Research Paper Craniofacial Anomalies| Volume 50, ISSUE 8, P1040-1046, August 2021

Distinguishing craniomorphometric characteristics and severity in metopic synostosis patients

Published:January 19, 2021DOI:


      The decision about which metopic synostosis patients should undergo surgery remains controversial. Multiple measures for radiographic severity have been developed in order to determine the optimal criteria for treatment. The aim of this study was to perform an extensive craniomorphometric analysis of patients who underwent surgery for metopic synostosis to validate and compare the various severity scales developed for this non-syndromic craniosynostosis. A comparative morphometric analysis was performed using computed tomography scans of preoperative metopic synostosis patients (n = 167) and normal controls (n = 44). Measurements included previous and newly developed metopic severity indices. Volumetric and area analyses were used to determine the degree of anterior cranial area and potential volume restrictions. Of the severity indices measured, the frontal angle, endocranial bifrontal angle (EBF), adjusted EBF (aEBF), anterior cranial fossa angle, horizontal cone angle, and bitemporal/biparietal distance ratio were significantly different in the metopic subjects relative to controls overall. However, metopic index, orbital rim angle, foramen ovale distance, and cranial volume exhibited no significant difference from controls. Only the frontal angle and aEBF correlated with the changes in anterior cranial dimensions observed in metopic synostosis. In conclusion, the frontal angle and aEBF provide the most accurate measures of severity in metopic synostosis.

