Comparative Evaluation of Measurement Methods for Positional Skull Deformities in Infants: A Prospective Analysis.

Background: Early identification of cranial deformities in infants is essential for timely intervention and preventing long-term complications. In Uganda, particularly in rural areas, access to specialised paediatric healthcare remains limited, making it difficult to diagnose and manage cranial abnormalities early. This study takes a unique approach by using the PhotoMeDAS system. This non-invasive technology allows accurate cranial measurements through QR-based imaging to define normative cranial index ranges for Ugandan infants. By analysing key cranial parameters associated with head shape, symmetry, and overall growth patterns, this study aims to establish reference values that can serve as a baseline for clinical assessments. Methods: A cross-sectional study was conducted in healthcare centres in Lugazi, Uganda, collecting cranial measurements from 195 infants aged 0–2 years old. The data was collected using the PhotoMeDAS system, a non-invasive technology that allows accurate cranial measurements through QR-based imaging. The primary cranial variables analysed included Head Circumference (HC), Cephalic Index (CI), Cranial Vault Asymmetry Index (CVAI), Pseudovolume Index (PVI), and Frontal Angle (FA). HC was measured to establish general growth patterns, while the CI provided insights into head shape classification (dolichocephalic, mesocephalic, or brachycephalic). The CVAI assessed cranial symmetry, detecting potential cases of plagiocephaly, while the PVI evaluated the proportionality of cranial growth relative to the perimeter. Finally, the FA was considered to assess anterior cranial development and forehead morphology. For the management and optimisation of processes, Microsoft Visio was used to create flow diagrams that facilitated the organisation of the paediatric campaign.SPSS and Excel were employed for statistical analysis, evaluating the relationship between cranial indices and variables such as sex, age, and ethnicity. Normality tests (Kolmogorov-Smirnov), chi-square tests, and ANOVA were applied to identify distribution patterns and significant variations among subgroups. In addition, Python was used to process cranial images obtained during the paediatric research. Results: This study provides the first normative dataset for cranial indexes in Ugandan infants, highlighting significant variations in head morphology according to age and sex. The CI revealed a predominantly mesocephalic distribution, with a small proportion of dolichocephalic and brachycephalic cases. The CVAI showed a low prevalence of significant asymmetry, suggesting minimal cases of plagiocephaly in the sample. The PVI indicated proportional cranial growth trends, with expected increases in head size over time. The FA exhibited slight variations across age groups, reflecting dynamic changes in forehead development during early childhood. These findings have the potential to impact healthcare practices significantly, guiding early diagnosis and intervention strategies for cranial deformities in Ugandan infants. Conclusion: This study fills a crucial gap in paediatric cranial morphology research by establishing the first cranial index reference values for Ugandan infants. These findings provide essential data for healthcare professionals to facilitate early diagnosis, guide preventive strategies, and improve clinical assessments in low-resource settings where specialised care is scarce. Further research is needed to investigate genetic and environmental influences on cranial development and compare these normative values with populations from different geographical and ethnic backgrounds. This emphasis on the need for further research suggests the potential for future developments in the field.

-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. -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. -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). -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.

ObjectiveTo compare a new ultrasound measurement method with calliper cephalometry in infants with deformational plagiocephaly (DP) and to assess the differences of two methods according to the severity of DP.MethodsFifty-two infants with DP were divided into two groups according to the degree of cranial vault asymmetry (CVA); group 1 included 42 infants with CVA over 10 mm, and group 2 included 10 infants with CVA under 10 mm. Cranial vault asymmetry index (CVAI) and occipital angle ratio (OAR) were measured by using calliper and ultrasound measurements, respectively. The occipital angle was defined as the angle between the lines projected along the lambdoid sutures of the skull.ResultsThe occipital angles of the affected sides were significantly greater than those of unaffected sides in both groups. The CVAI and OAR were significantly greater in group 1 than in group 2 (CVAI, 9.3%±2.3% vs. 4.6%±1.5%; OAR, 1.05±0.4 vs. 1.01±0.0; p<0.05). The OAR was positively correlated with the CVAI in all infants (r=0.789) and in group 1 (r=0.784; p<0.05).ConclusionOur study revealed that OAR using the new ultrasound measurement was positively correlated with the CVAI in infants with DP. Therefore, the occipital angle measurement using ultrasound combined with cephalometry could provide better understanding about the characteristics of the overall cranial bone and lambdoid suture complex in infants with DP.

Association between cranial morphology and dysgnathias in adolescents and adults: A prospective case-control study.

