left sides of the face in patients with an impacted canine. However, these differences were not statistically significant. In patients with an impacted canine, surface differences between the right and left halves of the face were not found to be statistically different from the control group.Conclusion
There was no difference in the amount of facial asymmetry between patients with unilateral maxillary impacted canine and patients with normal tooth alignment in the control group.
Background
Positional plagiocephaly (PP) is a cranial deformation frequent amongst children and consisting in a flattened and asymmetrical head shape. PP is associated with excessive time in supine and with congenital muscular torticollis (CMT). Few studies have evaluated the efficiency of a manual therapy approach in PP. The purpose of this parallel randomized controlled trial is to compare the effectiveness of adding a manual therapy approach to a caregiver education program focusing on active rotation range of motion (AROM) and neuromotor development in a PP pediatric sample.
Methods
Thirty-four children with PP and less than 28 week-old were randomly distributed into two groups. AROM and neuromotor development with Alberta Infant Motor Scale (AIMS) were measured. The evaluation was performed by an examiner, blinded to the randomization of the subjects. A pediatric integrative manual therapy (PIMT) group received 10-sessions involving manual therapy and a caregiver education program. Manual therapy was addressed to the upper cervical spine to mobilize the occiput, atlas and axis. The caregiver educational program consisted in exercises to reduce the positional preference and to stimulate motor development. The control group received the caregiver education program exclusively. To compare intervention effectiveness across the groups, improvement indexes of AROM and AIMS were calculated using the difference of the final measurement values minus the baseline measurement values. If the distribution was normal, the improvement indexes were compared using the Student t-test for independent samples; if not, the Mann-Whitney U test was used. The effect size of the interventions was calculated using Cohen’s d.
Results
All randomized subjects were analysed. After the intervention, the PIMT group showed a significantly higher increase in rotation (29.68 ± 18.41°) than the control group (6.13 ± 17.69°) ( p = 0.001). Both groups improved the neuromotor development but no statistically significant differences were found. No harm was reported during the study.
Conclusion
The PIMT intervention program was more effective in increasing AROM than using only a caregiver education program.
The study has been retrospectively registered at clinicaltrials.gov, with identification number NCT03659032 . Registration date: September 1, 2018.
Zur Kopforthesentherapie in der Behandlung von Säuglingen mit lagerungsbedingten Schädelasymmetrien gibt es bisher kaum Studien, die den optimalen Behandlungsbeginn unter Berücksichtigung der Ausprägung der Asymmetrie untersuchen. Ziel der vorliegenden Studie war es daher, den Einfluss des Alters und des Schweregrades der Asymmetrie bei Therapiebeginn auf die Therapiedauer und das Therapieergebnis zu analysieren. Hierzu wurden 144 Patienten mit lagerungsbedingtem Plagiozephalus untersucht, die mittels Kopforthese behandelt wurden. Es erfolgte eine Einteilung in drei Altersgruppen (Altersgruppe I: < 24 Wochen mit N = 38 Säuglingen / Altersgruppe II: ≥ 24 bis < 32 Wochen mit N = 79 Säuglingen / Altersgruppe III: ≥ 32 Wochen mit N = 27 Säuglingen) und je zwei Schweregrade (mild-to-moderate: 30°-CVA >3mm bis <12mm / moderate-to-severe: 30°-CVA ≥12mm). Anhand stereophotogrammetrischer Datensätze wurden das Ausmaß und die Reduktion der Asymmetrie in den verschiedenen Untergruppen sowie die Therapiedauer miteinander verglichen. Es zeigte sich, dass es in allen Altersgruppen zu einer signifikanten Reduktion der Asymmetrie kam, wobei sich dieser Effekt mit steigendem Alter verringerte. Ein Therapieerfolg (= CVAI <3,5%) wurde bei Patienten mit mild-to-moderate Asymmetrie in Altersgruppe I zu 83%, in Altersgruppe II zu 69% und in Altersgruppe III zu 40% erreicht. Bei Patienten mit einer schwerwiegenderen, moderate-to-severe Asymmetrie ergab sich eine symmetrische Kopfform zu 50% in Altersgruppe I, zu 30% in Altersgruppe II und nur zu 7% in Altersgruppe III. Die durchschnittliche Therapiedauer stieg von 18,6 Wochen in Altersgruppe I, 20,0 Wochen in Altersgruppe II und 25,3 Wochen in Altersgruppe III an. Das Alter bzw. der Schweregrad der Asymmetrie bei Behandlungsbeginn wurden durch die multiple Regressionsgleichung ins Verhältnis gesetzt. Dadurch kann zukünftig die zu erwartende Verbesserung der Asymmetrie durch eine Kopforthesentherapie abgeschätzt werden. Zusammenfassend kann somit festgestellt werden, dass das Alter bei Therapiebeginn sowie der Ausprägungsgrad einer lagerungsbedingten Asymmetrie einen entscheidenden Einfluss auf Dauer und Effektivität der Kopforthesentherapie haben. Die Erfolgsrate der Therapie ist maßgeblich von diesen beiden Einflussfaktoren abhängig. Die aufgestellte Regressionsgleichung ermöglicht eine Vorhersage der Reduktion einer lagerungsbedingten Schädelasymmetrie.
Zusammenfassung und Ziele: Der lagerungsbedingte Plagiocephalus (LP) ist die häufigste Schädeldeformitäten im Säuglingsalter. Es existiert eine Vielzahl unterschiedlicher zweidimensionaler und dreidimensionaler Messungen und Messmethoden zur Erfassung des Schweregrades eines LP. Die uneinheitliche Durchführung dieser verschiedenen Messungen führt zu einer mangelnden Vergleichbarkeit der Ergebnisse in der Literatur und erschwert den wissenschaftlichen Diskurs. Außerdem wird bei Durchführung von linearen Messungen der kindliche Schädel als dreidimensionales Objekt auf eine zweidimensionale Messung reduziert und nach Aufassung des Autors nur unzureichend abgebildet. Daher wurden im Rahmen der vorliegenden Studie bereits gebräuchliche Parameter kritisch evaluiert und neu entwickelte dreidimensionale Parameter qualitativ überprüft. Zudem soll anhand eines dreidimensionalen Parameters eine neue Klassifikation zur Erfassung des Schweregrades eines LP erstellt werden. Methoden: In der Studie wurden in der Patientengruppe 210 Kinder mit einem mittleren Alter von 6.5 ± 1,9 Monaten untersucht. 119 Kinder zeigten eine moderate Asymmetrie (CVA 3-12 mm) und 91 Kinder eine schwere Asymmetrie (CVA > 12 mm) Die Kontrollgruppe bestand aus 50 Kindern mit einem mittleren Alter von 6.4 ± 0.6 Monaten (CVA < 3mm) Von allen Probanden wurde ein Scan des kindlichen Schädels mittels non-invasiver 3D Stereophotogrametrie durchgeführt, sowie eine klinische Untersuchung und händische Kephalometrie mittels Präzisionsbeckenzirkel vorgenommen. Nach Auswertung der Scans durch geeignete Analysesoftware wurden insgesamt 12 Parameter untersucht. Ergebnisse: Bei den ROC Analysen für den Vergleich der Gruppen „kein Plagiocephalus“ zu „moderater und schwerer Plagiocephalus“ erreichen die Parameter 30°Diagonalendifferenz und Iln(Q4Q2/Q3Q1)I den max. AUC 1. Der Parameter „Asymmetrie“ (Händische Messung) erreicht einen AUC von 0,991. Den niedrgisten Wert zeigt der Parameter ACAI (AUC 0,694). Für den Vergleich der Gruppen „kein + moderater Plagiocephalus“ zu „schwerer Plagiocephalus“ erreicht der Parameter 30°Diagnonalendifferenz den max. Wert 1. Der Parameter Iln(Q4Q2/Q3Q1)I erreicht einen AUC von 0,986. Den niedrigsten Wert zeigt der Parameter „Cranial Index“ (AUC 0,551) Nach Neueinteilung der Probandengruppe anhand der errechneten Schwellenwerte für den Volumenparameters Iln(Q4Q2/Q3Q1)I wächst die Kontrollgruppe um ein Kind und die Gruppe „schwere Asymmetrie“ um acht Kinder an. Die Gruppe „moderate Asymmetrie“ reduziert sich um ingesamt neun Kinder. Schlussfolgerung: Ein großes Problem bei der Klassifikation des LP besteht in der Vielzahl an unterschiedlichen Messmethoden und Messverfahren, wobei die Mehrzahl der Klassifizierungsversuche auf zweidimensionalen Messmethoden beruhen. Der entwickelte, dreidimensionale Volumenparameter Iln(Q4Q2/Q3Q1)I ist sehr gut zur Klassifizierung des LP geeignet und zeigt gute Vergleichbarkeit mit dem bisherigen Goldstandard. Bisher existierte keine dreidimensionale Klassifikation einer lagerungsbedingten Schädelasymmetrie, was in der vorliegenden Arbeit erstmalig erreicht wurde.
