Facial asymmetry correction with moulded helmet therapy in infants with deformational skull base plagiocephaly

Discrepancies Between Objective and Subjective Outcomes of and Quality of Life During Molding Helmet Therapy for Cranial Deformities

Positional skull deformities have been on the rise for decades and can be treated with molding helmets in early childhood. Parents often fear later cosmetic stigmatization, but also a reduced quality of life (QoL) during treatment. The aim of this study was to examine therapy results in our patient collection from a new perspective. Cranial vault asymmetry (CVA), cranial vault asymmetry index (CVAI), and cranial index (CI) were compared before and after molding helmet therapy. Correction was defined by a decrease in CVA <3.5 mm and CI <90%. Subjective therapy outcome, side effects and QoL from the parents' perspective were determined using a questionnaire. There were 25 patients included. Differences between pretherapeutic and posttherapeutic CVA, CVAI, and CI were significant (P<0.01). An objective correction according to the defined values was observed in only 12% of cases. However, 76% of parents stated that their child's skull shape was normal after therapy. There were 60 side effects reported in 23 cases. The QoL of 21 children was assessed as unimpaired during helmet therapy. Even though complete normalization was rarely observed, the parameters were significantly different after therapy, and subjective reduction in skull deformity was common.

Stereophotogrammetric head shape assessment in neonates is feasible and can identify distinct differences between term-born and very preterm infants at term equivalent age

The development of head shape and volume may reflect neurodevelopmental outcome and therefore is of paramount importance in neonatal care. Here, we compare head morphology in 25 very preterm infants with a birth weight of below 1500 g and / or a gestational age (GA) before 32 completed weeks to 25 term infants with a GA of 37–42 weeks at term equivalent age (TEA) and identify possible risk factors for non-synostotic head shape deformities. For three-dimensional head assessments, a portable stereophotogrammetric device was used. The most common and distinct head shape deformity in preterm infants was dolichocephaly. Severity of dolichocephaly correlated with GA and body weight at TEA but not with other factors such as neonatal morbidity, sex or total duration of respiratory support. Head circumference (HC) and cranial volume (CV) were not significantly different between the preterm and term infant group. Digitally measured HC and the CV significantly correlated even in infants with head shape deformities. Our study shows that stereophotogrammetric head assessment is feasible in all preterm and term infants and provides valuable information on volumetry and comprehensive head shape characteristics. In a small sample of preterm infants, body weight at TEA was identified as a specific risk factor for the development of dolichocephaly.

Assessing the quality of life in infants with deformational plagiocephaly

This was a parent-reported outcome study on the impact of helmet therapy on the quality of life of infants with deformational plagiocephaly and their caregivers. Using survey-based analysis, we compared the quality of life in infants with deformational plagiocephaly with a cohort of their healthy peers. In addition, we compared infant quality of life before and after helmet therapy to evaluate the impact of this mainstay therapy for deformational plagiocephaly. Our results demonstrated that infants with plagiocephaly and their caregivers had a significantly decreased quality of life compared with healthy controls. This reframes our understanding of deformational plagiocephaly and emphasizes the need for therapeutic intervention in these individuals. A common therapeutic option - helmet remolding therapy - was shown to have no negative impact on quality of life, underscoring this as an appropriate therapeutic option. These data will allow us to counsel our future parents more effectively regarding the impact of deformational plagiocephaly and helmet therapy.

Significant Factors in Cranial Remolding Orthotic Treatment of Asymmetrical Brachycephaly

This retrospective chart review focuses on determining the most effective time to begin cranial remolding orthosis (CRO) treatment for infants with asymmetrical brachycephaly. Subjects with asymmetrical brachycephaly started CRO treatment between 3 and 18 months of age. These infants had a cranial vault asymmetry index (CVAI) ≥ 3.5 and a cranial index (CI) ≥ 90. Subjects were excluded if they had any comorbidities affecting growth, dropped out of treatment, were lost to follow-up, or were noncompliant. Factors which were found to statistically influence treatment outcomes were subject initial age, initial CVAI, and initial CI. Overall, younger subjects were more likely to achieve a corrected head shape. The presence of prematurity or torticollis had statistically nonsignificant effects on the success of treatment. Initial CI was found to be a stronger predictor than initial CVAI as to which subjects achieved correction. The less severe the starting CI, the more likely the subject was to achieve full correction. The clinical understanding is that it requires more cranial growth to "round out" a full posterior skull flattening than an asymmetry. Based on the study results, infants with asymmetrical brachycephaly should be treated as early as possible to increase chances of achieving full correction of the deformity.

