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Obtaining a Positive Model for Craniofacial Deformities: An Empiric Review of Casting Procedures

Sorensen, Aaron J. CPO, MBA; Phillips, Melodie R. PhD

JPO Journal of Prosthetics and Orthotics: October 2004 - Volume 16 - Issue 4 - p S39-S41
Consensus Topics

AARON J. SORENSEN, CPO, MBA, is affiliated with Restorative Health Services, Nashville, TN.

MELODIE R. PHILLIPS, PhD, is affiliated with Middle Tennessee State University, Murfreesboro, TN.

Copyright © 2004 American Academy of Orthotists and Prosthetists.

Correspondence: Aaron J. Sorensen, CPO, MBA, President and CEO, Restorative Health Services, 311 18th Avenue North, Nashville, TN 37203; e-mail:

What is the preferred technique for obtaining a model of the infant’s skull and the type of orthotic treatment that will be recommended? This study investigates the frequency and use rates of the determination of positive models by orthotists. The objective of the study is to ultimately allow the Craniofacial Society to develop a set of recommended standards in training orthotists. Standards will assist in generating the best possible outcomes from treatment and assessment techniques.

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Cranial orthosis treatment has proven to be extremely beneficial to infants ranging from 3 months to 18 months of age. Treatment before the age of 4 months is often limited to a repositioning strategy. If no (or minimal) response is noted, then a cranial orthosis treatment is generally recommended.

The benefits of cranial orthosis treatment, however, have been a source of debate in the medical and insurance communities. It has become the position of many insurers that the treatment is primarily a cosmetic outcome that is deemed ineligible for insurance coverage. This can limit the accessibility of treatment to certain socioeconomic groups.

Research as to the long-term impact of plagiocephaly is just now being reported. In one study of children with persistent deformational plagiocephaly, 39.7% of affected children required special services throughout elementary school.1 These special services included special education, physical therapy, occupational therapy, and speech therapy. The control group exhibited a rate of only 7.7% requiring special services. To date, the use of orthotic treatment has not been associated with developmental delays in affected children.

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The objective of this study was to assess the type of orthotic designs used to treat deformational plagiocephaly, the casting techniques used, and the systems used to collect data by practitioners. To reach this objective, a survey was developed that included multiple items to assess each research construct.

Survey distribution followed two separate tracks. In track one, the researcher delivered the survey electronically to Orthomerica Products, Inc. Orthomerica then distributed this survey to current customers when delivering cranial orthoses fabricated to order. In track two, the researcher mailed surveys directly to customers who were members of the Craniofacial Society and Consensus Study participants. Respondents were assured of the anonymity of their responses. Track one survey distribution was administered by Orthomerica to guarantee anonymity to its customers before their responses were forwarded to the researcher. Orthomerica managed the removal of all identifying information before sending the survey results to the researchers. Track two responses were returned directly to the researcher.

The number of usable responses from the study totaled 63. One survey had to be removed for poor quality of fax return. No surveys had to be eliminated strictly for partial answers or incomplete forms. The number of surveys actually administered was not known by the researcher because a condition of anonymity was required for all surveys administered by Orthomerica. Therefore, exact response rates are unknown.

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Findings indicate that the survey yielded 56 respondents using helmet designs and 56 using band designs. This is possible because the survey allowed for firms to mark either type of device used in the treatment of deformational plagiocephaly. Of the respondents indicating use of cranial bands, 16 specifically indicated using the STARband by Orthomerica. The positive model for helmet and band designs was gathered by the casting techniques summarized in Table 1

Table 1

Table 1

In determining the primary material used in the casting process (if hand casts were used), respondents were asked to indicate if they primarily used plaster, fiberglass, or other materials. It was determined that 84% of respondents used plaster (Figures 1 and 2) as compared with 5% indicating fiberglass, 2% using soft casting materials, and 11% not indicating any primary choice.

Figure 1.

Figure 1.

Figure 2.

Figure 2.

The survey asked respondents to indicate which anatomic landmarks are indicated in the casting process. Respondents were asked to mark as many as were used in the process; hence, many landmarks were indicated by some respondents. Total responses then exceeded the 63 completed surveys.