Ziel: Die Einblicke in die physiologischen Wachstumsprozesse des Säuglingskopfes, besonders innerhalb des ersten Lebensjahres, sind wichtiger Bestandteil in der Diagnostik und Therapie von Schädeldeformitäten. In der vorliegenden, prospektiv angelegten Longitudinalstudie wurden Wachstumsdurchschnittswerte des Säuglingskopfes in den ersten Lebensmonaten erhoben sowie dynamische Wachstumsprozesse evaluiert. Material und Methode: Es wurden dreidimensionale stereophotogrammetrische Aufnahmen des Säuglingskopfes von insgesamt 40 Säuglingen mit unauffälliger Kopfform durchgeführt. Die Aufnahmen erfolgten in einem Intervall von 2 Monaten zum 4., 6., 8. und 10. Lebensmonat. Es wurden wachstumsbezogene Variablen (horizontale, sagittale und koronare Zirkumferenz, Länge, Breite, Breite-Längen-Verhältnis CI, Höhe) und symmetriebezogene Variablen (30°Diagonalendifferenz, Ear Offset, anteriorer und posteriorer kranialer Asymmetrieindex) zur Analyse erhoben. Ergebnisse: Wachstumsbezogene Variablen: Mit Ausnahme des CI nahmen alle wachstumsbezogenen Variablen zum jeweils folgenden Scantermin signifikant zu. Der CI zeigte erst ab dem 6. Lebensmonat eine signifikante Verringerung. Die größte Wachstumsdynamik war zwischen dem 4. und 6. Lebensmonat zu beobachten. Der relative Zuwachs des Gesamtvolumens liegt hier bei 12,94%. Die Werte der männlichen Probanden lagen erwartungsgemäß signifikant über denen der weiblichen Probanden (Ausnahme: CI, Breite und Höhe zum 4. Lebensmonat). Die zeitliche Entwicklung des Gesamtvolumens und der horizontalen Zirkumferenz konnte mithilfe einer nichtlinearen Regression als Wachstumskurve dargestellt werden. Symmetriebezogene Variablen: Bei den symmetriebezogenen Variablen konnten keine signifikanten Veränderungen festgestellt werden. Schlussfolgerung: In dieser Longitudinalstudie konnten erstmals physiologische Wachstumsprozesse des Kopfes im Säuglingsalter analysiert werden.
Background:
Especially in the first 6 months of life, skull deformities manifesting as a uni- or bilateral flattening of the occiput often give rise to questions of differential diagnosis and potential treatment. In this review, the authors summarize the current understanding of risk factors for this condition, and the current state of the relevant diagnostic assessment and options for treatment.
Methods:
The recommendations given in this selective review of the literature are based on current studies and on existing guidelines on the prevention of sudden infant death, the recommendations of the German Society for Pediatric Neurology (Deutsche Gesellschaft für Neuropädiatrie), and the American guidelines on the treatment of positional plagiocephaly in infancy.
Results:
Pre-, peri-, and postnatal risk factors can contribute to the development of positional skull deformities. These deformities can be diagnosed and classified on the basis of their clinical features, supplemented in unclear cases by ultrasonography of the cranial sutures. The putative relationship between positional skull deformities and developmental delay is currently debated. The main preventive and therapeutic measure is parent education to foster correct positioning habits (turning of the infant to the less favored side; prone positioning on occasion when awake) and beneficial stimulation of the infant (to promote lying on the less favored side). If the range of motion of the head is limited, physiotherapy is an effective additional measure. In severe or refractory cases, a skull orthosis (splint) may be useful.
Conclusion:
The parents of children with positional skull deformities should be comprehensively informed about the necessary preventive and therapeutic measures. Treatment should be initiated early and provided in graded fashion, according to the degree of severity of the problem. Parental concern about the deformity should not be allowed to lead to a rejection of the reasonable recommendation for a supine sleeping position.
Purpose:
The purpose of this study was to quantitatively analyse pre-speech/early language skills in healthy full-term infants with moderate or severe deformational plagiocephaly (DP) and in infants without any skull asymmetry.
Methods:
At 6 and 12 months, 51 children with DP (41 moderate, 10 severe cases) were studied, along with 15 infants serving as control. Deformational plagiocephaly (DP) was objectively determined based on cranial vault asymmetry (CVA) using 3D stereophotogrammetry (3dMDhead System® and Analytics 4.0, Cranioform®). Articulatory skills in babbling were assessed using the articulatory skill (ART-index) and mean syllable number (MSN). At 12 months, standardized parental questionnaires were used to evaluate early language outcomes.
Results:
Overall, 3546 vocalizations were studied. Statistical tests did not reveal any significant differences of the ART-index between the three groups (ANOVA, F[2,63] = 0.24, p = 0.24). MSN likewise did not differ between the three shape groups (Kruskal-Wallis, p = 0.84). Among the children assigned to the at-risk group for language outcomes at 12 months were seven members of the symmetrical shape group (vs. seven assigned to the normally developing group), nine of the moderate DP group (vs. 27), and one of the severe DP group (vs. six). Fisher's exact test was used to analyse whether helmet therapy in the moderate DP group affected the results by influencing language outcomes, but did not reveal any significant influence (p = 0.712).
Conclusions:
The results of this study do not support arguments suggesting that DP is a cognitive risk condition. The suggestion that a direct neurophysiological relationship exists between a DP condition and a cognitive developmental delay remains controversial.
Background:
Only a few studies investigating the optimal time point at which to start orthotic treatment for deformational plagiocephaly take into account the severity of skull asymmetry. The present study performs a three-dimensional analysis of the effects of age and severity of asymmetry on the final outcome.
Methods:
A total of 144 patients with deformational plagiocephaly treated by molding orthosis were examined and divided into three age groups (group I, <24 weeks; group II, ≥24 to <32 weeks; and group III, ≥32 weeks) and two severity levels (mild to moderate, 30-degree cranial vault asymmetry ≥3 mm to ≤12 mm; and moderate to severe, 30-degree cranial vault asymmetry >12 mm). The extent of the reduction of asymmetry was analyzed using three-dimensional stereophotogrammetry.
Results:
Therapy with molding orthosis led to a significant reduction in asymmetry in all defined age groups. Efficacy of reduction decreased with increasing age. Successful treatment (cranial vault asymmetry index <3.5 percent) was achieved in 83, 69, and 40 percent of patients with mild to moderate asymmetry in groups I, II, and III, respectively; and in 50, 30, and 7 percent of patients with moderate to severe asymmetry in groups I, II, and III, respectively. The average duration of treatment increased from 18.6 weeks to 25.3 weeks (age groups I and III).
