Oral Maxillofacial Surg Clin N Am 16 (2004) 439 – 446

Positional plagiocephaly: evaluation and management

John Caccamese, DMD, MDa, Bernard J. Costello, DMD, MDb,
Ramon L. Ruiz, DMD, MDc,*, Ann M. Ritter, MDd
a
Department of Oral and Maxillofacial Surgery, University of Maryland Medical System, 419 West Redwood Street,
Suite 410, Baltimore, MD 21043, USA
b
Department of Oral and Maxillofacial Surgery, University of Pittsburgh Medical Center, Magee-Women’s Hospital,
Children’s Hospital of Pittsburgh, 3471 Fifth Avenue, Suite 1112, Pittsburgh, PA 15213, USA
c
Oral and Maxillofacial Surgery/Pediatric Craniofacial Surgery, Southwest Florida Oral and Facial Surgery,
5285 Summerlin Road, Suite 101, Fort Meyers, FL 33919, USA
d
Department of Pediatric Neurosurgery, Children’s Hospital of North Carolina, University of North Carolina at Chapel Hill,
148 Burnett-Womack Building, Chapel Hill, NC 27599, USA

Plagiocephaly is a clinically descriptive term for
an oblique or asymmetric head shape that does not
imply a definitive diagnosis. Throughout the scien-
tific literature, however, plagiocephaly frequently has
been used broadly to describe asymmetries of the
anterior or posterior cranial vault, often without
differentiating between synostotic (ie, fused sutures)
and nonsynostotic (ie, patent suture) deformities [1].
Understanding the heterogenous nature of plagio-
cephaly is critical because treatments vary dramati-
cally depending on the specific underlying diagnosis.
Depending on the specific cause of the cranial vault
deformity, the required management may range from
observation to more extensive intervention, including
major surgery for reconstruction of the cranial vault.
Congenital anomalies may be classified into sev-
eral basic categories: (1) malformations, which result
during embryogenesis (eg, craniosynostosis) and are
morphologic defects of an organ, part of an organ, or a
larger area of the body that result from an intrinsically
abnormal developmental process, (2) deformations,
which occur later in fetal life or postnatally and are
alterations in the form or position of a previously nor-
mally formed structure secondary to nondisruptive me-
* Corresponding author.
E-mail address: pedmaxillofacial@aol.com (R.L. Ruiz).
chanical forces (eg, positional plagiocephaly), and (3)
disruptions, which are morphologic defects of an
organ or part of an organ that result from the
breakdown or interference with an originally normal
structure (eg, amniotic band disruptions) [2].
During the first 2 years of life, brain growth oc-
curs at a rapid rate. In the newborn, the presence of
open cranial vault sutures (eg, metopic, coronal,
sagittal, and lambdoid) creates a flexible complex of
cranial bones that allows the brain to expand. This
flexibility of the cranium, which allows unrestricted
brain development, also may permit the cranial vault
to be deformed. ‘‘Positional plagiocephaly’’ is
defined as a cranial vault asymmetry in the presence
of patent cranial vault sutures. This type of skull
molding or deformational plagiocephaly is commonly
seen in neonates and infants, and previous intra-
uterine constraint, the birthing process, or repetitive
sleep positioning all can contribute to the severity of
the cranial vault asymmetry. In contrast, craniosynos-
tosis is a malformation that occurs almost universally
during fetal development and is defined as the pre-
mature fusion of a cranial vault suture or sutures that
results in arrested skeletal growth and a head shape
abnormality. The different forms of craniosynostosis
each produce unique craniofacial dysmorphologies.
Clinicians must be able to differentiate between
the dysmorphic craniofacial patterns produced by

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440 J. Caccamese et al / Oral Maxillofacial Surg Clin N Am 16 (2004) 439 – 446
these different causes. This article presents the current
diagnostic approach, differential diagnosis, and treat-
ment options for positional plagiocephaly.
Incidence and etiology of positional plagiocephaly
During the first few days of life, cranial molding
that resulted from the passage of the child’s head
through the birth canal or early decent into the
mother’s pelvis is frequently noted. This asymmetry
usually resolves spontaneously within the first sev-
eral weeks of life in most infants. No treatment is
required other than routine observation during well-
baby check-ups.
