American Journal of Physical Anthropology

Shape and volume of craniofacial cavities in intentional skull deformations

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American Journal of Physical Anthropology AJPA-2012-00138.R1 Research Article 25-Sep-2012 Khonsari, Roman; King's College London, Stem Cell Biology and Craniofacial Development Olszewski, Raphael; Hopital Saint-Luc, Friess, Martin; MNHN, Nysj, Johan; Uppsala University, Odri, Guillaume; CHU Nantes, Malmberg, Filip; Uppsala University, Nystrm, Ingela; Uppsala University, Messo, Elias; Uppsala University, Hirsch, Jan; Uppsala University, Cabanis, Emmanuel-alain; Universit Pierre et Marie Curie Paris 6, Centre Hospitalier National dOphtalmologie des XV-XX, department of neuroradiology Kunzelmann, Karl-Heinz; Ludwig-Maximilians-Universitt, Salagnac, Jean-Michel; CHU Nantes, Corre, Pierre; CHU Nantes, Sharpe, Paul; King's College London, Philippe, Charlier; Service d'Anatomie et Cytologie Pathologiques, CHRU de Lillle orbit, maxillary sinus, bone thickness, haptic-aided semi-automatic segmentation, intracranial volume

Key Words:

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Shape and volume of craniofacial cavities in intentional skull deformations Running title: Craniofacial abnormalities in intentional deformations

Khonsari RH (1, 2,*), Friess M (3,*), Nysj J (4), Odri G (5), Malmberg F (4), Nystrm I (4), Messo E (6), Hirsch JM (6), Cabanis EAM (7), Kunzelmann KH (8), Salagnac JM (1), Corre P (1), Sharpe PT (2), Ohazama A (2), Charlier P (9), Olszewski R (10) (1) Service de Chirurgie Maxillofaciale et Stomatologie, CHU Htel-Dieu, Nantes, France (2) Department of Craniofacial Development, Dental Institute, King's College London, UnitedKingdom (3) Dpartement Hommes, Natures, Socits & CNRS UMR 7206, Musum National d'Histoire Naturelle, Muse de l'Homme, Paris, France (4) Centre for Image Analysis, Uppsala University, Uppsala, Sweden (5) Clinique Chirurgicale Orthopdique et Traumatologique, CHU Htel-Dieu, Nantes, France (6) Department of Surgical Sciences, Oral and Maxillo-facial Surgery, Medical Faculty, Uppsala University, Uppsala, Sweden (7) Service de Neuroradiologie, Centre Hospitalier National Ophtalmologique des XV-XX, Paris, France (8) Poliklinic fr Zahnerhaltung und Parodontologie, Ludwig-Maximilians-Universitt Mnchen, Germany (9) Service d'anatomopathologie, Hpital Raymond-Poincar, Garches, France (10) Service de Chirurgie Maxillofaciale et Stomatologie, Hpital Saint-Luc, Universit Catholique de Louvain, Bruxelles, Belgique (*) these authors contributed equally to this work Article statistics Keywords 19 pages, 6 figures, 2 tables, 11 supplementary tables orbit; maxillary sinus; bone thickness; haptic-aided semi-automatic segmentation; intracranial volume; intentional skull deformation

Corresponding author Roman H. Khonsari Service de chirurgie maxillofaciale et stomatologie Centre Hospitalier Universtaire de Nantes 1 place Alexis Ricordeau, 44000 Nantes, France tel 0033685967200 email roman.khonsari@kcl.ac.uk

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Abstract

Intentional cranial deformations (ICD) are described worldwide but are especially prevalent in preColombian cultures. While the medical consequences of ICDs are poorly understood, their morphological impact on the external skull geometry is well documented. The purpose of this study was to assess consequences of ICD on three cranial cavities (intracranial cavity, orbits, maxillary sinuses) and on the cranial vault thickness, in order to screen for anomalies related to the external constraints exerted by the deformation device.