Conclusion:
Age at the beginning of treatment and severity of asymmetry have a definite impact on the duration and effectiveness of molding orthosis therapy.
Clinical question/level of evidence:
Risk, II.
The recommendation for infants to sleep supine has decreased the incidence of sudden infant death
syndrome by more than a half, but as another consequence, a dramatic rise has been observed in
the incidence of acquired cranial asymmetry (deformational plagiocephaly, DP). According to
recent data, almost half of otherwise healthy infants are affected by some degree of DP at 7 to 12
weeks of age, and especially in the USA and some Central European countries, major effort is put
into treatment of severe DP. However, little is known of the prognosis of DP in the absence of
intervention, and although primary preventive strategies are often recommended, a lack of
evidence on the effectiveness of such measures persists. Furthermore, although 3D imaging is
nowadays frequently used on infants with DP, no data is available on the accuracy of the
measurements used to quantify cranial asymmetry.
In the present study, the efficacy of a primary preventive program in reducing the incidence of
DP was tested in a randomized, controlled trial. The course of DP in the absence of active
treatment was studied throughout the first year of life, and factors impacting the prognosis of DP
were investigated. The diagnostic accuracy of four 3D stereophotogrammetry-based
measurements was also analyzed and compared, with a goal of determining their optimal cut-off
values for DP.
DP was less prevalent and less severe in the intervention group infants at the end of the RCT
(3 months). The point prevalence of DP peaked at 3 months, whereafter spontaneous improvement
in DP was seen throughout the follow-up period until 12 months of age. A preferential infant head
position at 3 months was the strongest predictor of a subsequently unfavorable course of DP.
Cranial asymmetry seen at birth was transient, and none of the older infants with torticollis had
presented neck imbalance at birth, but rather appeared to develop the condition postnatally
concomitantly with DP. Although all studied asymmetry-related measurements performed well
regarding diagnostic accuracy, OCLR produced the most accurate classification of DP.
In conclusion, primary preventive guidelines would likely aid in reducing the burden from both
DP itself and associated healthcare costs, although substantial spontaneous improvement from DP
can usually be expected. The cut-off values defined for the asymmetry-related measurements have
clinical implication in both making the diagnosis of DP and determining the target outcomes for
treatment.
Studies have attempted to categorize infant cranial asymmetry in a variety of ways using both observational and quantitative techniques, but none have created a clinical tool that can serve as a treatment guide based on clinical outcomes. In 2006, a research team from Children's Healthcare of Atlanta published the results of a prospective analysis of 224 patients with cranial asymmetries and their treatment outcomes. As a continuation of the previous work, the researchers have identified a plagiocephaly severity scale based on those outcomes to assist medical professionals who treat patients with cranial abnormalities. Our hypothesis is to validate the proposed severity scale that categorizes the clinical presentation and severity of plagiocephaly.Of the 224 patients enrolled, 207 patients were placed in an experimental group and 17 patients who refused treatment were placed in a control group. Digital head shape data were collected. Cross-correlation matrices were computed across variables and regression models resulted in the identification of 5 meaningful variables. A 5-level clinical classification scale was created. Five 1 × 5 analyses of variance were computed to compare each classification level.Four of the 5 analyses of variance identified significant overall effects for classification. A model was developed from the empirical data and the model was tested for accuracy, resulting in 12.1% overall error. The model was validated for both experimental and control groups.The results show that the severity scale is a meaningful outcome-based scale that assists clinicians in developing a treatment plan for treating plagiocephaly. The scale has been validated across a large heterogeneous study sample.
To verify and determine the cause of an increase in the referral of infants with plagiocephaly without synostosis (PWS) to a single tertiary craniofacial center.
A chart review was performed for 269 infants with a diagnosis of PWS who presented to a single tertiary craniofacial center between 1979 and 1994. The pattern of referral for PWS was analyzed using both simple linear regression and time series regression analyses. In addition, the referral pattern for PWS was compared with that for infants seen at the same center who received a diagnosis of synostotic plagiocephaly. Changes in the distribution of several demographic, perinatal, and clinical variables during the study period were also assessed. Finally, in an effort to identify correlates of the risk of PWS developing, characteristics of patients who were Missouri residents and presented between 1992 and 1994 were evaluated and compared with those of the 1993 Missouri live birth cohort.
The Cleft Palate and Craniofacial Deformities Institute, St Louis Children's Hospital, Washington University Medical Center.
The average annual number of referrals to our center for PWS in the period 1992 to 1994 was more than sixfold greater than that for the preceding 13 years. There was a statistically significant increase in the annual number of referrals to our center during the 16-year study period. Moreover, there was evidence that the average annual increase in referrals was significantly greater during the last 3 years (1992 through 1994) of the study than in the first 13 years. This shift in the referral patterns is roughly contemporaneous with the American Academy of Pediatrics recommendations regarding infant sleep position. There was no evidence that either the mean number of referrals or the average annual increase in referrals for patients with synostosis changed during the study period. Among patients with PWS, the average age at presentation did not change during the study period. There were also no significant changes in the distribution of other demographic, perinatal, and clinical variables. When compared with the Missouri birth cohort, infants with PWS were significantly more likely to be boys and to have been delivered by forceps. There was also some evidence that patients with PWS were more likely to be born prematurely and to be products of multiple-gestation pregnancies. These associations were, however, of only borderline statistical significance.
Referrals to our center for PWS increased markedly in 1992 relative to previous years. The temporal coincidence of this increase with the American Academy of Pediatrics recommendation to avoid the prone sleeping position, to reduce the risk of sudden infant death syndrome, suggests a possible causal relationship. If this association is causal, education regarding the need for head position rotation coupled with that for sudden infant death syndrome should obviate positional PWS.
Plagiocephaly is a term commonly used to describe congenital forehead asymmetry. Previous classification systems based on the various etiologies of dysmorphic crania have been used in an effort to categorize the patients into groups and to assist in treatment planning. The system most commonly used today was described by Bruneteau and Mulliken in 1992. The authors separated frontal plagiocephaly into three types: synostotic, compensational, and deformational. The present study was undertaken in order to define a simple system for classifying plagiocephaly based on Bruneteau and Mulliken's system using the patients' preoperative craniofacial computed tomography scans. The involvement of the entire coronal ring in synostotic plagiocephaly led to the choice of 20 skull base landmarks as the basis of the analysis. Nine lateral landmarks (the superior orbital fissure, the optic foramen, the zygomatic arch, the greater palatine foramen, the foramen ovale, the mastoid tip, the hypoglossal canal, the external auditory canal, and the internal auditory canal) and two midline landmarks (the crista galli and the internal occipital protuberance) were used. The changes that occurred in these landmarks were analyzed in 30 patients. The results demonstrated that Bruneteau and Mulliken's classification system underestimated the number of different subtypes of plagiocephaly. As a result, three major types of frontal plagiocephaly and several different subtypes based on the different etiologies were described. Type I plagiocephaly includes plagiocephaly resulting from cranial suture synostosis. Type II includes those with a nonsynostotic etiology. Type III describes patients with craniofacial microsomia-associated plagiocephaly. Statistical analysis was unavailable because of the small number of patients in each subtype. With a larger number of patients, we hope to refine this system for use by the surgeon in preoperative diagnosis and surgical planning. The analysis is unique in its ability to quantitate changes from normal on the x-, y-, and z-coordinates, and therefore allows for identification of both horizontal (frontal bone deviation) and vertical (ear shear) growth disturbances.
