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Modeling and biomechanical analysis of craniosynostosis correction with the

use of finite element method

Article · September 2013

DOI: 10.1002/cnm.2506 · Source: PubMed

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INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING
Int. J. Numer. Meth. Biomed. Engng. 2013; 29:916–925
Published online 2 August 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cnm.2506

COMPUTATIONAL METHODS FOR BIOMEDICAL IMAGE PROCESSING

AND ANALYSIS

Modeling and biomechanical analysis of craniosynostosis

correction with the use of finite element method

Wojciech Wolański 1 , Dawid Larysz 2 , Marek Gzik 1 and Edyta Kawlewska 1, * ,†

1 Department of Biomechatronics, Silesian University of Technology, Gliwice, Poland
2 Department of Neurosurgery, Medical University of Silesia, Katowice, Poland

SUMMARY
Craniosynostosis is a skull malformation because of premature fusing of one or more cranial sutures. The
most common types of craniosynostosis are scaphocephaly (with the sagittal suture fused) and trigono-
cephaly (with the metopic suture fused). In this paper we describe and discuss how finite element analysis
and three-dimensional modeling can be used for preoperative planning of the correction of craniosynostosis
and for the postoperative evaluation of the treatment results. We used the engineering software M IMICS
M ATERIALISE to obtain three-dimensional geometry from computed tomography scans, and applied finite
element method for the sake of biomechanical analysis. These simulations help to improve the surgical
treatment, making it more accurate, safer, and faster. Copyright © 2012 John Wiley & Sons, Ltd.

Received 6 February 2012; Revised 29 April 2012; Accepted 25 June 2012

KEY WORDS: craniosynostosis; biomechanics; preoperative planning; modeling; skull

1. INTRODUCTION

Craniosynostosis is a condition in infants that results in an abnormal head shape because of pre-
mature fusion of one or more sutures [1, 2]. Because the brain cannot expand in the direction of
the fused suture, it is forced to grow in the direction of the open sutures, thus oftentimes causing
an abnormal head shape and deformed facial features. Some cases of craniosynostosis contribute
to increased pressure on the brain and developmental delays [3]. Craniosynostosis is estimated to
affect 1 in 2000 live births. It can be a feature of an inherited syndrome, or sporadic. The cause of
the sporadic cases remains unknown [4, 5].
There are a few types of craniosynostosis, depending on which suture has fused prematurely:
– trigonocephaly (metopic suture fused) – triangular head,
– scaphocephaly (sagittal suture fused) – long, boat-shape head,
– brachycephaly (bicoronal suture fused) – short head,
– plagiocephaly (unilateral coronal or lambdoid suture fused in cases of anterior or posterior
plagiocephaly respectively).
The most common types of craniosynostosis are trigonocephaly (TRI) and scaphocephaly (SCP)
[6, 7]. Trigonocephaly occurs when the metopic suture (on the frontal bone) is fused. The triangular
shape of the forehead is characteristic of this malformation. This may be accompanied by complica-
tions in neuropsychological development, problems with vision and ocular hypotelorism may also
occur. In trigonocephaly, it is necessary to rebuild the whole forehead to obtain the regular shape of
the head.

*Correspondence to: Edyta Kawlewska, Department of Biomechatronics, Silesian University of Technology,

Gliwice, Poland.
† E-mail: [email protected]

Copyright © 2012 John Wiley & Sons, Ltd.

 MODELING AND BIOMECHANICAL ANALYSIS OF CRANIOSYNOSTOSIS CORRECTION 917

Figure 1. Exemplary view of skull cross-sections obtained from CT scanning and three-dimensional model
with scaphocephaly.

In scaphocephaly, the sagittal suture is fused, causing the growth in AP (antero-posterior) direc-
tion. With the abnormal growth the temporal brain lobe could be locally pressed, which could lead
to disorders of hearing, sounds perception or pronunciation.
Engineering support is helpful in such cases, as it facilitates virtual planning of the incisions and
allows to simulate the results of the treatment.
The main purpose of correction of a craniosynostotic skull is to reopen the cranial sutures with
bone slots to free the skull bones and allow proper brain development inside.
The aim of this paper is to analyze the relationships between various possibilities of bone
osteotomies and skull rigidity.
Finite element analysis methods were used to obtain the deformation clouds of different surgery
schemes. Then the best options of cranial vault correction were chosen according to the simulation
results of the deformation distribution.
In our study we included one patient with scaphocephaly and another with trigonocephaly. Three-
dimensional models of their skulls were generated on the basis of computed tomography (CT) scans
(Figure 1).