We used a medical CT-scan on 39 deformed and 19 control skulls. We measured the thickness of the skull vault using qualitative and quantitative methods. We computed the volumes of the orbits, of the maxillary sinuses and of the intracranial cavity using haptic-aided semi-automatic segmentation. We finally defined 3D distances and angles within orbits and maxillary sinuses, and applied this landmarking to the 58 skulls.

Our results show specific bone thickness patterns in some types of ICD. Our findings confirm that volumes of the cranial cavities are not affected by ICDs but that the shapes of the orbits and of the maxillary sinuses are modified in circumferential deformations.

We conclude that ICDs can modify the shape of the cranial cavities and the thickness of their walls but conserve their volumes. These results provide new insights on the paleopathology of ICDs and call for similar investigations in subjects with deformational plagiocephalies and craniosynostoses.

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Intentional cranial deformations (ICD) are described in all cultures (Dingwall, 1931) including Western Europe. By applying an external device on the skull of newborns during the first year of life, the purpose of this practice was to interfere with normal skull growth and induce the appearance of a specific skull outline (Gerszten et al., 1995). Two main deformation types are described in South-American pre-Colombian cultures: the anteroposterior deformation (AP), where the skull was squeezed between two rigid frontal and occipital plates held together by bands, and the circumferential deformation (C) where the skull was molded into a tubular shape by tight cloths (Dingwall, 1931; Antn, 1989). In France, a specific kind of skull deformation is known as the Toulouse deformation (T) and is obtained by mechanisms similar to C deformations (Dingwall, 1931). The pathological consequences of ICD are poorly understood, due to the lack of modern medical data on individuals subjected to this practice. The main health-related question with ICDs is the risk of cognitive impairment (Lekovic et al., 2007), and this issue is still not solved. To address the problem of ICD from a craniofacial point of view, we focused our study on the cranial cavities and on their walls. We first explored the consequences of the skull deformations on three medically relevant craniofacial structures by measuring the volumes of the intracranial cavity, of the orbits and of the maxillary sinuses. We used an innovative technique based on haptic-aided semiautomatic segmentation (Nystrm et al., 2011). We then analyzed modifications in the thickness of the skull vault and described the 3D structure of the orbits and the maxillary sinuses. The conservation of the volumes despite changes in 3D shape illustrated the fact that skull growth modules (Lieberman, 2011) can adapt to abnormal external constraints. We nevertheless disclosed typical modifications in shapes and bone thickness that could be related to specific deformation types.

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MATERIAL AND METHODS

We considered 19 non-deformed (NC) skulls, 24 skulls with antero-posterior (AP, Fig. 1a) deformations, 8 skulls with circumferential (C, Fig. 1b) deformations and 7 skulls with Toulouse (T) deformations. We followed the major distinction into circumferential and antero-posterior deformations proposed previously (Antn, 1989; Cheverud et al., 1992; Kohn et al., 1993; Friess and Baylac, 2003) with AP erect and oblique as variants of the latter. The Toulouse-type is akin to circumferential deformations in that it is achieved by soft tissue and results in a similar shape. For the purposes of this study, it was considered a separate group. All AP and C deformed skulls are from Bolivia, while all T types are from south-western France. Undeformed skulls were sampled from the same two regions. Only adult individuals, selected based on the fusion of the spheno-occipital synchondrosis, were included. Information on sex was not generally available, and therefore not taken into account in our analyses. All skulls are part of the collections of the Muse de lHomme in Paris. Each skull was subjected to paleopathological examination in order to rule out craniosynostoses (based on the patency of skull vault sutures), trauma sequellae (Fig. 1c) and taphonomic deformations (Fig. 1d). The skulls were scanned using a standard medical CT-scan according to a previously published protocol adapted to anthropological material (Badawi-Fayad et al., 2005 and table S1).

