Jan-Falco Wilbrand

Objectification of cranial vault correction for craniosynostosis by three-dimensional photography.

PURPOSE Correction of craniosynostosis is necessary in predominant cases. Surgical planning usually requires a preoperative CT to estimate the bony and intracerebral structures. A postoperative CT scan would involve a significant dose of radiation, which carries an elevated risk of malignant tumor development in later life. This study was performed to demonstrate the quality of three-dimensional (3D) photogrammetry when objectifying perioperative changes in craniofacial surgery. PATIENTS AND METHODS Twenty-eight patients with different premature craniosynostoses were analyzed photogrammetrically before and after surgical correction. 3D changes in cranial distances, symmetry and volumes were evaluated. A statistical covariance analysis excluded changes in cranial shape caused by physiological head growth. RESULTS The Cephalic Index in Scaphocephaly changed from 75.1% to a median value of 77.4%. The anterior symmetry ratio for coronal synostoses improved from 0.943 to 0.949 (a value of 1.0 represents perfect symmetry). The posterior symmetry ratio improved from 0.733 to 0.808 postoperatively in one single lambdoidal synostosis. In trigonocephaly, the median anterior skull volume rose from 528 to 601 ml. CONCLUSIONS 3D photogrammetry has great potential to track and objectify the clinical course of surgical correction of craniosynostoses. Craniofacial changes become highly reproducible and demonstrate clinical utility based on this technology.

Three-dimensional photographic analysis of outcome after helmet treatment of a nonsynostotic cranial deformity.

Cranial asymmetries due to nonsynostotic deformation of the skull have been reported with increasing frequency during the last decade. Conservative approaches using helmets and physiotherapy have been shown to be effective in their treatment. Traditionally, documentation has been carried out using anthropometric caliper measurements. The present study evaluates the use of a new three-dimensional photographic system in the improved validation of changes in head deformities. This prospective analysis introduces a new technique for digital anthropometric measurement. The study series comprised 181 children with nonsynostotic head deformities. Three-dimensional photographs were obtained before and after treatment with an orthotic helmet device. The oblique head diagonals and head width and length were measured from three-dimensional photographs using 3dMD customer software. The cranial vault asymmetry index, cranial vault asymmetry, and cranial index were compared before and after treatment. The measurements obtained on three-dimensional images were able to demonstrate significant improvement in early infant cranial deformity after treatment with an orthotic helmet. The cranial vault asymmetry index in plagiocephaly was reduced by 7.16%, and cranial vault asymmetry was reduced by 0.86 cm. The cranial index in brachycephaly decreased by 7.32%. In children with combined plagiocephaly and brachycephaly, the cranial vault asymmetry index improved by 5.77%, cranial vault asymmetry improved by 0.71 cm, whereas the cranial index changed by 5.48%. Three-dimensional photogrammetry can support treatment control in patients with deformational plagiocephaly. This new technology offers several advantages such as easy acquisition of images, detection of landmarks without patient movement, repeatable measurements without patient discomfort, and the opportunity for unbiased evaluation. Abbreviations: CVAI, cranial vault asymmetry index; CVA, cranial vault asymmetry; CI, cranial index

Complications in helmet therapy.

OBJECTIVE Helmet therapy is an established method to correct positional head deformity in early infancy. Side effects such as skin erythema or pressure sores are well known for helmet therapy, but not yet adequately discussed in current literature. PATIENTS AND METHODS Retrospectively, all patient-sheets of infants treated by individual orthotic therapy in the years 2007 and 2008 were sighted and complications were noted. Complications were classified and sorted by their frequency and descriptive statistics was performed. The treatment to cure complications was recorded and success in complication control was analysed. RESULTS Altogether, 410 patients fit the inclusion criteria for this investigation. Complications were apportioned into pressure sores, local ethanol erythema, unsatisfying fit of the helmet or loss of the helmet, skin infection, failed correction of head deformity, and subcutaneous abscess in one case. Non-compliance is to be noticed in a high number, but mainly occurred towards the end of the treatment period. CONCLUSION Helmet therapy represents a safe therapeutic tool for the correction of positional cranial deformity. Complications have to be clear in number and severity for parental elucidation. Most complications can easily be avoided or eliminated by proper instruction of the parents.

Accuracy of photographic assessment compared with standard anthropometric measurements in nonsynostotic cranial deformities.

