1. Cranial Remolding for Deformational Plagiocephaly
Presented by:
Amanda Pozarnsky, CO, BSPO
Board Eligible Prosthetist

2. History of Cranial Remolding
How long has cranial remolding existed????

3. History of Cranial Remolding
For thousands of years, cranial remolding techniques have been used for aesthetic purposes

4. History of Cranial Remolding
Clarren developed the first cranial remolding orthosis
Today – updated design, same basic principle.

5. Causes of Deformational Plagiocephaly
Positioning in womb
Positioning in early infancy
Prematurity increases risk
“Back to Sleep Campaign”
Car seats and other seating systems
Torticollis
Head preference towards one side

6. Positioning in Womb Deformation can occur in the womb
Limited room in the womb
Multiple births

7. Positioning in Early Infancy
Secondary deformational forces caused by sleep and daytime supine positioning
Premature birth increases risk
Car seats, swing

8. Torticollis
Torticollis is the tightness or contracture of the sternocleidomastiod muscle
Typically causes tilt and rotation of the head with loss of ROM
85% of infant’s with plagiocephaly have been diagnosed with torticollis

9. Why has there been an increased incidence of cranial deformation?
The American Academy of Pediatrics started the “Back to Sleep” Campaign
Recommend babies sleep in the supine position to reduce the incidence of SIDS
Incidence of SIDS reduced by >50%
Conversely, increased incidence of
deformational plagiocephaly
Brachycephaly especially

10. Diagnoses of Cranial Deformities
Plagiocephaly – Asymmetrical flattening of the occipital bone with opposite changes of the frontal bone and ear offset
Brachycephaly – Symmetrical flattening of the occipital bone, increase in width (M-L)
Scaphocephaly – Symmetrical flattening of the parietal bones with elongated length (A-P)
Asymmetric Brachycephaly – Combination of Plagiocephaly and Brachycephaly

11. Head Preference Towards One Side
Patient has tendency to look towards one side, but DOES NOT HAVE TORTICOLLIS.
Usually caused by habit
Parents need to alter stimulation
Feeding
Car seat placement
Crib position

12. Clinical Signs of Plagiocephaly
Trapezoidal head shape when viewed in the transverse plane
Anterior ear shift
Bossed forehead
Facial Asymmetries

13. Contraindications of Cranial Remolding Orthoses
Craniosynostosis – Orthoses are commonly used postoperatively to correct or maintain endoscopic surgical correction
Hydrocephaly – may be used if treated with a shunt and cleared by doctor
Under 3 months of age – Repositioning efforts should be used
Over 24 months of age - The skull is fully fused and no longer pliable
N.B. 18 months is commonly the stated end point due to majority of the sutures being fused and the lack of growth at that age

14. Indications (most insurance requirements)
Must be between 3-18 months old
2 months of repositioning efforts
Tummy Time
Plagiocephaly - Asymmetry exceeding 6mm in any anthropometric measurement
Brachycephaly – Two standard deviations from the norm in cephalic ratio

15. Ideal Protocol Initiate between 3- 6 months old
Insurance may take up to six weeks to authorize
4-7 months of helmet therapy
Must wear helmet 23 hours/day
Follow-up visits every 2-4 weeks

16. Brand Names of Cranial Remolding Orthoses aka “helmets” aka “bands”
All Cranial Remolding Orthoses are regulated by the Federal Drug Administration, FDA
STARbandTM from Orthomerica
All helmets are BPA Free
DOC band® from Cranial Tech
The Boston Band from Boston Brace
Hanger Cranial Band from Hanger O&P

17. STARscanner The STARscanner is a laser data acquisition system
Non-invasive laser
No radiation
Scan takes 1.5 seconds to capture image
FDA approved
Quantitative Data
Data used to document for insurance coverage

18. Plaster Casting
Before CAD-CAM technology, practitioners had to take a plaster cast of the patient’s head
Patients did not tolerate the plaster casting well
Plaster casting is very messy & time consuming
Many O&P offices still use plaster casting technique

19. Union Orthotics & Prosthetics Co.
We are the only facility in Western PA with the STARscanner
We have 4 offices throughout Western PA with Cranial Remolding Specialists
Pittsburgh
Cranberry
South Hills
Greensburg