Craniofacial Asymmetry from One to Three Years of Age: A Prospective Cohort Study with 3D Imaging

Deformational plagiocephaly (DP) is considered a risk factor for facial asymmetry. This cohort-based, prospective, follow-up study used three-dimensional (3D) stereophotogrammetry to assess the development of facial asymmetry in a normal birth cohort and to investigate the impact of DP on facial asymmetry for the age range of one to three years. The study sample consisted of 75 children: 35 girls (47%) and 40 (53%) boys recruited from Oulu University Hospital. A total of 23 (31%) subjects had a history of DP in infancy. 3D facial images were obtained at the mean (SD) age of 1.01 (0.04) year old at T1 and 3.02 (0.14) years old at T2. To determine facial asymmetry, both landmark-based and surface-based facial symmetry methods were used. As measured with the surface-based methods, upper facial symmetry improved from T1 to T2 (p < 0.05). As measured with the landmark-based methods, facial symmetry improved on the upper and lower jaw from T1 to T2 (p < 0.05). The asymmetric effect of DP on the upper parts of the face tends to correct spontaneously during growth. Results indicate that previous DP does not seem to transfer to facial or occlusal asymmetry at the age of three years old.

The Effects of Helmet Therapy Relative to the Size of the Anterior Fontanelle in Nonsynostotic Plagiocephaly: A Retrospective Study

Helmet therapy is an important nonsurgical approach for patients with nonsynostotic plagiocephaly, but its effectiveness may depend on certain anatomical features. We retrospectively examined the effects of helmet therapy according to the size of the anterior fontanelle. Two hundred patients with nonsynostotic plagiocephaly who underwent helmet therapy between 2016 and 2018 were included. Data regarding age at treatment onset and treatment duration were collected. Patients were divided into two groups depending on the age at treatment initiation: the 12-23 weeks group and the >23 weeks group. Patients were also divided based on the anterior fontanelle size to analyze the effects of helmet therapy according to the severity of plagiocephaly in each group as the change in the cranial vault asymmetry index (CVAI). Therapeutic effects were evaluated using the cranial vault asymmetry (CVA), CVAI, anterior symmetry ratio, posterior symmetry ratio (PSR), and overall symmetry ratio at baseline and treatment completion. Treatment initiation at age 12-23 weeks resulted in better effects than that after age 24 weeks. There were no sex-dependent differences in therapeutic effects. Greater changes in the CVA, CVAI, and PSR were associated with larger anterior fontanelles. Therefore, the anterior fontanelle size could be a prognostic factor for estimating helmet therapy outcomes.

Separation of Craniopagus Twins by a Multidisciplinary Team

Conjoined twins who are classified as craniopagus (joined at the cranium) have a rare congenital anomaly. Despite advances in surgical techniques and critical care, the rate of complications and death is still high among twins with total fusion in which the superior sagittal sinus is shared. Here, we describe total-fusion craniopagus twins who at 10 months of age underwent successful surgical separation performed by a multidisciplinary team. Computer-aided design and modeling with a three-dimensional printer, custom-designed cranial distraction and constriction devices, and intraoperative navigation techniques were used. These techniques allowed for separation of the twins at an early age and harnessed the regenerative capacity of their young brains.

Helmet Treatment of Infants With Deformational Brachycephaly

Deformation of the cranium in infancy represents a spectrum of deformity, ranging from severe asymmetric yet proportional distortion of the skull in plagiocephaly, to nearly symmetric yet disproportional distortion in brachycephaly. As such, the condition is best described as deformational plagiocephaly-brachycephaly with isolated plagiocephaly and/or isolated brachycephaly being at either ends of the spectrum. Due to its symmetric appearance, deformational brachycephaly is often incorrectly dismissed as being less concerning, and it has sometimes erroneously been reported that brachycephaly cannot be treated successfully with a cranial orthosis. We prospectively report on 4205 infants with isolated deformational brachycephaly treated with a cranial orthosis from 2013 to 2017. These results demonstrate that the orthosis is successful in the treatment of deformational brachycephaly with an 81.4% improvement toward normal (95.0 to 89.4) in cephalic index. We furthermore demonstrate that entrance age influences treatment results, with younger infants demonstrating both improved outcomes and shorter treatment times.