2. MATERIALS AND METHODS

The correction of complicated skull deformations must be planned individually for each patient
[8–10]. In this paper a 3-month-old boy with diagnosed TRI and a 5-month-old boy with SCP are
considered. The three-dimensional models of skull geometry were obtained on the basis of CT
scanning that was carried out in the course of primary diagnosis. With the use of M IMICS V 14.12
(Materialise N.V., Leuven, Belgium) [11] software it was possible (based on the Hounsfield scale) to
separate the bone tissue from the images. In the beginning, the analysis of bone thickness (Figure 2)
was carried out to determine the possibility to perform endoscopic surgery instead of a classic, more
invasive approach. Virtual incisions were simulated in each case, and biomechanical analysis was
performed for each of the models.
The virtual surgery was then performed with the strict cooperation of a neurosurgeon. The
planning procedure is outlined in Figure 3.

2.1. Virtual surgery planning

At the beginning, the elementary skull dimensions that determine the shape of skull and the
severity of deformation was measured [10]. On the basis of six anatomical points: euryon left (eu.l),

Copyright © 2012 John Wiley & Sons, Ltd. Int. J. Numer. Meth. Biomed. Engng. 2013; 29:916–925
DOI: 10.1002/cnm
918 W. WOLAŃSKI ET AL.

Figure 2. Results of the skull bone thickness analysis (a) in a 3-month-old boy with trigonocephaly and
(b) in a 5-month-old boy with scaphocephaly.

Figure 3. Procedure scheme in preoperative planning of surgical treatment in craniosynostosis.

euryon right (eu.r), porion left (po.l), porion right (po.r), metopion (me), and opisthocranion (op),
the cephalic index was calculated, which is the relation between maximal skull width and maximal
length, multiplied by 100% (Figure 4).
The normal cephalic index value for an infant up to 6 months of age is equal 83.75 ˙ 7.25.
Also, the forehead angle in case of trigonocephaly was calculated. The results with surgery
suggestions are presented in Table I.
The considered patients were selected to design the simulation of the surgical treatment plan
according to virtual preoperative planning scheme. Several osteotomy plans were considered for the
reconstruction, and to simulate the deformation distribution.
In scaphocephaly, the inverted modified ‘’ procedure was applied to perform the skull shape cor-
rection, and in trigonocephaly the whole frontal bone was remodeled using two variants of incisions
(Table II).
Three-dimensional cranial models generated in M IMICS software from patients’ CT images
along with bone thickness analysis (Figures 2(a) and (b)) revealed that it was possible to perform
endoscopic surgery instead of classical treatment (evaluation on the basis of our previous research).

Copyright © 2012 John Wiley & Sons, Ltd. Int. J. Numer. Meth. Biomed. Engng. 2013; 29:916–925
DOI: 10.1002/cnm
 MODELING AND BIOMECHANICAL ANALYSIS OF CRANIOSYNOSTOSIS CORRECTION 919

Figure 4. Basic craniometry measurements: (a) cephalic index for scaphocephaly and (b) forehead angle
for trigonocephaly.

Table I. Basic craniometry results before the virtual surgery.

Case Dimension Description Before surgery Normal value Surgery suggestion
eu.r-eu.l Maximal skull width [mm] 90.75 120.97 ˙ 6.44 increase
SCP me-op Maximal skull length [mm] 148.79 138.76 ˙ 13.06 decrease
maximal width
cephalic index CI D maximal length  100% 60.99 83.75 ˙ 7.25 increase
TRI po.r-me-po.l Forehead angle [deg] 96.58 — increase

2.1.1. Scaphocephaly surgery. The correction of skull shape was performed on the basis of inverted
‘’ procedure, which assumes four incisions along bicoronal, lambdoid, and sagittal sutures to
separate the parietal bones.
In variant ‘1’, the inverted modified ‘’ procedure was applied with two additional half-incisions
in the middle of both parietal bones to reduce the rigidity in this region, obtain optimal cosmetic
postoperative effects, and allow proper brain expansion from the inside (Figure 5(a)).
In variant ‘2’, apart from the standard incisions, the parietal bones were divided into two parts by
additional slots to obtain the maximal possibility of subsequent repositions (Figure 5(b)).