Another group of children demonstrates normo-
cephalic morphology after birth but subsequently
develops cranial vault asymmetry during early post-
natal development. This positional plagiocephaly is
the result of postnatal external forces, usually from
repetitive sleep positioning, that act on a flexible
cranium. Previous reports have estimated the inci-
dence of positional plagiocephaly as low as 1:300 and
as high as 1:2 infants under the age of 1 year [3,4]. In
contrast, the incidence of lambdoid suture cranio-
synostosis, which also produces posterior plagio-
cephaly, is approximately 1:150,000 live births [2].
Unilateral coronal craniosynostosis is another rele-
vant condition because it produces anterior cranial
vault asymmetry that may be confused with deforma-
tional changes. It has a relative incidence of approxi-
mately 1:10,000 live births [5].
In 1992, the American Academy of Pediatrics
started the ‘‘Back to Sleep’’ campaign, which
recommended that infants be placed on their sides
or backs during sleep to reduce the risk of sudden
infant death syndrome (SIDS) [6]. Since instituting
the campaign in 1992, the incidence of SIDS has
decreased by 40%. At the same time, however, a
significant increase in the number of children referred
for management of posterior plagiocephaly without
synostosis was observed [7]. Early on, several centers
reported a sudden increase in the number of unilateral
lambdoid ‘‘synostosis’’ cases being seen. Later, it was
realized that the increased number of referrals was
actually repetitive sleep positioning that caused non-
synostotic posterior plagiocephaly [1,7].
Positional preference also has been recognized as
a significant contributor to cranial asymmetry since
the early 1990s. Positional preference merely refers to
an infant or child’s preference in maintaining the head
turned to one side most of the time. Active move-
ments of the head to the opposite side are few, and
passive mobility may be limited. Positional prefer-
ence may be associated with torticollis, ocular con-
ditions, scoliosis of infancy, limited abduction of the
contralateral hip, and foot abnormalities [8].
In a recent study performed in the Netherlands that
involved a large cohort of patients, the prevalence of
positional preference was noted to be 8.2% and was
seen most commonly in children younger than 16 weeks
of age. First-born children, premature children, and
breech positioned infants were at the highest risk for
positional preference. Supine sleeping positioning
and repetitive positioning during feeding were posi-
tively correlated with positional preference [8].
Another potential contributing factor to positional
plagiocephaly is congenital muscular torticollis
(CMT). CMT is an abnormal head tilt that results
from congenital tethering of one of the sternocleido-
mastoid muscles. The result of this unilateral muscu-
lar problem is a persistent aberrant head position that
causes skull molding and asymmetry, which affect
the anterior or posterior cranial vault. One theory
regarding the cause of CMT has proposed that late
intrauterine constraint leads to venous occlusion and
damage of the sternocleidomastoid muscle [9,10].
This insult generally results in unilateral fibrosis and
shortening of the sternocleidomastoid muscle. Other
suggested causes include intrinsic malformations or
‘‘pseudo-tumors’’ of the sternocleidomastoid muscu-
lature, neurologic disorders, and hemiatrophy/hyper-
trophy [9,10]. Whatever the cause, the fetal head is
molded while obliquely compressed by the muscle
tethering. Consequently, contralateral deviation of the
chin, lateral neck flexion, and decreased range of
motion are frequently noted on examination. In
infants in whom CMT is severe, the cranial asym-
metry becomes more pronounced in the first few
months of life as the infant’s head is maintained in a
relatively fixed position.
On physical examination, head tilt, limited neck
range of motion, and contralateral facial flattening
should be noted. Persing et al [4] recommend the
rotating chair test to aid in making the diagnosis of
CMT associated with positional plagiocephaly. To
perform this test, the examiner holds the infant while
the parent keeps the infant’s interest. The examiner
rotates in the chair and observes the infant’s range of
neck motion. The difference in neck mobility toward
and away from the affected side may aid in making
the diagnosis of CMT [1].
Slate et al [11] noted asymptomatic cervical spine
subluxations in half of their study population with
CMT. This finding coincided with a 62% rate of
difficult or breech deliveries. Whether these findings
were the result of birth trauma or unfavorable
intrauterine positioning was not clear.
