Accuracy of Photographic Assessment Compared With Standard
Anthropometric Measurements in Nonsynostotic Cranial Deformities
Heidrun Schaaf, M.D., D.D.S., Jan-Falco Wilbrand, M.D., D.D.S., Rolf-Hasso Boedeker, Ph.D.,
Hans-Peter Howaldt, M.D., D.D.S., Ph.D.
Objective: Anthropometric landmarks of the skull have traditionally been
used to describe cranial deformities resulting from nonsynostotic plagiocephaly or brachycephaly. Recently, digital photography has become an important
tool for characterizing facial and cranial pathologies. The purpose of this study
was to compare standard anthropometric cranial measurements with measurements taken from cranial photographs.
Patients: Standardized digital images in the supracranial view and cranial
anthropometric measurements were obtained from 122 children between the
ages of 3 and 15 months. The photographs were assessed using Quick CephH
software. The cephalic index and cranial vault asymmetry index were used to
indicate the degree of cranial deformity. Children were classified into
plagiocephaly, brachycephaly, and the combination of both. To determine
interobserver variability, two clinicians separately measured the cephalic index
and cranial vault asymmetry index from digital photographs in 70 infants of the
plagiocephalic group.
Results: To compare interassay reliability for these methods of obtaining the
cephalic index and cranial vault asymmetry index, the differences between
photographically and anthropometrically derived values were plotted against
anthropometrically derived values alone (Bland-Altman plots). The photographic method satisfied the limits of agreement (cephalic index, 7.51%; cranial
vault asymmetry index, 6.57%) and showed slightly lower values represented
by the respective bias (cephalic index, 1.79%; cranial vault asymmetry index,
3.03%). Comparison between observers revealed excellent agreement, detected by the intraclass correlation coefficient of .982 for the cephalic index and
.946 for the cranial vault asymmetry index.
Conclusion: Our results demonstrate that digital photography is a reliable
tool for quantifying cranial deformities. Furthermore, it is rapid, noninvasive,
and reproducible. However, we continue to use both methods in clinical
practice.
KEY WORDS:
anthropometry, brachycephaly, digital photography, plagiocephaly
Photographic anthropometry was used in clinical medical genetics long before digital photography was implemented. In particular, photographic evaluations help to
clarify verbal descriptions of craniofacial morphometry
(Ferrario et al., 1993; Butler et al., 1995; Hovis and Butler,
1997; Butler et al., 1998). Since the introduction of digital
photography, many have commented on its promise as a
diagnostic tool, but a reliable, standardized method of
photographic assessment has yet to be defined (Guyot et
al., 2003). Various studies have attempted to implement
digital photography in clinical assessment and verify its
reliability and reproducibility. In ophthalmology, a standardized digital photography system with computerized
eyelid measurement was developed (Coombes et al., 2007).
In the field of orthodontics, researchers characterized facial
morphology using standardized photographs and compared their results with standard cephalometric measurements (Ferrario et al., 1993; Zhang et al., 2007).
The diagnostic evaluation of cranial deformities via
digital photographic methods is promising for several
reasons. When treating children, taking photographs is
relatively quick and does not deleteriously affect the child
Dr. Schaaf is Specialist–Maxillofacial Surgery and Senior Staff Member
and Dr. Wilbrand is Senior Staff Member, Department of Maxillofacial
Surgery, University Hospital Giessen and Marburg GmbH, Giessen,
Germany. Dr. Boedeker is Chair, Institute of Medical Informatics,
University of Giessen, Germany. Dr. Howaldt is Chair, Department of
Maxillofacial Surgery, University Hospital Giessen and Marburg GmbH,
Giessen, Germany.
Submitted February 2009; Accepted January 2010.
Address correspondence to: Dr. Heidrun Schaaf, Department of
Maxillofacial Surgery, University Hospital Giessen, Klinikstrasse 29,
35385 Giessen, Germany. E-mail Heidrun.Schaaf@uniklinikum-giessen.
de.
