Diagnosis and Non-Surgical Treatment of Cranial Deformities in Children Under 2 Years of Age: Modern Methods and Approaches

Skull deformity is a structural change in the shape or size of the skull bones that can be caused by external or internal factors. It often occurs due to constant pressure on certain areas of the skull or due to impaired bone development. In children under two years of age, skull deformity often occurs due to a number of physical, physiological, and external factors that affect the flexibility of the skull bones. Since the sutures and fontanelles on the skull have not yet grown, and the bones remain soft, any prolonged or excessive pressure on the skull can lead to deformities. An important factor is the position in which the child spends most of their time: for example, when the newborn often lies on its back, this creates constant pressure on the occipital part of the skull, which can change its shape.

The uniform development of bone tissue can also be disrupted due to muscle tone. Infants with insufficient control of the neck and back muscles may experience a situation where the child cannot change the position of the head evenly, which leads to excessive pressure on one of its parts. Muscle weakness or asymmetry in tone, for example, in the case of congenital torticollis, also contributes to an uneven distribution of pressure.

Another factor is the state of intrauterine development. If the foetus is in a restricted position during pregnancy or exerts excessive pressure on the skull due to the narrowness of the uterus, incorrect position, or multiple pregnancies, this can affect the shape of the infant’s skull even before birth. There is also the influence of hormonal factors that affect the development of bone tissue. In particular, the levels of calcium and other minerals in the mother and child play an important role in bone strength, and their deficiency can reduce the density of bone structures in the skull, making it more susceptible to deformities.

External mechanical factors after birth also include prolonged exposure to car seats, baby strollers, or cribs, which can restrict natural head movements. Inappropriate care methods, such as not spending enough time on the child’s stomach, can also reduce the overall strength of the neck muscles, which increases the risk of deformities.

Types of skull deformities include both natural and artificial shape changes that can occur due to various factors. Artificial deformity of the skull, or so-called “artificial craniality”, is a modification of its shape, carried out intentionally. For this purpose, special devices are used, superimposed on the child’s head at an early age, gradually changing the shape of the skull. This type of deformity has been used in many cultures and has remained a subject of interest for anthropologists and researchers of human morphology, as it affects the modularity and overall integration of skull structures [12].

Craniosynostosis is a pathological condition in which one or more cranial sutures heal prematurely, which prevents the normal growth of the skull and leads to the development of a characteristic deformity. Depending on which suture has undergone premature fusion, the skull takes on a certain shape. For example, if the sagittal suture grows together, an elongated deformity called “scaphocephaly” occurs, and when the coronal sutures grow together, a wide and short skull structure is formed. Craniosynostosis is both an aesthetic and functional problem that requires surgical intervention to improve the shape and prevent complications [13, 14].

Positional deformity of the skull, or plagiocephaly, occurs due to constant pressure on one side of the head, often associated with the infant’s sleeping position. It causes unilateral flattening of the skull and is quite common among young children, especially after the recommendations of doctors to put the child to sleep on his back to prevent sudden infant death syndrome. Positional plagiocephaly can be corrected using positioning techniques or special orthopaedic helmets that gradually correct the shape of the skull [15]. Brachycephaly is also a positional deformity in which the skull becomes short and wide. This is conditioned by a restriction in expansion in the anteroposterior direction. It often occurs because the child is constantly lying on their back. Correction of this deformity depends on the severity, and in some cases a special corrective helmet is used to achieve a more symmetrical skull shape [16].

Crouzon syndrome is a genetic disorder characterised by premature fusion of the cranial sutures, which causes abnormalities in the development of the skull and face. Patients with this syndrome have a flat middle part of the face, hypoplasia of the orbits leading to exophthalmos, and signs such as a broad front view (frontal) part and nasal deformity [17]. Apert syndrome is a rare congenital disorder associated with premature fusion of the cranial sutures, which is accompanied by severe finger fusion (syndactyly) on the hands and feet. It is caused by mutations in the FGFR2 or FGFR3 genes, which lead to facial abnormalities, in particular, hypoplasia of the middle part of the face and specific dental and maxillary abnormalities [18].