 J. Caccamese et al / Oral Maxillofacial Surg Clin N Am 16 (2004) 439 – 446
Other researchers have suggested a less severe
variant of CMT called sternocleidomastoid imbal-
ance, in which the position of the neck is not fixed
but only intermittently tilted with a normal range of
motion attributable to a weakened sternocleidomas-
toid. This condition may be more common than
CMT and more amenable to physical therapy [12].
If left untreated, however, the resultant head defor-
mity remains the same. When positional plagio-
cephaly is associated with CMT, it is imperative
that it be recognized and addressed early. Cervical
spine anomalies and extraocular muscle disorders
must be ruled out, and appropriate physical therapy
is undertaken at an early age.
Diagnosis
Routine surveillance of an infant’s head shape
should be incorporated into periodic well-child visits
during the first year of life [1]. The presence of a
cranial vault asymmetry during the early postnatal
period should alert the examiner to the possibility of
craniosynostosis. Early referral to a craniofacial or
neurosurgical specialist is indicated when there is a
persistent cranial asymmetry or a skeletal pattern
consistent with synostosis. Understanding the differ-
ences between craniosynostosis and positional pla-
giocephaly is important, because craniosynostosis
usually requires surgical reshaping of the cranial
vault to increase intracranial volume and correct the
dysmorphic shape. Conversely, positional plagio-
cephaly is a disorder that does not require surgery
in most cases. A diagnostic dilemma for pediatricians
frequently occurs because the two conditions may
seem to have similar morphologic features. As a
result, an important initial step in the management
of abnormal head shape is the determination of an
accurate diagnosis separating synostotic from non-
synostotic plagiocephaly.
Diagnosis of positional plagiocephaly primarily is
based on a thorough history and physical examination
and is confirmed radiographically. History taking
should include details of the parental medical history
and family history, the antenatal and birth histories of
the child, giving consideration to any exposures or
complications of the pregnancy, and a current medical
history for the infant. A detailed history often
provides information that strongly suggests the
diagnosis even before the actual clinical evaluation.
For example, when an infant presents with positional
plagiocephaly, parents frequently report that the
child’s head shape was well rounded at the time of
birth and the asymmetry subsequently developed
441
during the first 3 to 6 months of life. By contrast,
patients with craniosynostosis-related plagiocephaly
have a history of cranial deformity noticed immedi-
ately or shortly after birth. This significant difference
is consistent with the fact that craniosynostosis is an
intrauterine event, with the deformity starting during
fetal development, and plagiocephaly secondary to
repetitive positioning occurs only after external forces
have had ample time to mold the cranium during
early postnatal growth.
Infants with positional posterior plagiocephaly
frequently present with a characteristic, recognizable
cranial vault morphology that is highly suggestive, if
not diagnostic, for the condition. Examiners who are
familiar with the specific asymmetry typically en-
countered in positional plagiocephaly are able to dif-
ferentiate it from the dysmorphic pattern associated
with lambdoid suture craniosynostosis (Figs. 1 and 2).
On clinical examination, patients with benign posi-
tional skull molding (ie, positional plagiocephaly)
exhibit occipitoparietal flattening on the side of the
posterior cranial vault affected by external forces
(eg, repetitive sleep positioning). At the same time,
ipsilateral frontal bossing and anterior displacement
of the ear on the affected side are found. The mor-
phologic pattern is consistent with a flexible cranial
Fig. 1. Illustration of cranial vault dysmorphology character-
istic of posterior positional plagiocephaly. Postnatal external
forces, such as repetitive sleep positioning, cause unilateral
occipitoparietal flattening. Because the sutures are open and
the cranial vault complex is flexible, all of the structures on
the affected side are displaced anteriorly. Additional findings
include ipsilateral frontal bossing and forward displacement
of the ear. The outline of the cranial vault, as viewed from
above, develops a form that resembles a parallelogram.
442 J. Caccamese et al / Oral Maxillofacial Surg Clin N Am 16 (2004) 439 – 446
Fig. 2. Bird’s-eye view of a child with benign positional
skull molding (ie, positional plagiocephaly) secondary to
repetitive sleep positioning. Three key findings are present
on clinical examination: unilateral occipitoparietal flatten-
ing, ipsilateral frontal bossing, and ipsilateral forward
displacement of the ear.
vault that allows forward movement of all structures
on the side subjected to external deformational forces.
