Helmet therapy efficacy and its prediction in Japanese infants with positional plagio- and brachycephaly.

PURPOSE: To provide additional information on optimal start times and therapeutic effectiveness based on treatment outcome of Japanese infants with positional plagio- and brachycephaly (PPB) receiving cranial molding helmet therapy (CMHT). METHODS: In this retrospective cohort study, data from a 3D head scanning system was analyzed from 2173 Japanese infants who completed CMHT. Anterior and posterior symmetry ratio (ASR and PSR) and longitudinal to transverse diagonal ratios (LD/TDR) were calculated based on skull shape at helmet design and at completion of therapy. The outcomes were evaluated using the regression analysis and a predictive model using cranial parameters was developed. RESULTS: The earlier the start of therapy, the greater the therapeutic effect on ASR, PSR, and LD/TDR (ASR, -0.134 percent points (ppt)/day; PSR, -0.086 ppt/day; and LD/TDR, -0.131 ppt/day). In the predictive model, in addition to starting age of the therapy, sex (male), the degree of deformity of the head (DoD) (moderate and severe), quadrant volume, PSR, and head circumference at the start of treatment also had a positive effect on changes in ASR, DoD (moderate and severe), ASR, LD/TDR and transverse diameter for PSR, sex (male), DoD (moderate), quadrant volume, PSR, and head circumference for LD/TDR. CONCLUSION: The starting age of therapy had a relatively smaller contribution to outcome effects. Applying the cranial parameter obtained at the start of treatment to the predictive model helps to predict the effect of CMHT and whether PPB can be treated with CMHT in infants of older age.

Facial asymmetry in children with either unilateral lambdoid craniosynostosis or positional posterior plagiocephaly.

BACKGROUND: In unilateral lambdoid craniosynostosis (ULC), the posteriorly situated lambdoid suture of the cranial vault fuses prematurely. Positional posterior plagiocephaly (PPP) causes flattening of the posterior side of the head, either through external forces or through underlying differences in brain development. Both conditions cause occipital flattening of the head, but the aetiology is different. MATERIALS AND METHODS: Eight ULC children were compared with 16 sex- and age-matched PPP children. 3D computer tomography scans of all 24 children were analysed with Dolphin imaging software. The location and symmetry of the temporomandibular joint (Co), and the symmetry of the maxillary anterior nasal spine (ANS) and the mandibular symphysis (Pgn) were analysed. Furthermore, the mandibular bone (Co-Pgn) length, corpus length, ramus height, positional changes in the external acoustic meatus (PoL) and the distance from the orbital margin to the articular fossa were measured. RESULTS: In all eight ULC children, the Co was anteriorly displaced on the affected side compared with the unaffected side. In all ULC and PPP children, the ANS, which is considered the bony maxillary midpoint, was shifted towards the affected side. In all ULC children, the mandibular bone (Co-Pgn) was shorter on the affected side. The PoL was antero-inferiorly positioned in all ULC children on the affected side compared with the unaffected side. CONCLUSIONS: Our results show that both types of posterior plagiocephaly are associated with an asymmetric position of the Co and asymmetry of the mandible and maxilla. Facial asymmetry was more frequently seen in ULC than PPP children.

UCSQ Method Applied on 3D Photogrammetry: Non-Invasive Objective Differentiation Between Synostotic and Positional Plagiocephaly.

