***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective We defined parameters that could differentiate between positional and synostotic plagiocephaly and defined a diagnostic chart for decision making . Design Prospect i ve study . Setting We examined 411 children with non-syndromic skull abnormalities between January 2011 and December 2012 . Participants A total of 8 infants under 1 year of age with proven unilateral non-syndromic lambdoid synostosis ( LS ) and 261 children with positional deformity were examined to outline the specific clinical features of both diagnoses . After clinical examination , an ultrasound revealed either a closed suture suggestive of LS or a patent lambdoid suture suggestive of positional deformity . For patients with synostosis , plain radiographs , MR imaging and follow-up examinations were performed . In cases of open sutures , only follow-ups were completed . Main outcome measure Clinical , imaging , genesis and treatment differences between positional plagiocephaly and LS . Results In all 8 cases of unilateral LS and 258 cases of positional plagiocephaly , the diagnosis was established by clinical examination alone . In three cases of positional plagiocephaly , diagnosis was determined after an additional ultrasonography . MR imaging revealed a unilateral tonsillar herniation in five of the eight children with LS and hydrocephalus in one child . Conclusions We have suggested a list of clinical features that specify the underlying cause of posterior plagiocephaly . An additional ultrasound scanning confirmed the diagnosis without any risks of ionising radiation or sedation as in a CT scan Deformational plagiocephaly , cranial asymmetry secondary to positioning , continues to be a leading cause of head shape abnormalities in infants . Treatment recommendations include nonintervention , positioning therapies , and helmet therapy . Although most agree that surgical intervention is rarely indicated , the ideal therapy is not agreed on . Some even debate the necessity of treatment , especially third-party payers . The purpose of this prospect i ve study is to use an objective outcome analysis tool , computerized tomography , to assess the efficacy of a soft shell helmet therapy .  Sixty-nine children with a diagnosis of deformational plagiocephaly were enrolled in this study to assess the success of a soft shell helmet for the correction of cranial asymmetry .  Computed tomography scanning was done before therapy and 6 months after the initiation of therapy . Three-dimensional reconstructions of these scans were reformatted into a st and ardized orientation by utilizing the nasion ( radix ) , frontozygomatic suture lines , and posterior aspect of the foramen magnum . Intracranial volumes were calculated on a quadrant basis , and asymmetry was evaluated with regard to the hemispheres ( left versus right ) and the posterior quadrants . Thirty-four children ( 27 boys and 7 girls ) completed the study protocol . The side involved was the right in 62 % of cases and the left in 38 % . Mean age at the initial scan was 6.3 months , and mean age at the follow-up scan was 14 months . Mean duration of helmet therapy  was 7 months . Compliance with therapy was average to above average in 88 % of the children and poor in 12 % . There was a 36 % to 54 % improvement in asymmetry in the compliant patients over the 6-month study period . Soft shell helmet therapy is an effective technique to decrease cranial asymmetry based on objective outcome measurements . Additionally , it is cost-effective , with the total cost of therapy for the helmet and office visits ranging from $ 600 to $ 700 . This therapy compares favorably with other more expensive and time-consuming therapies that have been reported in the literature Cranial asymmetries due to nonsynostotic deformation of the skull have been reported with increasing frequency during the last decade . Conservative approaches using helmets and physiotherapy have been shown to be effective in their treatment . Traditionally , documentation has been carried out using anthropometric caliper measurements . The present study evaluates the use of a new three-dimensional photographic system in the improved validation of changes in head deformities . This prospect i ve analysis introduces a new technique for digital anthropometric measurement . The study series comprised 181 children with nonsynostotic head deformities .  