The head shape associated with positional plagio-
cephaly has been described as having a parallelo-
gram deformity when examined from above (bird’s-
eye view) [13]. By comparison, the cranial vault de-
formity seen with lambdoid suture craniosynostosis is
characterized by distinctly different features (Fig. 3,
Table 1). When a lambdoid suture is absent, there is
arrested skeletal growth across the affected occipital
and parietal bones, which also results in significant
flattening or posterior plagiocephaly, but that is where
the similarities to positional plagiocephaly end. In
lambdoid synostosis, the arrested growth causes
retraction of the ipsilateral forehead. The cranial base
involvement seen in synostosis also causes posterior-
inferior displacement of the ipsilateral ear. Because
of compensatory growth that occurs at the sutures
that remain open, contralateral frontal bossing is seen.
From bird’s-eye view, the deformity is often de-
scribed as having a trapezoidal shape (Fig. 3).
Although the diagnosis of positional plagio-
cephaly primarily is made on the clinical evaluation
of the presenting dysmorphology, confirmatory radio-
graphic studies are required. After careful clinical
examination is performed, a complete skull series of
plain radiographs is usually sufficient to establish
definitively the diagnosis and exclude the possibility
of craniosynostosis (Fig. 4). A diagnostic, high-
quality study permits adequate visualization of all su-
Fig. 3. Illustration of cranial vault dysmorphology character-
istic of posterior plagiocephaly secondary to unilateral
lambdoid suture craniosynostosis. In this example, arrested
development across the right lambdoid suture causes flat-
tening of the occipital and parietal bones. The lack of cranial
growth on the affected side also produces retraction of the
forehead on the right (ipsilateral) side, and the right ear is
displaced posteriorly and inferiorly when compared with the
left. Compensatory overgrowth also occurs at the sutures
that remain open, which causes contralateral frontal bossing.
From a bird’s-eye view, the cranial vault may take on the
shape of a trapezoid.
ture areas to establish that the cranial vault sutures are
patent. In cases in which plain radiographic images
do not permit conclusive evaluation of the sutures,
the use of a complete craniofacial CT scan is indicated
(Fig. 5). CT evaluation allows a more detailed view of
the suture regions and provides additional informa-
tion about the three-dimensional skeletal morphology.
Such detailed studies are used more commonly for
surgical planning in patients with surgical problems
(ie, synostosis) but may also be of value in cases of
Table 1
Nonsynostotic versus synostotic plagiocephaly
Positional plagiocephaly Lambdoid synostosis
Occipitoparietal flattening Occipitoparietal flattening
Ipsilateral frontal bossing Ipsilateral frontal flattening
Forward displacement of Posterior displacement of
the ipsilateral ear the ipsilateral ear
No bony ridging Bony ridging along involved
suture region
 J. Caccamese et al / Oral Maxillofacial Surg Clin N Am 16 (2004) 439 – 446 443

Fig. 4. (A – D) A complete skull series of plain radiographs is frequently adequate imaging for confirmation of the diagnosis of
positional plagiocephaly. Diagnostic films provide a clear view of all open major cranial vault suture regions.

suspected positional plagiocephaly, in which the plain
film study results are equivocal.
In addition to confirming the status of the cranial
vault sutures, radiographic imaging studies also
provide insights regarding the morphology of the
cranial base. Lo et al [14] detailed changes in the
endocranial base seen in unilateral coronal and uni-
lateral lambdoid synostosis and compared them to
those of skull molding. They made the observation
that the endocranial base of infants with craniosyn-
ostosis was likely to deviate from the 0°- to 180°-
anteroposterior axis by more than 7° toward the
affected suture, whereas this was not the case in po-
sitional plagiocephaly.