Introduction: Infants treated for positional cranial asymmetry involving plagiocephaly, brachycephaly, and scaphocephaly are often treated with cranial reshaping orthotic helmets to encourage symmetrical cranial growth. The Michigan Cranial Reshaping Orthosis is a bivalve helmet that accommodates overall cranial growth during the therapy period while still directing cranial growth toward the desired areas. This design differs from standard one-piece helmets that allow limited volume for overall cranial growth. This study examines the efficacy and success rate of this low-profile design. Materials and Methods: Visual inspection and manual measurements taken throughout the helmet therapy period, using a flexible tape measure and an AP-ML gauge, indicate significant cranial asymmetry correction. However, measurement inconsistencies due to soft tissue compression and clinician technique may limit the accuracy of outcome measures. Seventy subjects treated for plagiocephaly and/or brachycephaly with the Michigan Cranial Reshaping Orthosis were identified in this retrospective study. Data were compiled from Omega Tracer (Ohio Willow Wood Company, Mount Sterling, OH, USA) computer-aided design clinical database of three-dimensional cranial scans taken before and after helmet therapy. Cranial helmet therapy treatment timeline was verified through the electronic medical record database. Cranial landmarks were defined on each three-dimensional image. Measurements between defined points were compared on the initial assessment scanned image and the final discharge scanned image for each patient. Results: Comparison of initial and final three-dimensional scans showed improved symmetry in the relevant measures of cranial vault asymmetry index (CVAI) and cephalic ratio (CR) in 84.3% of subjects. Children in the plagiocephaly-only group showed 28.8% improvement in CVAI. Although sample size was low, children in the brachycephaly-only group showed 4.66% improvement in CR. Children in the combined plagiocephaly/brachycephaly group showed 41.4% improvement in CVAI and 2.60% improvement in CR. Overall, a 33.5% in CVAI and 2.10% improvement in CR were seen. These results are comparable to other studies of remolding helmet efficacy. Conclusions: The data in the present study, therefore, support the use of the Michigan Cranial Reshaping Orthosis as a viable option in the treatment of plagiocephaly and/or brachycephaly when the primary method of treatment is utilization of a cranial remolding helmet.

Purpose: to develop and validate algorithms that enable a novice user to quantitatively measure the head shape parameters associated with deformational plagiocephaly, and brachycephaly (DPB) using a smartphone or tablet. Method: We have developed a technology (called SoftSpot^TM) based on advanced imaging algorithms to detect different types and severity of DPB from top-view photos of the head acquired by a novice user at the point-of-care, i.e. in pediatric offices, and at home. Currently, the head shape parameters are measured using either a 3D scanner or a mechanical caliper by a specialist such a pediatric neurosurgeon or an orthotist. In our approach, the head contour is extracted semiautomatically using the intelligent scissors method. We then automatically compute two indices used in the clinical determination of the DPB: the cranial index (CI), and the cranial vault asymmetry index (CVAI). In this paper, we also present methods to quantify, and compensate for the user variability in the acquisition of photos, including camera angle, and distance from the head, by combining the results from different camera positions. We compared the results of our technology with ground truth measurements from 53 infants with DPB, and normal cranial parameters. Accuracy analysis was performed by Bland Altman (BA) method, and the Spearman correlation test. Results: The Spearman correlation coefficients between the new 2D method, and the 3D ground truth were 0.94 (p&lt;0.001), and 0.96 (p&lt;0.001) for CI and CVAI, respectively. Different camera angles, and distances from the head resulted in variation in CI and CVAI in the range of [-2.0, 6.0], and [-4.0, 4.0] units, respectively. The limit of agreement was reduced from [-3.6, 5.3], and [-3.6, 4.2] to [-0.5, 3.0], and [-1.3, 1.6] for CI and CVAI, respectively, by combining results from different camera angles, and positions in our method. The overall accuracy of the proposed technology for DPB detection was 100%. Conclusions: Photographic 2D images can be accurately analyzed to assess DPB at the point-of-care. By compensating for the error from variable camera angles, and distance from the head, our technology eliminates user variability. The algorithms will be packaged in a mobile application to enable the use of the technology at the point-of-care.

Analysis of the correlation between deformational plagiocephaly and neurodevelopmental delay

Helmet therapy is widely accepted in the treatment of severe positional plagiocephaly. The improvement of the cranial asymmetry under therapy is evident, but parents are also concerned about the ear shift. Our study investigated the influence of helmet therapy on the position of the ears and analyzed the reliability of clinical observations regarding cranial asymmetry and ear shift. Three-dimensional stereophotogrammetry of 80 infants with severe positional plagiocephaly was performed before and after helmet therapy. The cranial vault asymmetry index (CVAI) and ear shift were measured and statistically compared. The correlation between the change of CVAI and ear shift was investigated. Three surgeons visually evaluated the treatment results on three-dimensional images independently with a standard questionnaire. The results were compared with the three-dimensional measurements. Sixty infants had a relevant initial ear shift. Under therapy, the shift was improved significantly by a mean of 29.8% (P < 0.001). Twenty infants with an initial straight ear line statistically deteriorate under therapy (P < 0.0001). We found no strong linear correlation between the changes of the CVAI and the ear shift. Analysis of the questionnaire revealed a good correlation between the clinical impression and three-dimensional measurements for the head asymmetry, whereas observations regarding changes in the ear shift were not reliable. Helmet treatment significantly improves an initial malposition of the external ear in infants with positional plagiocephaly. A severe ear shift can be associated with a moderate CVAI and vice versa. In contrast to the CVAI, small changes of the ear shift cannot be evaluated reliably by clinical investigation.

