Management of nonsyndromic craniosynostosis

Quantifying dysmorphologies of the neurocranium using artificial neural networks

BACKGROUND

Craniosynostosis, a congenital condition characterized by the premature fusion of cranial sutures, necessitates objective methods for evaluating cranial morphology to enhance patient treatment. Current subjective assessments often lead to inconsistent outcomes. This study introduces a novel, quantitative approach to classify craniosynostosis and measure its severity.

METHODS

An artificial neural network was trained to classify normocephalic, trigonocephalic, and scaphocephalic head shapes based on a publicly available dataset of synthetic 3D head models. Each 3D model was converted into a low-dimensional shape representation based on the distribution of normal vectors, which served as the input for the neural network, ensuring complete patient anonymity and invariance to geometric size and orientation. Explainable AI methods were utilized to highlight significant features when making predictions. Additionally, the Feature Prominence (FP) score was introduced, a novel metric that captures the prominence of distinct shape characteristics associated with a given class. Its relationship with clinical severity scores was examined using the Spearman Rank Correlation Coefficient.

RESULTS

The final model achieved excellent test accuracy in classifying the different cranial shapes from their low-dimensional representation. Attention maps indicated that the network's attention was predominantly directed toward the parietal and temporal regions, as well as toward the region signifying vertex depression in scaphocephaly. In trigonocephaly, features around the temples were most pronounced. The FP score showed a strong positive monotonic relationship with clinical severity scores in both scaphocephalic (ρ = 0.83, p < 0.001) and trigonocephalic (ρ = 0.64, p < 0.001) models. Visual assessments further confirmed that as FP values rose, phenotypic severity became increasingly evident.

CONCLUSION

This study presents an innovative and accessible AI-based method for quantifying cranial shape that mitigates the need for adjustments due to age-specific size variations or differences in the spatial orientation of the 3D images, while ensuring complete patient privacy. The proposed FP score strongly correlates with clinical severity scores and has the potential to aid in clinical decision-making and facilitate multi-center collaborations. Future work will focus on validating the model with larger patient datasets and exploring the potential of the FP score for broader applications. The publicly available source code facilitates easy implementation, aiming to advance craniofacial care and research.

Implementation of Upper Extremity Trauma Registry: A Pilot Study

Background

Hand traumas are common in young men and their complications can have negative effects on their occupation and economic activities. On the other hand, most of the hand injuries are related to occupation accidents and thus necessitates preventive measures. The goal of a clinical registry is assisting epidemiologic surveys, quality improvement preventions.

Methods

This article explains the first phase of implementing a registry for upper extremity trauma. This phase includes recording of demographic data of patients. A questionnaire was designed. Contents include patients' characteristics, pattern of injury and past medical history in a minimal data set checklist. This questionnaire was filled in the emergency room by general practitioners. For 2 months the data were collected in paper based manner, then problems and obstacles were evaluated and corrected. During this period a web based software was designed. The registry was then ran for another 4 months using web based software.

Results

From 6.11.2019 to 5.3.2020, 1675 patients were recorded in the registry. Random check of recorded data suggests that accuracy of records was about 95.5%. Most of the missing data was related to associated injuries and job experience. Some mechanisms of injury seems to be related to Iran community and thus warrants special attention for preventive activities.

Conclusion

With a special registry personnel and supervision of plastic surgery faculties, an accurate record of data of upper extremity trauma is possible. The patterns of injury were remarkable and can be used for investigations and policy making for prevention.

Titanium or Biodegradable Osteosynthesis in Maxillofacial Surgery? In Vitro and In Vivo Performances

Osteosynthesis systems are used to fixate bone segments in maxillofacial surgery. Titanium osteosynthesis systems are currently the gold standard. However, the disadvantages result in symptomatic removal in up to 40% of cases. Biodegradable osteosynthesis systems, composed of degradable polymers, could reduce the need for removal of osteosynthesis systems while avoiding the aforementioned disadvantages of titanium osteosyntheses. However, disadvantages of biodegradable systems include decreased mechanical properties and possible foreign body reactions. In this review, the literature that focused on the in vitro and in vivo performances of biodegradable and titanium osteosyntheses is discussed. The focus was on factors underlying the favorable clinical outcome of osteosyntheses, including the degradation characteristics of biodegradable osteosyntheses and the host response they elicit. Furthermore, recommendations for clinical usage and future research are given. Based on the available (clinical) evidence, biodegradable copolymeric osteosyntheses are a viable alternative to titanium osteosyntheses when applied to treat maxillofacial trauma, with similar efficacy and significantly lower symptomatic osteosynthesis removal. For orthognathic surgery, biodegradable copolymeric osteosyntheses are a valid alternative to titanium osteosyntheses, but a longer operation time is needed. An osteosynthesis system composed of an amorphous copolymer, preferably using ultrasound welding with well-contoured shapes and sufficient mechanical properties, has the greatest potential as a biocompatible biodegradable copolymeric osteosynthesis system. Future research should focus on surface modifications (e.g., nanogel coatings) and novel biodegradable materials (e.g., magnesium alloys and silk) to address the disadvantages of current osteosynthesis systems.