In order to study the shape of the orbit, we defined 11 bilateral 3D landmarks: posterior choanae, lacrimal canal, fronto-zygomatic suture, fronto-nasal suture, superior orbital fissure (antero-superior end), superior orbital fissure (postero-inferior end), anterior clivus, medial inferior orbital fissure, foramen caecum, planum sphenoidale and small wing of the sphenoid. We also used one midline landmark, the anterior nasal spine. The details of the 3D anatomical position of the landmarks are given in figure 2. These 23 landmarks were used to define 6 planes (table 1). Based on these 6 planes and the landmarks, 5 angles and 8 distances were measured (table 2). The

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landmarking and the measurements were performed using Maxilim (Medicim, Leuwen, Belgium) according to Olszewski et al. (2008) and Olszewski et al. (2010). The same procedure was applied to the maxillary sinuses, for which 3 specific landmarks were defined: the naso-palatine canal, the trigeminal canal and the lateral sphenoidal notch (figure 2). The following 3 landmarks defined for the orbital analysis were also used for the sinuses: posterior choanae, lacrymal canal and anterior nasal spine. This set of 9 sinus landmarks was used to define 3 planes (table 1) and 3 distances (table 2). In order to test the reliability of our landmarking, we first computed the intraclass correlation coefficient after two-way random single measures for absolute agreement (ICC 2.1 model, Shrout et al., 1979) for the intra-observer reliability of the orbit measures, and the ICC for the inter- and intra-observer reliabilities of the sinus measures based on two land markings by two blinded independent observers (RHK and RO). We then used the 3D coordinates of the landmarks from a subset of 10 normal skulls in order to calculate the Euclidian distance between two successive measurements made on each skull by the same observer (Richtsmeier et al., 1995; Olszewski et al., 2008; Plooij et al., 2009; Olszewski et al., 2010), and checked if this distance was smaller than an anatomical relevant threshold of 1.5 mm using a one-tailed Student t-test. In order to analyze the angle and distance values, due to the small number of skulls in the C and T groups, we used the KruskalWallis (KWT) one-way analysis of variance by ranks as a nonparametric alternative to the one-way analysis of variance (ANOVA) and the Dunnett post-hoc test (DT) in order to spot the group with discriminant values compared to the non-deformed group. The difference was considered significant when p<0.05. The difference was defined as a trend when 0.05<p<0.1.

The total thickness of the skull vault was measured and plotted using the Wall Thickness Analysis module of VGStudio Max (Volume Graphics, Heidelberg, Germany). Briefly, the skulls were cropped along a horizontal plane passing anteriorly above the frontal sinus and posteriorly

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above the external occipital protuberance. For each skull, the average total thickness, its standard deviation and the skull vault volume were computed within this skull spherical cap. The skull vault volume was computed by considering the space between the external limit of the outer table and the internal limit of the inner table along the cropped spherical cap. A red-green-blue (respectively 015-30 mm) continuous color map for thickness values was plotted over the 3D rendering of the spherical cap. Discrete measurements of thickness using the CT-scan data were also performed. For each skull we defined three planes (mid-sagittal, coronal through metopion and coronal through vertex). The mid-sagittal plane was defined as going through nasion, bregma and basion; the coronal plane was defined as perpendicular to the mid-sagittal plane. Thickness measurements were obtained following the half-maximum-height (HMH) protocol (Spoor et al., 1993). This standard technique relies on the computation of the limit between two tissues (or one tissue and air) as the median threshold value on the Hounsfield scale. Measurements were taken by a single observer (MF) at metopion, center of the frontal and parietal, and the highest point above the lambda-inion chord. Computations were performed in ImageJ (Rasband, 1997-2012).

The volume of the orbits was obtained using a haptic-aided semi-automatic segmentation method (Nystrm et al., 2011). In brief, we first extracted the boundaries of the orbital bones by using hysteresis thresholding followed by morphological boundary extraction. The thresholds we used in this step were based on the Hounsfield numbers for bone tissue. Using a haptic 3D input device (table S2), we then placed four landmarks on the orbital rim. These landmarks were subsequently used to calculate a planar barrier that defined the anterior limit of the orbital cavity. The resulting barrier was rasterized and included into the boundary map. We proceeded by computing a distance potential force from the modified boundary map and initialized a deformable simplex mesh as a coarse sphere inside the orbit. This simplex mesh was then automatically deformed by the distance potential force to fit the orbit. During the deformation process, we could