Three-dimensional photographs were obtained before and after treatment with an orthotic helmet device . The oblique head diagonals and head width and length were measured from three-dimensional photographs using 3dMD customer software . The cranial vault asymmetry index , cranial vault asymmetry , and cranial index were compared before and after treatment . The measurements obtained on three-dimensional images were able to demonstrate significant improvement in early infant cranial deformity after treatment with an orthotic helmet . The cranial vault asymmetry index in plagiocephaly was reduced by 7.16 % , and cranial vault asymmetry was reduced by 0.86 cm . The cranial index in brachycephaly decreased by 7.32 % . In children with combined plagiocephaly and brachycephaly , the cranial vault asymmetry index improved by 5.77 % , cranial vault asymmetry improved by 0.71 cm , whereas the cranial index changed by 5.48 % . Three-dimensional photogrammetry can support treatment control in patients with deformational plagiocephaly . This new technology offers several advantages such as easy acquisition of images , detection of l and marks without patient movement , repeatable measurements without patient discomfort , and the opportunity for unbiased evaluation . Abbreviations : CVAI , cranial vault asymmetry index ; CVA , cranial vault asymmetry ; CI , cranial Background The child with posterior plagiocephaly may have positional molding or unilateral lambdoid synostosis . Molding responds to conservative treatment , lambdoid synostosis requires surgical reconstruction . CT is diagnostic , but uses ionizing radiation , may need sedation , and the incidence of lambdoid fusion is only 2–3 % . Objective The purpose of this prospect i ve study was to evaluate  ultrasound  as a screening test of lambdoid sutural patency using CT as the reference st and ard . Material s and methods In total , 41 children having head CT examinations were enrolled over 6 months . Of those , 29 were referred for abnormal head shape and suspected synostosis , of whom two had lambdoid fusion ; 12 were referred for indications not related to head shape and found to have a normal study .  Ultrasound scanning and interpretation of the lambdoid sutures was performed blinded to the CT reference st and ard . The lambdoid suture was read as patent or fused if a hypoechoic gap could or could not be seen between the hyperechoic calvarial bones , respectively . Results The mean sensitivity and specificity of ultrasound in distinguishing a patent from fused lambdoid suture by three blinded pediatric radiologists was 100 % and 89 % , respectively . Conclusions Sonography of the lambdoid sutures shows excellent preliminary promise as a screening test of lambdoid sutural patency Objective Unilateral positional plagiocephaly is the most common deformity of the head in infants . As part of a prospect i ve controlled clinical study , the pathomorphology of the positional plagiocephaly in early infancy was examined . The goal was to use noninvasive three-dimensional ( 3D ) imaging to generate , for the first time ever , a st and ard data base of infants without head deformities , to quantify the asymmetry of the positional plagiocephaly , and to evaluate the effectiveness of functional growth control using head orthesis . Patients and methods In the present study , 3D soft-tissue data of the entire head were collected from a total of 40 infants : 20 with positional plagiocephaly ( 6.0 ± 0.97 months ) and 20 infants without a head deformity ( 6.4 ± 0.3 months ) . Functional growth was controlled using a custom-made head orthesis . To evaluate the therapy , pre- and posttherapeutic scans were evaluated in three dimensions . Results Compared with the control group , infants with positional plagiocephaly demonstrated a reduced maximum length of the head , an increased head height , a shift in the ear axis as well as asymmetric anterior and posterior volumes of the neurocranium in lateral comparisons . Therapy using head orthesis led to a significant improvement of the asymmetry , with a reduction of the diagonal difference and an adjustment of the posterior volumes . Conclusion Conservative growth control of extrinsically deformed infant skulls represents an interdisciplinary medical expansion of the orthodontic therapeutic spectrum . To prevent potential effects of positional plagiocephaly on the viscerocranium , head orthesis therapy is advisable in infancy . ZusammenfassungZielDer einseitige lagerungsbedingte Plagiozephalus ist die häufigste Kopfdeformität i m Säuglingsalter . I m Rahmen einer prospektiv kontrollierten klinischen Studie wurde die Pathomorphologie des Lagerungsplagiozephalus i m Säuglingsalter untersucht . Ziel war es , durch Einsatz der nichtinvasiven dreidimensionalen Bildgebung erstmals eine Norm date