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        • Kolar J.C.
        An epidemiological study of nonsyndromal craniosynostoses.
        J Craniofac Surg. 2011; 22: 47-49
        • van der Meulen J.
        • van der Hulst R.
        • van Adrichem L.
        • Arnaud E.
        • Chin-Shong D.
        • Duncan C.
        • Habets E.
        • Hinojosa J.
        • Mathijssen I.
        • May P.
        The increase of metopic synostosis: a pan-European observation.
        J Craniofac Surg. 2009; 20: 283-286
        • Mocquard C.
        • Aillet S.
        • Riffaud L.
        Recent advances in trigonocephaly.
        Neurochirurgie. 2019; 65: 246-251
        • Bottero L.
        • Lajeunie E.
        • Arnaud E.
        • Marchac D.
        • Renier D.
        Functional outcome after surgery for trigonocephaly.
        Plast Reconstr Surg. 1998; 102 (discussion 959–960): 952-958
        • Yang J.F.
        • Brooks E.D.
        • Hashim P.W.
        • Reuman H.S.
        • Travieso R.
        • Terner J.
        • Mayes L.C.
        • Steinbacher D.M.
        • Persing J.A.
        • McPartland J.C.
        The severity of deformity in metopic craniosynostosis is correlated with the degree of neurologic dysfunction.
        Plast Reconstr Surg. 2017; 139: 442-447
        • Braun T.L.
        • Eisemann B.S.
        • Olorunnipa O.
        • Buchanan E.P.
        • Monson L.A.
        Safety outcomes in endoscopic versus open repair of metopic craniosynostosis.
        J Craniofac Surg. 2018; 29: 856-860
        • Hormozi A.K.
        • Shahverdiani R.
        • Mohammadi H.R.
        • Zali A.
        • Mofrad H.R.
        Surgical treatment of metopic synostosis.
        J Craniofac Surg. 2011; 22: 261-265
        • Shaffrey M.E.
        • Persing J.A.
        • Delashaw J.B.
        • Shaffrey C.I.
        • Jane J.A.
        Surgical treatment of metopic synostosis.
        Neurosurg Clin N Am. 1991; 2: 621-627
        • Nguyen D.C.
        • Patel K.B.
        • Skolnick G.B.
        • Naidoo S.D.
        • Huang A.H.
        • Smyth M.D.
        • Woo A.S.
        Are endoscopic and open treatments of metopic synostosis equivalent in treating trigonocephaly and hypotelorism?.
        J Craniofac Surg. 2015; 26: 129-134
        • Weinzweig J.
        • Kirschner R.E.
        • Farley A.
        • Reiss P.
        • Hunter J.
        • Whitaker L.A.
        • Bartlett S.P.
        Metopic synostosis: defining the temporal sequence of normal suture fusion and differentiating it from synostosis on the basis of computed tomography images.
        Plast Reconstr Surg. 2003; 112: 1211-1218
        • Vu H.L.
        • Panchal J.
        • Parker E.E.
        • Levine N.S.
        • Francel P.
        The timing of physiologic closure of the metopic suture: a review of 159 patients using reconstructed 3D CT scans of the craniofacial region.
        J Craniofac Surg. 2001; 12: 527-532
        • Beckett J.S.
        • Chadha P.
        • Persing J.A.
        • Steinbacher D.M.
        Classification of trigonocephaly in metopic synostosis.
        Plast Reconstr Surg. 2012; 130: 442e-447e
        • Ezaldein H.H.
        • Metzler P.
        • Persing J.A.
        • Steinbacher D.M.
        Three-dimensional orbital dysmorphology in metopic synostosis.
        J Plast Reconstr Aesthet Surg. 2014; 67: 900-905
        • Naran S.
        • Mazzaferro D.
        • Wes A.
        • Vossough A.
        • Bartlett S.P.
        • Taylor J.A.
        A craniometric analysis of cranial base and cranial vault differences in patients with metopic craniosynostosis.
        J Craniofac Surg. 2017; 28: 2030-2035
        • Wang J.Y.
        • Dorafshar A.H.
        • Liu A.
        • Groves M.L.
        • Ahn E.S.
        The metopic index: an anthropometric index for the quantitative assessment of trigonocephaly from metopic synostosis.
        J Neurosurg Pediatr. 2016; 18: 275-280
        • Lu X.
        • Forte A.J.
        • Steinbacher D.M.
        • Alperovich M.
        • Alonso N.
        • Persing J.A.
        Enlarged anterior cranial fossa and restricted posterior cranial fossa, the disproportionate growth of basicranium in Crouzon syndrome.
        J Craniomaxillofac Surg. 2019; 47: 1426-1435
        • Lu X.
        • Forte A.J.
        • Wilson A.
        • Steinbacher D.M.
        • Alperovich M.
        • Alonso N.
        • Persing J.A.
        Cranial fossa volume and morphology development in Apert syndrome.
        Plast Reconstr Surg. 2020; 145: 790e-802e
        • Cronin B.J.
        • Brandel M.G.
        • McKee R.M.
        • Hashmi A.
        • Oviedo P.
        • Buckstaff T.
        • Cahill G.
        • Mannix E.
        • Reid C.M.
        • Lance S.
        • Vinocur D.
        • Meltzer H.S.
        • Gosman A.A.
        A comparison of intracranial volume growth in normal children and patients with metopic craniosynostosis.
        J Craniofac Surg. 2020; 31: 142-146
        • Posnick J.C.
        • Lin K.Y.
        • Chen P.
        • Armstrong D.
        Metopic synostosis: quantitative assessment of presenting deformity and surgical results based on CT scans.
        Plast Reconstr Surg. 1994; 93: 16-24
        • Birgfeld C.B.
        • Saltzman B.S.
        • Hing A.V.
        • Heike C.L.
        • Khanna P.C.
        • Gruss J.S.
        • Hopper R.A.
        Making the diagnosis: metopic ridge versus metopic craniosynostosis.
        J Craniofac Surg. 2013; 24: 178-185
        • Cohen S.R.
        • Persing J.A.
        Intracranial pressure in single-suture craniosynostosis.
        Cleft Palate Craniofac J. 1998; 35: 194-196
        • Anderson P.J.
        • Netherway D.J.
        • Abbott A.
        • David D.J.
        Intracranial volume measurement of metopic craniosynostosis.
        J Craniofac Surg. 2004; 15 (discussion 1017–1018): 1014-1016
        • Grandhi R.
        • Peitz G.W.
        • Foley L.M.
        • Bonfield C.M.
        • Fellows-Mayle W.
        • Hitchens T.K.
        • Mooney M.P.
        The influence of suturectomy on age-related changes in cerebral blood flow in rabbits with familial bicoronal suture craniosynostosis: a quantitative analysis.
        PLoS One. 2018; 13e0197296
        • Netherway D.J.
        • Abbott A.H.
        • Anderson P.J.
        • David D.J.
        Intracranial volume in patients with nonsyndromal craniosynostosis.
        J Neurosurg. 2005; 103: 137-141
        • Posnick J.C.
        • Armstrong D.
        • Bite U.
        Metopic and sagittal synostosis: intracranial volume measurements prior to and after cranio-orbital reshaping in childhood.
        Plast Reconstr Surg. 1995; 96 (discussion 310–315): 299-309
        • Calandrelli R.
        • Pilato F.
        • Massimi L.
        • Marrazzo A.
        • Panfili M.
        • Di Rocco C.
        • Colosimo C.
        Orbito-facial dysmorphology in patients with different degrees of trigonocephaly severity: quantitative morpho-volumetric analysis in infants with non-syndromic metopic craniosynostosis.
        Childs Nerv Syst. 2020; 36: 1263-1273