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refine the simplex mesh one or several times and also apply haptic forces on selected mesh faces to guide or correct the segmentation. As a final step, we rasterized the simplex mesh and calculated the orbital volume. The procedure is summed up in figure 4. The same segmentation method, but without the landmark positioning step, was used to compute the maxillary sinus and intracranial volumes, as no artificial limit such as the one required for the orbital opening had to be defined for these two cavities. RESULTS

The qualitative analysis of the vault thickness showed constant frontal bone thinning in AP skulls when compared with ND controls (Fig. 5). Furthermore, we found a characteristic notch at the level of the bregma in C deformations (Fig. 6) that was not observed in any other group, associated with a lateral parietal and temporal bone thinning. The T skulls did not present bone thickness modifications (Fig. 6). The comparison of average thicknesses and vault volumes between groups did not show any significant differences. Nevertheless, there was a trend for C skulls to have more dispersed thickness values (KWT: 0.1003, DT: 0.0081, see table S3 for further details). Interestingly, for AP deformations, discrete thickness measurements showed a significant thinning at the metopion in midline sagittal sections, affecting the outer (KWT: 0.0051, DT: 0.0092) and inner (KWT: 0.0417, DT: 0.0234) tables, as well as the total thickness (KWT: 0.0121, DT: 0.0329). The outer table (KWT: 0.0068, DT: 0.0305) and the total thickness (KWT: 0.0197, DT: 0.0124) were reduced in midline sagittal sections at the occiput for AP deformations. The total thickness of the frontal bone was also reduced in coronal sections for C deformations (KWT: 0.0007, DT: 0.0011) and had a tend toward reduction for AP deformations (KWT: 0.0007, DT: 0.0635). The parietal bone thickness was preserved in all deformed skulls. In T deformations, we observed an increase in the thickness of the diploe at the metopion (KWT:0.0055, DT: 0,0133). See table S4 for further details.

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Volumes of the orbits and the maxillary sinuses were not affected in AP, C or T deformations. The volume of the cranial cavity was overall normal but there was a trend toward increased volume in C skulls (KWT: 0.0813, DT: 0.0296). Further details are provided in table S5.

We confirmed the inter- and intra-individual reproducibilities of the measured distances for the sinuses and the intra-individual reproducibility of the measured distances and angles for the orbits (tables S6, S7 and S8). We also confirmed the inter-individual reproducibility of landmark placement in 3D (table S9). Based on these landmarks, we found that the shape of the orbits was significantly modified in C deformations (full details in table S10). Briefly, we described a bilateral increase in the vertical orbital angle (KWT: 0.0085, DT: 0.0003 for the left angle and KWT: 0.0302, DT: 0.0017 for the right angle). We also found bilateral decreases in the anterior orbitals width (KWT: 0.0014, DT: 0.0001 for the left width and KWT: 0.0023, DT: 0.0001 for the right width), in the lateral orbital depth (KWT: 0.0009, DT: 0.0023 for the left depth and KWT: 0.0032, DT: 0.0012 for the right depth), in the median orbital depth (KWT: 0.0236, DT: 0.0489 for the left depth and KWT: 0.0027, DT: 0.0056 for the right depth) and deep orbital heights (KWT: 0.0191, DT: 0.0182 for the left height and KWT: 0.0143, DT: 0.0729 for the right height). The overall shape of the orbit in C deformations was reduced mediolaterally. Orbital height was increased anteriorly but decreased posteriorly.

This deformation pattern was also partly found in AP deformations, where a decrease in the lateral orbital depth was reported (KWT: 0.0009, DT: 0.0073 for the left depth and KWT: 0.0032, DT: 0.0218 for the right width) and in T deformations, where a decrease in the deep orbital height was observed (KWT: 0.0191, DT: 0.0084 for the left height and KWT: 0.0143, DT: 0.0129 for the right height). For all deformation patterns, orbits thus had a trend for being shallow, reduced mediolaterally with an anterior increase in height and a posterior decrease. Further details are

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provided in table S10.