DOI: 10.1597/09-026
447
448 Cleft Palate–Craniofacial Journal, September 2010, Vol. 47 No. 5
FIGURE 1 Representative images of the most common positional head deformities. A: Plagiocephaly. B: Brachycephaly. C: A combination of deformities. The
picture shows the full supracranial view of the skull including both ears and the tip of the nose; parents support the head in slight extension.
or the parents. A digital picture is an archivable document
like a snapshot and measurements are repeatable. The
photograph is a more objective method than the caliper and
less dependent on the examiner. The major advantage of
the photograph is that the landmarks can be selected on a
static surface without any movement. Furthermore, it gives
the opportunity for unbiased assessment by masking the
observer, for example, in clinical trials. The use of clinical
digital photography offers the quick transfer to other
colleagues for interdisciplinary discussion. Several pictures
can be taken with slightly varying perspectives, and the
ones fulfilling the requirements for standardized photography can be selected. However, very few previous studies
have examined the use of this method in assessing cranial
deformities. An early study applied superior and frontal
photographs of the head to evaluate the degree of
plagiocephaly (Donegan et al., 1996); whereas, a more
recent report described a measurement methodology based
on black-and-white photography (Clarren, 1981). A very
recent review by McGarry et al. (2008) described standard
head shape measurements used in the treatment of children
with deformational plagiocephaly and concluded that
further research in this field is required to facilitate
classification. In a recent publication discussing the effect
of conservative treatment of positional plagiocephaly,
Bialocerkowski et al. (2005) emphasized the need for a
standardized outcome measure.
The cephalic index (CI) and cranial vault asymmetry index
(CVAI) were initially introduced to help define head
deformity in the treatment of positional plagiocephaly
(Loveday and de Chalain, 2001). However, a previous
prospective cohort study that examined infants with a wide
range of CI values and oblique cranial length ratios predicted
that the majority of cases would resolve before 2 years of age
without treatment (Hutchison et al., 2004).
Craniofacial anthropometric measurements are obtained
using sliding calipers, which are widely touted as a simple,
cheap, and noninvasive method of evaluating deformity
(Farkas, 1994; Littlefield et al., 1998; Kelly et al., 1999;
Mulliken et al., 1999; McGarry et al., 2008). However,
previous studies have questioned the reliability of using
calipers as diagnostic devices in cranial measurements. For
example, care is required to accurately locate bony
landmarks and to prevent inaccurate measurements due to
the displacement of soft tissue; furthermore, it is difficult for
the infant to remain still for the extended period required to
complete all measurements (St. John et al., 2002).
Our objective was to evaluate the clinical value of
standardized photographic measurements compared with
the traditional cranial measurements obtained using calipers.
The CI and CVAI were calculated for both methods.
MATERIAL AND METHODS
Digital photographs were obtained from 122 children
between the ages of 3 and 15 months, all of whom had been
diagnosed with nonsynostotic cranial deformities. Figure 1
shows three representative images of the most common
positional deformities assessed here, including plagiocephaly, brachycephaly, and a combination of both.
This study included children for whom photographic
documentation and clinical measurements were obtained
before treatment with a molding helmet. Photographs and
clinical measurements were obtained on the same day.
Photographs were selected in agreement with European
standards, according to the additional picture set for standardized facial and cranial photography (Ettorre et al., 2006; Schaaf
et al., 2006). All photographs were taken under standardized
conditions using a single-lens reflex (SLR) camera. The local
ethical committee approved the study protocol.
Schaaf et al., PHOTOGRAPHIC VERSUS STANDARD ANTHROPOMETRIC MEASUREMENTS IN CRANIAL DEFORMITIES 449
Digital SLR cameras provide high-quality pictures
combined with the possibility of variation of lenses. For
this study we used a fixed focal length (90 to 105 mm), highquality macro lens, which assures a maximum depth of
field. Lighting is performed by multi-flashlight installation
with three soft boxes positioned with a constant distance of
1 to 1.5 m at either side and above the patient. The
background for all pictures is a light blue color (‘‘sky blue,’’
RAL 5012). Under these conditions, high aperture settings
(f . 16) and short exposure time (.125 milliseconds)
mostly have been used. For each picture taken, a manual
setting of exposure time and aperture setting is possible
because digital pictures can be assessed immediately and
the setting can be adjusted. A constant distance from the
infant to the camera is desired. The height of the camera is
positioned at the same level as the focal point.
The full supracranial view of the skull included both
ears and the tip of the nose as anatomical landmarks.
Rotation of the head should be avoided and can be
controlled by the appearance of these landmarks and
their symmetry. Children were placed on parents’ lap in
front of the blue background. Then the full supracranial
oblique images with slight extension of the head, showing
the nose and zygoma, were obtained while the head was
supported by the parents’ arm. This method facilitates
the detection of skull deformities with midfacial involvement.
