Surgical and Radiologic Anatomy

https://doi.org/10.1007/s00276-020-02518-3

ORIGINAL ARTICLE

Classification of the midpalatal suture maturation in individuals older

than 15 years: a cone beam computed tomographic study
Luisa Gatti Reis1 · Rosangela Almeida Ribeiro2 · Robert Willer Farinazzo Vitral2 · Henrique Nogueira Reis3 ·
Karina Lopes Devito4 

Received: 1 March 2020 / Accepted: 9 June 2020

© Springer-Verlag France SAS, part of Springer Nature 2020

Abstract
Purpose  The aim of this study was to classify the maturation of the midpalatal suture (MPS) in a sample of individuals
aged 15 years and older.
Methods  Tomographic images in axial sections of the MPS of 289 female individuals and 198 male individuals aged between
15 and 40 years were analyzed and classified in stages of maturation (A, B, C, D, and E), stage A represents the earliest
maturation stage of the suture and in stage E the fusion of the MPS has occurred in the maxilla. The Kruskal–Wallis and
Student–Newman–Kells tests were used to compare the chronological ages among different maturation stages. Spearman’s
correlation coefficient was used to assess the correlation between patient’s age and the maturation stages of the MPS.
Results  Stage A was not observed in the sample. Stages B and C represent, respectively, 1.03% and 34.09% of the sample,
stage D was found in 16.63% of the sample while stage E was the most prevalent stage found (48.25%). For females, it was
revealed no statistically significant difference in the mean ages among stages C, D and E (p = 0.4753). For males, a statisti-
cally significant difference was observed, with the mean age of individuals in stages D and E of the MPS maturation higher
than in other stages (p = 0.0001). There was a significant, but weak, correlation between patient’s age and the maturation
stages of the suture (rs = 0.11/p = 0.01).
Conclusion  No individuals in stage A of suture maturation were found and stage B was identified in only 1% of the sample.
The majority of the patients (64.88%) presented at least partial fusion of the MPS (stages D and E).

Keywords  Radiology · Anatomy · Orthodontics · Cone-beam computed tomography · Cranial sutures

Introduction Haas [10]. Rapid maxillary expansion (RME) has since been
routinely used in orthodontics as treatment in cases of max-
The possibility of widening maxillary arches through the illary atresia [22] and its possible results, such as posterior
opening of the midpalatal suture (MPS) was first described crossbite and dental crowding [17]. Other benefits of this
by Angell [4] in his pioneering work and reintroduced by expansion treatment include widening of the nasal cavity
[12, 17], its use in the correction of both Class II and Class
III malocclusions and esthetic purposes [17].
* Karina Lopes Devito The achievement of good results with the RME treatment
karina.devito@ufjf.edu.br
is mainly related to the individual’s condition of the MPS.
1
Faculty of Dentistry, Federal University of Juiz de Fora, In patients who have a fully matured suture, the maxillary
Juiz de Fora, MG, Brazil bones that make up the palatal vault have enough interdigita-
2
Department of Social and Pediatric Dentistry, Faculty tion to impose strength and resist the opening of the suture
of Dentistry, Federal University of Juiz de Fora, Juiz de Fora, through RME [18, 22]. For those individuals the surgically
MG, Brazil assisted rapid maxillary expansion (SARME) is often indi-
3
Faculty of Medical and Health Sciences, SUPREMA, cated [9].
Juiz de Fora, MG, Brazil In order to obtain success in the RME treatment the per-
4
Department of Dental Clinic, Faculty of Dentistry, Federal centage of fusion of the MPS in each individual is regarded
University of Juiz de Fora, Rua José Lourenço Kelmer, s/n, as more important than the presence or lack of fusion [14,
São Pedro, Juiz de Fora, MG 36036‑900, Brazil