Objective Anthropometric landmarks of the skull have traditionally been used to describe cranial deformities resulting from nonsynostotic plagiocephaly or brachycephaly. Recently, digital photography has become an important tool for characterizing facial and cranial pathologies. The purpose of this study was to compare standard anthropometric cranial measurements with measurements taken from cranial photographs. Patients Standardized digital images in the supracranial view and cranial anthropometric measurements were obtained from 122 children between the ages of 3 and 15 months. The photographs were assessed using Quick Ceph® software. The cephalic index and cranial vault asymmetry index were used to indicate the degree of cranial deformity. Children were classified into plagiocephaly, brachycephaly, and the combination of both. To determine interobserver variability, two clinicians separately measured the cephalic index and cranial vault asymmetry index from digital photographs in 70 infants of the plagiocephalic group. Results To compare interassay reliability for these methods of obtaining the cephalic index and cranial vault asymmetry index, the differences between photographically and anthropometrically derived values were plotted against anthropometrically derived values alone (Bland-Altman plots). The photographic method satisfied the limits of agreement (cephalic index, 7.51%; cranial vault asymmetry index, 6.57%) and showed slightly lower values represented by the respective bias (cephalic index, 1.79%; cranial vault asymmetry index, 3.03%). Comparison between observers revealed excellent agreement, detected by the intraclass correlation coefficient of .982 for the cephalic index and .946 for the cranial vault asymmetry index. Conclusion Our results demonstrate that digital photography is a reliable tool for quantifying cranial deformities. Furthermore, it is rapid, noninvasive, and reproducible. However, we continue to use both methods in clinical practice.

A prospective randomized trial on preventative methods for positional head deformity: physiotherapy versus a positioning pillow.

OBJECTIVE To evaluate the impact of stretching exercises versus available bedding pillows on positional head deformities. STUDY DESIGN Fifty children aged 5 months or younger with positional head deformity were included in this prospective clinical trial (n=20 plagiocephaly, n=10 brachycephaly, n=20 combination). A random distribution was performed for treatment with the bedding pillow alone (n=25) or with stretching exercises (n=25) for 6 weeks. Anthropometric caliper measurements were done before and after that interval. Cranial vault asymmetry index (CVAI) and cranial index (CI) were calculated and analyzed using a descriptive statistical general linear model. RESULTS ΔCVAI in the stretching group was 2.09% for plagiocephaly and 2.34% for combined head deformities. Using the bedding pillow, ΔCVAI was 3.01% in plagiocephal children and 2.86% for combined head deformity. The ΔCI in the stretching group was 0.94% for isolated brachycephal children and 2.24% for combined head deformity. ΔCI in the pillow group was 3.63% for brachycephaly and 3.23% in children with combined head deformities, respectively. CONCLUSIONS Bedding pillows and stretching exercises both resulted in improvements in positional cranial deformation. For children with combined plagiocephaly and brachycephaly, improvement in cranial asymmetry was slightly greater when using bedding pillows versus stretching.

Treated Versus Untreated Positional Head Deformity.

Background:Positional head deformity in early childhood is asserted to be a benign and in some cases spontaneously correcting entity encountered in craniofacial surgery. Although many authors have stated that helmet therapy is indicated in moderate and severe cases of deformational plagiocephaly and brachycephaly; others have reported resolution of these conditions within the first 2 to 3 years of life. A recent randomized controlled trial found that helmet therapy does not have beneficial effects for patients with positional head deformity. Methods:The authors evaluated the clinical course of positional cranial deformation during a period of 5 years and compared the anthropometric parameters of orthotically treated versus untreated children within this timeframe. Results:Although the patients were matched with respect to their cranial deformation at baseline, there were significant differences in the cranial vault asymmetry (CVA), cranial vault asymmetry index (CVAI), and oblique cranial length ratio (OCLR) between Groups 1 and 2 at the initial point (P < 0.05). The mean CVA was 0.95 cm in Group 1 (no helmet) and 1.74 cm in Group 2 (helmet). The mean CVAI at baseline was 7.25 for Group 1 and 13.77 for Group 2. Approximately 5 years after the first examination, the authors found clear improvement in the mean CVA in Group 2 (&Dgr;CVA 1.35 cm) compared with Group 1 (&Dgr;CVA 0.01 cm) and the mean CVAI. Conclusions:In contrast to recently published studies, the authors found clear improvement in nonsynostotic head deformity treated with an individual molding helmet and no clear evidence of improvement of absolute measurements in untreated cranial deformity within a 5-year follow-up period.