Application of Deep Learning Techniques for Automated Diagnosis of Non-Syndromic Craniosynostosis Using Skull X-Ray

ABSTRACT

Non-syndromic craniosynostosis (NSCS) is a disease, in which a single cranial bone suture is prematurely fused. The early intervention of the disease is associated with a favorable outcome at a later age, so appropriate screening of NSCS is essential for its clinical management. The present study aims to develop a classification and detection system of NSCS using skull X-ray images and a convolutional neural network (CNN) deep learning framework. A total of 56 NSCS cases (scaphocephaly [n = 17], trigonocephaly [n = 28], anterior plagiocephaly [n = 8], and posterior plagiocephaly [n = 3]) and 25 healthy control infants were included in the study. All the cases underwent skull X-rays and computed tomography scan for diagnosis in our institution. The lateral views obtained from the patients were retrospectively examined using a CNN framework. Our CNN model classified the 4 NSCS types and control with high accuracy (100%). All the cases were correctly classified. The proposed CNN model may offer a safe and high-sensitivity screening of NSCS and facilitate early diagnosis of the disease and better neurocognitive outcome for patients.

Three-Dimensional Stereophotogrammetry in the Evaluation of Craniosynostosis: Current and Potential Use Cases

ABSTRACT

Three-dimensional (3D) stereophotogrammetry is a novel imaging technique that has gained popularity in the medical field as a reliable, non-invasive, and radiation-free imaging modality. It uses optical sensors to acquire multiple 2D images from different angles which are reconstructed into a 3D digital model of the subject's surface. The technique proved to be especially useful in craniofacial applications, where it serves as a tool to overcome the limitations imposed by conventional imaging modalities and subjective evaluation methods. The capability to acquire high-dimensional data in a quick and safe manner and archive them for retrospective longitudinal analyses, provides the field with a methodology to increase the understanding of the morphological development of the cranium, its growth patterns and the effect of different treatments over time.This review describes the role of 3D stereophotogrammetry in the evaluation of craniosynostosis, including reliability studies, current and potential clinical use cases, and practical challenges. Finally, developments within the research field are analyzed by means of bibliometric networks, depicting prominent research topics, authors, and institutions, to stimulate new ideas and collaborations in the field of craniofacial 3D stereophotogrammetry.We anticipate that utilization of this modality's full potential requires a global effort in terms of collaborations, data sharing, standardization, and harmonization. Such developments can facilitate larger studies and novel deep learning methods that can aid in reaching an objective consensus regarding the most effective treatments for patients with craniosynostosis and other craniofacial anomalies, and to increase our understanding of these complex dysmorphologies and associated phenotypes.

Comparison of the mechanical properties of biodegradable and titanium osteosynthesis systems used in oral and maxillofacial surgery

To guide the selection of osteosynthesis systems, this study compared the mechanical properties of biodegradable and titanium osteosynthesis systems. SonicPins Rx and xG were subjected to pull-out tests. Additionally, 15 biodegradable (Inion CPS 2.0 and 2.5 mm; LactoSorb 2.0 mm; Macropore 2.0 mm; Polymax 2.0 mm; BioSorb FX 2.0 mm; ResorbX 2.1 mm; Osteotrans-MX 2.0 mm with plate thicknesses 1.0 and 1.4 mm; SonicWeld Rx_plate/Rx_pins, xG_plate/Rx_pins and xG_plate/xG_pins 2.1 mm without and with tapping the burr hole) and six titanium (CrossDrive (2006), CrossDrive (2018), MaxDrive; all 1.5 and 2.0 mm) straight, four-hole osteosynthesis systems were evaluated. All systems were subjected to tensile, bending and torsion tests. Pull-out loads of the SonicPins were comparable (P = 0.423). Titanium systems’ tensile loads were higher than biodegradable systems (P < 0.001). CrossDrive (2018) and MaxDrive systems’ tensile and torsional stiffness were lower, accompanied with higher ductility, than corresponding CrossDrive (2006) systems (P < 0.001). Bending stiffness of 1.5 mm titanium systems was comparable to, and of the 2.0 mm systems higher than, all biodegradable systems (P < 0.001). Regarding biodegradable systems, Inion CPS 2.5 mm had highest tensile load and torsional stiffness, SonicWeld 2.1 mm highest tensile stiffness, and BioSorbFX 2.0 mm highest bending stiffness (P < 0.001). On the basis of the results of this study, the CrossDrive (2018) and MaxDrive 1.5 mm titanium systems are recommended for midface fractures (e.g., zygomatic or maxillary fractures) and osteotomies (e.g., Le Fort I osteotomy), and the CrossDrive (2018) and MaxDrive 2.0 mm titanium systems for mandibular fractures and osteotomies when a titanium osteosynthesis system is used. When there is an indication for a biodegradable osteosynthesis system, the SonicWeld 2.1 mm or BioSorbFX 2.0 mm are recommended for midface fractures and osteotomies, and the Inion CPS 2.5 mm biodegradable system for mandibular osteotomies and non-load bearing mandibular fractures, especially when high torsional forces are expected (e.g., mandibular symphysis fractures).