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15, 19]. Until adolescence, the treatment presents good prog-
nosis with significant skeletal gains [22]. However, when the
RME treatment is performed in individuals after the pubertal
growth spurt, there is greater response at the dentoalveo-
lar level [5]. Acute pain [7], dehiscence formation, alveolar
bone bending, mucosal ulceration or necrosis, poor stability
[24], buccal dentoalveolar tipping and gingival recession in
the posterior teeth [2, 5] are side effects that may be associ-
ated with this response. SARME is a treatment option that
could be performed at any time during the patient’s life,
however, its main disadvantage is the increase in morbidity
[2, 3, 11, 15].
The treatment of transverse maxillary deficiency in non-
growing individuals demands careful attention so as to
choose the treatment option best suited for each case [2].
Although chronological age has traditionally guided the
clinical decision between traditional RME and SARME,
there is no consensus in the literature as to when RME is
not possible to be performed anymore [3]. Previous histo-
logical studies have shown great variability regarding suture
closure according to patients’ age [14, 15, 19]. These studies
identified subjects aged 27 years, 32 years [19], 54 years
[14], and 71 years [15] who presented no signs of fusion in
the suture margins. Indeed, in a histologic microradiographic
study, Melsen [18] made no specific statement on when the
ossification of the suture precisely happens. Persson and
Thilander [19] found that the youngest patient with oblit-
eration of the MPS was a 15-year old girl, whereas in the
same sample there was a 27-year old woman whose suture
was not yet fused. This shows that the degree of maturation
of the MPS varies greatly in patients in the post pubertal
growth stage [22].
The closure of the MPS is influenced not only by the
patients’ chronological age, but also by the great variability
individuals present among themselves [2, 6, 7, 19], such as
nutritional deficiencies, the population’s ethnicity, the skel-
etal development itself and or the structures that surround
the suture. Therefore, clinicians should be advised not only
to be cautious about using the chronological age factor, but
also to individually analyze the maturation of the MPS in
each patient prior to RME.
Revelo and Fishman [20] proposed a method for individ-
ual analysis of the development of the MPS using occlusal
radiographs. These 2D radiographs are most often requested
when RME is required in an adult patient in order to assess
Table 1  Demographic characteristics of the sample
15–20 years n (%) 21–25 years n (%) 26–30 years n (%)
Female 59 (12.11) 135 (27.72) 45 (9.24)
Male 34 (6.98) 74 (15.19) 40 (8.21)
Total 93 (19.10) 209 (42.91) 85 (17.45)
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Surgical and Radiologic Anatomy
the maturation of the suture [23]. However, this method for
individual assessment presents some limitations. The over-
lapping images in 2D radiographs makes them difficult to
assess, as superimposition of the vomer and external nose
structures could lead to false radiological interpretation [23,
24]. In fact, Wehrbein and Yildizhan [23] false-positively
assessed suture maturation in 50% of their radiographs.
Angelieri et al. [2] proposed an individual assessment
method of the MPS maturation using cone beam computed
tomography (CBCT) scans, in order to determine the degree
of maturation of the suture prior to intervention. Unlike
occlusal radiographs, these scans offer a volumetric image
of the oral and maxillofacial structures [2], which makes it
possible to isolate the area of the MPS without superimpo-
sition of other anatomical structures [2]. The evaluation of
the scans could provide clinicians with more reliable clinical
data to aid in the treatment of maxillary atresia particularly
in late adolescents and young adult patients [2].
The results of RME are unpredictable when performed
in patients who have already stopped growing [2, 5–7, 18,
19]. However, chronological age has been considered unreli-
able for determining the maturation status of the suture [2].
Therefore, the clinical dilemma of whether an individual in
the post pubertal growth stage could be treated with RME
as a less invasive alternative to a surgical procedure is a
relevant question [2].
The aim of this study was to classify the maturation of
the MPS according to the method proposed by Angelieri
et al. [2] in a sample of individuals aged 15 years and older.
Material and methods
Baseline diagnostic CBCT images of 487 subjects were
analyzed. The sample was composed of 289 women
(59.34%) and 198 men (40.66%), as shown in Table 1.
The ages ranged from 15 to 40 years, with a mean age
of 25.30 (± 5.89) years. The formula applied to calculate
the sample size was n = Z2 p q/e2 (Eq. 1, by Cochran [8]),
where Z2 is the abscissa of the normal curve that cuts off
an area α at the tails (1—α equals the desired confidence
level, e.g., 95%), e is the desired level of precision, p is
the estimated proportion of an attribute that is present in
the population, and q is 1—p. The value for Z is found in
31–35 years n (%) 36–40 years n (%) Total n (%)
28 (5.75) 22 (4.52) 289 (59.34)
29 (5.95) 21 (4.31) 198 (40.66)
57 (11.70) 43 (8.83) 487 (100)
Surgical and Radiologic Anatomy