Estimation of legal age using calcification stages of third molars in living individuals

The increased number of adolescents and young adults with unknown or inaccurately given date of birth is a current issue in justice and legal medicine. The objective of this study was to determine the extent to which third molar calcification stages assessed on panoramic X-rays could be useful as additional criteria for forensic age estimation in living individuals, focusing on the legally important ages 17 and 18. In a retrospective multi-center study, the developmental stage of each individuals third molar was analyzed using Demirjians scale in 2360 cases. Additionally, sex, age and ancestry were assessed. Individuals with the lowest calcification stage of all present molars in stage H were ≥18 years with a likelihood of ≥99.05% in the female (n=388), and ≥99.24% in the male (n=482) population. The lowest calcification stage of all present third molars proved to be useful as an additional reliable criterion for the determination of an age ≥18 years.

Lethal cervical abscess following bisphosphonate related osteonecrosis of the jaw

CONTEXT Bisphosphonates are common drugs used in the management of bone metabolic diseases. Because of their recently increased use, their adverse effects, especially bisphosphonate-related osteonecrosis of the jaw (BRONJ), are monitored more frequently. BRONJ is a critical challenge in craniofacial surgery and is difficult to treat. Its occurrence is either spontaneous or follows dentoalveolar surgery. Typical complications of BRONJ are painful exposed bone, pathological fractures, extra-oral fistula, and local infections. OBJECTIVE The aim of this paper is to report a rare case of bacterial embolism in the internal jugular vein after a BRONJ-induced submandibular abscess resulting in bacterial sepsis, multi-organ failure syndrome, and death. CASE ILLUSTRATION A 59-year-old female patient developed severe BRONJ (stage II) with recurrent abscesses after oral osteoporosis therapy with alendronic acid. A subsequent submandibular abscess led to bacterial embolism of the left internal jugular vein, causing sepsis and death. DISCUSSION Prevention, early detection and management of BRONJ remain a crucial challenge in craniofacial clinical practice. Despite several therapeutic approaches described in the current literature, none have undergone bedside application. CONCLUSION Considering this report of death after recurrent abscesses following BRONJ, the use of bisphosphonates should be carefully monitored in order to prevent such severe complications.

Comparison of miniplate versus lag-screw osteosynthesis for fractures of the mandibular angle

OBJECTIVES Treating mandibular angle fractures is common in maxillofacial surgery. The aim of this study was to compare lag screw fixation and miniplates. STUDY DESIGN This retrospective investigation compared patients treated with miniplates (n = 24) and with lag screws (n = 21). Inclusion criteria were a solitary angle fracture without comminution or other reasons for load-bearing osteosynthesis. The main parameters for the outcome analysis were fracture gaps at 4 defined measuring points on postoperative radiography. Postsurgical complications were recorded. RESULTS Fracture gaps measured in panoramic radiographs differed significantly between the lag-screw (average 0.56 mm) group and the group using 1 miniplate (average 0.85 mm) and 2 miniplates (1.40 mm). Miniplate fixation resulted in a wider fracture gap, especially in the region of the lower margin of the mandible. CONCLUSION Lag-screw fixation demonstrated smaller fracture gaps compared with miniplate fixation.

Nonsynostotic cranial deformity: a six-month matched-pair photogrammetric comparison of treated and untreated infants.

Objective To photogrammetrically objectify changes in nonsynostotic craniofacial deformity in orthotically treated versus untreated infants. Design A statistical retrospective pairwise comparison of two respective three-dimensional (3D) photo scans of 80 children performed in a 6-month time lag. Patients Two comparable samples of children (40 treated, 40 untreated) with nonsynostotic cranial deformity. Interventions Respective 3D photo scans were matched using Cranioform Analytics 4.0 software. Main Outcome Measures Median change of 30° Cranial Vault Asymmetry Index (CVAI), modified CVAI (CVAImod), Cranial Index (CI), and posterior symmetry ratio (PSR). Results We found an improvement in Δ30° CVAI by 3.3% (treated) and by 1.31% (untreated), respectively. CVAImod improved by 3.46% in the treated group and by 1.55% in the untreated group. CI improved by 4.41% in the treated group and by 3.68% in the untreated group, and PSR improved by 0.71 in the treated group and 0.49 in the untreated group. Although improvement of cranial asymmetry was higher in those children treated with an individual molding orthosis, we could not document a statistically significant difference between the two groups. Conclusions Helmet therapy may be less appropriate for the correction of brachycephaly than for cranial asymmetry. Nonsynostotic cranial deformity shows some spontaneous correction. Photogrammetry presents an accurate method to objectify craniofacial changes in early infancy.