Dynamic Orthotic Cranioplasty (DOC) was developed to treat craniofacial deformities associated with positional plagiocephaly. This investigation describes the treatment of more than 750 patients with the DOC Band since 1988. All patients undergoing DOC treatment were fit with a custom fabricated orthosis made from a plaster impression taken from the infant's head. When the orthosis was applied, the corrective pressure was directed to hold growth at the calvarial prominences and redirect symmetrical growth. A detailed medical history was obtained and anthropometric measurements were taken at start, exit, 12, 18, and 24 months follow-up. This information was recorded in a database created in Microsoft Excel. Mean length of treatment was 4.3 months with an average entrance age of 6.9 months. Analysis of anthropometric data showed significant reduction in mean cranial vault, skull base, and facial asymmetries. Correction of the more difficult skull base was documented with computed tomography. Our anthropometric and clinical observations document complete or near complete correction of asymmetry for a wide variety of head shapes. Based on the results of this investigation, we are able to support the earlier claims of our pilot study, which concluded that DOC is effective in the treatment of positional plagiocephaly.
Deformational plagiocephaly refers to the development of an abnormal head shape in infants resulting from externally applied molding forces, which may occur either prenatally or postnatally. We have observed that an unexpectedly high number of multiple-birth infants have presented to our center with this condition. The purposes of this investigation were to: 1) determine the significance of this observation; and 2) examine the risk factors that may make this population more susceptible to the development of plagiocephaly.
A retrospective review of our database was performed to identify those infants who were of multiple-birth origin. The parents of these infants were contacted by phone to complete a survey regarding the prenatal and postnatal history of their child. Similar information was obtained for the state of Arizona from the Office of Vital Statistics. A chi2 analysis was used to compare the incidence of multiple births in Arizona with the incidence of multiple births in our treatment population.
Between 1993 and 1996, 69 (8.6%) of the 801 infants treated for deformational plagiocephaly at our Phoenix center were of multiple-birth origin. Four infants who had been treated postoperatively after surgery for craniosynostosis, as well as 5 patients who had been referred from out of state, were excluded from further study. The chi2 analysis of the remaining 60 patients confirmed that a statistically significant number of plural-birth infants had presented with deformational plagiocephaly. Four risk factors were identified as having occurred at high frequency in this population: in utero constraint, supine sleeping position, torticollis, and prematurity.
The current findings of this investigation confirm that a significant number of multiple-birth infants have presented to our clinic with deformational plagiocephaly. Compared with their singleton counterparts, plural infants seem to be at higher risk for the development of deformational plagiocephaly, because they are more likely to be exposed to multiple risk factors.deformational plagiocephaly, multiple birth, plurality.
Infants with positional plagiocephaly often exhibit complex multistructural asymmetries that affect the face and skull base as well as the cranial vault. Dynamic Orthotic Cranioplasty (DOC) was developed as a nonsurgical alternative for the treatment of positional plagiocephaly. The effectiveness of DOC has been discussed elsewhere. The purpose of this study was to assess the influence of factors such as entrance age, treatment time, and initial severity on the effectiveness of correction.
The study sample consisted of 258 children with cranial vault asymmetry (CVA) treated prior to 1 year of age. In addition, 246 patients (92%) exhibited concurrent skull base (SBA) and orbitotragial depth (OTDA) asymmetries. All patients had been diagnosed with nonsynostotic plagiocephaly, did not have other contributing medical conditions, were compliant with DOC protocol, and had complete anthropometric measurements at entrance and exit from treatment.
Mean age at start of treatment was 6.5 (+/-1.9) months (range, 2.8 to 11.0 months), with an average treatment time of 4.1 (+/-2.2) months. The effects of the treatment variables were analyzed using three-way analysis of variance. As expected, initial severity was significantly associated with the amount of correction (p = .0001). However, treatment time was not significant (p > .05). Most importantly, the analysis revealed that, having accounted for initial severity, entrance age had a statistically significant effect [F(1,254) = 8.36, p = .0042] on the correction of CVA. Similar results were identified for both the SBA [F(1,254) = 5.53, p = .0195] and the OTDA [F(1,254) = 5.22, p = .0231] asymmetries.
These findings support clinical observations that earlier intervention results in significantly improved treatment of plagiocephaly, independent of the severity of the presenting asymmetries.
Although referrals for nonsynostotic plagiocephaly (NSP) have increased in recent years, the prevalence, natural history, and determinants of the condition have been unclear. The objective of this study was to assess the prevalence and natural history of NSP in normal infants in the first 2 years of life and to identify factors that may contribute to the development of NSP.
Two hundred infants were recruited at birth. At 6 weeks, 4 months, 8 months, 12 months, and 2 years, the head circumference shape was digitally photographed, and head shape was quantified using custom-written software. At each age, infants were classified as cases when the cephalic index was > or =93% and/or the oblique cranial length ratio was > or =106%. Neck rotation and a range of infant, infant care, socioeconomic, and obstetric factors were assessed.
Ninety-six percent of infants were followed to 12 months, and 90.5% were followed to 2 years. Prevalence of plagiocephaly and/or brachycephaly at 6 weeks and 4, 8, 12, and 24 months was 16.0%, 19.7%, 9.2%, 6.8%, and 3.3% respectively. The mean cephalic index by 2 years was 81.6% (range: 72.0%-102.6%); the mean oblique cranial length ratio was 102.6% (range: 100.1%-109.4%). Significant univariate risk factors of NSP at 6 weeks include limited passive neck rotation at birth, preferential head orientation, supine sleep position, and head position not varied when put to sleep. At 4 months, risk factors were male gender, firstborn, limited passive neck rotation at birth, limited active head rotation at 4 months, supine sleeping at birth and 6 weeks, lower activity level, and trying unsuccessfully to vary the head position when putting the infant down to sleep.
There is a wide range of head shapes in infants, and prevalence of NSP increases to 4 months but diminishes as infants grow older. The majority of cases will have resolved by 2 years of age. Limited head rotation, lower activity levels, and supine sleep position seem to be important determinants.
Objectives
Infants with positional plagiocephaly often exhibit complex multistructuraI asymmetries that affect the face and skull base as well as the cranial vault. Dynamic Orthotic Cranioplasty (DOC) was developed as a nonsurgical alternative for the treatment of positional plagiocephaly. The effectiveness of DOC has been discussed elsewhere. The purpose of this study was to assess the influence of factors such as entrance age, treatment time, and initial severity on the effectiveness of correction.
Methods
The study sample consisted of 258 children with cranial vault asymmetry (CVA) treated prior to 1 year of age. In addition, 246 patients (92%) exhibited concurrent skull base (SBA) and orbitotragial depth (OTDA) asymmetries. All patients had been diagnosed with nonsynostotic plagiocephaly, did not have other contributing medical conditions, were compliant with DOC protocol, and had complete anthropometric measurements at entrance and exit from treatment.
Results
Mean age at start of treatment was 6.5 (±1.9) months (range, 2.8 to 11.0 months), with an average treatment time of 4.1 (±2.2) months. The effects of the treatment variables were analyzed using three-way analysis of variance. As expected, initial severity was significantly associated with the amount of correction (p = .0001). However, treatment time was not significant (p > .05). Most importantly, the analysis revealed that, having accounted for initial severity, entrance age had a statistically significant effect [F[1,254) = 8.36, p = .0042] on the correction of CVA. Similar results were Identified for both the SBA [F[1,254) = 5.53, p = .0195] and the OTDA [F[1,254) = 5.22, p = .0231] asymmetries.
Conclusions
These findings support clinical observations that earlier intervention results in significantly improved treatment of plagiocephaly, independent of the severity of the presenting asymmetries.