nbank von Säuglingen ohne Kopfdeformitäten zu generieren , die Asymmetrie des Lagerungsplagiozephalus zu quantifizieren und die Effektivität der funktionellen Wachstumssteuerung mittels Kopforthese zu evaluieren . Patienten und Method ikInsgesamt wurden von 40 Säuglinge ( 20 Säuglinge mit Lagerungsplagiozephalus : 6,0 ± 0,97 Monate , 20 Säuglinge ohne Kopfdeformität : 6,4 ± 0,3 Monate ) die 3D-Weichteil date n des gesamten Kopfes erhoben . Die funktionelle Wachstumssteuerung erfolgte mittels individuell angefertigter Kopforthese . Zur Evaluation der Therapie wurden die prä- und posttherapeutischen Scans dreidimensional ausgewertet . ErgebnisseSäuglinge mit Lagerungsplagiozephalus  wiesen gegenüber der Kontrollgruppe eine reduzierte maximale Kopflänge , eine vergrößerte Kopfhöhe und eine Verschiebung der Ohrachse auf sowie i m Seitenvergleich asymmetrische anteriore und posteriore Volumina des Neurokraniums . Die Therapie mittels Kopforthese führte zu einer signifikanten Verbesserung der Asymmetrie mit Reduktion der Diagonalendifferenz und Angleichung der posterioren Volumina . SchlussfolgerungDie konservative Wachstumssteuerung des extrinsisch deformierten Säuglingsschädels stellt eine interdisziplinäre medizinisch-relevante Ausweitung des kieferorthopädischen Spektrums dar . Um potenzielle Folgen des Lagerungsplagiozephalus auf das Viszerokranium zu verhindern ist eine Kopforthesentherapie i m Säuglingsalter angezeigt Appropriate management of posterior plagiocephaly requires differentiation of occipitoparietal flattening caused by lambdoid synostosis from that caused by deformational forces . In a 2 1/2-year prospect i ve study of 115 infants presenting with unilateral posterior cranial flattening , only one child had synostotic posterior plagiocephaly ( lambdoid synostosis ) , whereas 114 infants had deformational posterior plagiocephaly . Deformational occipitoparietal flattening was more common on the right ( 61 percent ) than on the left ( 30 percent ) , and minor contralateral frontal flattening was not unusual ( 52 percent ) . The ipsilateral ear was anteriorly displaced in virtually all infants ( 97 percent ) . Some infants had ipsilateral torticollis ( 19 percent ) ; a few had contralateral torticollis ( 8 percent ) . Gender ratio was 3:1 , male : female . A total of 114 infants with deformational posterior plagiocephaly were treated conservatively either by head positioning in the crib ( n = 63 ) or with a molding helmet ( n = 51 ) . Outcome was assessed by pretreatment and posttreatment anthropometry on 53 of these infants , who were either positioned ( n = 17 ) or helmeted ( n = 36 ) . Improvement occurred in 52 of 53 patients ( mean follow-up 4.6 months ) , i.e. , the difference in length between the long and short transcranial axis diminished in 52 infants ( mean 1.2 to 0.7 cm ) , did not progress in any child , and was unchanged in one infant . At an average age of 10 months , posterior cranial symmetry was better in infants treated with a helmet ( mean difference 0.6 cm ) than in those managed by positioning ( mean difference 1.0 cm ) ( p < 0.001 ) . Age at initiation of helmet therapy ( from 2 to 9 months ) was unrelated to rate of improvement . In a 10-year retrospective study , the authors identified 12 infants who had an operation for posterior plagiocephaly . All but one had confirmed premature lambdoid fusion ; thus , this condition accounted for 3.4 percent of all primary operations performed for craniosynostosis during this decade ( n = 323 ) . In retrospect , the physical findings of synostotic posterior plagiocephaly were not clearly different from those of deformational posterior plagiocephaly . Plain radiography was sometimes used to confirm the clinical diagnosis . Neither sutural narrowing , deep interdigitations , nor perisutural sclerosis indicated lambdoid synostosis . Computed tomography ( CT ) was necessary if the physical findings were suspicious for lambdoid synostosis or if plain films did not give a definitive diagnosis . Axial CT scans ( n =  
    Output:
    
Clinical examination is most often sufficient to diagnose plagiocephaly ( quality , Class III ; strength , Level III ) .
Within the limits of this systematic review , the evidence suggests that imaging is rarely necessary and should be reserved for cases in which the clinical examination is equivocal .
When needed , 3-dimensional cranial topographical photo , skull x-rays , or ultrasound imaging is almost always sufficient for definitive diagnosis .
Computed tomography scanning should not be used to diagnose plagiocephaly , but it may be necessary to rule out craniosynostosis .