Although current radiographic imaging techniques
have become increasingly refined, allowing for
detailed visualization of the cranial anatomy (includ-
ing the sutures), wide variation remains regarding the
radiographic descriptions used for positional plagio-
cephaly and craniosynostosis. At some medical
centers, radiologists continue to use outdated and
confusing terminology, such as ‘‘fibrous synostosis’’
or ‘‘impending synostosis,’’ to describe cranial vault
sutures that otherwise appear patent on a radiograph
or CT scan. The idea is that the suture appears
radiographically normal but somehow will demon-
strate abnormal physiology. We know that the
premature fusion of cranial vault sutures (ie, cranio-
synostosis) is an intrauterine event that is present at
birth when it occurs. Unfortunately, some centers still
use this type of inappropriate terminology, which has
an impact on the clinical decision making related to
patients with abnormal head shape. The result may be
confusion among health care providers and even
surgical intervention for a patient with a nonsurgical
problem (ie, positional plagiocephaly). As recently as
the 1990s, posterior positional plagiocephaly was
misdiagnosed frequently and treated inappropriately
as unilateral lambdoid synostosis. This was realized
at many centers with increasing numbers of lambdoid
synostosis cases being treated and what some sur-
geons termed ‘‘functional lambdoid synostosis’’ when
the histopathologic diagnosis did not support true
synostosis [11,13]. From a chronologic standpoint,
444 J. Caccamese et al / Oral Maxillofacial Surg Clin N Am 16 (2004) 439 – 446

Fig. 5. (A – D) Complete craniofacial CT scan with three-dimensional reconstructions for evaluation of a cranial vault asymmetry.
The study reveals that all of the cranial vault sutures are open, which rules out craniosynostosis. CT imaging provides the
most detailed view of the sutures and quantitative data about the cranial vault morphology.

this activity coincided with the initiation of the
American Academy of Pediatrics’ ‘‘Back to Sleep’’
campaign. We know that the cranial asymmetry of
unilateral lambdoid synostosis is distinct from that of
posterior positional plagiocephaly; perhaps more im-
portantly, we recognize positional plagiocephaly as a
nonsurgical problem in most patients [1,6,7,13 – 19].
Treatment
The treatment of positional plagiocephaly is
generally nonsurgical. If craniosynostosis is con-
firmed, then reconstruction of the cranial vault to
increase intracranial volume and establish a more
normal morphology is completed using a team ap-
proach with a pediatric neurosurgeon and pediatric
craniofacial surgeon. Positional plagiocephaly does
not result in restriction of brain growth. As a result,
there are no associated negative functional neurologic
consequences, so operative intervention is not indi-
cated. Despite the lack of neurologic insult, there
may be a significant skeletal deformity that must
be addressed.
When the degree of skeletal asymmetry is mild
and is detected early in life, providing parental in-
struction about alternating head movements and
avoiding repetitive positioning is usually the most
appropriate initial measure. Parents are instructed to
monitor and encourage frequent changes in their
children’s head position throughout the course of the
day and avoid repetitive sleep positioning. Reposi-
tioning of a baby’s head while in carriers and car seats
is an important component of this regimen. Parents
are also taught to lay infants down to sleep in the
supine position and alternate the right and left
occipital regions. When awake, children should be
fed from the right and left sides to discourage the
 J. Caccamese et al / Oral Maxillofacial Surg Clin N Am 16 (2004) 439 – 446
development of a voluntary position preference.
Supervised ‘‘tummy time’’ should be encouraged
once infants are capable of lifting their head and have
acceptable arm strength. Generally, these guidelines
should be followed until the physician is confident
that the deformity is improving or until infants are
sitting and crawling consistently and spending less
time on their back.
Infants who present with positional skull molding
and moderate to severe plagiocephalic skull defor-
mity benefit from treatment with a custom-made cra-
nial orthotic device (Fig. 6). Orthotics are of two basic
varieties: (1) custom-fitted molding helmets that
facilitate passive cranial reshaping and (2) dynamic
or ‘‘active’’ orthotic cranioplasty devices that use
the growth potential of the brain and skull and mild
constrictive forces to mold the cranial skeleton (eg,
DOC Band, Cranial Technologies, Tempe, Arizona;
STAR Band, Orthomerica, Newport Beach, Califor-
nia). Clarren et al [9] first reported the use of custom
helmet therapy for infants with CMT and positional
plagiocephaly. Others have since described the use of
‘‘dynamic’’ and passive devices with similar efficacy
[15,19 – 21]. The idea is to apply direct pressure or
limit further growth and deformity in the areas of
frontal and occipital prominence, while the helmet is
relieved over adjacent flattened areas to allow for
ongoing brain growth to drive cranial vault expansion
and remodeling. Physicians recommend that the
orthotic be worn for 22 to 23 hours a day to obtain
Fig. 6. A child with positional plagiocephaly undergoing
nonsurgical treatment with the use of a custom-made cranial
orthotic device.
