Research
Research validating the sphenoid bone as the keystone for craniofacial asymmetry and distortion and corresponding pain.

Am J Orthod Dentofacial Orthop. 2003 Dec;124(6):656-62.
Asymmetry of the sphenoid bone and its suitability as a reference for analyzing craniofacial asymmetry.
Kim YH, Sato K, Mitani H, Shimizu Y, Kikuchi M.

Division of Orthodontics, Department of Lifelong Oral Health Science, Graduate School of Dentistry, Tohoku University, 4-1 Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan. kim8376@wonju.yonsei.ac.kr

The purposes of this study were to evaluate the asymmetry of the sphenoid bone and to determine its suitability as a reference for analyzing asymmetry of the skull. Thirty-seven dry skulls from India were divided into group A (n = 18), with a right-left length discrepancy of less than 2 mm for both the external acoustic meatus-frontozygomatic suture and external acoustic meatus-subspinale, and group B (n = 19), with a right-left length discrepancy of more than 2 mm for either of these 2 parameters. The skulls were then examined with regard to the percentage of asymmetry of the sphenoid bone, the angles between the cranial base and the facial axis, and the distance between reference surfaces of the sphenoid bone and facial landmarks by 3-dimensional measurement system. The following results were obtained: 1. Asymmetry of the sphenoid bone, while slight, was found in both groups. There were no significant differences between the 2 groups. 2. The cranial base and the facial axis did not form a right angle in group A, and there were no significant differences between the 2 groups. 3. The distances between reference surfaces of the sphenoid bone and the lower landmarks of the facial bone were greater than those of the upper landmarks. 4. The external acoustic meatus was the most suitable reference for analysis of craniofacial asymmetry.

Odontostomatol Proodos. 1990 Apr;44(2):101-6
Morphology of the sphenoid bone in individuals with syndromes which affect the craniofacial complex

Papagrigorakis MJ, Spyropoulos ND.
Department of Orthodontics, University of Athens, Greece.

Anatomically, the sphenoid bone can be characterized as the center of the skull. It represents the crossroads where various factors which contribute--each in its own way--to the craniofacial complex, are combined. The morphology of the sphenoid bone is changeable and the opinion that it serves the functional needs for the viability of the individual was formulated in the literature. The findings from the study of 20 patients exhibiting various syndromes that affect the craniofacial complex lead to the conclusion that there is an admirable adaptability and mutual support of the elements which contribute to the formation of the craniofacial complex, the sphenoid bone being one of them, with significant potential and effect on adjacent structures.

Angle Orthod. 2003 Aug;73(4):381-5.
Craniofacial asymmetry in development: an anatomical study.
Rossi M, Ribeiro E, Smith R.

Department of Anatomy, Bahiana School of Dentistry, Bahia, Brazil.

The purpose of this study was to evaluate the occurrence of craniofacial asymmetries in four areas of human skulls of various age groups to test the hypothesis that there is craniofacial symmetry before the chewing habit is established. The data were obtained from 95 skulls of fetuses, infants, children, and adults, from the collection of Federal University of São Paulo. The following measurements were taken on each skull with a digital caliper: from the infraorbital foramen to the anterior nasal spine (IOF); from the greater palatine foramen to the posterior nasal spine (GPF); from the spinous foramen to the basion (SF); and from the spinous foramen to the zygomatic arch (ZA). On different occasions, each measurement was taken three times on both sides of the skull in random order. The mean of the right-side measurements were subtracted from the mean of the left-side measurements, and the differences were transformed into percentages. Comparisons were made by analysis of variance. The presence of cranial asymmetry was statistically significant throughout the whole sample. The minimum value found was 2.8% and the maximum 6.5%. All age groups presented the same degree of asymmetry of distances IOF, GPF, and SF. The group of infants presented a higher degree of asymmetry on distance ZA, followed by the groups of fetuses, children, and adults. This study confirmed statistically significant craniofacial asymmetry in fetuses and infants (before dentition). Therefore, the hypothesis that craniofacial asymmetry only appears after establishment of the chewing habit was not supported.

Bosn J Basic Med Sci. 2004 Jul;4(3):40-6.
Study on skull asymmetry.
Sarac-Hadzihaliloviç A, Dilberoviç F.

Department of Anatomy, School of Medicine, University of Sarajevo, Bosnia and Herzegovina.