Deforming plagiocephaly is a curvature of the shape of the skull caused by external pressure on the child’s head after birth. This is one of the most common disorders of the skull shape in children, which is associated with the risk of motor development disorders. To correct the shape of the skull, a special orthopaedic helmet can be used, which improves the appearance and motor skills of the child [19]. Trigonocephaly is characterised by a triangular head shape that occurs due to premature fusion of the metopic suture, which causes a wedge-shaped forehead and narrowing of the anterolateral part of the head. In children with this deformity, there may be an increase in intracranial pressure, which can affect the development of the nervous system. Treatment for trigonocephaly involves cranioplasty, which is usually performed before the child reaches one year of age [20].

Thus, cranial deformities can occur both for natural causes associated with developmental pathologies, and as a result of artificial exposure chosen for cultural or therapeutic reasons. Each type of deformity requires an individual approach to diagnosis and treatment.

Cranial deformities in young children are a complex medical problem that requires modern diagnostic approaches and effective treatment methods. Abnormal skull shapes can be both congenital and acquired in nature and often lead to functional disorders, such as developmental delay or cognitive impairment. Early detection of these pathologies is important to ensure proper development of the child, and modern methods of diagnosis and treatment can reduce the risk of negative consequences.

In recent years, significant progress has been made in the diagnosis and treatment of cranial deformities in children. There are many diagnostic approaches, from visual assessment to high-tech techniques such as computed tomography and magnetic resonance imaging. Therapeutic methods have also expanded significantly: along with conservative approaches, such as the use of orthopaedic helmets, surgical correction methods are actively used.

The purpose of this section is to conduct a comparative review of modern methods of diagnosis and treatment of cranial deformities in young children. The importance of analysing different approaches lies in determining their effectiveness, safety, and availability, which are key factors in choosing the right method for a particular patient. Table 2 shows a list of modern methods for diagnosing cranial deformities and their characteristics.

The latest methods for diagnosing cranial deformities are characterised by a significant variety of technical approaches and capabilities, allowing the selection of the optimal tool depending on the specifics of the case and the patient’s needs. In particular, low-dose 3D computed tomography is an important method for obtaining high-quality images of bone structures. This study allows detailed planning of surgical interventions for complex deformities, reducing radiation exposure and ensuring maximum accuracy. However, even when the radiation dose is reduced, this method still involves a certain level of radiation exposure, which may limit its use, especially for children or patients who need multiple repeated examinations.

The innovative EOS imaging method also provides high-quality images with a very low radiation dose, but allows performing diagnostics in an upright position, which allows simultaneously assessing both deformities of the skull and spine. This is especially useful for patients with complex postural disorders or for those who need a comprehensive approach to the treatment of craniocerebral abnormalities. EOS imaging, however, has some limitations in terms of the accuracy of mapping the bone structures of the skull compared to 3D CT, which may sometimes require supplementation with other methods.

Functional magnetic resonance imaging is a unique method because it provides real-time information about brain activity, helping to assess how cranial deformities can affect functional areas of the brain. This is especially important for planning surgery, when it is necessary to preserve key neural connections and not disrupt vital functions. However, functional magnetic resonance imaging (fMRI) is a technologically complex and expensive procedure that requires special equipment and qualified personnel, which can increase its cost and limit its availability for widespread use.

Another method from the MRI group is diffusion tensor imaging, which focuses on visualising the white matter pathways of the brain and can detect potential neural connection disorders caused by cranial deformities. Diffusion tensor imaging (DTI) provides an opportunity to analyse neuronal connections in detail and can be indispensable for patients with disorders affecting the nervous system. However, like fMRI, DTI is quite an expensive method and requires special equipment, which can limit its use.

Three-dimensional ultrasound provides radiation-free images of the skull and is non-invasive, making it ideal for diagnosis in infants and young children with soft bones. This is a safe method that can be repeated without risk to health. However, this method is less effective for adults, as denser bones make it difficult to get a clear image.

Optical 3D scanning, which uses light technology to create accurate three-dimensional models of the skull surface, is a fast and safe method for assessing external deformations. Its main advantage is that the method does not require a contact examination and is completely devoid of radiation exposure. However, this approach is limited to analysing only external structures, and its capabilities are insufficient to assess internal changes in the skull bones, which is sometimes important for accurate diagnosis.

