The Incidence of Complications Associated With Molding Helmet Therapy: An Avoidable Risk in the Treatment of Positional Head Deformities?

Molding helmet therapy using an individual head orthosis presents a widely accepted treatment option for children with positional head deformities; however, studies addressing the incidence of complications during helmet therapy are rare. The current study evaluates the incidence of complications in 205 children with positional head deformity undergoing molding helmet therapy. Children were classified according to the severity of their deformity as presented by the Cranial Vault Asymmetry Index (CVAI) and the Cephalic Index (CI). Fifty-nine (28.8%) of our patients presented a moderate and 146 (71.2%) a severe form of a positional head deformity. Of these children, 166 (81.0%) were diagnosed for plagiocephaly, 19 (9.3%) were brachycephalic, and 20 (9.7%) showed a combination of plagiocephaly and brachycephaly. Overall, 54 children (26.3%) showed minor complications during their helmet molding including pressure sores (13.7%), ethanol erythema (2.9%), skin erosions/skin infections (4.3%), or deficient fitting (5.4%). Children with a combination of plagiocephaly and brachycephaly (n = 20) showed the highest risk for complications, which was significantly higher compared with children with plagiocephaly (50% vs 22.3%; P = 0.012). Irrespective of the type of positional head deformity, no statistical difference was revealed between the moderate and the severe form. Minor complications are a relatively frequent event during helmet molding therapy. Especially children with a combination of plagiocephaly-brachycephaly are at high risk for complications. A reduction of this rate might be reached by a close follow-up for a short period between helmet manufacturing adjustments.

Cranial vault remodeling in microcephalic osteodysplastic primordial dwarfism type II and craniosynostosis.

This is a survey of the long-term result after various surgical treatments in a child with microcephalic osteodysplastic primordial dwarfism type II (MOPD II) and craniosynostosis. We report a 17-year-old patient with MOPD II but some unusual clinical signs including bilateral knee dislocation, a misplaced upper lobe bronchus, and hypoplasia of the anterior corpus callosum. Because of premature fusion of several cranial sutures, the child developed signs of increased intracranial pressure with somnolence and papilledema. Cranial vault remodeling with fronto-orbital advancement was performed twice at the age of 16 and 21 months to open the abnormally closed suture, increase the intracranial volume, and relieve the elevated intracranial pressure. Following this procedure, the child's neurologic situation recovered significantly. Surgical procedure of fronto-orbital advancement and the performed reoperation in our patient were safe with no major complications intraoperatively and postoperatively with good functional and satisfying aesthetic outcomes in the long-term follow-up, expressed by the patient, his parents, and the surgeons.

Magnetic resonance imaging in isolated sagittal synostosis.

Isolated fusion of the sagittal suture is the most prevalent form of craniosynostosis. Although the typical clinical appearance usually points the way to the right diagnosis, computed tomographic (CT) scans are still recommended as necessary tools for both the diagnosis of scaphocephaly and the preoperative planning. Because CT scans are accompanied by the biological effects of ionizing radiation, some authors have already postulated the use of magnetic resonance imaging (MRI) especially because MRI seems to be valuable for detecting intracranial anomalies compared with CT scans. Hence, we investigated the preoperative MRIs of 42 children with isolated sagittal synostosis to evaluate the frequency of brain anomalies and their therapeutic consequences.In our study, 10 patients (23.8%) showed pathologic MRI findings such as ventricular dilatation and hypoplastic corpus callosum, whereas 32 patients (76.2%) had an unremarkable MRI except a pathognomonic secondary deformation of the brain caused by the abnormally shaped skull, which was present in all patients. Seven patients showed clinically significant symptoms including papilledema or psychomotoric developmental delay; however, the clinical appearance was not predictive for pathologic MRI findings and vice versa.As the detection of brain anomalies had no influence on the surgical procedure or led to any additive therapy in our patients, we conclude that evaluation of possible pathologic brain findings does not legitimate the general use of MRI in clinically normal children with isolated sagittal synostosis.

Solitary infantile myofibroma of the skull.

Infantile myofibromatosis is a proliferative disorder characterized by the development of single or multiple nodular lesions in the soft tissue, skeleton, and internal organs. These tumors can occur at any anatomic site, but in one third of the cases, the head and neck region is involved. Here, we report a case of an infantile myofibroma occurring in a 7-year-old girl presented as a solitary lesion in the head and neck area. The clinical heterogeneity and the misleading histopathologic appearances may render the diagnosis difficult. Usually, treatment of choice is surgical removal of the tumor; however, the low rate of recurrence and the possibility of spontaneous regression may lead to conservative surgery or therapeutic abstention.

A system for context-aware intraoperative augmented reality in dental implant surgery.

PURPOSE: Large volumes of information in the OR are ignored by surgeons when the amount outpaces human mental processing abilities. We developed an augmented reality (AR) system for dental implant surgery that acts as an automatic information filter, selectively displaying only relevant information. The purpose is to reduce information overflow and offer intuitive image guidance. The system was evaluated in a pig cadaver experiment. METHODS: Information filtering is implemented via rule-based situation interpretation with description logics. The interpretation is based on intraoperative distances measurement between anatomical structures and the dental drill with optical tracking. For AR, a head-mounted display is used, which was calibrated with a novel method based on SPAAM. To adapt to surgeon specific preferences, we offer two alternative display formats: one with static and another with contact analog AR. RESULTS: The system made the surgery easier and showed ergonomical benefits, as assessed by a questionnaire. All relevant phases were recognized reliably. The new calibration showed significant improvements, while the deviation of the realized implants was <2.5 mm. CONCLUSION: The system allowed the surgeon to fully concentrate on the surgery itself. It offered greater flexibility since the surgeon received all relevant information, but was free to deviate from it. Accuracy of the realized implants remains an open issue and part of future work.