2.1.2. Trigonocephaly surgery. The correction of the skull shape was performed with total remod-
eling of the triangular forehead.
In variant ‘1’, first the frontal bone was separated from the skull. It was possible by making two
incisions: above the orbital and along the coronal sutures. Then, another incision was performed
along the metopic (frontal) suture that was prematurely fused. After that, the separated bones were
parted in transverse plane to obtain the optimal, more spherical skull contour (Figure 6(a)).
Variant ‘2’ assumed three incisions like the ones in the variant ‘1’, and two additional incisions
in the middle of each half of the frontal bone. The separated elements were repositioned to obtain a
pleasing forehead shape (Figure 6(b)).
All the incisions and repositions of the skull bones were consulted with the neurosurgeon. The
virtual surgery gave him the possibility to choose the optimal variant of treatment that should be
followed in a real-life operation.

2.2. Modeling of correction

Three-dimensional geometrical models were exported to *.stl files, and then imported to ANSYS
(ANSYS, Inc., The Netherlands) environment to perform the biomechanical analysis with the use of

Copyright © 2012 John Wiley & Sons, Ltd. Int. J. Numer. Meth. Biomed. Engng. 2013; 29:916–925
DOI: 10.1002/cnm
920 W. WOLAŃSKI ET AL.

Table II. Variants of incisions in scaphocephaly and trigonocephaly virtual correction.

Case Variant 1 Variant 2
Scaphocephaly

Inverted modified procedure: Inverted modified procedure: four

four incisions from , plus incisions from , plus additional full
additional half-incisions in the incisions in the middle of the parietal
middle of the parietal bones bones
Trigonocephaly

Remodeling of the forehead by one Three incisions such as in variant 1 and

incision along the metopic suture two additional incisions in the middle of
and two incisions along the each half of the frontal bone.
coronal sutures to separate the
frontal bone.

Figure 5. Plan of incisions in scaphocephaly: (a) variant 1, inverted ‘’ procedure with additional half-slots
in the middle of both parietal bones and (b) variant 2, inverted ‘’ procedure with additional slots in the
middle of both parietal bones.

finite element method. The models were supported on the lower surface of the skull base. Intracra-
nial pressure of constant value of 2.66 kPa was loaded through the inside surface of the cranial
bone models.

Copyright © 2012 John Wiley & Sons, Ltd. Int. J. Numer. Meth. Biomed. Engng. 2013; 29:916–925
DOI: 10.1002/cnm
 MODELING AND BIOMECHANICAL ANALYSIS OF CRANIOSYNOSTOSIS CORRECTION 921

Figure 6. Plan of incisions in trigonocephaly: (a) variant 1 with standard incision along the metopic suture
and (b) variant 2, with additional slots in the middle of each half of the frontal bone.

Table III. Material properties of skull bones obtained by selected authors.

Skull bones properties
Authors Young’s modulus [MPa] Poisson ratio References
Couper and Albermani (2005) 420 0.21 [12]
Coats and Margulies (2006) 300 0.19 [13]
Baumer et al. (2009) 238 0.20 [14]
Gzik et al. (2009) 380 0.22 [15]

The skull bones were defined as an isotropic elastic material with the following properties:
Young’s modulus: 380 MPa and Poisson’s ratio: 0.22. In Table III are shown the material prop-
erties of skull bones that have been used in similar analysis by other researchers. Also presented are
our own results [15], obtained in previous experimental tests. We compared our results with that of
other authors and we used them to identify the material properties of models.
The desired relocations of bone fragments were simulated in M IMICS and the distances between
the original and the reshaped skull models measured to determine the deformation values to be fed
into the ANSYS environment as the boundary conditions. It was established that a tilt of bones
equaling 12 mm ensured an improved shape of the skull in trigonocephaly, and a relocation of 10
mm was sufficient for the correction of scaphocephaly (Figures 7(a) and (b)).

3. RESULTS

After the virtual surgery, the cephalic index in the patient with scaphocephaly increased from 60.99
to 67.03, which is a positive outcome. In the patient with trigonocephaly, the forehead angle was
increased from 96.58° to 125.65°. In both cases, the skull contour is now more circular, therefore the
improvement of the shape is sufficient. It should be noted however, that the full evaluation of treat-
ment effects will become possible in several months after the surgery, by which time the growing
brain will have altered the shape of the skull.
The biomechanical analysis rendered the color map of stress and deformations (Figures 8(a) and
(b), Figures 9(a) and (b)) that occur during the correction. The Huber–von Mises yield criterion
was used to calculate the reduced stress. Both in scaphocephaly and trigonocephaly, the maximum
stresses were significantly lower than the allowable stress (Table IV). The generated models that
present the real deformation were imported back to M IMICS environment. It was possible to com-
pare the postulated correction that was performed manually in M IMICS with the neurosurgeon’s

Copyright © 2012 John Wiley & Sons, Ltd. Int. J. Numer. Meth. Biomed. Engng. 2013; 29:916–925
DOI: 10.1002/cnm
922 W. WOLAŃSKI ET AL.