As for virtual surgical planning and 3D printing, this is a modern approach that combines computer modelling and 3D printing technologies for the manufacture of individual implants and detailed planning of surgical interventions. This method provides high accuracy during operations and reduces their duration, but it requires significant financial costs and preparation time, which can complicate its implementation in clinical practice.

Stereophotogrammetry is a non-contact method that uses photographs from different angles to create three-dimensional images, helping to assess the shape and symmetry of the skull without direct contact with the patient. This is a safe and fast method of visualisation, but like optical 3D scanning, it is limited to analysing external characteristics. Among other new methods, it is worth noting ultrasound holography, which uses ultrasound waves to create holographic images of the internal structures of the skull. This method has significant potential as a safe alternative to X-ray examinations, but it is still limited in detail and requires further research and improvement to produce more accurate images.

Ultimately, 4D imaging, which combines three-dimensional imaging with time measurement, allows observing dynamic changes in the skull during movement or growth, which is important for studying the functional aspects of deformities. This method allows assessing how the skull structure changes in real time, which is useful for determining the effect of deformities on the patient’s functional capabilities. However, due to the complexity and high cost of the equipment, its use is limited to research centres and specialised clinics.

Thus, each of these methods has its own unique advantages and disadvantages, which determine the feasibility of their use depending on specific clinical needs, patient age, complexity of pathology, and availability of resources. Table 3 shows the latest methods of treating cranial deformities and their characteristics.

Methods of non-surgical treatment of cranial deformities, such as cranial remodelling orthotics, positional therapy, physical therapy, 3D-printed orthoses, dynamic orthosis therapy, laser therapy, kinesiotaping, electrical muscle stimulation, and biofeedback therapy, offer a multifaceted approach to the correction of craniofacial deformities in young children. Each method has its own advantages and limitations, which depend on the type of deformation, the degree of complexity and individual needs of the child.

Cranial remodelling orthotics using corrective helmets are effective for treating severe forms of positional plagiocephaly, brachycephaly, and scoliocephaly. This approach allows gradually correcting the shape of the skull due to light pressure on convex areas and creating conditions for growth in flattened areas. However, this method requires regular supervision by a specialist and significant financial costs, which can become an obstacle for families. Moreover, the child must always wear a helmet, which can be psychologically and physically uncomfortable. Positional therapy is a less invasive approach that uses changing the position of the child’s head to reduce pressure on flattened areas. This is a simple, economical, and safe method for mild forms of deformities that can be practised at home under the supervision of parents. However, its effectiveness is limited, especially with significant deformations, and it takes a long time to achieve a visible result. Positional therapy may be less effective for children who have already developed a significant deformity.

Physical therapy, in particular kinesiotherapy, helps to correct muscle tone and improve the child’s motor skills. This is especially true for torticollis, which often accompanies deformities of the skull. Physical exercises for the neck and shoulder girdle help to reduce asymmetry and improve overall mobility, although the effectiveness of this method depends on the regularity of training and the experience of the specialist performing the therapy. 3D-printed orthoses provide the ability to create individually customised devices that exactly match the child’s anatomy. They are easy to use and provide high correction accuracy. This method is innovative and potentially more affordable in the future due to the reduced cost of 3D printing. However, it is still technologically dependent and requires a certain level of availability of high-tech equipment.

Dynamic orthosis therapy allows adapting the device to the child’s growth, which reduces the need for frequent replacement and allows maintaining the corrective effect for a long time. This approach is convenient and cost-effective, but efficiency can be reduced in cases of complex deformations that require more effort to correct. Non-invasive laser therapy, based on stimulating cellular metabolism and improving blood circulation, is useful for mild forms of deformities. It can speed up natural correction and is safe, but has limited effectiveness for more serious deformities. This method is not yet generally accepted and requires additional research to determine its long-term effectiveness.

Kinesiotaping, which involves applying elastic tapes to correct muscle tone, helps to maintain a symmetrical head position and is an additional method to physical therapy. It is easy to use, but the effectiveness depends on the correct technique of applying tapes, which requires an experienced specialist.

Electrical stimulation of the neck and shoulder girdle muscles provides an additional corrective effect for muscle weakness, which helps to restore symmetry. This method requires professional supervision and can cause discomfort in children. Biofeedback therapy is safe and non-invasive, helping the child learn to control muscle activity, which is especially useful for older children. However, it requires a certain level of consciousness from the child, so its use is limited in children under two years of age.