The posterior width of the maxillary sinuses was decreased in C deformations (KWT: 0.0126, DT: 0.0057 for the left width and KWT: 0.0068, DT: 0.0378 for the right width). More details are provided in table S11. DISCUSSION

Orbital volume and shape in intentional deformations The conservation of the orbital volume in ICD is not a surprise as the eye is the major determinant of this parameter (Enlow, 1968). Interestingly, in C deformations, the shape of the orbit is significantly modified: the orbit is shallow and narrow compared to non-deformed skulls. C deformations mainly affect the vertical dimension of the cranial part of the orbit, that is the measures involving the sphenoid and the frontal bones, which is consistent with the fact that the deformational forces are applied on the skull and not on the face. Furthermore, the modification of the orbital shape in C deformations is consistent with the overall narrowing and vertical extension of the face previously reported (Antn, 1989; Kohn et al., 1993). Despite the absence of an effect on volumes, the significant shape modifications we found in C deformations can potentially induce variable degrees of exophthalmia, as the orbital volume is preserved while the orbit becomes shallow and narrow. The same conclusion can be drawn to a lesser extent for AP and T deformations, which exhibit lesser degrees of orbital deformation.

Influence of external forces on the maxillary sinuses The conservation of the volume of the maxillary sinus in C skulls is more surprising, knowing that we found a significant decrease of the posterior width of this cavity due to the deformation. In fact, it is generally believed that maxillary sinuses are formed passively as a consequence of the growth of the surrounding structures. Sinuses do not possess an inner structure

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equivalent to the eyeball in the orbit that would drive their growth and prevent their collapse (Rae et al., 2008; Witmer et al., 2008). Due to the sinus deformation we report, we would have expected a decrease in the volume of the maxillary sinuses. In the case of C deformations, as the growth of the maxillary sinuses mainly occurs around the third year of life (Enlow, 1968), the orbital deformation most probably influenced sinus growth: the orbital floor being the sinus roof, the posterior mediolateral narrowing of the orbit could account for the posterior narrowing of the maxillary sinus. Interestingly, we show here that the volume of the maxillary sinus is maintained in situations of abnormal mechanical stress, suggesting the presence of specific and unknown regulatory mechanisms for this parameter.

Effect of intentional deformations on intracranial structures The intracranial volume is not decreased in ICDs and even has a trend for increasing in C deformations (KWT: 0.0813, DT: 0.0296). Based on this parameter, it thus seems unlikely that ICDs could directly induce an increase in intracranial pressure. Accordingly, cultural data are not in favor of a decrease in intellectual abilities due to ICDs (Dingwall, 1931). Nevertheless, the conservation of the intracranial volume is not sufficient to affirm the absence of increase in intracranial pressure: it is known for instance that venous congestions due to compressions in the cranio-occipital joint can lead to hydrocephalus by indirect mechanisms (Di Rocco et al., 2011). Our data does not allow to conclude on the issue of the cognitive status in ICDs, but does not support the impairment hypothesis either. More generally, the issue of cognitive impairment in ICDs is of particular interest when related to the same problem in patients with craniosynostosis. The conservation of the intracranial volume in cases of ICD with extreme deformation (Figs. 1a-1b) is in line with the fact that in craniosynostoses, hydrocephalus cannot be solely related to the deformation of the skull.