Non-syndromic craniosynostosis in children: Scoping review

BACKGROUND

Craniosynostosis (CS) is a complex condition consisting of the early fusion of one or more cranial sutures in the intrauterine stage. The affected infant exhibits abnormal head shape at time of birth or shortly thereafter. It can be observed in normal individuals (non-syndromic CS or NSCS) or as a part of a multisystem syndrome. The purposes of the present article were to carry out a scoping review on Non-Syndromic CS and to discuss the most important findings retrieved.

MATERIAL AND METHODS

The steps of this scoping review were as follows: first, to pose a research question; second, to identify relevant studies to answer the research question; third, to select and retrieve the studies; fourth, to chart the critical data, and finally, to collate, summarize, and report the results from the most important articles. Relevant articles published over a 20-year period were identified and retrieved from five Internet databases: PubMed; EMBASE; Cochrane Library; Google Scholar, and EBSCO.

RESULTS

Fourteen articles were finally included in the present scoping review. The following four most important clinical issues are discussed: (i) normal cranial development, clinical manifestations, and pathogenesis of NCSC; (ii) clinical evaluation of NCSC; (iii) treatment and post-surgical follow-up; and (iv) additional considerations.

CONCLUSIONS

NSCS may be present with associated head shapes. Multiple early surgical reconstructive options are currently available for the disorder. Pediatric Dentistry practitioners must be familiarized with this condition and form part of a multi-approach health team as those responsible for the opportune oral health care of the affected child.

Surgical correction of craniosynostosis. A review of 100 cases

PURPOSE

Provide outcome data for open cranial vault reshaping at a single institution by a single craniofacial surgeon treating 100 patients.

METHODS AND SUBJECTS

A total of 100 patient records were reviewed. Criteria for selection included patients less than three years of age undergoing primary surgery with open cranial vault reshaping and a minimum follow up time of 2 years.

RESULTS

Of the 100 patients (27 female, 73 male) treated 6 were syndromic and 94 nonsyndromic. Average age and weight were 8.9 months and 9.51 kg, respectively. The oldest child was 30 months and the youngest 5 months at the time of surgery. The estimated blood volume lost was 42.7% of total calculated blood volume ranging from 16.6% to 336%. Average surgical time was 216.7 min. Complications included 2 hematomas, 2 wound infections, 1 subgaleal abscess, 6 dural tears, 3 patients requiring reoperation for residual deformity, 4 cases requiring coronal scar revision, 1 sagittal sinus bleed, and 1 intraoperative death.

CONCLUSIONS

Our review of 100 open repairs of patients with craniosynostosis demonstrates good long-term results with an overall low complication rate. The outcome data will assist in developing future prospective studies aimed at improving the multidisciplinary care of these patients.

Craniosynostosis: Esthetic protocol in open technique

Introduction:

The past two decades have seen advances relative to the treatment of patients with craniosynostosis in the areas of resorbable fixation, imaging, and both intraoperative and perioperative management. The purpose of this study is to present open cranial vault reshaping techniques and anesthetic protocol used at Louisiana State University Health - Shreveport, USA.

Materials and Methods:

The surgical procedure of choice was single-stage open cranial vault reshaping with barrel-staving and orbital bandeau advancement as needed for supra-orbital rim deficiencies.

Results:

The outcomes of single-stage cranial vault reshaping with selective postoperative dynamic orthotics yielded symmetrical and consistent clinical results with only three children out of over 100 cases requiring later surgical correction.