The aim of this study is to determine the type of skull as well as to examine its internal appearance and configuration of skull base. Special attention is given to the direction and position of the pyramid of the temporal bone, the volume and appearance of all the three cranial fossas, and the direction and appearance of crista alaris--all of those compared to the skull type. Considering the obtained results (specially for crista alaris and middle fossa) we can ascertain outstanding independence of sphenoid bone and its parts in the formation of cranial base. Located in the middle of the skull, in front of strong pyramids transversal axis and two vertical axis, frontal crest and internal occipital crest, it by itself with her lesser wing presents an important transversal axis of cranial base. Cases in which crista alaris with its position does not follow the type of skull (in 20 % cases crista alaris does not follow skull protuberances), may probably be explained by strong and independent development of this bone, which is placed among other bones of cranial base like a peg. It also, by itself dictates form and configuration of the middle part of skull. That is also confirmed by middle fossa which, according to its position in the middle of cranial base and relation with sphenoid bone, shows significant deviation with respect to posterior fossa (follows the type of skull in 47 % cases).


J Manipulative Physiol Ther. 2006 Sep;29(7):561-5.
Reversible pelvic asymmetry: an overlooked syndrome manifesting as scoliosis, apparent leg-length difference, and neurologic symptoms.
Timgren J, Soinila S.

Unit of Physiatry, Helsinki University Central Hospital, Helsinki, Finland.

OBJECTIVE: The objective of this study was to investigate the occurrence of pelvic asymmetry in neurologic patients with symptoms not explained by their neurologic diagnosis. METHODS: We analyzed 150 consecutive neurologic patients referred to physiatric consultation based on their clinical examination findings. RESULTS: We observed pelvic asymmetry associated with either C-type or S-type scoliosis and apparent leg-length difference in 87% of the patients. Symmetry could be reestablished by all patients, although 15% showed immediate or imminent relapse. Maintenance of symmetry showed a highly significant (P < .001) correlation with improvement in functional ability and reduction of pain as evaluated during the last visit to the physiatrist. In the follow-up questionnaire, 78% of the patients reported improvement in functional ability and reduced pain. CONCLUSIONS: Our results support the view that leg-length difference and scoliosis may be more often of reversible nature than previously considered. Acquired postural asymmetry of the sacroiliac joint may be a neglected cause of several neurologic and other pain-related symptoms that can be relieved by a simple and safe treatment.

You can move the skull and the cranial bones do move:

Cranio. 2002 Jan;20(1):34-8.
Radiographic evidence of cranial bone mobility.
Oleski SL, Smith GH, Crow WT.

Philadelphia College of Osteopathic Manipulative Medicine, PA 19131, USA.

The purpose of this retrospective chart review was to determine if external manipulation of the cranium alters selected parameters of the cranial vault and base that can be visualized and measured on x-ray. Twelve adult patient charts were randomly selected to include patients who had received cranial vault manipulation treatment with a pre- and post-treatment x-ray taken with the head in a fixed positioning device. The degree of change in angle between various specified cranial landmarks as visualized on x-ray was measured. The mean angle of change measured at the atlas was 2.58 degrees, at the mastoid was 1.66 degrees, at the malar line was 1.25 degrees, at the sphenoid was 2.42 degrees, and at the temporal line was 1.75 degrees. 91.6% of patients exhibited differences in measurement at 3 or more sites. This study concludes that cranial bone mobility can be documented and measured on x-ray.


J Dent Res. 2007 Jan;86(1):12-24.
Remodeling the dentofacial skeleton: the biological basis of orthodontics and dentofacial orthopedics.
Meikle MC.