OBJECTIVE: Objective differentiation between unilateral coronal synostosis (UCS) and positional posterior plagiocephaly (PPP) based on 3D photogrammetry according to Utrecht Cranial Shape Quantificator (UCSQ). DESIGN: Retrospective study. SETTING: Primary craniofacial center. PATIENTS, PARTICIPANTS: Thirty-two unoperated patients (17 UCS; 15 PPP) (age < 1 year). INTERVENTIONS: Extraction of variables from sinusoid curves derived using UCSQ: asymmetry ratio forehead and occiput peak, ratio of gradient forehead and occiput peak, location forehead and occiput peak. MAIN OUTCOME MEASURE(S): Variables, derived using 3D photogrammetry, were analyzed for differentiation between UCS and PPP. RESULTS: Frontal peak was shifted to the right side of the head in left-sided UCS (mean x-value 207 [192-220]), and right-sided PPP (mean x-value 210 [200-216]), and to the left in right-sided UCS (mean x-value 161 [156-166]), and left-sided PPP (mean x-value 150 [144-154]). Occipital peak was significantly shifted to the right side of the head in left-sided PPP (mean x-value 338 [336-340]) and to the left in right-sided PPP (mean x-value 23 [14-32]). Mean x-value of occipital peak was 9 (354-30) in left- and 2 (350-12) in right-sided UCS. Calculated ratio of gradient of the frontal peak is, in combination with the calculated asymmetry ratio of the frontal peak, a distinctive finding. CONCLUSIONS: UCSQ objectively captures shape of synostotic and positional plagiocephaly using 3D photogrammetry, we therefore developed a suitable method to objectively differentiate UCS from PPP using radiation-free methods.

Delayed Presentation of Unicoronal Craniosynostosis-Masked by Ipsilateral Posterior Deformational Plagiocephaly.

Despite a greater awareness of the differential diagnosis of head shape abnormalities among pediatricians, the effect of deformational forces on calvarial morphology can complicate the diagnosis of craniosynostosis. In this report, we describe 2 patients diagnosed with unicoronal craniosynostosis (UCS) in a delayed fashion due to the presence of concomitant posterior deformational plagiocephaly (PDP). In both cases, the severity of each patients' PDP obscured changes typically associated with UCS. This unique presentation underscores the importance of having a high index of suspicion for possible premature suture fusion despite the presence of concomitant PDP.

Validation of Skully Care as a Fast Method for Quantifying Positional Cranial Deformities.

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.

Perceptions and Preferences of Laypersons in the Management of Positional Plagiocephaly.

BACKGROUND: Uncertain clinical evidence for treating positional plagiocephaly, especially with helmet therapy, creates difficulties in counseling parents of patients. This study investigates layperson perceptions and treatment preferences for positional plagiocephaly to provide patient-oriented evidence for management. METHODS: Adult laypersons were recruited through crowdsourcing to view digitally-modified images of normal, mildly, moderately, or severely plagiocephalic infant heads. Participants provided demographic information and rated the infant's head shape and potential related social difficulties, likelihood of consulting a physician for treatment options, and likelihood of seeking helmeting treatment for the infant. RESULTS: Nine hundred forty-five individuals participated in the study. Perception of head shape, prediction of future embarrassment and social difficulties, likelihood of seeking physician evaluation, likelihood of choosing helmet therapy, and willingness-to-pay for helmet therapy were pairwise-different between 4 plagiocephaly severities (corrected-P < 0.001 for all), except between normocephaly (n = 194) and mild (n = 334) plagiocephaly or between moderate (n = 203) and severe (n = 214) plagiocephaly. Younger respondents were more likely to consult a physician (uncorrected-P = 0.016) and choose helmet therapy (uncorrected-P = 0.004) for infants with normocephaly or mild plagiocephaly. Parents of children with physical disabilities were 6 times as likely as other participants to choose helmet therapy for mild plagiocephaly (corrected-P = 0.036). CONCLUSIONS: Laypersons perceived moderate and severe plagiocephaly as equally abnormal and mild plagiocephaly as normal, consistent with their treatment preferences. Parents of physically disabled children were significantly more likely than other participants to choose helmet therapy. Our findings provide medical professionals with lay perspectives on positional plagiocephaly that may facilitate effective counseling of parents.

Infant/toddler motor skills as predictors of cognition and language in children with and without positional skull deformation.

PURPOSE: To estimate associations between early motor abilities (at two age points, 7 and 18 months on average) and cognitive/language outcomes at age 3. To determine whether these associations are similar for children with and without positional plagiocephaly and/or brachycephaly (PPB). METHODS: The Bayley Scales of Infant/Toddler Development 3 were given at all age points to 235 children with PPB and 167 without PPB. Linear regressions assessed longitudinal associations between fine and gross motor scales and cognition/language. Item analyses examined the contributions of specific motor skills. RESULTS: Associations between 7-month motor skills and cognition/language were modest overall (effect sizes [ES] = - 0.08 to 0.10, p = .13 to .95). At 18 months, both fine and gross motor skills were associated with outcomes for children with PPB (ES = 0.21 to 0.41, p < .001 to .01), but among those without PPB, only fine motor skills were associated with outcomes (ES = 0.21 to 0.27, p < .001 to .001). CONCLUSIONS: Toddlers' motor skills were associated with cognition and language at 3 years, particularly among children with PPB. Interventions targeting early motor development in infants and toddlers with PPB may have downstream benefits for other outcomes.