Discussion:

Our review of techniques provides a safe protocol for management of craniosynostosis with symmetrical clinical head shape. The techniques presented here are aimed at improving the multidisciplinary management of these patients.

Craniosynostosis

Craniosynostosis is a complex condition, characterized by the premature fusion of one of more of the cranial sutures. They can be seen individually or as part of multisystem syndromes. This review uses computed tomography (CT) with three-dimensional reconstructions to help describe some of the types and classifications of craniosynostosis, as well as describing some of the associations and the management of craniosynostosis.

Evaluation and management of nonsyndromic craniosynostosis

Craniosynostosis (craniostenosis) is premature fusion of the sutures of the cranial vault. Several factors can affect the growth of the cranial vault during embryonic life and after birth, leading to different types of craniosynostosis; these can be classified on the basis of the specific sutures that are fused. Prognosis is improved by early diagnosis, and it is important to establish the correct approach to these patients on the basis of clinical and neuroradiological investigation. The first priority is to identify the type of craniosynostosis and to distinguish between the types that require surgical intervention and those that do not. We report on the different forms of nonsyndromic craniosynostosis, their clinical and neuroradiological diagnoses, and surgical strategies.

CONCLUSION

The aim of this review is to provide to paediatricians a correct diagnostic approach and management of children affected from nonsyndromic craniosynostosis, for which a careful physical, ophthalmological and neurological examination is fundamental, whereas brain Computed tomography and magnetic resonance imaging are necessary for patients in which the diagnosis is uncertain or for cases of syndromic craniosynostosis.

Management of facial asymmetry

Asymmetries of the craniofacial region encompass a multitude of diverse and potentially complex abnormalities that may be the result of numerous causes. The expression and degree of asymmetry for a given condition, although a highly variable process, is the ultimate determinant of the nature of its treatment. This article highlights some of the key features and treatment strategies for various common facial asymmetries.

Mechanical strength and stiffness of biodegradable and titanium osteofixation systems

PURPOSE

To present relevant mechanical data to simplify the selection of an osteofixation system for situations requiring immobilization in oral and maxillofacial surgery.

MATERIALS AND METHODS

Seven biodegradable and 2 titanium osteofixation systems were investigated. The plates and screws were fixed to 2 polymethylmethacrylate (PMMA) blocks to simulate bone segments. The plates and screws were subjected to tensile, side bending, and torsion tests. During tensile tests, the strength of the osteofixation system was monitored. The stiffness was calculated for the tensile, side bending, and torsion tests.

RESULTS

The 2 titanium systems (1.5 mm and 2.0 mm) presented significantly higher tensile strength and stiffness compared with the 7 biodegradable systems (2.0 mm, 2.1 mm, and 2.5 mm). The 2.0 mm titanium system showed significantly higher side bending and torsion stiffness than the other 8 systems.

CONCLUSION

Based on the results of the current study, it can be concluded that the titanium osteofixation systems were (significantly) stronger and stiffer than the biodegradable systems. The BioSorb FX (Linvatec Biomaterials Ltd, Tampere, Finland), LactoSorb (Walter Lorenz Surgical Inc, Jacksonville, FL), and Inion (Inion Ltd, Tampere, Finland) 2.5 mm systems have high mechanical device strength and stiffness compared with the investigated biodegradable osteofixation systems. With the cross-sectional surface taken into account, the Biosorb FX system (with its subtle design) proves to be the far more superior system. The Resorb X (Gebrüder Martin GmbH & Co, Tuttlingen, Germany) and MacroPore (MacroPore Biosurgery Inc, Memphis, TN) systems present to be, at least from a mechanical point of view, the least strong and stiff systems in the test.

Diagnostic imaging in the management of craniosynostoses

Craniosynostoses are the most frequent craniofacial malformations. However, with a prevalence of 3-6 cases per 10,000 live births they are amongst the rarely seen diseases and their definite diagnosis thus poses a challenge to the physician. When an abnormal calvarial configuration is detected, a radiological evaluation is necessary to characterize the deformity and to guide the corrective surgical procedure. The demand for clear diagnostic criteria is justified by the severity of the disease and the possible consequences of delayed diagnosis. In addition to the clinical signs (deformation of the head), conventional skull X-rays show typical radiological alterations and are used for basic diagnostics. Diagnostic tests that may be performed to confirm the diagnosis and assess the extent of the problem, include computed tomography (CT), 3D-CT, magnetic resonance imaging (MRI) scans, and ultrasonography. In the present review we will describe the most important clinical and radiological characteristics of craniosynostosis by means of clinical, radiological and operative situs examples.