Department of Oral Sciences, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin, New Zealand. murray.meikle@dent.otago.ac.nz

Orthodontic tooth movement is dependent upon the remodeling of the periodontal ligament and alveolar bone by mechanical means. Facial sutures are also fibrous articulations, and by remodeling these joints, one can alter the positional relationships of the bones of the facial skeleton. As might be expected from the structure and mobility of the temporomandibular joint (TMJ), this articulation is more resistant to mechanical deformation, and whether functional mandibular displacement can alter the growth of the condyle remains controversial. Clinical investigations of the effects of the Andresen activator and its variants on dentofacial growth suggest that the changes are essentially dento-alveolar. However, with the popularity of active functional appliances, such as the Herbst and twin-block based on 'jumping the bite', attention has focused on how they achieve dentofacial change. Animal experimentation enables informed decisions to be made regarding the effects of orthodontic treatment on the facial skeleton at the tissue, cellular, and molecular levels. Both rat and monkey models have been widely used, and the following conclusions can be drawn from such experimentation: (1) Facial sutures readily respond to changes in their mechanical environment; (2) anterior mandibular displacement in rat models does not increase the mitotic activity of cells within the condyle to be of clinical significance, and (3) mandibular displacement in non-human primates initiates remodeling activity within the TMJ and can alter condylar growth direction. This last conclusion may have clinical utility, particularly in an actively growing child.

Short, compressed faces are suboptimal and do not allow for full movement of the jaw, which can cause pain and dysfunction down the road:

J Clin Pediatr Dent. 2000 Fall;25(1):23-8.
Cephalometric studies of children with long and short faces.
Tsai HH.

Department of Pedodontics, School of Dentistry, China Medical College, 91 Hsueh Shih Road, Taichung 404, Taiwan. asipopo@tcts.seed.net.tw

The purpose of this study was to investigate the facial morphologic characteristics in children with long and short faces. Lateral cephalometric radiographs of 46 children with long faces and 42 children with short faces were used. Both boys and girls with long faces exhibited upright incisors, excessive upper dentoalveolar development, shorter posterior face height, shorter ramus height and mandibular body, greater gonial angle and backward rotation of mandible when compared with those with short faces.

Distortions and dysfunctions in the TMJ and TMD have consequences for facial asymmetry and pain.

J Orofac Pain. 2004 Spring;18(2):108-13.
Joint tenderness, jaw opening, chewing velocity, and bite force in patients with temporomandibular joint pain and matched healthy control subjects.
Hansdottir R, Bakke M.

Department of Oral Medicine, Clinical Oral Physiology, Oral Pathology and Anatomy, Section of Clinical Oral Physiology, School of Dentistry, Faculty of Health Sciences, University of Copenhagen, Denmark.

AIMS: To evaluate the effect of temporomandibular arthralgia on mandibular mobility, chewing, and bite force. METHODS: Twenty female patients (ages 19 to 45 years) with unilateral temporomandibular joint (TMJ) pain during chewing (49 +/- 27 mm on a 100-mm visual analog scale) and provocation, as well as TMJ tenderness, were studied. The TMJ conditions were classified as disc derangement disorders (n = 9), osteoarthritis (n = 7), and inflammatory disorders (n = 4). The patients were compared with matched healthy volunteers without orofacial pain or tenderness. Exclusion criteria were the presence of fewer than 24 teeth or malocclusion. The methods used were (1) algometric assessment of the pressure pain threshold (PPT) over the TMJ; (2) clinical recordings of maximum jaw opening; (3) computerized kinematic assessment of maximum vertical distance, velocity, and cycle duration during chewing of soft gum; and (4) measurement of unilateral molar bite force. RESULTS: The mean (+/- SD) PPT in the patients' painful side (69 +/- 20 kPa; P = .000001) was significantly lower than in the control subjects (107 +/- 22 kPa). Jaw opening was also significantly less (P = .00003) in the patients (42 +/- 9 mm) than in the controls (52 +/- 4 mm). Chewing cycle duration and maximum closing velocity were significantly different (P < or = .03) in the patients (948 +/- 185 milliseconds and 142 +/- 46 mm/s, respectively) versus the controls (765 +/- 102 milliseconds and 173 +/- 43 mm/s, respectively), and bite force was significantly lower (P = .000003) in the patients (238 +/- 99 N) than in the controls (394 +/- 80 N). Both bite force and jaw opening in patients were significantly correlated (P < or = .02) with PPT (r = 0.53 and 0.63, respectively). CONCLUSION: These systematic findings supplement results from acute pain experiments and confirm indications from unspecified patient groups that the clinical presence of long-standing TMJ pain is associated with marked functional impairment. This impairment might be a result of reflex adaptation and long-term hypoactivity of the jaw muscles.


Eur J Orthod. 1998 Dec;20(6):701-12.
Adolescent female craniofacial morphology associated with advanced bilateral TMJ disc displacement.
Nebbe B, Major PW, Prasad NG.