statistical tables that contain the area under the normal
curve. Considering α = 5%, Z = 1.96, p = 0.25 [21], and
q = 0.75, the minimum sample size was 288 patients.
The CBCT scans were selected from the archive of
the Dental Radiology Clinic at the Dental School of the
Federal University of Juiz de Fora (UFJF, Juiz de Fora,
MG, Brazil). All images were acquired in the same scan-
ner (I-Cat ®, Imaging Sciences International, Hatfield,
Pennsylvania, USA), with an acquisition protocol of
120 kV, 8 mA, 26.9 s rotation, 0.25 mm voxel and an
FOV between 6 × 23 and 8 × 23 cm. The inclusion criteria
were individuals from a Brazilian population, with ages
ranging from 15 to 40 years, availability of good quality
CBCT images, absence of orthodontic appliance at the
examination, no previous traditional RME treatment or
orthognathic surgery, absence of cleft lip and palate, no
syndromic conditions nor patients with maxillomandibu-
lar lesions and or anomalies. This research was a descrip-
tive and retrospective study and was approved by the eth-
ics committee in research of UFJF—protocol 2.450.263.
I-Cat ® Vision Software (Imaging Sciences Interna-
tional, Hatfield, PA, USA) was used to perform image
analysis, in the MPR screen. The standard axial slice was
obtained according to the following protocol: in the coro-
nal section the median sagittal plane was aligned with
the nasal septum; in the sagittal section the horizontal
plane was aligned with the hard palate. Thus, the stand-
ard axial slice used in the evaluation of the images was
obtained. For those cases in which the palate presented a
pronounced curvature or was very thick, two distinct axial
slices were used.
The methodology proposed by Angelieri et al. [2] was
used in the evaluation of the scans. According to this
protocol, there are five maturation stages of the suture:
A, B, C, D and E (Table 2).
All images were analyzed by one calibrated examiner
(LGR), who was experienced in the evaluation of CBCT
images. A month later the same examiner reclassified a
random selection of 10% of the sample in order to check
the reliability of the chosen MPS classification method.
Statistical analysis
A weighted kappa coefficient was calculated to assess the
intraexaminer agreement. To verify the normality of the data
the Kolmogorov–Smirnov test was applied. Chronological
age was compared among the maturation stages of the suture
using the Kruskal–Wallis and Student–Newman–Keuls
tests. Spearman’s correlation coefficient was used in order
to assess the correlation between patient’s age and the matu-
ration stages of the MPS. The statistical software used was
SPSS software version 15.0 (SPSS Inc., Chicago, USA) and
the level of significance was 5% (p ≤ 0.05).
Results
The kappa coefficient for the evaluation of the intraexam-
iner agreement was 0.8774, which demonstrates substantial
agreement [16].
Table 3 presents the distribution of the maturation stages
of the midpalatal suture as observed in the sample, which
showed great variability with regards to chronological age.
Stage A was not observed in any of the subjects evaluated.
Stage B was found in 5 female individuals, corresponding to
1.03% of the sample. Stage E was the most prevalent stage
verified in the present research (48.25%). The majority of
the sample presented at least partial fusion of the MPS, cor-
responding to stages D and E (64.88%). However, 35.12% of
the sample presented no signs of union in the suture margins,
as seen in the frequencies of stages B and C (Fig. 1).
The comparison of ages at the different stages of mat-
uration is presented in Table 4. Only stages C, D and E
were compared, since no individuals were found in stage
A and only 5 female patients were classified as stage B.
For females, no statistically significant difference was
observed (Kruskal–Wallis/p = 0.475). For males, a statisti-
cally significant difference was observed between the stages
(Kruskal–Wallis/p = 0.001). However, in an analysis of the
minimum and maximum values, the three stages included
individuals of all age groups. This shows that individuals

Table 2  Skeletal maturation stages of the MPS by Angelieri et al. [2]

Stage Description

A Represents the earliest maturation stage of the suture, and in this stage the suture was identified as a relatively straight high-density line
at the midline
B The suture presents an irregular shape and was identified as a scalloped high-density line at the midline
C The suture is seen as two parallel, scalloped, high-density lines close to each other and separated in some areas by small low density
spaces
D The complete fusion of the suture has occurred in the palatine bone and the radiographic image of the suture was identified as two scal-
loped, high density lines at the midline on the maxillary portion of the palate that were not visible in the palatine bone
E Fusion of the suture has occurred in the maxilla. It is not possible to identify the MPS. As to bone density, it is the same as in other parts
of the palate