20. How is a scan turned into a helmet?
Orthomerica uses CAD- CAM software to carve a foam replica of the patient’s head
The foam head mold is then corrected using plaster
The helmet is fabricated on top of the modified foam mold

21. How Does the Helmet Work?
The helmet contacts the “bossed” areas to resist growth
Growth then takes the “path of least resistance” as bone growth is redirected to fill in the empty space inside the helmet

22. Acquiring a Cranial Remolding Orthosis
After the STARscan, it takes approximately ten days for Orthomerica to fabricate a helmet
FDA requires Orthomerica to make and have the helmet delivered to us for fitting within 14 days of the scan

23. STARband Side-opening band 3/16 ” copolymer shell
½” copolymer foam liner
If adjustments are necessary, we can remove foam from inner surface of the helmet

24. STARlight Side-opening band ¼” clear plastic shell
Able to heat and flare plastic to adjust helmet
Recommended for pt’s with eczema or extreme skin sensitivity

25. Bi-Valve Helmets
Both the STARband and STARlight are available in a Bi-Valve design
Used to treat post-op sagittal synostosis and scaphocephaly

26. Challenging Presentations
Severe torticollis’ “C” Shape

27. Scan Comparison
Once a patient has completed 3 months of helmet therapy, a scan comparison is performed
Scan comparisons are also offered when a patient is discharged from helmet therapy

28. Scan Comparison
A scan comparison allows an overlay of cross sections from the original scan (red) and the scan after 3 months of treatment (blue)
Great tool to track measurements and growth toward correction

29. Scan Comparison- Brachycephaly

30. Scan Comparison- Plagiocephaly

31. Discharge Criteria from Helmet Therapy
In order to prevent reoccurrence of deformity.
Crawling
Independent sitting
Multiple sleeping positions
Torticollis not a concern on positioning
Other common reasons to cease use:
Age- Growth rate insignificant
Parents choose to cease use

32. Do Babies Tolerate the Helmet Well?
Most babies tolerate the helmet well
Very few may experience discomfort due to excessive sweating until body naturally adjusts (1-2 weeks)

33. Should we be concerned? Bulging above the ears/side opening
No concern! It is simply subcutaneous fluid pooling around the snug trimlines
Yes, it feels as hard as bone, but the large plates of the skull cannot grow out an opening that small
Usually occurs after a few months of use when orthosis becomes more snug

34. Should we be concerned?
Red, peeling, sunburn like appearance in the shape of the orthosis
This is contact dermatitis
No adjustments to the orthosis will help
Cease STARband use until it has cleared up on its own or with mild ointments prescribed by pediatrician

35. Why put holes in the helmet?
Holes are usually drilled into the helmet in the area of flatness to aid in ventilation
Holes can also be used to ensure there is sufficient room for growth toward symmetry
These cannot be added to bossed areas

36. Who do I refer my patient to?
Children’s Hospital of Pittsburgh
Craniofacial Department
Pediatrician

37. Alexandra’s P.H.A.T.E. Raise Awareness Support Group
Provide resources to fight insurance denials
Donate STARbands to families in need
Facebook
Twitter

38. Alexandria’s P.H.A.T.E.

39. Decorate the Helmet

40. References
Derrow, Amy. MD. “Basic Dermatology Essential for All STARband Users.” Orthomerica STARsummit. Orlando, FL. 21 Oct 2009.
NICHD Back to Sleep Education Campaign (August 2011). National Institute of Health. Retrieved August 29, 2010 from
Norquist, Blake. CO. “STARscanner Cranial Comparison Utility.” Orthomerica STARsummit. Orlando, FL. 20 Oct 2010.
Norquist, Blake. CO. “Surgical Approaches for the Relief of Craniosynostosis.” Orthomerica STARsummit. Orlando, FL Oct 2009.
Smith, Aaron. CO, LO. “Challenges – The Questions, The Answers, The Messy, Smelly, and Sometimes Frustrating Side of Cranial Remolding.” Orthomerica STARsummit. Orlando, FL Oct 2010.
Tate, Gary. “Alexandra’s P.H.A.T.E.” Orthomerica STARsummit. Orlando, FL. 20 Oct 2010.

41. Questions ?