Prevalence and severity of positional plagiocephaly in children and adolescents.

OBJECT: Though positional posterior plagiocephaly (PPP) is considered common in infants since the pediatric recommendations of "Back to Sleep", several aspects of its natural history still remain unclear. The aim of this study is to understand the actual prevalence and severity of PPP in children and adolescents. METHODS: Head CT scans performed for head trauma during the period September 2016-September 2017 were retrospectively analyzed in a total of 165 children ranging from 0 to 18 years of age (101 boys). Cranial vault asymmetry index (CVAI) was calculated at the level of the superior orbital rim. CVAI values greater 3.5% was considered index of asymmetry. The results were analyzed according to different age groups: group I: 1 month to 1 year of age (37 children), group II: 2 to 4 years (32 children), group III: 5 to 8 years (36 children), group IV: 9 to 12 years (27 children), and group V: 13 to 18 years (33 children) and the severity of asymmetry according to CVAI values: mild group (CVAI range 3.5-7%), moderate group (CVAI range 7-12%), and severe group (CVAI > 12%). RESULT: The total prevalence of PPP in the 165 children was 25%. While the prevalence in infants of group I was estimated to be 40.5%, it was 15.6% in group II, 30.5% in group III, 18.5% in group IV, and 12% in group V. The mean and maximum degrees of deformation were 3.5% and 15.1%, respectively. Most children had a mild asymmetry. One child (group II) presented a severe asymmetry. The degree of the asymmetry varied according to the groups but moderate asymmetry could be found at all ages even in groups IV and V. CONCLUSION: This study analyzing PPP in an unselected unbiased pediatric population shows that PPP has a high prevalence in adolescents. It confirms that the prevalence of deformational plagiocephaly is more common than usually reported and that PPP may persist at a late age.

Treatment of Deformational Plagiocephaly With Physiotherapy.

Non-synostotic plagiocephaly consists in an asymmetry of the skull due to mechanical forces applied in utero or postnatally: main differential diagnosis is with true synostotic asymmetry, which is caused by the premature closure of a suture. The correction of positional forms is mostly conservative, with 3 main strategies: counterpositioning, physiotherapy and helmet therapy. There is no synthesized evidence on which is the most effective. The Authors evaluate the modification of antropometric measurments before and after a pediatric physical therapy program in a sample of patients with non-synostotic skull asymmetry, in order to evaluate the improvements in the skull shape. The hypothesis being tested was that physical therapy alone could improve the antropometric measurments. The authors enrolled in this study 24 patients diagnosed of non-synostotic asymmetry, clinically and with ultrasound, referred to the Maxillo-facial Unit of Policlinico Umberto I, Rome, within 2013 and 2016. A standardized pediatric physical therapy intervention program was designed: it consisted in a combination of excercises and manipulative procedures to reduce positional preference, musculoskeletal disorders and cranial deformity. Infants received 16 sessions of physical therapy, of 40 minutes each, once a week, for four months. The Authors evaluate the variation of four anthropometric measurments, performed before and after the physical therapy program: Argenta scale, Oblique Diameter Difference Index (ODDI), Cranial Proportional Index (CPI) or Cephalic Ratio (CR), Cranial Vault Asymmetry Index (CVAI). Craniometric evaluations were extrapolated by standardized 2D digital photographs of frontal, sagittal and transverse planes, by the same physician to minimize bias. The management of positional cranial deformities is still controversially discussed and especially the effects of physiotherapy and osteopathy have been only marginally researched. Statistical analysis revealed the effectiveness of the protocol: all anthropometric measurements improved with a high rate, major in youngest children (P < 0.5) and in more severe first presentations (P < 0.05 or P < 0.01). The results suggest manipulative approach may improve the outcome in the long term follow up of cranial asymmetries.