Therefore, non-surgical methods of treating cranial deformity at an early age can be effective, but their choice should be based on the individual characteristics of the child, the degree of deformity and the financial capabilities of the family. Because early intervention is key, a combined approach involving multiple techniques is often the most effective, allowing for the best results without the need for surgery.

At the beginning of this study, each child underwent a comprehensive diagnosis to assess the extent of skull defects. The main purpose of this procedure was to determine the degree of abnormalities in the structure of the skull bones, which is crucial for an accurate understanding of the anatomical features and abnormalities in each child. For this survey, the latest method was chosen – optical 3D scanning, which provides the most detailed image of the object and allows for the detection of even minor changes or defects.

The use of 3D scanning to study skull defects in childhood was a real breakthrough. One of the main advantages of the method is its absolute non-invasiveness, which means no pain or discomfort for the patient. Children do not experience physical or psychological difficulties during the procedure, which makes diagnostics convenient and, most importantly, safe. In addition, the method does not use ionising radiation, which is potentially dangerous for the body, especially for children. Therefore, optical 3D scanning is ideal for surveys where a safe approach that can be repeated repeatedly is important. In addition to safety, the 3D scanning method also provides high accuracy of results, which is important for detecting the smallest defects that could go unnoticed when using conventional examination methods such as X-rays or MRI. The resulting images have a high resolution and allow forming a three-dimensional model of the skull, which reflects in detail the structure of bones, their shape, size, and possible deformations. This model gives doctors and researchers the opportunity to conduct a thorough analysis and objectively assess the situation. Another important feature of this method is the ability to store all received data in digital format. This helps to record the initial indicators for each patient, which allows conducting long-term monitoring of changes. If necessary, the latest results can be easily compared with the previous ones, assessing the effectiveness of treatment or the development of certain deviations over time. With this method, doctors can develop more personalised treatment plans tailored to the patient’s specific needs.

Overall, the choice of optical 3D scanning as the main diagnostic method in this study was conditioned by a combination of its accuracy, safety, and convenience, which is especially important for working with children. As a result of applying this method, it was possible to collect valuable data on the anatomical features of the skull in children, which is an important basis for further stages of research and development of appropriate therapeutic measures aimed at eliminating the detected defects or minimising their impact on the child’s development. The resulting images of several respondents are shown in Appendix A.

Presented 3D reconstructions of the skull of young children show different projections of the skull: top view (axial), sagittal, and frontal, which provides a comprehensive assessment of its morphology. The use of colour mapping shows the depth or degree of deviation of the surface from the reference plane, which is useful for clearer visualisation of asymmetries and deformations. The polygonal grid on the surface of the 3D model indicates the use of the triangulation method for surface reconstruction and allows quantitative measurements of craniometric parameters. Various imaging options (with a smooth surface and with a polygonal grid, with or without colour mapping) are designed to comprehensively analyse the shape of the skull and identify potential craniosynostosis, plagiocephaly, brachycephaly, scaphocephaly, and other craniofacial abnormalities. 3D models of skulls are designed to provide an objective assessment of its morphology and dynamics of the process in cases where the clinical picture is not sufficiently pronounced for visual examination. In this way, it was also possible to measure some parameters, such as anterior-posterior skull size, lateral skull size, left anterior size, right anterior size and head circumference to better illustrate the dynamics of changes, which are presented in Table 4.

Establishing standard indicators of craniometric parameters in children of the first two years of life is difficult due to the high dynamics of their growth. In general, in children under 2 years of age, AP usually increases gradually. In newborns, this size is approximately 95–110 mm and gradually increases to about 120–140 mm at the age of 2 years. It is important to consider the individual growth rate, so the size may vary slightly.

The lateral size or width of the skull in children under 2 years of age also gradually increases. On average, this parameter is 85–95 mm in newborns and can reach 120–130 mm by the age of 2 years. LA and RA are usually examined to detect skull asymmetry, although the exact norm values may vary depending on clinical data, as these measurements are more individual. Normally, both indicators should be close in size and be about half of the anteroposterior size (about 50–70 mm in children under 2 years of age). A difference of more than 5 mm between the left and right dimensions may indicate asymmetry.

