Orthothic Treatment of Positional Plagiocephaly

Timothy R. Littlefield, M.S.

In 1992, the American Academy of Pediatrics (AAP) published the results of a multinational investigation which studied the relationship between infant sleeping position and the frequency of Sudden Infant Death Syndrome (SIDS) [1]. In this report, the Academy recommended that infants sleep either on their backs or sides in order to reduce the risk of SIDS. A recent addendum to this report (December, 1996) has suggested that the supine position is preferred over side positioning to further reduce these risks.

Following the publication of this report, craniofacial centers around the world have observed an increase in the number of children presenting with abnormal head shapes [2,3]. Consistent with previous reports, many of these patients were diagnosed as having synostosis of the lambdoidal suture and were treated by surgery [4]. Yet upon surgical intervention it was often discovered that the sutures had not prematurely fused, leading many surgeons to question the etiology of this deformation. Multiple centers soon concluded that these deformations were positional in nature, developing from the extended time an infant spent in a supine position whether in a crib, car seat, or infant swing.[5-7]. This condition was termed positional or deformational plagiocephaly and is often characterized by a parrollelogram shaped head. In 1988, the DOC Band was designed to provide a nonsurgical alternative for the correction of positional plagiocephaly. Between 1988 and 1995, we have treated over 750 cases of positional plagiocephaly with the Dynamic Orthotic Cranioplasty and have documented the efficacy of our treatment through anthropometric and photographic techniques. We have demonstrated a significant improvement in the Cranial Vault Asymmetry (CVA), Skull Base Asymmetry (SBA), and Orbitotragial Depth Asymmetry (OTDA) of these infants.

Dynamic Orthotic Cranioplasty

Two typical head shapes occur in positional plagiocephaly. The first is a symmetric, trapezoidal shape known as brachycephaly where the back of the head has become wide and the length shorter than ordinary. The second, and more common, is a parallelogram shaped head which is referred to as being plagiocephalic. These deformities can arise from both intrauterine and positional molding influences including intrauterine crowding [8,9], prematurity [10], neck tightness or torticollis [11], and sleeping position[12]. In both cases, it is desired to return the shape of the head to a more normal configuration, which for brachycephaly means decreasing the cephalic index[(head width/ head length) xl00)], and for plagiocephaly means reducing the existing asymmetries of the face, cranial vault, and skull base. For brevity, only the correction and results of treatment for the parallelogram shaped plagiocephalic head are discussed here.

Figure 1. shows a bird's eye view of the typical parallelogram shaped head seen for treatment in our Phoenix center. When an infant is placed in a supine sleeping position at a young age, the soft cranium is susceptible to gravitational molding forces, and a small flat spot, typically in the occipital-parietal region, will occur. As the infant is routinely placed on their back, the head will continue to return to this flat spot which will progressively get larger, leading to an anterior displacement of the ipsilateral forehead and ipsilateral ear. Anthropometric measurements on this head will identity asymmetry in the face, cranial vault, and skull base.

The DOC Band is an orthotic device which corrects these asymmetries through application of a mild dynamic force in the prominent areas (large arrows, Figure 1. ). This mild force inhibits in the already prominent areas, and encourages growth in the flattened regions. The band is most effective when it is worn during the time of rapid brain growth (3-6 months of age) as it harnesses this growth to help correct the asymmetries. This device is custom made for each patient from a plaster of paris mold taken of the infant at the beginning of treatment. The Band is worn by the infant 23 hours a day, allowing one hour for bathing and hygiene. Weekly appointments allow the adjustment of the band to ensure proper growth and to monitor the skin for any breakdown which may indicate that too large of a pressure is being applied. An infant wearing the DOC Band is shown in Figure 2. .


To document the effectiveness of the DOCB and, fourteen anthropometric measurements as outlined by Farkas [14] were obtained throughout the course of the treatment. Of particular interest are the asymmetries of the face (Orbitotragial), cranial vault, and skull base. Table 1. summarizes the results of over 300 (n=329) of these cases for which complete anthropometric data were obtained. The average age of entrance into the program was 6.82 months with mean treatment time of 4.35 months. Mean Cranial Vault Asymmetry (CVA) was corrected from 8.45 mm to 3.29 mm, mean Skull Base Asymmetry (SB A) was corrected from 6.03 to 3.16 mm, and mean Orbitotragial Asymmetry (OTDA) was corrected from 4.31 to 2.34 mm.