Head orthosis therapy in positional plagiocephaly: longitudinal 3D-investigation of long-term outcomes, compared with untreated infants and with a control group.

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.

Does shape affect function? Articulatory skills in babbling of infants with deformational plagiocephaly.

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.

Description of Mandibular Improvements in a Series of Infants With Congenital Muscular Torticollis and Deformational Plagiocephaly Treated With Physical Therapy.

BACKGROUND: Many infants with congenital muscular torticollis (CMT) have deformational plagiocephaly (DP), and a small cohort also demonstrate mandibular asymmetry (MA). The aim of this retrospective study was to evaluate mandibular changes in these infants with previous computed tomography (CT) scans who underwent physical therapy (PT) to treat CMT. METHODS: A retrospective study included patients presenting to a pediatric plastic surgery clinic from December 2010 to June 2012 with CMT, DP, and MA. A small subset of these patients initially received a 3D CT scan due to concern for craniosynostosis. An even smaller subset of these patients subsequently received a second 3D CT scan to evaluate for late-onset craniosynostosis. Patients were treated with PT for at least 4 months for CMT. Initial CT scans were retrospectively compared to subsequent CT scans to determine ramal height asymmetry changes. Clinical documentation was reviewed for evidence of MA changes, CMT improvement, and duration of PT. RESULTS: Ten patients met inclusion criteria. Ramal height ratio (affected/unaffected) on initial CT was 0.87, which significantly improved on subsequent CT to 0.93 ( P < .05). None of the patients were diagnosed with craniosynostosis on initial CT. One patient was diagnosed with late-onset coronal craniosynostosis on subsequent CT. CONCLUSIONS: We identified a small cohort of infants with MA, CMT, and DP. These patients uniformly demonstrated decreased ramal height ipsilateral to the affected sternocleidomastoid muscle. Ramal asymmetry measured by ramal height ratios improved in all infants undergoing PT.

[Synostosic and non-synostosic cranial deformities]. / Deformidades craneales sinostósicas y no sinostósicas.

In the last decades alterations in the skull shape have increased at the expense of plagiocephaly, as consequence of the American Academy of Pediatrics recommendations to sleep the infant in the supine position. The clinician must differentiate between positional plagiocephaly and craniosynostosis, since if a cranial synostosis is proven, the therapeutic behavior will be potentially neurosurgical. Although three-dimensional skull tomography with bone window is the study of greater sensitivity and diagnostic specificity, the majority of cases can be confirmed by the clinic, reserving the radiography or ultrasound with a suture approach for doubtful cases. Craniosynostosis must be early referral to a craniofacial team to define the indication, opportunity and most appropriate surgical technique, in order to avoid future neurocognitive and psychosocial complications. Children with positional plagiocephaly regardless of the treatment of cranial deformity may have a higher risk of motor development delay. For correction, repositioning and physiotherapy are suggested in mild to moderate forms, reserving the use of cranial orthesis in severe forms.

The Role of Age and Initial Deformation on Final Cranial Asymmetry in Infants with Plagiocephaly Treated with Helmet Therapy.

BACKGROUND/AIMS: To characterize the impact of cranial asymmetry and age at initiation of therapy on final cranial asymmetry in infants with deformational plagiocephaly treated with helmet orthotics. METHODS: We conducted a single-center retrospective review of 45 pediatric patients <12 months of age with deformational plagiocephaly who underwent STARband cranial orthotic helmet treatment. Cranial asymmetry was measured using a 3-dimensional laser surface scanner and defined as a cranial vault asymmetry index (CVAI) >3.5%. RESULTS: Twenty-one patients (47%) were <6 months of age at the start of helmet therapy. A greater initial CVAI or age at therapy initiation correlated with a greater final CVAI (univariate analysis, r = 0.53, p < 0.001; r = 0.42, p = 0.004). Subgroup analysis of 18 patients beginning therapy at 4-5 months of age and 20 patients beginning therapy at 6-8 months of age revealed that only a change in the initial CVAI was associated with a change in the final CVAI (r = 0.43, p = 0.007). CONCLUSION: In a comparison of patients who initiated helmet therapy at 4-5 and 6-8 months of age, only cranial asymmetry at the outset of therapy was correlated with final cranial asymmetry (r = 0.43, p = 0.007).