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 Surgical and Radiologic Anatomy

Table 3  Distribution of the maturation stages of the midpalatal suture

15–20 years 21–25 years 26–30 years 31–35 years 36–40 years Total n (%)
Female Male Female Male Female Male Female Male Female Male
n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

A 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
B 0 (0) 0 (0) 1 (0.20) 0 (0) 1 (0.20) 0 (0) 2 (0.41) 0 (0) 1 (0.20) 0 (0) 5 (1.03)
C 25 (5.13) 18 (3.70) 40 (8.21) 31 (6.36) 12 (2.46) 13 (2.67) 7 (1.44) 6 (1.23) 9 (1.85) 5 (1.03) 166 (34.09)
D 9 (1.85) 8 (1.64) 17 (3.49) 17 (3.49) 7 (1.44) 8 (1.64) 5 (1.03) 5 (1.03) 0 (0) 5 (1.03) 81 (16.63)
E 26 (5.34) 8 (1.64) 76 (15.60) 26 (5.34) 25 (5.13) 19 (3.90) 14 (2.87) 18 (3.70) 12 (2.46) 11 (2.26) 235 (48.25)
Total 60 (12.32) 34 (6.98) 134 (27.51) 74 (15.19) 45 (9.24) 40 (8.21) 28 (5.75) 29 (5.95) 22 (4.52) 21 (4.31) 487 (100)

of any age could present any of the three stages of the MPS
maturation (C, D and E).
The results of the Spearman’s coefficient showed that
there is significant correlation between patient’s age and the
maturation stages of the suture. However, this correlation
was classified as weak (rs = 0.11/p = 0.011).
Discussion
A continuous progress of skeletal maturation is expected
to happen as an individual gets older. The same applies to
the obliteration of the MPS [19], and hence chronological
age has often been used as the main deciding factor in the
treatment of patients with maxillary atresia [3]. Nonethe-
less, according to the result of the Spearman’s correlation,
which was significant but very weak, the correlation between
patients’ age and maturation stage of the suture is not as
obvious as one would think.
In fact, the present study showed great variability in the
maturation stages of the suture with regards to chronologi-
cal age (Tables 3 and 4). This corroborates the findings
of Angelieri et al. [2], who found that patients older than
11 years could present any of the maturation stages of the
suture.
In our study no individuals in stage A of suture matura-
tion were found, while stage B was found only in 1.03%
of the sample (Table 3). This low prevalence of the earli-
est maturation stages of the suture was expected, since the
sample is composed of individuals with a more advanced
chronological age. Stage C, the second most prevalent stage,
was identified in 34.09% of the sample. According to the
methodology proposed by Angelieri et al. [2] this stage rep-
resents critical timing for RME, since the start of fusion in
the palatine bone could be imminent. Therefore, stage C
indicates that these individuals might obtain success with
the traditional palatal expansion procedure without surgi-
cal assistance [2]. However, in order to verify the possible
clinical success of the RME treatment in a patient whose
suture is in stage C of maturation future longitudinal studies
are needed.
Partial fusion of the MPS (stage D) was verified in
16.63% of the sample and its complete fusion was observed
in 48.25% (stage E). In total, 64.88% of the sample had at
least partial fusion of the suture, indicating that the major-
ity of these individuals would probably not be able to suc-
cessfully undergo traditional RME treatment. These findings
corroborate clinical experience [3]. The poor prognosis of
the RME treatment in individuals who have stopped growing
[18] may be related to the fact that the expansion in these
patients provokes more dentoalveolar effects than skeletal
impact [5, 24]. This may be accompanied by side effects
such as buccal dentoalveolar tipping and gingival recession
in the posterior teeth [2, 5].
It should be noted that beyond the MPS, other craniofa-
cial structures offer resistance to palatal expansion. In fact,
other circunmaxillary sutures [13], zygomatic arch [7, 24]
and sphenoid bone [7] are also involved. Therefore, in order
to have a better prediction of the prognosis, these structures
should also be taken into consideration in future studies.
Although women generally reach skeletal maturation
before men, there is no consensus regarding the closure of
the MPS in relation to sex. Some studies showed no dif-
ference in the closure of the suture between females and
males [19, 20]. Our findings agree with the belief of Alpern
and Yurosko [1], for whom women reach skeletal maturity
earlier than the opposed sex, as evidenced by their recom-
mendation that SARME was to be performed in women over
20 years and men 25 years and older. In our study, females
reached the late stages of maturation of the MPS before
males. The mean age for stage D was 23.89 years in females
and 25.83 years in males; and for stage E was 24.96 years
in females and 27.71 years in males. For females, statistical
analysis revealed no statistically significant difference in the
mean ages between stages C, D and E. For males, a statis-
tically significant difference was observed, with the mean
age of individuals in stages D and E of the MPS maturation
higher than in other stages.