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Bone thickness and deformation device The qualitative analysis of the skull vault thickness in deformed skulls (Figs. 4-5) is of potential use in the reconstruction of the deformation device, if we hypothesize that the regions with increased thinning are the regions where the device was exerting the highest pressure. In fact, in hydrocephalus, where durable and excessive hydrostatic pressure is exerted on the inner side of the skull vault, a deformation pattern known as gyral impressions can appear, with numerous areas of bone thinning (Tuite et al., 1996; Sgouros, 2005). More interestingly, it has been shown in rats that self-activating hydrogel expanders, used in reconstructive surgery to augment soft-tissue space, induce localized thinning of the skull vault in the regions where the device exerts the highest pressure (Stuehmer et al., 2009; von See et al., 2010), while the bone surrounding the expander is not affected and keeps its normal thickness. These data support the use of thickness maps to reconstruct areas where deformation devices were exerting the highest pressures on the skull vault of children subjected to ICDs. Based on our data, we can thus hypothesize that in AP and C deformations, the devices were preferentially exerting frontal constraints (see table S4 for details), which is in line with the cultural data on the deformation devices used in pre-Columbian cultures (Dingwall, 1931). The thinning of the frontal bone in AP deformations we observed qualitatively is supported by our quantitative data, and affects the three layers of the vault. In skulls with moderate deformation and when the diagnosis of ICD is not straightforward, a local thinning of the bone occurring in areas expected to have been subjected to abnormal pressures (such as the frontal bones in AP and C deformations) could be of help in screening for deformations. Interestingly, the preservation of the global volume of the vault suggests that bone thickness modifications occur by a redistribution of a constant pool of vault bone rather by bone loss. This fact may account for the local increase of thickness we observed in T skulls in the region of the metopion.

Intentional skull deformations, positional plagiocephaly and craniosynostoses

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Currently, the most common cause of skull deformation is positional posterior plagiocephaly (Dec et al., 2011). The treatment of positional plagiocephaly is controversial: apart from the rare cases requiring surgery, craniofacial surgeons recommend either passive positional treatments or active helmet-based therapies (Marchac et al., 2011). Helmets have many common points with the devices used to induce ICDs, as they exert a continuous external pressure at defined points of the skull vault. Our results on the effects of ICDs on the orbits and the sinuses suggest that helmet therapy most probably induces changes in craniofacial morphology that require further investigations. The situation is different in craniosynostoses as the deformation is not due to focal zones of external pressure. It is known that craniosynostoses are not associated with major changes in intracranial and orbital volumes (Gault et al., 1990; Bentley et al., 2002; Hill et al., 2011). Precise cephalometric studies of the orbits and maxillary sinuses in craniosynostoses could be of help in revealing the differences between the effects of external active constraints and changes in skull shape due to premature suture fusions. CONCLUSION

ICDs subject the skull to abnormal external mechanical constraints and induce specific deformations in structures that are distant from the deformation devices. In fact, by focusing on the structure of craniofacial cavities in ICDs, we show here for the first time that the shapes of the orbits and the maxillary sinuses are modified by the deformations, and that the thickness of the vault is affected by the deformation. For this, we provide new tools for the measurement of the volumes of open cavities. This study calls for similar investigations in craniosynostoses and deformational plagiocephalies, where the distribution of internal and external constraints is different than in ICDs and where the shape of craniofacial cavities in affected individuals is currently not precisely described.

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Acknowledgements: Special thanks to Philippe Mennecier for having provided us with an access to the anthropological collections of the Muse de lHomme in Paris. This study was supported by a grant of the Fondation Les Gueules Casses.

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Figure legends

Figure 1. (a) antero-posterior deformation; (b) circumferential deformation; (c) zygomatic bone fracture; (d) taphonomic deformation witnessed by a post-natal spacing of the squamosal suture.

Figure 2. Skeletal landmarks used for orbital cephalometry.

Figure 3. Skeletal landmarks used for sinus cephalometry. The specific points defined for the study of the sinuses were: the nasopalatine canal (black arrow), the trigeminal canal (blue arrow) and the lateral sphenoidal notch.

Figure 4. Semi-automatic orbit segmentation. (a) Haptic-aided landmarking used to define the anterior limit of the orbital cavity. (b) Initialization of a deformable mesh inside the orbit. (c) The mesh is fitted to the orbit by a distance potential force computed from the CTscan. During the deformation process, the user can refine the mesh as well as reshape it by applying haptic interactive forces on selected mesh faces (yellow patches). (d) Segmented orbit. (e) Rasterized segmentation result (purple) overlaid on the multi-planar reformatting visualization. (f) Snapshot of the segmentation interface developed by the Centre for Image Analysis, Uppsala University, Sweden.