The value of ultrasound-assisted pinned resorbable osteosynthesis for cranial vault remodelling in craniosynostosis.

Resorbable osteosynthesis is a widespread tool in craniofacial surgery, however only a limited number of studies have focused on ultrasound-assisted pinned resorbable systems in the treatment of craniosynostosis. Thirty-eight children with various types of craniosynostosis including scaphocephaly, trigonocephaly, anterior and posterior plagiocephaly were treated using the Sonic Welding resorbable osteosynthesis system. All patients were evaluated for operation time, stability of the surgical results, rate of local infections and visibility or palpability of the osteosynthesis material in the follow-up ranging from 15 to 21 month. Mean operation time was not significantly higher compared to conventional osteosynthesis material and all remodelled cranial vaults showed immediate stability. Only one patient showed signs of an inflammatory skin reaction, which recovered spontaneously. The number of palpable or visible plates, respectively, increased during the first months with a maximum at 12 months (34 (89%) plates palpable, 26 (68%) plates visible). After this time point, the number decreased continuously until the end of the follow-up period at 21 months when 3 (20%) plates were palpable, 0 (0%) plates were visible). Ultrasound-assisted pinned resorbable systems seem to be a promising tool in craniofacial surgery providing a timesaving and stable osteosynthesis. An initial swelling of the plates during the first 12 months before the complete degradation might result in a palpable and visible bulge.

Bilateral coronal and sagittal synostosis in X-linked hypophosphatemic rickets: a case report.

Craniosynostosis can be gene-linked, or caused by metabolic diseases, such as rickets, which results from a deficiency or impaired metabolism of vitamin D, magnesium, phosphorus or calcium leading to hypomineralization of the bone. X-linked dominant hypophosphatemic rickets (XLHR) is the most prevalent genetic type of hypophosphatemic rickets and is caused by germ line mutations in the PHEX-gene. In XLHR, only few case reports of craniosynostosis were described. Here, we present a clinical report of an 18 months old child with XLHR and bilateral coronal and sagittal synostosis who was treated by subtotal cranial vault remodelling with fronto-orbital advancement and right-angled Z-osteotomies. As a consequence of the child's diminished bone regeneration capacity, surgery that is performed after the age of 1 year requires more extensive craniectomy, multiple osteotomies and rigid fixation for calvarial vault remodelling to prevent extensive bone defects.

Value of preoperative imaging in the diagnostics of isolated metopic suture synostosis: a risk-benefit analysis.

Radiographic evaluation including plain radiographies and computed tomographic (CT) scans are considered as a necessary tool for diagnosis of craniosynostosis. As recently concerns about harmful effects of ionising radiation in children have been raised, some authors have suggested the use of magnetic resonance imaging (MRI) as a helpful alternative in preoperative imaging of patients with isolated metopic synostosis. Besides confirming the diagnosis of trigonocephaly, MRI is the superior technique for the evaluation of underlying brain anomalies. However, if the benefit of preoperative imaging justifies possible side effects is still discussed controversially. Hence, this study investigated the value of preoperative imaging for the diagnosis of isolated synostosis of the metopic suture compared to a sole clinical examination. In a series of 63 cases with isolated metopic craniosynostosis operated at the Department of Oral and Maxillofacial Surgery, 48 (76.2%) patients received additional radiography or MRI investigation, while in 15 (23.8%) patients the diagnosis was based on clinical examinations only. In all patients, diagnosis was confirmed intra-operatively by a fused metopic suture. CT scans with three-dimensional reconstruction (12.5%) or plain radiographs (39.6%) did not provide any additional benefit for the diagnosis or the surgical treatment. In 23 patients (47.9%), MRI showed the typical soft-tissue alterations like triangular brain deformation in the frontal area. Besides these findings, no brain or other underlying anomalies were diagnosed which had required any additional treatment. The incidence of underlying brain abnormalities in isolated metopic synostosis seemed not to be different from that of the general population. As the characteristic clinical manifestations were sufficient for an accurate diagnosis of isolated metopic synostosis, and with respect to the biological effects of ionising radiation and risks of sedation especially in infants, preoperative imaging should be reduced to a minimum.

Trigonocephaly: results after surgical correction of nonsyndromatic isolated metopic suture synostosis in 54 cases.

Children with nonsyndromatic isolated metopic suture synostosis suffer from a significant deformity of the supraorbital ridges, the temporal regions and hypotelorism. We retrospectively analyzed 54 consecutive cases of isolated nonsyndromatic metopic synostosis treated over a 14-year-period. The data were evaluated using patients' clinical records, skull radiographs in two planes, CT-scans, MRI scans and pre-/post-operative photographs. Surgery with standardized fronto-orbital advancement was performed at a median age of 11.5 months. Follow-up ranged from 4.5 months to 177.4 months, with an average of 51.9 months. The average blood loss was less than 255ml and the average post-operative length of stay was 5 days. Not a single major complication was observed except for uncomplicated dural tears in six cases. According to the classification of Whitaker, results were considered good to excellent (Category I and II) in all except one case (Category IV). As the current techniques have been standardized for routine use, surgical risks are reasonably low with no mortality or permanent morbidity. We think that the treatment of single metopic synostosis is safe with very low reoperation rates and short length of hospital stay. Overall, our results showed acceptable minor complication rates and generally satisfactory aesthetic outcomes.