TMD Investigation Unit, Faculty of Dentistry, University of Alberta, Edmonton, Canada.

The aim of this study was to determine if cephalometric measurement differences occurred between two groups of similarly aged female adolescents which differed with respect to their diagnoses of temporomandibular joint disc position on magnetic resonance images (MRI). One group consisted of 17 female adolescents exhibiting complete bilateral disc displacement affecting the temporomandibular joints (TMJ), while the second group of 17 female adolescents was diagnosed as having bilateral normal disc position on MRI. Independent sample t-tests identified statistically significant differences in cephalometric measurements between the two groups, but no age difference between the two groups was evident. The group with bilateral total disc displacement exhibited the following significant angular differences from the group with normal disc position: an increased mandibular and palatal plane relative to sella-nasion; posterior rotation of the mandible as illustrated by an increased angle between the posterior border of the mandibular ramus and sella-nasion; and a decrease in Rickett's facial axis. Significant differences in linear cephalometric variables were also evident between the two groups. Total posterior facial height and ramus height were reduced in the totally disc displaced group. Furthermore, a slight increase in the middle anterior facial height was noted, with a decrease in the posterior cranial base vertical height in the totally disc displaced group.

Am J Orthod Dentofacial Orthop. 2005 Jul;128(1):87-95.
Relationship between internal derangement of the temporomandibular joint and dentofacial morphology in women with anterior open bite.
Byun ES, Ahn SJ, Kim TW.

Department of Orthodontics, College of Dentistry, Seoul National University, Korea.

INTRODUCTION: Anterior open bite is known to be associated with internal derangement of the temporomandibular joint (TMJ). This study examined the relationships between internal derangement and dentofacial morphology in women with anterior open bite. METHODS: Fifty-one women with anterior open bite were enrolled in this study. The sample was divided into 3 groups based on magnetic resonance imaging of bilateral TMJs: normal disk position, disk displacement with reduction, and disk displacement without reduction. One-way analysis of variance was used to compare the 3 groups with respect to the cephalometric variables, and Duncan's multiple comparisons were performed at the 95% confidence level to identify the differences among the 3 groups. RESULTS: Internal derangement of the TMJ was much more prevalent in subjects with a more posteriorly rotated mandibular ramus, a smaller mandible, and a greater tendency for a skeletal Class II pattern, although all subjects had an anterior open bite. These patterns were more severe as the internal derangement progressed to disk displacement without reduction. CONCLUSIONS: Some cephalometric characteristics, such as a decrease in posterior facial height, decrease in ramus height, and backward rotation and retruded position of the mandible, are associated with TMJ internal derangement in women with anterior open bite.

J Oral Rehabil. 2002 May;29(5):417-22.
Relationship between functional disc position and mandibular displacement in adolescent females: posteroanterior cephalograms and magnetic resonance imaging retrospective study.
Nakagawa S, Sakabe J, Nakajima I, Akasaka M.

Department of Pediatric Dentistry, Nihon University School of Dentistry, Tokyo, Japan. shojikum@m08.alpha-net.ne.jp

The purpose of this study was to investigate the relationship between the disc positions of temporomandibular joints (TMJ), the vertical and lateral mandibular displacement (VMD and LMD, respectively) and age in female adolescents with signs and symptoms of the temporomandibular disorders (TMD). The VMD and LMD were assessed, using posteroanterior (PA) cephalograms. The disc positions were assessed by magnetic resonance imaging (MRI) and categorized as follows: normal disc position, functional disc displacement and functional disc dislocation. Excluding patients with osteoarthritis, the total number of subjects was 54 female adolescents who were grouped into three: the bilateral normal disc position group, the unilateral or bilateral functional disc displacement group, and the unilateral or bilateral functional disc dislocation group. We compared the extent of VMD and LMD between the three groups, and investigated their correlation with age. Results indicate that functional disc displacement and dislocation are related to mandibular displacement, and VMD did not correlate with age but LMD did correlate with age. This study suggests that the onset of disc displacement is related to the mandibular displacement and disturbs normal growth of the mandible three-dimensionally.


Angle Orthod. 2007 Mar;77(2):288-95.
Orthodontic effects on dentofacial morphology in women with bilateral TMJ disk displacement.
Ahn SJ, Lee SJ, Kim TW.