445
maximal improvement in cranial shape. Progress is
followed weekly by an orthotist or physical therapist,
at which time skull growth and incremental correc-
tion of the deformity are evaluated. The inner lining
is modified accordingly or, in situations that involve
rapid growth or correction, a new band is fabricated.
The greatest benefit from the use of custom-made
cranial orthotic devices is achieved when they are
used before 1 year of life and ideally when they are
initiated before 6 months of age [22]. This benefit
arises because of the propulsive rate of brain growth
during this period, which drives outward expansion
and remodeling of the cranial vault. Usually, a cranial
orthotic is used for a 4-month period before the child
outgrows it and the band loses its ability to effect
cranial morphology. Because the speed of brain
expansion slows down after 1 year of life, treatment
performed between 12 and 18 months of age usually
is associated with diminished reshaping. By the time
a child is 18 to 24 months old, the benefit of cranial
orthotic treatment is limited, and after 24 months,
minimal to no changes are likely.
Cranial orthotic devices produce the most signifi-
cant improvements in the position of the cranial vault
segments to round out the shape of the head. Changes
in auricular position are more limited, and even
patients who achieve excellent correction of the cra-
nial shape often demonstrate persistent asymmetry in
their ear alignment and position. The same is true
when an underlying skull base asymmetry is noted.
Successful management of positional plagio-
cephaly requires that any contributing factors be
addressed at the same time that the cranial asymmetry
is treated. In patients with CMT, simultaneous
physical therapy and parent-directed exercises are
prescribed. If a patient demonstrates an abnormal
head tilt that is related to extraocular muscle im-
balance or cervical spine anomalies, then pediatric
ophthalmologic consultation and pediatric neurosur-
gical evaluation are undertaken, respectively.
Surgical treatment of infants with positional
plagiocephaly is not undertaken. In rare instances, a
child with an untreated skull deformity demonstrates
severe residual asymmetry after cranial growth is
finished. Fortunately, this is a rare occurrence and
usually is associated with a previous history that
involves repetitive positioning for prolonged periods
of time. For example, a child with a complicated
medical situation and history of prolonged bed rest
during early life may have developed a severe skull
asymmetry that went untreated. Although these
residual deformities do not affect brain function,
they may be severe and cause significant negative
psychosocial consequences. Surgical intervention is
446 J. Caccamese et al / Oral Maxillofacial Surg Clin N Am 16 (2004) 439 – 446
undertaken with a combined pediatric neurosurgical
and pediatric craniofacial approach similar to that
used in the management of craniosynostosis.
Summary
Plagiocephaly is the result of many causes.
Clinicians must be well versed in the differential
diagnosis of plagiocephaly to determine if treatment
should be surgical or nonsurgical. Craniosynostosis
is a fetal malformation and should be diagnosed
and treated relatively early in a child’s life with
cranio-orbital decompression and reshaping. Posi-
tional plagiocephaly is a nonsynostotic condition in
which there is a deformation of the cranial vault in
the presence of otherwise open, normally function-
ing sutures. The reported incidence of positional
plagiocephaly has increased with the implemen-
tation of ‘‘Back to Sleep’’ guidelines for the pre-
vention of SIDS. Pediatricians also have maintained
an increased awareness of the importance of early
referral for evaluation of abnormal head shape during
infancy. Positional plagiocephaly is a cranial vault
deformation in the presence of open cranial vault su-
tures with no negative neurologic consequences. A
distinct morphologic pattern and patent cranial su-
tures noted on confirmatory radiographic studies dis-
tinguish positional plagiocephaly from abnormal head
shapes secondary to craniosynostosis. Management
consists of conservative (nonsurgical) means, depend-
ing on the extent of the cranial asymmetry and any
contributing etiologic factors.
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