This Clinical Report was retired December 2016
Cranial asymmetry may be present at birth or may develop during the first few months of life. Over the past several years, pediatricians have seen an increase in the number of children with cranial asymmetry, particularly unilateral flattening of the occiput. This increase likely is attributable to parents following the American Academy of Pediatrics “Back to Sleep” positioning recommendations aimed at decreasing the risk of sudden infant death syndrome. Although associated with some risk of deformational plagiocephaly, healthy young infants should be placed down for sleep on their backs. This practice has been associated with a dramatic decrease in the incidence of sudden infant death syndrome. Pediatricians need to be able to properly diagnose skull deformities, educate parents on methods to proactively decrease the likelihood of the development of occipital flattening, initiate appropriate management, and make referrals when necessary. This report provides guidelines for the prevention, diagnosis, and management of positional skull deformity in an otherwise normal infant without evidence of associated anomalies, syndromes, or spinal disease.
A study was conducted to compare the perceived attractiveness of preterm infants with postnatal cranial molding to that of preterm and full-term infants without this deformation. Forty-two subjects who viewed photographs of infants selected preterm infants with postnatal cranial molding as the least attractive group of infants. Researchers have hypothesized that infant appearance is an antecedent to bonding and attachment. Nurses should implement measures such as the use of waterbed mattresses, which have been found to minimize the molding process, and include discussion of this measure when teaching parents about their preterm infants so that they are aware of causes and prevention of cranial molding. If an infant has developed postnatal cranial molding, the parents may require counseling to assist them in resolving their feelings about the discrepancy in the appearance of the infant and what they had anticipated prenatally.
Plagiocephaly is a term commonly used to describe congenital forehead asymmetry. Sixty patients with frontal plagiocephaly were evaluated retrospectively and separated into three types: synostotic (N = 24), compensational (N = 3), and deformational (N = 33). Categorization of frontal plagiocephaly as synostotic or deformational was reliably made by physical examination, focusing on the supraorbital rims, nasal root, ears, and malar eminences. Other anatomic parameters useful in the differential diagnosis included chin point, palpebral fissures, and facial height. This study documented that birth histories were similar for synostotic and deformational frontal plagiocephalic infants. However, other deformational anomalies were more common in deformational frontal plagiocephalic infants, whereas malformations had an equal incidence in deformational and synostotic frontal plagiocephalic infants. Torticollis was an associated finding in 64 percent of infants with deformational frontal plagiocephaly; almost all were ipsilateral. In contrast, head tilt, usually to the contralateral side, was noted in 14 percent of patients with synostotic frontal plagiocephaly. Female preponderance was noted in both synostotic (79 percent) and deformational (76 percent) frontal plagiocephaly. Left-sided involvement was seen in 73 percent of patients with deformational frontal plagiocephaly and in 46 percent of patients with synostotic frontal plagiocephaly. Premature pelvic descent, in the left occipital anterior position, may account for the high incidence of left-sided deformational plagiocephaly and ipsilateral torticollis.
In infancy, prior to cranial suture and fontanel calcification, the craniofacial skeleton can be easily deformed by an externally exerted force. In this study, the relationship between the sleep position and skull morphology was investigated. A group of 81 cleft lip and/or palate infants without other systemic anomalies was first seen in the craniofacial center at approximately 1 month of age. The sleep position of each infant was recorded as supine, prone, or mixed type. The body and skull growth were longitudinally measured at 1, 3, and 6 months of age. Infants sleeping in the supine sleep position tended to have a wider head width, shorter head length, and a larger cephalic index by 6 months of age. The opposite phenomena were observed in the prone sleep group. The mixed sleep group tended to have head width, head length, and cephalic index between those of the supine sleep group and the prone sleep group. During the first 3 months of life, the sleep position could mold the skull primarily in the dimension of head width. In conclusion, the supine sleep position may promote brachycephaly and the prone sleep position dolichocephaly.
Dynamic orthotic cranioplasty (DOC) was developed to treat asymmetrical head shape of a nonsynostotic origin, which is defined by the term positional plagiocephaly. These positional deformations have been found to correlate with a number of environmental factors. Infants with positional plagiocephaly may exhibit complex multistructural asymmetry affecting the cranial vault, face, and skull base, or expression may be local in nature. Between 1988 and 1993, we performed DOC on 124 infants with positional plagiocephaly. Through clinical, anthropometric, radiographic, and statistical evaluation, we found that DOC corrects positional deformation of the cranial vault, skull base, and upper face, with no evident relapse following treatment. The design and the global approach to deformation address a wide spectrum of abnormal head shapes. The procedure is dynamic and customized, and it does not rely on passive growth alone for improvement.
This focused review contains a suggested core of material that will help residents or practicing physiatrists critically review research papers published in the medical literature. Before accepting the results of a clinical trial, physiatrists must critique the experimental methods and study design carefully to decide whether to include these new ideas into their clinical practice. Medical research relies on statistical methodology, and statistics pervade the medical literature. This article begins with an introduction to rudimentary statistics. Fortunately, most studies depend on a rather small body of statistical concepts. The elements of experimental design--clinical trials, randomization, single-subject design, meta-analysis, epidemiological studies--are presented in a concise review. Finally, the elements of statistics and experimental design are integrated into a step-by-step method strategy for reading the medical literature.
Between 1975 and 1992, 426 children with craniofacial malformations were treated in the Department of Pediatric Neurosurgery at the Hôpital des Enfants de la Timone in Marseille. Plagiocephaly was present in 71 (16.6%). The authors present a reproducible analysis of the skull base in plagiocephaly based on these 71 patients. A control group of Mediterranean children (n = 20) was used for comparison. Clinical anthropometric patterns were analyzed in all cases. Comparison with the control group showed a difference only in the nasion-lambda distance. Data obtained from clinical anthropometry were compared for the involved and the uninvolved sides. A three-dimensional reconstruction was possible in 20 cases. The statistical correlation between the basal angles (nasion-pterional, nasion-petrosal, nasion-clino-basion, and zygomatic angles) of the involved and uninvolved sides allows a new nosographic identification of this complex malformation.
Plagiocephaly is a descriptive term that connotes an asymmetrically oblique or twisted head. Such cranial dysmorphology has a number of etiologies, the most common of which are unicoronal synostosis, unilambdoid synostosis, and plagiocephaly without synostosis. Use of the term plagiocephaly in the literature is often ambiguous in that at times it is used inclusively for all etiologies while at other times it is used exclusively as a synonym for unicoronal synostosis. Although differentiation by physical examination among unicoronal synostosis, unilambdoid synostosis, and plagiocephaly without synostosis usually is possible for an experienced observer, inexperienced observers often have difficulty making an anatomically accurate diagnosis even with the assistance of conventional skull radiographs. High-resolution CT scans, including three-dimensional osseous surface re-formations, have become a standard element in the evaluation of craniofacial anomalies in many centers. We hypothesized that the three major etiologies of plagiocephaly could be unambiguously differentiated by means of endocranial three-dimensional CT osseous surface re-formations. Archival pretreatment CT data on 15 unicoronal synostosis, 4 unilambdoid synostosis, and 15 plagiocephaly without synostosis patients were reviewed to define, qualitatively and quantitatively, the characteristics of the endocranial base morphologies for each group; in addition to visual dysmorphology specific to each group, there was a statistically significant difference in the angle of deviation from the midlines of the anterior and posterior cranial fossae among unicoronal synostosis, unilambdoid synostosis, and plagiocephaly without synostosis. Four radiologists experienced in reading images of craniofacial anomalies were oriented to the group characteristics and then instructed to perform differential diagnosis for each of the 34 patients using only the endocranial three-dimensional CT images. The raters were blind to all other clinical and diagnostic information. The raters correctly diagnosed unicoronal synostosis. Errors were made in differentiation of unilambdoid synostosis and plagiocephaly without synostosis. These errors resulted from the raters' reliance on image inspection rather than quantitation of anteroposterior fossae midline angulation. Such quantitation unambiguously differentiated between unilambdoid synostosis and plagiocephaly without synostosis in the "error" cases. The endocranial base dysmorphology of patients with plagiocephaly is etiology-specific for unicoronal synostosis, unilambdoid synostosis, and plagiocephaly without synostosis. Three-dimensional CT endocranial base images can assist differential diagnosis of plagiocephaly.