Department of Orthodontics, School of Dentistry and Dental Health Institute, Seoul National University, Korea.

OBJECTIVE: To determine the difference in skeletal response to orthodontic treatment between patients with bilateral disk derangement and normal disk position of the temporomandibular joint (TMJ). MATERIALS AND METHODS: Subjects consisted of 46 women whose malocclusions were treated only by orthodontics. All patients had TMJ magnetic resonance imaging (TMJ MRI) taken prior to orthodontic treatment. They were classified into three groups according to results of the TMJ MRI: bilateral normal disk position (BN), bilateral disk displacement with reduction (BDDR), and bilateral disk displacement without reduction (BDDNR). Twenty cephalometric variables were evaluated by the Kruskal-Wallis test to identify any differences in morphological changes between the three groups during orthodontic treatment. RESULTS: This study showed that patients with BDDNR had more severe sagittal and vertical skeletal discrepancies than those with BN and BDDR at the pretreatment stage with discrepancies maintained after treatment. Compared to patients with BN, BDDR patients exhibited significant changes in SNB, N perpendicular to pogonion, SN to mandibular plane angle, total anterior facial height, ramus inclination, and effective mandibular length during treatment. This means that patients with BDDR showed more backward movement and rotation of the mandible than those with BN. In contrast, patients with BDDNR who had the most severe skeletal discrepancies did not show any significant skeletal changes during orthodontic treatment compared to those with BN or BDDR. CONCLUSION: In patients with bilateral TMJ disk displacement, orthodontic treatment should be undertaken carefully to prevent backward rotation and movement of the mandible.

Am J Orthod Dentofacial Orthop. 2005 Nov;128(5):583-91.
Relationship between temporomandibular joint internal derangement and facial asymmetry in women.
Ahn SJ, Lee SP, Nahm DS.

Department of Orthodontics, Dental Research Institute, College of Dentistry, Seoul National University, Seoul, South Korea.

INTRODUCTION: Internal derangement (ID) of the temporomandibular joint (TMJ) can cause facial asymmetry. The purposes of this study were to analyze the relationship between facial asymmetry and TMJ ID by using posteroanterior cephalometric variables, and to compare the findings with the results of magnetic resonance imaging (MRI). METHODS: The sample consisted of women seeking orthodontic treatment at Seoul National University Dental Hospital who had routine posteroanterior cephalograms and bilateral MRIs of the TMJ. To eliminate the influence of condylar hyperplasia on facial asymmetry, only those with SNB angles less then 78 degrees were selected (n = 63). They were classified into 5 groups according to the results of the MRI: bilateral normal disk position, unilateral normal TMJ and contralateral disk displacement with reduction (DDR), bilateral DDR, unilateral DDR and contralateral disk displacement without reduction (DDNR), and bilateral DDNR. Fourteen variables from posteroanterior cephalograms were analyzed with 1-way ANOVA to evaluate differences among the 5 groups. RESULTS: Subjects with TMJ ID of greater severity on the unilateral side had shorter ramal height compared with those with bilateral normal or bilateral DDR or bilateral DDNR. In addition, the mandibular midpoint deviated toward the side where the TMJ ID was more advanced. CONCLUSIONS: Subjects with a more degenerated TMJ on the unilateral side might have facial asymmetry that does not come from condylar or hemi-mandibular hyperplasia.

Angle Orthod. 2000 Feb;70(1):81-8.
Craniofacial asymmetry and temporomandibular joint internal derangement in female adolescents: a posteroanterior cephalometric study.
Trpkova B, Major P, Nebbe B, Prasad N.

Department of Oral Health Sciences, University of Alberta, Edmonton, Canada. btrkova@gpu.srv.ualberta.ca

Unilateral or bilateral pathology of the osseous components of the temporomandibular joint (TMJ) can result in pronounced facial asymmetry because of dissimilar size and shape of the right and left sides of the mandible. To date, it is unknown whether abnormalities of the soft tissues of the TMJ are associated with greater than normal craniofacial asymmetry. In this study, we investigated the amount of craniofacial asymmetry in female orthodontic patients with unilateral or bilateral TMJ internal derangement (TMJ ID) relative to the amount in female patients without TMJ ID. The total sample consisted of 80 female adolescents. Bilateral TMJ magnetic resonance images were used as a database for objectively scoring the severity of TMJ ID. Craniofacial asymmetry was measured from posteroanterior cephalograms. Females with bilateral TMJ ID had significantly greater asymmetry in the vertical position of the antegonion. If the TMJ ID was more advanced on the right side, the ipsilateral ramus was shorter, resulting in significant asymmetry in this region. In all other craniofacial regions, the amount of asymmetry was not significant between females with normal TMJs and those with TMJ ID. The results indicate that a female orthodontic patient with bilateral TMJ ID or unilateral right TMJ ID may present with or develop a vertical mandibular discrepancy.