Head circumference is an important parameter for monitoring the overall development of the skull. On average, the length of the head circumference in newborns is about 34–36 cm. By 6 months, it can grow up to 42–44 cm, and by 2 years – reach 48–50 cm, this is one of the main parameters indicating the overall development of the brain and skull [27, 28].

A comparison was made between subgroups of children who began therapy before 6 months and after 6 months. The results showed that children who started treatment at an earlier age (before 6 months) demonstrated significantly greater improvements in head shape compared to those who started therapy later. This aligns with established data indicating that age is a crucial factor influencing the cranial remodeling potential. Younger patients achieved faster and more substantial improvements in head shape, which also allowed for a shorter treatment duration. Specifically, children who began wearing corrective helmets before 6 months required less time to achieve the desired result compared to those who started treatment at an older age. This highlights the importance of early intervention for optimal treatment outcomes, as the cranial remodeling capacity decreases with age.

The potential for cranial remodeling is known to be highly age-dependent, with younger children exhibiting a greater ability to modify the shape of their skulls. This is due to the increased flexibility and malleability of the cranial bones in early infancy, which allows for more significant and quicker changes in head shape when non-surgical treatment methods, such as corrective helmets, are applied. As the child grows, the sutures in the skull begin to fuse and the bones harden, reducing the cranial flexibility and, consequently, the effectiveness of treatments like helmet therapy.

The timing of treatment is crucial, as initiating therapy at a younger age typically leads to faster and more substantial improvements in head shape. Children who begin treatment before 6 months of age tend to require shorter durations of therapy, as the bones are more responsive to the corrective forces exerted by the helmets. In contrast, older children may need extended periods of treatment to achieve similar results, as their cranial bones are less pliable and more resistant to change. Therefore, early intervention is key in achieving optimal outcomes, as it allows for more efficient use of the therapeutic period and enhances the chances of correcting the deformities before the skull becomes less adaptable to changes.

Given the information provided on the dynamics of skull growth in children under two years of age, the values of AP and lateral size are within the age norm. However, there is an asymmetry between LA and RA, with a difference of 9 mm exceeding the threshold value of 5 mm, which indicates the existing deformation in most respondents. The value of the head circumference is slightly lower than the average for children of 6 months, although considering individual variability, it is impossible to unequivocally state deviations from the norm without additional data, such as the age of the child and other anthropometric indicators.

Treatment of cranial deformities in children was carried out using individually made corrective helmets. The choice of corrective helmets for the treatment of cranial deformities in young children is conditioned by a number of advantages of this method. Helmet therapy is a non-invasive correction method that avoids surgical intervention and associated risks. Individual production of helmets based on 3D models of the head provides an accurate and personalised approach to treatment, considering the characteristics of each patient’s deformity. The constant but gentle pressure exerted by the helmet on certain areas of the skull effectively directs its growth, helping to correct the shape without discomfort for the child. The high effectiveness of helmet therapy has been confirmed by numerous clinical studies. In addition, this method is relatively easy to use, well tolerated by patients and allows achieving significant results in a relatively short time. Considering all these factors, corrective helmets are the optimal choice for treating cranial deformities in young children, providing safe, effective and comfortable correction.

Thus, the helmet was made based on a 3D model of the child’s head obtained by scanning. The inner surface of the helmet was modelled in such a way as to create pressure on the protruding areas of the skull and provide space for growth in the sinking zones. This directed the growth of the skull in the desired direction and gradually correct the deformity. Fixing the helmet on the child’s head was carried out using special belts and fasteners. The design of the helmet provided holes for ventilation and comfortable wearing. Regular check-ups with a doctor (every 1–2 months) helped to monitor the correction process and, if necessary, adjust the internal shape of the helmet in accordance with the dynamics of skull growth. Children wore helmets for 23 hours a day, taking them off only for an hour for hygiene procedures. The duration of treatment was 5 months.