The anatomic landmarks most commonly identified by respondents included the ears/tragus (92%), center of the face (71%), eyebrows (68%), and the inferior border of the occiput (29%). Additional landmarks reported did not exceed 20% for any given factor, including center of occiput and maxillofacial juncture.

The most problematic assessment for the survey was determination of when definitive modifications were made. Most respondents failed to answer this question (71%). This could reflect one of two problems. Either there was concern that proprietary information was being requested or there was some confusion about what the question was asking. In either case, it would be difficult to assess any meaning from the answers given by the majority of respondents. Of the respondents that did answer the question, 5% indicated that modifications were completed in the software program before carving a positive model. Thirteen percent indicated that modifications were made by hand after the positive model was carved.

The survey assessed the anterior casting borders used by practitioners throughout the industry. This question was an open-ended response allowing for free discussion of borders used. A majority of respondents indicated that the casting procedure covered the anterior eyebrow, the occiput, and the posterior nape of the neck. Results indicate the most commonly used landmark is the eyebrow.

Posterior casting borders were also assessed. Responses indicate a fairly consistent use of the occiput (18) and midneck or nape of the neck (16). Several other borders, however, were indicated by respondents, including C5 level, C7 level, shoulder, and occipital protuberance.

Lateral casting borders indicated by respondents also varied greatly with distal to ears to top of neck (14) being most commonly reported. Additional borders include the distal mandible (5), ear lobe (4), and covering ears to mandible level (5).

In attempting to determine the casting borders used by respondents in the industry, a number of difficulties were encountered. Concerns over consistent use of terminology among respondents could have resulted in a greater variety of answers than is reflective of actual techniques. Respondent attempts to be as descriptive as possible resulted in many similar (but not identical) terms. Further study should be conducted without using a free answer framework. This could reveal if part of the disparate results merely reflects terminology chosen by respondents as opposed to true differences in technique. The development of some consistent terms for recommended landmarks should be used for the proper and consistent development of positive models.

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As deformational plagiocephaly continues to be a growing problem for pediatricians and practitioners, it appears that two orthotic treatment approaches have received similar levels of acceptance in the medical community. The helmet and band techniques appear to be equally accepted as a treatment alternative. Future research offers the opportunity to identify which of these approaches actually provides more effective treatment to patients. This effectiveness could be measured in terms of degree of correctness in the affected patients, cost-effectiveness of one treatment over another, and general comfort levels of parents and patients with the two alternatives.

The continued efforts of practitioners to identify a uniform approach to casting and treatment could lead to advances in the field in terms of cost efficiencies, patient satisfaction, and physician comprehension and understanding. This would be a welcome advance in the field.

It is interesting to note that although an even split was identified between helmet and band users, the use of computer-aided casting continues to be limited. The increased use of this technique could assist in the development of more uniform procedures. Unfortunately, at this time, many smaller orthotic firms simply might not have the capital to invest in expensive equipment. This could be further compounded by the insurance industry’s attempts to limit reimbursements or simply classify these treatments as cosmetic and refuse reimbursement.

It is worthwhile to note that the use of computer-aided casting could prove to be advantageous when marketing to parents. Because the initial positive model development through casting is somewhat traumatic to parents and children, computer-aided casting could assist in alleviating parental woes. It could also increase physician comfort in prescribing these treatments.

Although the purpose of this study was to identify consistencies and differences among practitioners and their techniques for treating deformational plagiocephaly, several problems were encountered in collecting the data. First, the general concern over the divulgence of proprietary information tended to limit the number of responses and the quality of responses in many cases. This concern was somewhat unfounded because many of the firms responding are using the STARband and their casting techniques are widely available. Those firms with U.S. Food and Drug Administration approval for their own designs could have had a more serious concern in discussion techniques. Although anonymity was provided to the best of the researcher’s ability, many respondents chose to e-mail or fax back responses; hence, their concern over anonymity was justified. Further work will need to be done with a standard mail survey to remove these concerns from respondents.

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The researcher acknowledges the assistance of Orthomerica in completing this project. Without their assistance, completion of this project would not have been possible.

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1. Miller RI, Clarren SK. Long-term developmental outcomes in patients with deformational plagiocephaly. Pediatrics 2000;105:1–5.
© 2004 American Academy of Orthotists & Prosthetists