Previous work has identified parameters that are useful
in the evaluation of cranial deformities. The CI is an
anthropometric measure based on the ratio of head width
to head length. Width was measured from the left euryon to
the right euryon, and length was measured from the
glabella to the opisthocranion on both the digital photograph and on the patient. The glabella is defined as the
most prominent midline point between the eyebrows and is
identical to bony glabella on the frontal bone (Farkas,
1994). Opisthocranion is the point situated in the occipital
region of the head and is most distant from the glabella;
that is, it is the most posterior point of the line of greatest
head length (Farkas, 1994).
In contrast, the calculation of the CVAI requires
diagonal measurements A and B, and as such, we recorded
the distances from the right frontotemporale to the left
euryon and vice versa. These landmarks and distance
measures were also consistent with standard documentation in anthropometry (Farkas, 1994). The CVAI is used to
indicate asymmetrical deformity and is calculated as
follows: CVAI 5 (diagonal A 2 diagonal B) 3 100/
diagonal A, where A , B (Loveday and de Chalain, 2001).
Therefore, CVAI represents a meaningful assessment
method independent of head size.
A single clinician using a metric anthropometric spreading caliper (Bertillon AA 842 C, 320 mm [12L inches];
Aesculap AG, Tuttlingen, Germany) performed all clinical
measurements. For the photographic measurements the
Quick CephH software (Quick CephH Studio; Quick CephH
Systems, San Diego, CA, USA), an orthodontic diagnosis
and treatment planning application for cephalometric
analysis, was used (Fig. 2). The children’s photographs were
imported to the program for application of an individual
analysis with anthropometric landmarks. Linear measurements on photographs can be obtained easily by clicking on
two anthropometric landmarks in the picture. The computer
program generates a numerical value. Both parameters CI
and CVAI were a quotient of two distances, so the results are
independent of a unit and of comparative value.
Data analyses were performed by SAS 9.1.3 (SAS
Institute, Cary, NC, USA). Bland-Altman plots were
generated to compare and analyze data gathered using
each method (Bland and Altman, 1986). Therefore the
differences between photographic and clinical anthropometric measurement methods were plotted against the
clinical anthropometric measurement alone. The BlandAltman scatter diagram shows the bias, that is, the average
difference between the methods (ideal bias 5 0) and the
limits of agreement, defined as 1.96 standard deviations
that describe the range for 95% of comparison points. In
addition, the precision of the estimated limits of agreement
were determined by calculating the 95% confidence
intervals for the limits of agreement (Bland and Altman,
1999).
To evaluate interobserver variability, two different
investigators examined digital photographs from the
plagiocephalic group (n 5 70). Intraobserver and interobserver variation were determined considering the betweenand within-subject variation by intraclass correlation
coefficient (ICC) under an analysis of variance framework
using PROC GLM of SAS. In order to determine the
interrater reliability, the ICCs were calculated by an SAS
macro provided by Hamer (1990) using the ratio of mean
squares from the variance table. Out of the six different
ICCs proposed by Shrout and Fleiss (1979), ICC (3,k) was
chosen, which is applicable when all subjects are rated by
the same raters, who are assumed to be the entire
population of raters. In addition, reliability is given for
the mean of all ratings assuming no subject-by-rater
interaction. Using the ICC statistics, interrater reliability
of ..81 was defined as excellent agreement, between .61
and .80 as good agreement, between .41 and .60 as
moderate agreement, between .21 and .40 as fair agreement,
and less than .21 as poor agreement. The ICCs were
calculated using a SAS macro (Hamer, 1990).
RESULTS
In total, we collected photographs of 122 children who
were treated from 2004 to 2007; subjects were included only
if their photographs were suitable for standardized
photographic measurements. Seventy infants were diagnosed with a plagiocephalic deformity, five with brachycephaly, and 47 with a combination of both deformities.
The median age at the initial examination was 28.29 weeks
450 Cleft Palate–Craniofacial Journal, September 2010, Vol. 47 No. 5
FIGURE 2 Method of photographic measurement using Quick CephH software for tracing photographs. A: The CI was established based on the ratio of head
width to length. B: The diagonal measurements were recorded for the CVAI.
for those with plagiocephaly, 27.29 weeks for those with
brachycephaly, and 29.86 weeks for those with combined
deformities.