The initial efficacy of treatment with the DOC Band was documented by Ripley et al [15] who evaluated 124 patients between 1988 and 1993. Our continuing efforts to quantitatively document the correction achieved, support those claims by Ripley that the DOC Band is effective in reducing the asymmetries in the plagiocephalic head. In fact, very little difference between the numbers reported could be found. The exception being that as we continue to treat more patients we become more willing to attempt corrections of more severe cases which enter treatment at a later age. Additionally, the DOC Band is being prescribed more frequently to be used post operatively to assist with maintaining the stability and effectiveness of surgical cranioplasty [16].

Much debate still exists in the craniofacial and neurosurgical communities over the importance of correcting these asymmetries, and the degree to which they may self correct if left alone. We have followed individuals who were unable to undergo DOC treatment, as well as our patients after leaving the DOC treatment program and have documented that the residual asymmetries did not correct further without intervention. Many similar devices on the market have met with limited success as they attempt to correct for plagiocephaly by means of passive growth into a preconstructed "helmet". This type of passive correction will allow some molding of the cranium into a predetermined form, but can not achieve the same degree of asymmetry reduction as has been documented by the DOC Band. In fact, the DOC Band is the only device which has been able to correct asymmetries of the skull base, as is evidenced by the ears being brought into symmetry. DOC, DOC Band, Dynamic Orthotic Cranioplasty are Trademarks of Cranial Technologies, Inc. The DOC Band (tm) is covered by U.S. patents #5,094,229, #5,308,312. Other patents pending.

AAP Task Force in Infant Positioning and SIDS. Pediatrics 1992; 89:1120.
Turk, A.; McCarthy, J; Thorne, C; Wisoff, J.; "The 'Back to Sleep Campaign' and Deformational Plagiocephaly: Is there Cause for Concern?" J Craniofac Surg 1996; 7:12
Argent, L; David, L.; Wilson, J.; Bell, W.; "An Increase in Infant Cranial Deformity with Supine Sleeping Position", J Craniofac Surg 1996; 7:5
Haung, M.; Gruss, J.; Clarren, S.K..; Mouradian, W.; Cunningham, M.; Roberts, T.; Loeser, J.; Cornell, C; "The Different Diagnosis of Posterio Plagiocephaly: True Lambdoid Synostosis versus Positional Molding". Plast Reconstru Surg 1996; 765-774
Bruneteau, R; Mulliken, J.; "Frontal plagiocephaly: synostotie, compensational, or deformational", Plast Reconst Surg 1992; 89:21-31
Ortega, B.; "Some Physicians Do Unnecessary Surgery On Heads of Infants", The Wall Street Journal, Friday, February 23, 1996.
Persing, J.; Editorial: "Occipital Deformities", J Craniofac Surg 1996; 7:4
Baum, J.D..; Searls D.;"Head shape and size of pre-term low birth-weight infants". Dev Med Child Neurol 1971; 13:576-581
Clarren, S.K.; Smith, D.W.; "Congenital Deformities". Pediatric Clinics of North America, 24, (4), 665-677.1977.
Larg, R.H.; Due, G.; "Head growth and changes in head configuration in healthy preterm and term infants during the first six months of life". Hel Paediatr 1977; 32:431-442.
Clarren, S.; Smith, D.; Hanson, J.; "Helmet treatment for plagiocepahly and congenital muscular torticollis". J Pediatr 1979; 94:443.
Budreau, G.; "Postnatal cranial molding and infant attractiveness: implications for nursing". Neonatal Network 1987; 5:13.
Moss, M.; "The pathogenesis of artificial cranial deformation". Am J Phys Anthropol 1958; 16:269-286
Farkas, L.; Anthropometry of the head and face in medicine. New York: Elsevier, 1981.
Ripley, C; Pomatt, J.; Beals, S.; Joganic, E.; Manwaring, K.; Moss, D.; "Treatment of positional plagiocephaly with dynamic orthotic cranioplasty", J Craniofac a 994; 5:150
Joganic EF, BealsSP, RipleyCE, Manwaring KM, Moss SD, Pomatto J; "Enhancement of craniofacial reconstruction by post-surgical dynamic orthotic cranioplasty". Proceedings of the VI congress of the International Society of Craniofacial Surgery. October 1995.