A Craniometric Analysis of Cranial Base and Cranial Vault Differences in Patients With Metopic Craniosynostosis.

PURPOSE: The effect of synostosis is not confined to the immediate vicinity of the suture. The authors hypothesized metopic craniosynostosis results in migration of lateral structures from midline, and differences in segmental volume of the cranial fossa. METHODS: A retrospective case-controlled cohort analysis of patients with nonsyndromic metopic craniosynostosis was performed. Craniometric angles, distances to landmarks from midline, cephalic index, and segmented volume ratios were calculated. A comparison group consisted of patients without cranial pathology or with mild positional plagiocephaly. RESULTS: Twenty patients with metopic craniosynostosis and 19 controls were identified. The bifrontal angle was significantly more acute in metopic patients. Distance from midline to the medial carotid, the foramen ovale, and the hypoglossal canal were all significantly longer in metopic patients. Ratio of anterior third to total cranial vault volume was significantly smaller in metopic patients; however, ratio of middle third to total cranial vault volume was significantly larger. As the bifrontal angle decreased by 1°, the volume of the anterior third of the cranial vault was observed to decrease by 0.17% (P < 0.001). CONCLUSIONS: Patients with metopic craniosynostosis show a distinct and significant transverse lateralization of structures of the anterior skull base relative to midline, significant restriction of the anterior third of the cranial vault, and compensatory expansion of the middle third. There is a linear relationship between the bifrontal angle and the subsequent change in anterior third cranial vault volume. LEVEL OF EVIDENCE: IV; Therapeutic.

Diagnostic Yield of Routine Skull Radiographs in Infants With Deformational Plagiocephaly.

OBJECTIVE: Differentiating synostotic and nonsynostotic plagiocephaly can be challenging, and many providers routinely obtain screening skull radiographs when evaluating an infant with plagiocephaly. However, the diagnostic yield of radiographs has not been studied in this clinical setting. DESIGN: This study was a retrospective chart review. SETTING: The study took place in a tertiary care center. PATIENTS: We retrospectively reviewed the records of all patients referred to Children's Medical Center (Dallas, TX) between the years 2010 to 2012 with a diagnosis of plagiocephaly. After an initial evaluation, skull radiographs were obtained to rule out craniosynostosis. We reviewed clinical and demographic data and radiographic findings to determine the diagnostic yield of routine screening radiographs in infants presenting with plagiocephaly. RESULTS: There were 1219 patients in total, and 1213 of these patients received screening four-view conventional skull radiographs. Six had computed tomography without prior radiographs. Of the patients in the skull radiograph group, 24% (289 of 1213) had abnormal radiographic findings, and 7.6% of this group (22 of 289) had findings that were indicative of craniosynostosis. Of these 22 patients, 12 obtained follow-up studies, and only three patients (0.2% of skull group) had true craniosynostosis. In comparison, 50% (three of six) in the group of patients who underwent computed tomography without prior conventional screening radiographs had true craniosynostosis. CONCLUSIONS: Routine screening skull radiographs have a low diagnostic yield in differentiating between synostotic and nonsynostotic plagiocephaly in patients presenting to a tertiary care deformational plagiocephaly clinic. Considering the costs and radiation exposure, the benefit of the routine use of skull radiographs in patients with deformational plagiocephaly is questionable.

The course of positional cranial deformation from 3 to 12 months of age and associated risk factors: a follow-up with 3D imaging.