The musculoskeletal system has direct impact on the shape of the head and the face:

Plast Reconstr Surg. 2004 Jan;113(1):24-33.
Craniofacial deformity in patients with uncorrected congenital muscular torticollis: an assessment from three-dimensional computed tomography imaging.
Yu CC, Wong FH, Lo LJ, Chen YR.

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Institute of Public Health, National Yang Ming University, Taipei, Taiwan.

Congenital muscular torticollis is caused by idiopathic fibrosis of the sternocleidomastoid muscle that restricts movement and pulls the head toward the involved side. Deformation of the craniofacial skeleton will develop if the restriction is not released and result in aesthetic and functional problems. The purpose of this study was to use three-dimensional computed tomography imaging for qualitative and quantitative evaluation of the craniofacial deformity in a series of patients with uncorrected congenital muscular torticollis, and to assess age as a precipitating factor for severity of the deformity. A total of 14 patients from 1 month to 24 years of age were included. The skull images were rotated into standard orientation and reconfigured for evaluation of the cranium, endocranial base, and facial skeletal structures. The midlines of cranial base and facial bone, angle of midline deviation, width of each hemicranium and hemiface, and the orbital index were defined and measured. The results showed that the cranium and cranial base deformation took place as early as in infant stage, with the most prominent change occurring in the posterior cranial fossa. Facial bone asymmetry started to appear after 5 years of age, at which time the mandibular and occlusal abnormalities were observed. The deformity of the orbits and maxilla occurred at an older age, characterized by the deviation and decreased vertical height on the affected side. The severity of the observed deformities increased with age. The angle of midline deviation was 2.48 +/- 1.68 degrees in the cranial base and 3.26 +/- 3.28 degrees on the facial bone. Both of the midline deviations were significantly correlated with age. Compared with the contralateral side, the width of the ipsilateral posterior hemicranium was longer (54.36 +/- 6.72 mm versus 50.81 +/- 6.55 mm), and the width of the ipsilateral lower hemiface was shorter (35.30 +/- 7.27 mm versus 43.49 +/- 11.34 mm). Both differences were statistically significant. Measurement of the orbital index demonstrated a significantly flatter orbit on the ipsilateral side (89.48 +/- 0.11 versus 92.74 +/- 0.08). This study showed that the cranium and cranial base deformity occurred early in patients with uncorrected torticollis, while the facial bone deformity occurred in childhood stage. The cranial and facial deformity became more severe with age. Early release of the muscle restriction is advised to prevent craniofacial deformation.


Plagiocephaly is essentially a “misshapen head”. Here are several studies that used devices to move the cranial bones and correct the plagiocephaly and corresponding asymmetries associated with it. This provides theoretical proof that misshapen heads and facial asymmetry go hand in hand, and that there is more than one way to physically correct it.


J Oral Maxillofac Surg. 2005 Mar;63(3):419.

Anthropometric analysis of mandibular asymmetry in infants with deformational posterior plagiocephaly.
St John D, Mulliken JB, Kaban LB, Padwa BL.

Harvard School of Dental Medicine, Boston, MA, USA.