The management of infants with posterior plagiocephaly has been controversial both because of widely differing estimates in the literature of the relative frequencies of true lambdoidal synostosis vs positional molding and because of divergent approaches to treating this problem in different institutions. Based on our experience, we hypothesized that the vast majority of children with posterior plagiocephaly did not have true synostosis and that the cosmetic impairment in such patients could be effectively treated with nonsurgical modalities.
Between 1992 and 1995, we prospectively applied in 71 infants a consistent management philosophy for these malformations that has incorporated a detailed evaluation of sutural anatomy as the basis for a physiologic approach to treatment. This approach has been directed at distinguishing true synostosis from deformational plagiocephaly and at avoiding surgery for patients with deformational abnormalities by using a combination of nonsurgical modalities to restore normal cranial growth dynamics. All children first underwent skull radiographs to determine whether the lambdoidal sutures were patent. In equivocal cases, computed tomography was also performed. Patients without true synostosis were enrolled on a course of positional therapy. In patients that did not improve after 2 to 3 months, a custom-fitted orthoplastic molding helmet was applied to facilitate passive skull recontouring.
Forty children had patent sutures based on skull radiographs, and 29 others, in whom the radiographs were equivocal, had open sutures based on computed tomography, thus establishing the diagnosis of deformational plagiocephaly in 69. Predisposing factors for this deformity included a strong positioning preference during early infancy (n = 67), torticollis (n = 10), prematurity (n = 6), and developmental delay (n = 2). Only two patients had true lambdoidal synostosis; in each case, this was associated with synostosis of the posterior sagittal suture and was managed effectively with cranial reconstructive surgery. Thirty-five patients with deformational plagiocephaly had a dramatic improvement in their cranial contour with positional therapy alone; 34 patients failed to improve and were treated with molding helmets. All but five children, each of whom was more than 6 months old at initial intervention (P < .025), developed a normal or nearly normal head shape with these measures.
The vast majority of children with posterior plagiocephaly do not have true synostosis and can be effectively managed by nonsurgical means. The impact of positional preference on the development of this process is discussed.
One hundred consecutive infants who presented with occipital plagiocephaly over 15 years were analyzed retrospectively to determine results of both surgical and nonsurgical management. Eighteen infants who showed obvious progression of their deformity or radiological signs of fusion of the lambdoid suture had surgical resection of one or both lambdoid sutures and the remaining 82 infants were treated nonsurgically with physical therapy and advice on sleeping position. Of the 18 surgical cases 9 were found at operation to have true lambdoid synostosis, 7 had marked internal ridging of the lambdoid suture and 2 had an open suture. After a mean follow-up period of 6 months all parents of the 82 children treated nonsurgically were satisfied with their child's cosmetic appearance: 63% showed improvement in their plagiocephaly and 27% stabilized. There were no surgical complications in the 18 operative cases, all of whom had a good cosmetic result. From these results we conclude that the majority of infants referred to neurosurgeons with occipital plagiocephaly can be successfully managed nonsurgically. A small proportion of cases (18% with radiological signs of fusion or pronounced ridging of the suture) appeared to benefit from surgery. The clinical, radiological and pathological differentiating features of the surgical and nonsurgical cases are discussed.
In April 1992, the American Academy of Pediatrics recommended back or side sleeping for healthy newborns to reduce the risk of sudden infant death syndrome. Subsequently, the US Public Health Service organized a health care coalition to promote a "Back to Sleep Campaign" to advocate back or side sleeping for infants. Since 1992, our craniofacial anomalies center has witnessed a marked increase in the incidence of infants with defomational changes of the cranium and face. The purpose of this project was to study the etiologies of deformational plagiocephaly and possible correlation with infant head position. We reviewed 52 consecutive patients presenting with deformational plagiocephaly from January 1992 to December 1994. A diagnosis of deformational plagiocephaly was determined by (1) history (date when head shape change was first noted), (2) clinical examination (occipital flattening, contralateral forehead flattening, lowering of the eyebrow, and ear shearing), and (3) skull radiographs (patent cranial sutures). All infants had medical photography to document baseline craniofacial morphology and any follow-up changes after nonsurgical therapy. Cranial asymmetry was first noted after birth at a mean time of 3.6 months. All infants were initially positioned on their back/side. In 52 patients, 61% had right-sided flattening of the occiput (vs 39% left-sided). All infants had flattening of the occiput, contralateral brow lowering or inferior displacement of the brow, contralateral forehead flattening, and posterioinferior displacement of the ear. All skull radiographs demonstrated patent sutures. Follow-up of patients ranged from 3 to 22 months with a mean of 10.5 months. Follow-up clinical examination and photography demonstrated significant improvement of cranial form in all patients with recommended frequent head turning (73%), helmet molding (23%), and surgery (4%). Our unit has seen an increase in the number of infants with deformational plagiocephaly over the last three years. All of the affected infants in this study had been managed according to the officially recommended protocol of back/side positioning. These findings suggest a possible relationship between this type of infant positioning and the development of a deformational plagiocephaly. However, cranial asymmetry in this group of patients decreased significantly with nonsurgical therapy. We have not recommended cranial vault remodeling surgery for the mild and moderate types of this deformity. However, if there is evidence of increasing asymmetry of deformational plagiocephalic infants during follow-up and evidence of severe variants of these deformities, surgical correction of the cranial vault is recommended.
Abnormalities of the occipital cranial suture in infancy can cause significant posterior cranial asymmetry, malposition of the ears, distortion of the cranial base, deformation of the forehead, and facial asymmetry. Over the past 2 years, we have noted a dramatic increase in the incidence of deformation of the occipital skull in our tertiary referral center. Our patient referral base has not changed appreciably over the past 5 years and patients have been referred from the same primary practitioner base. The timing of this increase correlates closely with the acceptance in our area of recommended changes in sleeping position to supine or side positioning for infants because of the fear of sudden infant death syndrome (SIDS). A total of 51 infants with occipital cranial deformity, with a mean age of 5.5 months at presentation, have been evaluated and treated by a single craniofacial surgeon in the 16-month period from September 1993 to December 1994. Older infants were treated with continuous positioning by the parent keeping the infant off the involved side. Younger infants and those with poor head control were treated with a soft-shell helmet. Mean timing of initial diagnosis and start of treatment was 5.5 months. Mean duration of helmet for positional treatment was 3.8 months. To date, only 3 of 51 patients have required surgical intervention, and other patients demonstrated spontaneous improvement of all measured parameters. Follow up has ranged from 8 to 24 months. We believe that most occipital plagiocephaly deformities are deformations rather than true cranio-synostoses. Despite varying amounts of suture abnormality evidenced on computed tomographic scans, most deformities can be corrected without surgery. In cases where progression of the cranial deformity occurs, despite conservative therapy, surgical intervention should be undertaken at approximately 1 year of age. The almost universal acceptance in the State of North Carolina of positioning neonates on their backs to avoid SIDS, may well increase the incidence of these deformities in the future.
The literature on occipital plagiocephaly (OP) was critically reviewed to determine the feasibility of establishing treatment recommendations.