Deformational plagiocephaly is reported in up to 46.6 % of healthy infants, with the highest point prevalence at around 3 months of age. Few prospective studies on the natural course of skull deformation have been conducted, and we know of no studies using 3D imaging starting from the highest point prevalence period. In this prospective, population-based cohort study, we describe the course of cranial asymmetry and shape in an unselected population using 3D stereophotogrammetry and investigate factors associated with late cranial deformation and failure to recover from previous deformation. We evaluated 99 infants at 3, 6, and 12 months of age. We acquired 3D craniofacial images and performed structured clinical examinations and parental interviews at each visit. Eight outcome variables, representing different aspects of cranial shape, were calculated from a total of 288 3D images. Scores of asymmetry-related variables improved throughout the observation period. However, the rate of correction for cranial asymmetry decreased as the infants grew older, also in relation to the rate of head growth, and a significant amount of asymmetry was still present at 12 months. Positional preference at 3 months predicted an unfavorable course of cranial asymmetry after 3 months, increasing the risk for DP persisting. What is known: • The prevalence of deformational plagiocephaly spontaneously decreases after the first months of life. • Limited neck range of motion and infant positional preference increase the risk of deformational plagiocephaly during the first months of life. What is new: • Positional preference at 3 months predicts an unfavorable spontaneous course of deformation also from three to 12 months of age, presenting a potential target for screening and treatment. • The spontaneous rate of correction for cranial asymmetry decreases after 6 months of age, also in relation to the rate of head growth.

Sonographic Analysis of Changes in Skull Shape After Cranial Molding Helmet Therapy in Infants With Deformational Plagiocephaly.

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.

Facial twist (asymmetry) in isolated unilateral coronal synostosis: does premature facial suture fusion play a role?

BACKGROUND: Unilateral coronal synostosis (UCS) often causes notable facial twist in affected patients. This condition occurs when the midface deviates toward the synostotic side, and the lower face deviates away from the synostotic side. The exact underlying mechanism for this phenomenon remains unclear. It has been proposed that premature fusion of facial sutures may play a role in the formation of facial twist. The purpose of this study was to determine whether asymmetrical facial suture fusion is present in patients with UCS. METHODS: A single-center retrospective study was designed. Our study group consisted of 23 patients with a confirmed diagnosis of isolated UCS. Our control group consisted of 17 age-matched patients with deformational plagiocephaly and 11 normocephalic control subjects. The computed tomography scans of the faces were examined for the presence of facial suture fusions on both synostotic and nonsynostotic sides. All results with P < 0.05 were considered statistically significant. RESULTS: We found an increased incidence of fusion of the frontomaxillary, nasofrontal, and nasomaxillary sutures on the side of synostosis in UCS when compared with the nonsynostotic side and when compared with patients with deformational plagiocephaly or normocephalic patients. CONCLUSIONS: Asymmetrical premature fusion of facial sutures can potentially be contributing to the facial twist that is seen in patients with UCS.

Assessment of Head Shape by Craniofacial Teams: Structuring Practice Parameters to Optimize Efficiency.

INTRODUCTION: Since the initiation of the "Back to Sleep Campaign" by the American Academy of Pediatrics in 1992, the incidence of referrals for positional plagiocephaly has increased by 600%. Although patients with positional plagiocephaly rarely require operative intervention, they often do require treatment with cranial molding helmets or positioning changes. The increased volume of patients makes the task of separating cases of craniosynostosis from positional head shape problems more difficult. The authors sought to determine how providers are handling this increased workload of head shape abnormality patients, especially with respect to the largest practices. MATERIALS AND METHODS: An electronic survey was created and distributed to members of the American Society of Maxillofacial Surgeons and the American Cleft Palate Association (ACPA). Practices were categorized by head shape patient volume as low (<4 new patients/month), medium (5-20 new patients/month), and high (>21 new patients/month). A Pearson's χ test was used to determine characteristics that differed significantly with practice volume. RESULTS: Response rate was 6.6%, with 88 responses. Regarding head shape evaluation, 17.6% of practices used a laser scanner (portable or stationary), 35.3% used caliper anthropometric measurements, 28.5% used two-dimensional digital photography, and 9.4% used three-dimensional digital photography. In high-volume centers, 80% had a dedicated head shape clinic (P < 0.0005), 33.3% used a stationary laser scanner (P = 0.023), and 53.3% used a licensed independent provider (LIP) such as a nurse practitioner or physician assistant in the initial evaluation of head shape abnormalities (P = 0.032). Although using a multidisciplinary clinic was not a significant difference amongst groups, the most common additional provider in multidisciplinary clinic was orthotics (68%). CONCLUSIONS: High-volume practices are significantly more likely to use LIPs, stationary laser scanners, and plain films, as well as organizing head shape abnormality patients into a dedicated clinic.