PURPOSE: The incidence of deformational posterior plagiocephaly has increased dramatically since 1992. We tested the hypothesis that mandibular asymmetry, associated with this condition, is secondary to anterior displacement of the ipsilateral temporomandibular joint. The response to molding helmet therapy was also evaluated. PATIENTS AND METHODS: A caliper was used to measure mandibular dimensions in 27 infants (16 boys and 11 girls) with deformational posterior plagiocephaly; the mean age was 6.2 months (range, 3 to 12 months). Anthropometric measures included ramal height (condylion-gonion), body length (gonion-gnathion), and condylion-gnathion. Gonial angle was calculated from the law of cosines: C(2) = A(2) + B(2) - 2AB cos c. The position of the temporomandibular joint was accepted as corresponding to auricular position and measured from tragion to subnasal. Cranial asymmetry was measured, in the horizontal plane, from orbitale superius to the contralateral parieto-occipital point at the level of inion. Ten of 27 patients were remeasured 5 months after beginning helmet therapy to evaluate change in mandibular dimensions. RESULTS: Two thirds of infants (67%) had right-sided and one third (33%) had left-sided deformational posterior plagiocephaly. The mean auricular anterior displacement was 79.7 mm on the affected side and 83.4 mm on the unaffected side. The mean difference of 3.8 mm between the sides was statistically significant (P <.001). Transverse cranial dimension averaged 136.0 mm on the affected side and 146.8 mm on the unaffected side; this was also significant (P <.001). There was a significant positive correlation between auricular displacement and cranial asymmetry [R(23) =.59, P <.01). Auricular (temporomandibular joint) displacement also resulted in an apparent mandibular asymmetry with rotation of the jaw to the affected side. Mean mandibular measurements on the affected and unaffected sides were ramus height of 35.2 and 36.4 mm, body length of 59.0 and 60.3 mm, and gonial angle of 127.1 degrees and 126.8 degrees, respectively. Comparison of the affected with the unaffected sides, using a paired-samples t test, was not statistically significant. Improvement in cranial asymmetry occurred with helmet therapy, but there was no correction of auricular and temporomandibular joint position. CONCLUSIONS: This study supports the clinical observation that the mandibular asymmetry in deformational posterior plagiocephaly is secondary to rotation of the cranial base and anterior displacement of the temporomandibular joint (quantified by anterior auricular position) and not the result of primary mandibular deformity.

J Craniofac Surg. 2004 Jul;15(4):643-50.
Objective outcome analysis of soft shell helmet therapy in the treatment of deformational plagiocephaly.
Bruner TW, David LR, Gage HD, Argenta LC.

Department of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas, USA.

Deformational plagiocephaly, cranial asymmetry secondary to positioning, continues to be a leading cause of head shape abnormalities in infants. Treatment recommendations include nonintervention, positioning therapies, and helmet therapy. Although most agree that surgical intervention is rarely indicated, the ideal therapy is not agreed on. Some even debate the necessity of treatment, especially third-party payers. The purpose of this prospective study is to use an objective outcome analysis tool, computerized tomography, to assess the efficacy of a soft shell helmet therapy. Sixty-nine children with a diagnosis of deformational plagiocephaly were enrolled in this study to assess the success of a soft shell helmet for the correction of cranial asymmetry. Computed tomography scanning was done before therapy and 6 months after the initiation of therapy. Three-dimensional reconstructions of these scans were reformatted into a standardized orientation by utilizing the nasion (radix), frontozygomatic suture lines, and posterior aspect of the foramen magnum. Intracranial volumes were calculated on a quadrant basis, and asymmetry was evaluated with regard to the hemispheres (left versus right) and the posterior quadrants. Thirty-four children (27 boys and 7 girls) completed the study protocol. The side involved was the right in 62% of cases and the left in 38%. Mean age at the initial scan was 6.3 months, and mean age at the follow-up scan was 14 months. Mean duration of helmet therapy was 7 months. Compliance with therapy was average to above average in 88% of the children and poor in 12%. There was a 36% to 54% improvement in asymmetry in the compliant patients over the 6-month study period. Soft shell helmet therapy is an effective technique to decrease cranial asymmetry based on objective outcome measurements. Additionally, it is cost-effective, with the total cost of therapy for the helmet and office visits ranging from 600 dollars to 700 dollars. This therapy compares favorably with other more expensive and time-consuming therapies that have been reported in the literature.

Cleft Palate Craniofac J. 2002 Nov;39(6):582-6.
Deformational posterior plagiocephaly: diagnosis and treatment.
Teichgraeber JF, Ault JK, Baumgartner J, Waller A, Messersmith M, Gateño J, Bravenec B, Xia J.

Division of Plastic Surgery, University of Texas-Houston Medical School, Houston, Texas 77030, USA.