Figure 7. Schema of the direction and distribution of applied loads to correct (a) trigonocephaly (a) and
(b) scaphocephaly.

Figure 8. Map of displacements after the trigonocephaly correction obtained using FEM analysis: (a) variant
1 of trigonocephaly correction and (b) variant 2 of trigonocephaly correction.

support, with the automatic reposition that took place in ANSYS during the analysis, where the
assumed final displacements equaled 10 mm in scaphocephaly and 12 mm in trigonocephaly.

Copyright © 2012 John Wiley & Sons, Ltd. Int. J. Numer. Meth. Biomed. Engng. 2013; 29:916–925
DOI: 10.1002/cnm
 MODELING AND BIOMECHANICAL ANALYSIS OF CRANIOSYNOSTOSIS CORRECTION 923

Figure 9. Map of displacements after the scaphocephaly correction obtained with the use of FEM analysis:
(a) variant 1 of scaphocephaly correction and (b) variant 2 of scaphocephaly correction.

Table IV. Results of biomechanical analysis.

Maximal stress obtained Maximal allowable Maximal displacement
Case Variant in analysis [MPa] stress [MPa] [mm]
‘1’ 40.56 19.26
TRI
‘2’ 53.25 18.23
87,0
‘1’ 37.92 5.86
SCP
‘2’ 38.50 6.36

4. DISCUSSION

The surgical correction of craniosynostosis is a complex procedure and presents as an interdis-

ciplinary challenge. What is also important is that the procedure is comparatively rare even at
specialized centers [9, 16, 17]. Early surgery is beneficial with decreasing risks for intracranial
hypertension and subsequent developmental delay. There is a demand for less drastic but effec-
tive techniques. Among other issues, decreasing surgical time and blood loss are of importance in
small children undergoing surgery [17, 18]. Early endoscopy-assisted treatment of multiple-suture
craniosynostosis has not proved to be more effective than currently established open techniques.
However, it has been reported to be associated with less morbidity and mortality than traditional
procedures [19, 20]. Possibility of preoperative planning of surgical cranioplasty became a new
challenge especially in terms of close cooperation between engineers and surgeons.
Finite element method is widely used in the biomechanical investigations, but the preoperative
planning with the FEM analysis especially for craniosynostosis surgery is still not very popular.
The cranium mechanics simulation during the cranioplasty treatment shows that the engineering

Copyright © 2012 John Wiley & Sons, Ltd. Int. J. Numer. Meth. Biomed. Engng. 2013; 29:916–925
DOI: 10.1002/cnm
924 W. WOLAŃSKI ET AL.

support in planning is very significant to obtain the optimal effects of the surgery. The interdisci-
plinary cooperation of engineers with neurosurgeons enables to choose the best treatment scheme
to be more successful.
Preoperative planning allows the surgeons to predict the effects of the treatment. Applied qual-
itative and quantitative evaluation enables to choose the type of osteotomies in each patient. Also,
the qualification to endoscopic, minimal invasive surgery is possible on the basis of bone thickness
calculations. The numeric analysis enabled to ensure that the optimal solution was variant ‘1’ for
trigonocephaly and variant ‘2’ for scaphocephaly, because the criteria of minimizing incisions and
minimizing stress were satisfied and the final effect of the surgery was acceptable. Virtual planning
of the treatment was helpful for the neurosurgeon, because it was possible to ‘practice’ the incisions
before the real-life surgery. It is especially important in the endoscopic method.

5. CONCLUSIONS

Virtual models allow better visualization of a problem in individual cases and its crucial details such
as sutures and foramina. This could be helpful to prevent complications during surgery. Also, on the
basis of calculated stresses and strains, there is a possibility to avoid bone fracture during surgery. It
is especially significant in case of endoscopic treatment, because if this kind of complication occurs,
plain open surgery would be necessary, so the patient’s safety could be compromised. The individual
planning for each patient increases the quality of treatment and safety during the operation. Total
time of surgery decreases so the blood loss is also less.

ACKNOWLEDGEMENTS
This work was supported by Polish Ministry of Science and Higher Education, as the research project No.
N N501 157038, in years 2010-2012.

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Copyright © 2012 John Wiley & Sons, Ltd. Int. J. Numer. Meth. Biomed. Engng. 2013; 29:916–925
DOI: 10.1002/cnm

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