Using standard computerized search techniques, medical literature databases containing peer-review articles dating from 1966 were queried for key words related to OP. The titles of all articles were scanned for relevance, and copies of potentially relevant articles published in English were reviewed. Articles in which treatment was discussed were categorized according to their weight of evidence as Class I (prospective randomized controlled trials), Class II (clinical studies in which data are collected prospectively or retrospective analyses based on clearly reliable data), and Class III (most studies based on retrospectively collected data) to evaluate their contribution to developing a consensus on the treatment of OP. Of the 4308 articles identified, all but 89 were excluded. Based on the review of these articles, the actual incidence of OP is unknown, and no population-based studies of its incidence or prevalence exist. The reported incidence of lambdoid craniosynostosis ranges from 3 to 20% with differences in diagnostic criteria accounting for the variability. With the possible exception of a lambdoid suture that is replaced by a dense ridge of bone, no other diagnostic criteria have been agreed on. There were no Class I studies and only one Class II study provided comparisons of outcomes in more than one treatment group with outcomes in an untreated group. Recommended treatment options included observation only, mechanical interventions, and a variety of surgical techniques.
Controlled clinical trials are needed before any form of intervention can be recommended for the treatment of OP. If surgery, which is expensive and potentially dangerous, is to continue to play a role in the management of this condition, efforts should be made to determine if patients with untreated OP have suffered from lack of treatment.
Appropriate management of posterior plagiocephaly requires differentiation of occipitoparietal flattening caused by lambdoid synostosis from that caused by deformational forces. In a 2 1/2-year prospective study of 115 infants presenting with unilateral posterior cranial flattening, only one child had synostotic posterior plagiocephaly (lambdoid synostosis), whereas 114 infants had deformational posterior plagiocephaly. Deformational occipitoparietal flattening was more common on the right (61 percent) than on the left (30 percent), and minor contralateral frontal flattening was not unusual (52 percent). The ipsilateral ear was anteriorly displaced in virtually all infants (97 percent). Some infants had ipsilateral torticollis (19 percent); a few had contralateral torticollis (8 percent). Gender ratio was 3:1, male:female. A total of 114 infants with deformational posterior plagiocephaly were treated conservatively either by head positioning in the crib (n = 63) or with a molding helmet (n = 51). Outcome was assessed by pretreatment and posttreatment anthropometry on 53 of these infants, who were either positioned (n = 17) or helmeted (n = 36). Improvement occurred in 52 of 53 patients (mean follow-up 4.6 months), i.e., the difference in length between the long and short transcranial axis diminished in 52 infants (mean 1.2 to 0.7 cm), did not progress in any child, and was unchanged in one infant. At an average age of 10 months, posterior cranial symmetry was better in infants treated with a helmet (mean difference 0.6 cm) than in those managed by positioning (mean difference 1.0 cm) (p < 0.001). Age at initiation of helmet therapy (from 2 to 9 months) was unrelated to rate of improvement. In a 10-year retrospective study, the authors identified 12 infants who had an operation for posterior plagiocephaly. All but one had confirmed premature lambdoid fusion; thus, this condition accounted for 3.4 percent of all primary operations performed for craniosynostosis during this decade (n = 323). In retrospect, the physical findings of synostotic posterior plagiocephaly were not clearly different from those of deformational posterior plagiocephaly. Plain radiography was sometimes used to confirm the clinical diagnosis. Neither sutural narrowing, deep interdigitations, nor perisutural sclerosis indicated lambdoid synostosis. Computed tomography (CT) was necessary if the physical findings were suspicious for lambdoid synostosis or if plain films did not give a definitive diagnosis. Axial CT scans (n = 7) showed a symmetric forehead in all but one patient with lambdoid synostosis. CT studies also demonstrated that auricular position was indeterminate in synostotic posterior plagiocephaly, being anterior, posterior, or symmetric, whereas the ipsilateral ear was virtually always anterior in deformational posterior plagiocephaly.
The pathology, diagnosis and management of posterior plagiocephaly remains highly controversial. While the rationale for surgical management of true lambdoid synostosis is undisputed, opinions vary greatly on how to manage severe, unresolving, non-synostotic cases. We reviewed 39 cases of posterior plagiocephaly, 37 of which were treated conservatively. Of these, 34 patients had a significant improvement over the following year with sleep posture modification and/or physiotherapy. While only eight cases returned to complete normality, the remainder had deformities that were deemed mild by both mothers and surgeons, and did not merit surgery. Defining recalcitrant cases remains elusive as standard imaging is often unhelpful. While 3-D CT offers a much more accurate diagnosis of true lambdoid synostosis with bony union and allows objective assessment of the deformity, serial scans involve radiation doses that are difficult to justify. Clinical follow-up is the only reliable method at present.
To determine whether there was an increased rate of later developmental delay in school-aged children who presented as infants with deformational plagiocephaly without obvious signs of delay at the time of initial evaluation.
A retrospective medical record review of 254 patients evaluated at the Craniofacial Center of the Children's Hospital and Regional Medical Center in Seattle, Washington, from 1980 through 1991 was completed. Consenting patient families were interviewed via telephone to determine what, if any, special medical or educational problems had occurred for the children who had had plagiocephaly in infancy or their siblings with normal head shapes.
A total of 181 families from the medical record review could be notified about the study and 63 families agreed to participate in a telephone interview. The sample of participants for the telephone interview was random to and representative of the group as a whole. The families reported that 25 of the 63 children (39.7%) with persistent deformational plagiocephaly had received special help in primary school including: special education assistance, physical therapy, occupational therapy, speech therapy generally through an Individual Education Plan. Only 7 of 91 siblings (7.7%), serving as controls, required similar services (chi(2) = 21.24). Delays could not be specifically anticipated at the time of the diagnosis of deformational plagiocephaly from any simple set of factors including treatment with helmet therapy, although effected males with reported uterine constraint were at the highest risk for subsequent school problems.
Infants with deformational plagiocephaly comprise a high-risk group for developmental difficulties presenting as subtle problems of cerebral dysfunction during the school-age years. There is a need for additional research on the long-term developmental problems in infants with deformational plagiocephaly. plagiocephaly, facial asymmetry, torticollis, developmental delay.
A total of 105 infants with nonsynostotic posterior plagiocephaly were treated using a helmet or by head positioning. Effect of treatment was scored using a cosmetic outcome score (0-10 points) assigned by the parents. The onset of the observed skull deformity correction was not different for the helmet vs. nonhelmet treatment. Improvement was significantly better and faster in the helmet group compared with nonhelmet treatment (p < 0.01 and p < 0.001, respectively).
Active counterpositioning and orthotic helmets are the two main nonsurgical management options for positional plagiocephaly. The purpose of this study was to compare these two management regimens. We included a random sample of infants referred between January 1, 1998 and October 31, 1999 to Middlemore Hospital and Auckland Surgical Center, for management of positional plagiocephaly. Two-dimensional head tracings were taken for each infant, every 3 to 12 months. From these tracings, we obtained Cranial Index and Cranial Vault Asymmetry Index. Seventy-nine infants were assessed during an average of 48.2 weeks. Five infants had normal head tracings, and were therefore excluded from the study. Of the 74 infants included in this study, 45 were managed with active counterpositioning, and 29 with orthotic helmets. Average management time for active counterpositioning was 63.7 weeks, and 21.9 weeks for orthotic helmet treatment. For infants managed with active counterpositioning, the average change in Cranial Vault Asymmetry Index was 1.9%. In the orthotic group, average change in Cranial Vault Asymmetry Index was 1.8%. Orthotic helmets have an outcome comparable to that of active counterpositioning, although the management period is approximately three times shorter. Active counterpositioning generally had a slightly better outcome than orthotic management after the management period.