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Surgical and Radiologic Anatomy
Fig. 1  Maturation stages of the midpalatal suture. Tomographic
axial slice followed by schematic drawing. a Stage B, suture presents
irregular shape, seen as scalloped high-density line at the midline.
b Stage C, suture two parallel, scalloped, high-density lines close to
each other and separated in some areas by small low density spaces.
c Stage D, complete fusion of the suture has occurred in the palatine
bone and the radiographic image of the suture was identified as two
scalloped, high density lines at the midline on the maxillary portion
of the palate that were not visible in the palatine bone. d Stage E,
fusion of the suture has occurred in the maxilla. It is not possible to
identify the MPS. As to bone density, it is the same as in other parts
of the palate
The methodology proposed by Angelieri et al. [2] presents
its own setbacks, namely, the need for a CBCT examination
and a significant training required to successfully analyze
suture maturation in the images. However, it offers fewer
disadvantages than an unnecessary surgical intervention.
Comparing our study with the Angelieri et al. [3], which
also evaluated an adult population, the main advantages
would be a sample six times larger and with a more homoge-
neous distribution in relation to sex. In addition, in the study
by Angelieri et al. [3], their sample included subjects aged
from 18 to 66 years. In our sample, aged from 15 to 40 years
of age. Our sample of young individuals (15–17 years) was
chosen specifically because it represents the part of the pop-
ulation for which the fusion of the median palatal suture is
in this transition phase.
It is not the goal of the present study to determine a new
treatment protocol for maxillary expansion in adolescent and
young adult patients. However, the individual analysis of
the midpalatal suture through CBCT prior to intervention in
these cases may assist the clinician to reach a more accurate
diagnosis. The possibility of young adults presenting earlier
stages of maturation of the midpalatal suture should not be
discarded. The midpalatal suture was not fused in 35.12%
of the sample.
Conclusion
• In a sample composed of individuals aged 15 years and
older, no individuals in stage A of suture maturation were
found;
• Stage B was identified only in 1% of the sample;
• The midpalatal suture was not fused in 35.12% of the
sample;
• The majority of the patients (64.88%) presented at least
partial fusion of the midpalatal suture (stages D and E),
which corroborates clinical practice.
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 Surgical and Radiologic Anatomy

Table 4  Chronological age (years) for subjects at the different maturation stages of the midpalatal suture

Midpalatal suture stages Chronological age (years)

Female Mean SD Median Minimum Maximum

Stage A (n = 0) – – – – –
Stage B (n = 5) 31.40 5.22 33.00 23.00 36.00
Stage C (n = 93) 24.56 5.77 23.00a 16.00 39.00
Stage D (n = 38) 23.89 4.55 23.00a 17.00 35.00
Stage E (n = 153) 24.96 5.57 23.00a 16.00 40.00
Male Mean SD Median Minimum Maximum

Stage A (n = 0) – – – – –
Stage B (n = 0) – – – – –
Stage C (n = 73) 24.24 5.94 23.00a 15.00 40.00
Stage D (n = 43) 25.83 6.34 24.00ab 16.00 40.00
Stage E (n = 82) 27.71 6.14 26.00b 16.00 40.00

Medians followed by different letters indicate a statistically significant difference by the Kruskal–Wallis and Student–Newman–Keuls tests (com-
parison between stages C, D and E)

6. Bell RA (1982) A review of maxillary expansion in relation to rate

Author contributions  LGR: project development, data collection, data
analysis, manuscript writing. RAR, RWFV and HNR: data analysis,
manuscript editing. KLD: project development, data collection, data
analysis, manuscript writing.
Funding  This study did not receive funding.
Compliance with ethical standards  31(2):73–90
Conflict of interest  The authors declare no conflict of interest.
12. Huang J, Li CY, Jiang JH (2018) Facial soft tissue changes after
Ethical approval  Approval was obtained by the Ethics Committee of
the Federal University of Juiz de Fora, Protocol No. 2.450.263.
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