Figure 5. Thickness maps in dorsal view for 11 non-deformed skulls (a) compared with 11 skulls with antero-posterior deformation (b). The antero-posterior deformed skulls show a constant thinning of the frontal region. The red-blue color scale refers to bone thickness: red stands for 0 mm and blue for 30 mm.

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Figure 6. Lateral thickness maps for 3 skulls of the non-deformed (a), antero-posterior (b), circumferential (c) and Toulouse groups (d). The bregmatic bulging and the temporal thinning is apparent in the T group. The red-blue color scale refers to bone thickness: red stands for 0 mm and blue for 30 mm.

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Table 1. Orbital and sinus planes defined using 23 skeletal landmarks for the orbits and 9 skeletal landmarks for the sinuses (see figures 2 and 3 for the anatomical definition of the landmarks).
Name Horizontal maxillary plane Orbital floor Definition anterior nasal spine posterior choanes lacrymal canal postero-inferior end of the superior orbital fissure medial inferior orbital fissure antero-superior end of the superior orbital fissure postero-inferior end of the superior orbital fissure medial inferior orbital fissure foramen caecum planum sphenoidale small wing of the sphenoid antero-superior end of the superior orbital fissure anterior clivus fronto-maxillary suture fronto-maxillary suture fronto-zygomatic suture perpendicular to the horizontal maxillary plane Right lacrymal canal left lacrymal canal perpendicular to the horizontal maxillary plane posterior choane perpendicular to the horizontal maxillary plane perpendicular to the anterior sinus wall Type Plane defined by 3 points Plane defined by 3 points

Lateral orbital wall

Plane defined by 3 points

Orbital roof

Plane defined by 3 points

Medial orbital wall

Plane defined by 3 points

Anterior orbital wall (virtual boundary)

Plane defined by 2 points and perpendicular to another plane

Anterior sinus wall

Plane defined by 2 points and perpendicular to another plane

Medial sinus wall

Plane defined by 1 point and perpendicular to 2 other planes

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Table 2. Angles and distances used in orbital and sinus cephalometric analysis.
Name Medio-lateral orbital angle Median orbital angle Vertical orbital angle Relative lateral orbital angle Relative medial orbital angle Anterior orbital width Lateral orbital depth Definition median orbital wall lateral orbital wall left medial orbital wall right medial orbital wall orbital roof orbital floor lateral orbital wall orbital floor Medial orbital wall orbital floor fronto-zygomatic suture fronto-nasal suture fronto-zygomatic suture postero-inferior end of the superior orbital fissure fronto-maxillary suture postero-inferior end of the superior orbital fissure postero-inferior end of the superior orbital fissure orbital roof medial inferior orbital fissure orbital roof lacrymal canal orbital roof antero-superior end of the superior orbital fissure lateral orbital wall postero-inferior end of the superior orbital fissure anterior orbital wall Posterior choane anterior sinus plane Lateral sphenoidal notch medial sinus wall Lacrymal canal horizontal maxillary plane Type Angle between 2 planes Angle between 2 planes Angle between 2 planes Angle between 2 planes Angle between 2 planes Distance between 2 points Distance between 2 points

Median orbital depth

Distance between 2 points

Deep orbital height

Distance between a point and a plane

Sphenoidal orbital height Anterior orbital height Posterior orbital width

Distance between a point and a plane Distance between a point and a plane Distance between a point and a plane

Central orbital depth

Distance between a point and a plane

Medial sinus depth Posterior sinus width Anterior sinus height

Distance between a point and a plane Distance between a point and a plane Distance between a point and a plane

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Fig. 1

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Fig. 2 150x268mm (300 x 300 DPI)

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Fig. 3 218x141mm (72 x 72 DPI)

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Fig. 4 150x209mm (300 x 300 DPI)

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Fig. 5 254x70mm (300 x 300 DPI)

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Fig. 6 1013x568mm (96 x 96 DPI)

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