The objective of this study was to determine whether children with nonsyndromic craniosynostosis and plagiocephaly without synostosis demonstrated cognitive and psychomotor delays when compared with a standardized population sample. This was the initial assessment of a larger prospective study, which involved 21 subjects with nonsyndromic craniosynostosis (mean age, 10.9 months) and 42 subjects with plagiocephaly without synostosis (mean age, 8.4 months). Each child was assessed using the Bayley Scales of Infant Development-II (BSID-II) for cognitive and psychomotor development before therapeutic intervention (surgery for craniosynostosis and molding-helmet therapy for plagiocephaly without synostosis). The distribution of the scores was divided into four groups: accelerated, normal, mild delay, and significant delay. The distributions of the mental developmental index (MDI) and the psychomotor developmental index (PDI) were then compared with a standardized Bayley's age-matched population, using Fisher's exact chi-square test. Within the craniosynostosis group, the PDI scores were significantly different from the standardized distribution (p < 0.001). With regard to the PDI scores, 0 percent of the subjects in the craniosynostosis group were accelerated, 43 percent were normal, 48 percent had mild delay, and 9 percent had significant delay. In contrast, the MDI scores were not statistically different (p = 0.08). Within the group with plagiocephaly without synostosis, both the PDI and MDI scores were significantly different from the normal curve distribution (p < 0.001). With regard to the PDI scores, 0 percent of the subjects in the group with plagiocephaly without synostosis were accelerated, 67 percent were normal, 20 percent had mild delay, and 13 percent had significant delay. With regard to the MDI scores, 0 percent of the subjects in this group were accelerated, 83 percent were normal, 8 percent had mild delay and 9 percent had significant delay. This study indicates that before any intervention, subjects with single-suture syndromic craniosynostosis and plagiocephaly without synostosis demonstrate delays in cognitive and psychomotor development. Continued postintervention assessments are needed to determine whether these developmental delays can be ameliorated with treatment.
Orthotic devices do not improve plagiocephaly
The practice of head deformation by pressure to an infant's skull dates back to 2000 bc when the Ancient Egyptians used head binding to produce a cosmetically pleasing and fashionable skull shape.1 With an increasing incidence of plagiocephaly (asymmetric skull) this practice, with a modern slant, is re-emerging. A simple web search resulted in five “paediatric offices” offering such a service. If an Ancient Egyptian walked into clinic today with their child's head bound between two planks of wood, we would be informing social services. Should we, as paediatricians, be advocating modern orthotic devices for plagiocephaly or condemning them?
Plagiocephaly can be subdivided into synostotic, where one or more sutures are fused, and nonsynostotic, or deformational, plagiocephaly. Surgical treatment of the synostotic variety is undisputed as the deformity is likely to progress and there is a significant risk of raised intracranial pressure. However the treatment of deformational plagiocephaly is more controversial.
There are no population based studies to establish the precise incidence or prevalence of deformational plagiocephaly, but the number of referrals to both paediatric and surgical units is increasing.2–4
Posterior deformational plagiocephaly occurs more commonly on the right and there is a notable male predominance. The laterality may be in part a result of intrauterine position with 85% of vertex presentations lying on the left occipital anterior position. If the baby descends into the pelvis (fig 1), this may limit the growth of the right occiput and left frontal areas.5,6 The asymmetry may be further exacerbated postnatally—when the child is laid supine, the head will automatically roll to the flattened side, which then becomes the preferred side for sleeping.
This hypothesis also explains the increase in incidence of posterior deformational plagiocephaly since the “Back to Sleep” recommendations for …
The incidence of deformational posterior plagiocephaly has increased dramatically since 1992. We tested the hypothesis that mandibular asymmetry, associated with this condition, is secondary to anterior displacement of the ipsilateral temporomandibular joint. The response to molding helmet therapy was also evaluated.
A caliper was used to measure mandibular dimensions in 27 infants (16 boys and 11 girls) with deformational posterior plagiocephaly; the mean age was 6.2 months (range, 3 to 12 months). Anthropometric measures included ramal height (condylion-gonion), body length (gonion-gnathion), and condylion-gnathion. Gonial angle was calculated from the law of cosines: C(2) = A(2) + B(2) - 2AB cos c. The position of the temporomandibular joint was accepted as corresponding to auricular position and measured from tragion to subnasal. Cranial asymmetry was measured, in the horizontal plane, from orbitale superius to the contralateral parieto-occipital point at the level of inion. Ten of 27 patients were remeasured 5 months after beginning helmet therapy to evaluate change in mandibular dimensions.
Two thirds of infants (67%) had right-sided and one third (33%) had left-sided deformational posterior plagiocephaly. The mean auricular anterior displacement was 79.7 mm on the affected side and 83.4 mm on the unaffected side. The mean difference of 3.8 mm between the sides was statistically significant (P <.001). Transverse cranial dimension averaged 136.0 mm on the affected side and 146.8 mm on the unaffected side; this was also significant (P <.001). There was a significant positive correlation between auricular displacement and cranial asymmetry [R(23) =.59, P <.01). Auricular (temporomandibular joint) displacement also resulted in an apparent mandibular asymmetry with rotation of the jaw to the affected side. Mean mandibular measurements on the affected and unaffected sides were ramus height of 35.2 and 36.4 mm, body length of 59.0 and 60.3 mm, and gonial angle of 127.1 degrees and 126.8 degrees, respectively. Comparison of the affected with the unaffected sides, using a paired-samples t test, was not statistically significant. Improvement in cranial asymmetry occurred with helmet therapy, but there was no correction of auricular and temporomandibular joint position.
This study supports the clinical observation that the mandibular asymmetry in deformational posterior plagiocephaly is secondary to rotation of the cranial base and anterior displacement of the temporomandibular joint (quantified by anterior auricular position) and not the result of primary mandibular deformity.
Organic plagiocephaly is caused by premature synostosis of the coronal suture. The subject is dealt with in the context of a desire to categorize these types of asymmetries and to find asymmetry indices using computed tomography scan images. From a cephalometric point of view, the authors looked for a reproducible reference, independent of the structures to be studied-the vestibular orientation, which is based on the definition of a mediolabyrinthic plane, making it possible to assess the symmetry. One of the problems encountered in this study of the cranial vault is related to the difficulty of determining reproducible cranial indicators. Consequently, the authors propose an alternative method for studying the asymmetry using the tracing, measurement of radiuses, and the ratio between symmetrical radiuses from the origin of the vestibular indicator. When it came to putting this tool into practice, the authors opted to design a customized instrument. The tool was then applied to dry skulls considered to be symmetrical and to a few cases of plagiocephaly before and after surgery. The study of dry skulls, used as a reference, demonstrates the general shape of the curve representative of the symmetry evolution over the entire vault in healthy models. Analysis of pathological cases reveals the asymmetry of the cranial profiles (for example, homolateral frontal flattening, contralateral frontal prominence). It also makes it possible to assess the anterior, posterior, low, or high location of asymmetries of the vault. This analysis enables quantitative assessment of asymmetries using ratios, along with objective evaluation of postoperative results, with demonstration of surgical improvements and overcorrections. This analysis could make it possible to characterize asymmetries according to their shape. An attempted quantitative classification system for plagiocephalies according to four degrees of severity is proposed. The proposed analysis permits an objective, reproducible, and quantitative method for studying cranial vault asymmetries. A study on a larger population would make it possible to confirm these hypotheses and put forward new ones. Prospects for development could relate to study of all asymmetry problems affecting the base of the skull and the face.
Over the last decade, infants with deformities in the craniofacial skeleton have been seen at our craniofacial center, and similar observations have been noted in infants seen for evaluation and management after birth, where there are not any evident pathological findings such as craniosynostosis or another known genetic disorder. The known condition of deformational plagiocephaly has been related to a sequela of the infants being placed on their back for sleep. The change in the position of the infants to sleep on their back was altered from the traditional position, where infants were placed in the prone position for many decades in the past in the Western world. A special study was initiated to compile meaningful data to help those in the field pursue their treatment of affected children in a systematic and comprehensive manner. Avoidance of unnecessary surgery was essential in those children unless the deformational condition persisted and was not resolvable by nonsurgical means and change in the cultural habitat.