In addition, during one of the regular examinations, parents were asked questions to assess the subjective perception of the effectiveness of treatment and the comfort of the child. Collecting such information allowed for a more complete picture of the course of therapy and considering the individual characteristics of each patient. The question of adapting to wearing a helmet and the difficulty of caring for it helps to understand how easily the child and parents have integrated the helmet into everyday life, and identify potential problems associated with its use. The question of noticeable improvements in the shape of the head allows evaluating the effectiveness of treatment from the standpoint of parents who constantly monitor the child. The subjective assessment of parents is an important addition to the objective data obtained by 3D scanning. The question of the child’s comfort when wearing a helmet helps to identify potential inconveniences and prevent the development of skin irritations or other negative consequences. Focusing on the child’s comfort during sleep, eating, and activity allows us to assess the impact of the helmet on various aspects of their daily life. The information obtained allows adjusting the mode of wearing the helmet or making changes to its design to increase the comfort of the child. Parents’ responses are shown in Table 5.

Analysis of the results of a survey of 30 parents provides valuable information about the effectiveness, safety and tolerability of this method of therapy. Positive feedback from parents confirms the clinical effectiveness of helmets and their ability to correct the shape of the skull in young children. The easy adaptation to wearing a helmet, which was reported by 67% of parents, indicates a well-thought-out design of helmets and their ergonomics. This minimises stress for both the child and parents, contributing to a positive perception of treatment. It is important to note that even in cases where adaptation took longer (27%), parents successfully overcame the initial difficulties, which underscores the importance of supporting and advising specialists at the initial stage of therapy.

A high percentage of parents (60%) who reported a marked improvement in skull symmetry is a key indicator of the effectiveness of helmet therapy. This suggests that the soft but constant pressure exerted by the helmet actually directs the growth of the skull bones in the right direction. The moderate improvement observed in 33% of children can be explained by the individual rate of development and the degree of severity of the initial deformity. In such cases, it is important to continue monitoring and adjust the treatment plan if necessary. A small number of parents (7%) who have not yet noticed significant changes emphasise the importance of realistic expectations and understanding that correction of skull deformity is a gradual process.

The high level of comfort when wearing a helmet, noted by 90% of parents, is an important advantage of this method of treatment. This contributes to good tolerance of the helmet by the child and minimises the risk of side effects such as skin irritation. In general, the results of the survey show that helmet therapy is an effective, safe, and convenient method of treating cranial deformities in young children. However, it is important to keep in mind the need for an individual approach to each patient, regular monitoring, and correction of the treatment plan if necessary.

After completing a five-month course of daily treatment with corrective helmets, repeated measurements of the patients’ cranial parameters were performed. Detailed results of these measurements are presented in Table 6. To clearly demonstrate the changes that occurred in the shape of the skull during treatment, comparative images are shown in Appendix B.

Considering the high dynamics of skull growth in children of the first two years of life, the analysis of the results of a five-month course of helmet therapy in a group of patients shows a positive trend towards correction of deformities and compliance of changes with physiological norms. There is a positive trend, which is consistent with the physiological growth standards of children of this age range. The increase in the anterior-posterior size from 129 mm to 142 mm fits within the age norm (120–140 mm for children under 2 years of age), which indicates that there is no negative effect of helmets on the natural growth of the skull. A similar situation is observed with the side size, which increased from 123 mm to 129 mm, which also corresponds to the standard indicators (120–130 mm). The key result of therapy is a significant reduction in the asymmetry between LA and RA from 9 mm to 3 mm. This not only digitally demonstrates the corrective effect of helmets, but is also clinically significant, since a difference of less than 5 mm is considered normal. Thus, helmets not only do not interfere with the growth of the skull, but also actively contribute to its harmonisation. An increase in head circumference from 41.5 cm to 43.5 cm is also an important marker of adequate development. Considering the age of patients at the time of the second measurement (approximately 7–8 months), this indicator correlates with the standard values of 42–44 cm for 6-month-olds. This suggests that helmet therapy does not inhibit brain development and does not interfere with the normal growth of the skull. However, despite the positive averages, it is important to keep in mind individual variability and the need for a personalised approach to each patient.

Thus, the study demonstrated that optical 3D scanning is an effective, safe and accurate method for diagnosing cranial defects in young children. The use of individually made corrective helmets based on the obtained 3D models significantly improved the shape and symmetry of the skull during five months of treatment. Most parents noted the easy adaptation of children to helmets and a high level of comfort when wearing them. The results of measurements after therapy indicate positive dynamics of skull growth, which correspond to age norms, and confirm the effectiveness of a personalised approach in correcting cranial deformities in children.