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. 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. 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. Due to ethical reasons, the investigation is a non-randomized study. Parameters of facial symmetry were only assed for the treated and untreated groups. 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.

Volume measurements on three-dimensional photogrammetry after extended strip versus total cranial remodeling for sagittal synostosis: A comparative cohort study.

To investigate the effects of helmet therapy on plagiocephaly, according to head circumference, cephalic index (CI), and skull height. Plagiocephaly is a condition in which the skull is congenitally asymmetrical or affected by acquired factors such as compression in the womb or the habit of sleeping on one side. Although there are numerous studies on the effectiveness of helmet therapy for plagiocephaly, research on its effectiveness on skull shape is lacking. We conducted a prospective study on 400 patients who underwent helmet therapy. The infants were enrolled and the therapy was explained to the caregiver when the child had positional plagiocephaly and had a cranial vault asymmetry (CVA) exceeding 10 mm or a CVA index (CVAI) exceeding 3.5%. The CVA and CVAI changes were compared to investigate the effectiveness of helmet therapy according to head circumference, CI, and skull height. A significant treatment effect was observed for CI values between 90 and 103. The treatment effect was found to increase with greater skull height. However, no significant difference was observed in the effectiveness of helmet therapy according to head circumference. According to the findings, the effectiveness of helmet therapy in children with positional plagiocephaly is greater for children with higher skulls and for those with CI values between 90 and 103; it is unrelated to head circumference. Based on these results, we can provide predictions of the effectiveness of helmet therapy to caregivers of children with positional plagiocephaly.

Prevalence of head deformities in preterm infants at term equivalent age

INTRODUCTION: Positional plagiocephaly is a common condition with controversy regarding optimal treatment modality. Treatment options include repositioning exercises, watchful waiting, cranial molding orthotics, and in rare cases surgery. Conservative therapy with repositioning therapy (RT) +/- physical therapy (PT) is known to be successful in a large portion of these patients1. Recently an article in British Journal of Medicine2 featured in Wall Street Journal stated watchful waiting is as effective as helmet therapy. Our aim was to determine the effectiveness of helmet therapy for positional skull deformation in a single providers practice. MATERIALS AND METHODS: 4248 patients were seen and evaluated for positional plagiocephaly were assigned either conservative treatment (RT +/- PT, n=3186) or Helmet therapy (n=1062). Patients assigned to helmet therapy were treated by a single orthotist using the single orthotic manufacturer. Patients were followed until complete correction (Diagonal Difference<6, EPSR>90%, Cephalic Index 0.75–0.91, Cranial Vault Asymmetry Index<6). RESULTS: Age at initial evaluation ranged from 3–12 months. Complete correction was achieved in 75% of patients with conservative treatment (n=3186). 25% transitioned to helmet therapy (n=1062). Average helmet treatment duration was 5 months with 95% having complete correction of deformity with a single helmet. 5% of patients required a second helmet for additional correction (n=49) with 0.01% requiring a third helmet to achieve complete correction (n=8). Risk factors for failure of conservative therapy included advanced age, torticollis, and severity of cephalic ratio and diagonal difference. CONCLUSION: Conservative and helmet therapy can effectively treat positional plagiocephaly. In children who could benefit from helmet therapy, a single helmet fabricated by a skilled orthotist and followed by a craniofacial surgeon can correct deformational skull deformities in nearly all infants. These results are consistent with previous studies, but conflicts the BJM article. This is important, as this article can be the source of insurance denials for infants who could clearly benefit from cranial molding orthotics. Further large randomized trials would help answer this challenging question.

Craniosynostosis limits normal cranial growth, significantly affecting the growth and development of children. This increase in intracranial pressure results in significant cosmetic and functional losses. This study investigated the efficacy of combining molding helmets with suturectomy for craniosynostosis. Patients who underwent suturectomy and molding helmet therapy for craniosynostosis at a single institution between 2017 and 2024 were included. Changes in cephalic index (CI) and cranial vault asymmetry index (CVAI) were analyzed. A total of 14 patients (12 males, 2 females) were included, with a median age of 4.5 months (2-6mo). The affected sutures were as follows: sagittal (n=8), bilateral coronal (n=4), unilateral coronal (n=1), and lambdoid (n=1) sutures. The median duration of postoperative molding helmet therapy was 44.5 weeks. For the sagittal suture group, the median preoperative CI, median postoperative CI, and rate of change were 72.0 (68.3-85.8), 77.0 (72.1-86.4), and 0.0646, respectively. For the bilateral coronal suture group, measurements for the same parameters were 104.0 (99.3-110.0), 92.5 (89.1-94.5), and 0.1114, respectively. For the unilateral coronal group, the measured parameters were 89.0 (87.7-91.2), 84.0 (81.2-87.1), and 0.059, respectively. Although all suture types showed improvement in cranial shape, with sagittal synostosis showing the most significant change, our findings did not support the added benefit of molding helmet therapy. Overall, the study suggests that suturectomy is a crucial first step in craniosynostosis treatment, leading to improvements in cranial morphology and growth.

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.