To compare photographic and clinical anthropometric
measurement methods, differences between the CI values
derived from photography (CI-photo) and those derived
from anthropometry (CI-anthropometry) were plotted
against the values derived from anthropometry to generate
a Bland-Altman plot (Fig. 3). As shown in Figure 3, the
photographic method satisfied the limits of agreement,
which describe 1.96 standard deviations (7.51%). We noted
a bias of 1.79% (i.e., the average of the values of the CIphoto measurement method were slightly lower than the
average of the CI-anthropometry values). The precision,
which describes the range for 68% of comparison points, is
3.83, which was within acceptable ranges. Looking for the
most optimistic interpretation, considering the outer 95%
confidence intervals for the limits of agreement, all but one
difference value lies outside of these limits.
Very similar results were obtained for CVAI values
(Fig. 4), which fell within the limits of agreement (6.57%)
and showed a slightly higher bias of 3.03% versus the CI
comparison. The precision of 3.36 is nearly the same as for
the CI values, and considering the outer 95% confidence
intervals for the limits of agreement, only four values lie
outside of these limits. However, plots for both indices
showed that photographically derived values were progressively underestimated as the anthropometrically derived
values increased. Table 1 shows the CI and CVAI data of
all infants classified into the groups plagiocephaly, brachycephaly, and combined positional head deformity.
FIGURE 3 Bland-Altman plots were used to compare the differences
between photographically and anthropometrically derived values of cranial
index (CI-photo 2 CI-anthropometry) against anthropometrically derived
CI values. The dotted-dashed line (— - — - —) in the middle of the plot
represents the mean value of differences (bias); whereas, the outer dotteddashed lines represent the limits of agreement (±1.96 standard deviations).
The dashed lines (- - -) represent the lower/upper 95% confidence interval of
the lower/upper limit of agreement.
Schaaf et al., PHOTOGRAPHIC VERSUS STANDARD ANTHROPOMETRIC MEASUREMENTS IN CRANIAL DEFORMITIES 451
DISCUSSION
FIGURE 4 Bland-Altman plots were used to compare the differences between
photographically and anthropometrically derived values of cranial
vault asymmetry index (CVAI-photo 2 CVAI-anthropometry) against
anthropometrically derived CVAI values. The dotted-dashed line (— - — - —)
in the middle of the plot represents the mean value of differences (bias); whereas,
the outer dotted-dashed lines represent the limits of agreement (±1.96 standard
deviations). The dashed lines (- - -) represent the lower/upper 95% confidence
interval of the lower/upper limit of agreement.
Besides the main aim of the study (the comparison of
photographic and clinical anthropometric measurements),
interobserver variability was assessed as a side target. Here,
we chose the main group of infants with the diagnosis
plagiocephaly (n 5 70) because this group represents the
major diagnosis in head deformities.
Comparison between observers who separately evaluated
the plagiocephalic group was performed by variance
decomposition using general linear modeling analysis. The
ICC calculation provides the within-observer variabilities,
which were 3.36% for the CI and 2.324% for the CVAI.
Therefore, the probability that the difference between two
measurements from two different observers on the same
child will be larger than 5.08 (for the CI) and 4.226 (for the
CVAI), respectively, is less than 5%. (Calculated by 1.96 3
SQRT(2 3 3.36) 5 5.08 and 1.96 3 SQRT(2 3 2.324) 5
4.226 for the CI and CVAI, respectively). The interrater
reliability estimated by the ICCs revealed .982 for the CI and
.946 for the CVAI. Both values can be counted as an
excellent agreement between observers.
The method of obtaining anthropometric measurements
using sliding calipers is frequently described in the literature.
The comparison between photographic and clinical measurement is rarely discussed. An investigation on eyelid position in
Graves ophthalmopathy describes a fair to moderate agreement between these methods (Edwards et al., 2004).
Although previous studies examined the reliability and
validity of anthropometric measurements, interobserver
variability has been scrutinized lately (Mortenson and
Steinbok, 2006). We also investigated interobserver variability for the photographic method and found relatively
little variability, with an interrater variability of 3.36% for
the CI and 2.324% for the CVAI. Our ICC results of .982
for the CI and .946 for the CVAI seem to be comparable
with other investigations. In the literature the interrater
reliability of plagiocephalometry on 50 children, measured
three times by two examiners with a thermoplastic strip and
a tracing method on a photocopy, is described. For the
interrater reliability using Bland-Altman plots, investigators found 5.8% for the CI and an ICC of .92 (van
Vlimmeren et al., 2006).