OBJECTIVE: This study was designed to evaluate the effectiveness of helmet therapy (DOC band) in the correction of patients with moderate to severe posterior deformational plagiocephaly. DESIGN: In this prospective study, the infants were evaluated using 18 anthropometric measurements. PATIENTS: The charts of 248 patients seen between August 1, 1995, and July 31, 1999, were reviewed, and 125 met the criteria for inclusion in the study. All the patients had posterior deformational plagiocephaly with no other craniofacial deformities or medical conditions. Treatment was instituted prior to 1 year of age, and all patients were compliant with DOC band usage and had complete anthropometric measurements. RESULTS: The study recorded a 41.56% (p < .001) reduction in cranial vault asymmetry and a 40.23% (p <.001) reduction in cranial base asymmetry. Orbitotragial asymmetry was improved 18.72% (p = .0738). The age at which treatment was begun was not a significant factor in predicting treatment outcomes.

J Neurosurg. 1997 Nov;87(5):667-70.
Nonsurgical, nonorthotic treatment of occipital plagiocephaly: what is the natural history of the misshapen neonatal head?
Moss SD.

Department of Neurosurgery, Phoenix Children's Hospital, Arizona 85006, USA.

Management of neonates with nonsynostotic occipital plagiocephaly has been controversial, and there has been a lack of uniformity concerning its treatment. Patients with nonsynostotic occipital plagiocephaly have been treated surgically or with cranial remodeling orthotic devices and have shown improvement in asymmetry. The cost of orthotic treatment has risen, and its validity has been contested by many third-party insurance payers. The effectiveness of orthotic treatment has not been adequately compared to the natural history of nonsynostotic occipital plagiocephaly. A nonsurgical, nonorthotic treatment study was initiated in June 1995 at Phoenix Children's Hospital. All new patients referred with a diagnosis of nonsynostotic occipital plagiocephaly were categorized into two groups: those with mild-to-moderate asymmetry and those with moderate-to-severe asymmetry. Categories were determined by cephalic measurements. The patients with moderate-to-severe asymmetry were offered orthotic treatment with a cranial remodeling band. Those patients with mild-to-moderate asymmetry were treated with physiotherapy, repositioning of the head, and repeated notation of cephalic measurements without orthotic devices or surgery. Seventy-two neonates, seen consecutively, with mild-to-moderate, nonsynostotic occipital plagiocephaly were evaluated by noting cephalic measurements. The parents of six of these patients elected treatment with a cranial remodeling band and results in these patients were excluded from our data. The remaining 66, treated without orthotic devices, showed improvement in average cranial vault asymmetry (CVA) from 9.2 to 4.7 mm over an average treatment period of 4.5 months that commenced when the average age of the patient was 6.4 months. A comparison of the present data with data published in 1994 for neonates treated with a headband indicates that neonates with mild-to-moderate asymmetry who are treated aggressively with physiotherapy and repositioning have similar improvement in CVA.

J Craniofac Surg. 2001 Jul;12(4):308-13.
Active counterpositioning or orthotic device to treat positional plagiocephaly?
Loveday BP, de Chalain TB.

School of Medicine, University of Auckland, New Zealand. silas@xtra.co.nz

Active counterpositioning and orthotic helmets are the two main nonsurgical management options for positional plagiocephaly. The purpose of this study was to compare these two management regimens. We included a random sample of infants referred between January 1, 1998 and October 31, 1999 to Middlemore Hospital and Auckland Surgical Center, for management of positional plagiocephaly. Two-dimensional head tracings were taken for each infant, every 3 to 12 months. From these tracings, we obtained Cranial Index and Cranial Vault Asymmetry Index. Seventy-nine infants were assessed during an average of 48.2 weeks. Five infants had normal head tracings, and were therefore excluded from the study. Of the 74 infants included in this study, 45 were managed with active counterpositioning, and 29 with orthotic helmets. Average management time for active counterpositioning was 63.7 weeks, and 21.9 weeks for orthotic helmet treatment. For infants managed with active counterpositioning, the average change in Cranial Vault Asymmetry Index was 1.9%. In the orthotic group, average change in Cranial Vault Asymmetry Index was 1.8%. Orthotic helmets have an outcome comparable to that of active counterpositioning, although the management period is approximately three times shorter. Active counterpositioning generally had a slightly better outcome than orthotic management after the management period.
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