In another investigation on caliper measurements with 71
children, two examiners and three measurement sets, ICCs
indicated strong intrarater reliability (.98 to .99); whereas,
interrater reliability was moderate, with ICC values of .42
(Mortenson and Steinbok, 2006). By triplicating anthropometric measurements obtained by a single experienced
examiner, Littlefield found an intrarater repeatability of
61 mm (Littlefield et al., 1998).
Altogether, though, Mortenson states that no study
exists that has investigated the interrater reliability of
multiple, nonanthropometric examiners (Mortenson and
Steinbok, 2006). The clinical significance or relevance can
be discussed. Our results show that an experienced
examiner can identify the relevant landmarks repeatedly
within an acceptable range, which does not affect the
clinical diagnosis or treatment procedure.
Computed tomography imaging is an accurate, threedimensional technique to describe head asymmetry (Glat et
TABLE 1 Comparison of Anthropometrically and Photographically Derived Measurements of Cranial Index (CI, %) and Cranial Vault
Asymmetry Index (CVAI, %) in Infants With Plagiocephalic, Brachycephalic, or Combined Positional Head Deformities
Variable
Diagnosis
n
Minimum
Median
Maximum
Mean 6 SD
CI-anthropometry
CI-photo
CI-anthropometry
CI-photo
CI-anthropometry
CI-photo
CVAI-anthropometry
CVAI-photo
CVAI-anthropometry
CVAI-photo
CVAI-anthropometry
CVAI-photo
Plagiocephaly
Plagiocephaly
Brachycephaly
Brachycephaly
Combination
Combination
Plagiocephaly
Plagiocephaly
Brachycephaly
Brachycephaly
Combination
Combination
61
70
5
5
44
47
69
70
5
5
46
47
73.5
76.6
106.3
101.8
95.0
93.2
0.7
1.5
0.7
1.5
5.1
5.1
90.3
89.2
108.7
104.1
104.0
101.5
16.4
12.8
3.0
2.6
15.9
13.4
109.8
103.4
114.5
114.2
123.5
115.9
28.2
23.8
6.1
3.7
33.7
26.4
90.1 6 8.2
89.8 6 6.3
109.3 6 3.1
105.9 6 4.8
105.4 6 6.9
101.8 6 5.1
15.9 6 6.6
12.5 6 4.8
3.0 6 2.1
2.6 6 0.8
16.8 6 6.5
13.9 6 4.9
452 Cleft Palate–Craniofacial Journal, September 2010, Vol. 47 No. 5
al., 1996; O’Broin et al., 1999), but the required radiation
exposure is not justifiable in infants with nonsynostotic skull
deformities that can be diagnosed clinically. Accordingly, a
previous report compared digital photographic techniques
with a tracing method using a flexicurve ruler to evaluate
plagiocephaly in infants (Hutchison et al., 2005). In this
previous publication, the photographic technique showed
much less variability than the flexicurve method, and
although the flexicurve method produced a similar head
circumference, ear angle measurements were particularly
unreliable (Hutchison et al., 2005). Photographic methods
also have been used to identify landmarks or digitize the head
band (Hutchison et al., 2004, 2005; Zonenshayn et al., 2004).
Photographic evaluation is extremely advantageous in
young children because it is rapid, noninvasive, reproducible,
and provides a good clinical outcome. However, problems
may be encountered in children with long hair or those who
were photographed in a nonstandard position. As such, a
standardized procedure must be used to obtain photos for
cephalometric measurements. Previous studies have provided
several recommendations to ensure high quality and consistency among photographs taken from a standard set of views
(Ettorre et al., 2006; Schaaf et al., 2006).
CONCLUSION
Our results demonstrate that the evaluation of cranial
asymmetry based on digital photography is both accurate
and comparable to using standard anthropometry. However, a standardized method must be applied to obtain
reliable results. The quick, simple technique described here
was particularly useful in children; it facilitated the
diagnostic evaluation of CI and CVAI values and was
helpful in treatment planning and communication with
parents. In our hands, digital photography proved to be a
very useful tool regarding head shape, but the wellestablished caliper method in anthropometry should not
be omitted for the time being.
Acknowledgments. We thank Christine Scheibelhut and Dr. Joern PonsKühnemann (Institute for Medical Statistics, University of Giessen,
Germany) for their professional biometric support in this study.
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