EVALUATION OF MATURATION STAGES OF THE MID PALATAL …

EVALUATION OF MATURATION STAGES OF THE

MID PALATAL SUTURE IN POST

TAMILNADU POPULATION USING CONE

THE TAMIL NADU DR. M.G.R. MEDICAL UNIVERSITY

in partial fulfillment of th

ORTHODONTIC


MID PALATAL SUTURE IN POST-ADOLESCENTS

TAMILNADU POPULATION USING CONE-

COMPUTED TOMOGRAPHY

Dissertation submitted to


CHENNAI – 600 032

in partial fulfillment of the requirements for the degree of

MASTER OF DENTAL SURGERY

BRANCH V

ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS

2017-2020


ADOLESCENTS IN

-BEAM


e requirements for the degree of

AND DENTOFACIAL ORTHOPEDICS

CERTIFICATE - I

This is to certify that the dissertation entitled “EVALUATION OF

MATURATION STAGES OF THE MID PALATAL SUTURE IN POST-

ADOLESCENTS IN TAMILNADU POPULATION USING CONE-BEAM

COMPUTED TOMOGRAPHY” is the bonafide work done by Dr. NITHYA. P,

during the period of 2017-2020 under our supervision and guidance and to our

satisfaction. This dissertation is submitted in partial fulfillment, for the degree of

Master of Dental surgery awarded by TAMILNADU DR. M.G.R MEDICAL

UNIVERSITY, CHENNAI in the BRANCH V Orthodontics and Dentofacial

Orthopedics.

GUIDE PRINCIPAL

Dr. A. ANAND KUMAR, M.D.S., Dr. A. SIVAKUMAR, M.D.S.,

(HEAD OF THE DEPARTMENT)

POST GRADUATE

DEPARTMENT OF ORTHODONTICS

J.K.K. NATTRAJA DENTAL COLLEGE & HOSPITAL

KOMARAPALAYAM.

CERTIFICATE - II

This is to certify that this dissertation work titled EVALUATION OF

MATURATION STAGES OF THE MID PALATAL SUTURE IN POST-

ADOLESCENTS IN TAMILNADU POPULATION USING CONE-BEAM

COMPUTED TOMOGRAPHY of the candidate NITHYA.P with registration

number 24171901 for the award of MASTER IN DENTAL SURGERY in the branch

of Orthodontics and Dentofacial Orthopedics. I personally verified the website,

urkund.com for checking the plagiarism. It found that the uploaded thesis file from

introduction to conclusion pages showed 4% of plagiarism.

Guide & Supervisor Sign with Seal

ACKNOWLEDGEMENT

Each day has enlightened me with the source of knowledge, every moment has

taught me a new skill. As I walk through my path crossing each milestone, I desire

to be victorious. My urge to grow shall never die and so I move on bearing within

me humility and faith to achieve higher heights. I take this opportunity to express

my sense of gratitude that I express my heartfelt and sincere thanks to many people

who directly and indirectly have helped me, without whom this endeavor of mine

would have been unattainable. The least on my part would be to pen down a few

words of gratitude towards them.

First and foremost I thank the ALMIGHTY LORD for the blessings

showered upon me throughout my life and career.

I express my profound gratitude and respect to my Professor and guide

Dr. A. ANANDKUMAR, M.D.S., Head of the Department, Postgraduate

Department of Orthodontics for his invaluable counsel and encouragement not only

for this study but also throughout my postgraduate course. His innovative ideas,

strict discipline and continuous inspiration has helped me achieve this goal. I will

always be indebted to him for his wholehearted support extended to me.

My sincere thanks to Dr. A. SIVAKUMAR, M.D.S., Principal, J.K.K.

Natarajah Dental College & Hospital, for his kind advice and immense support

throughout the curriculum and also granting me permission to utilize the equipment

in the college for my study.

I am also thankful to Dr. S. SATHESH KUMAR, M.D.S., Professor, for

his inestimable aid, everlasting guidance, co-operation, support and encouragement

throughout my postgraduate course and during the preparation of this dissertation.

I am also thankful to Dr. DIVAKAR, M.D.S., Reader, for his everlasting

guidance, co-operation, kind support and encouragement throughout my

postgraduate course and during the preparation of this dissertation.

I extend my sincere thanks to Dr. V. KUMARAN M.D.S., and

Dr. S. M. VIGNESH PRASAD M.D.S., Senior Lecturers; Department of

Orthodontics and Dentofacial Orthopedics, J.K.K. Natarajah Dental College for their

kind advice, support, and encouragement throughout the completion of this study.

I extend my sincere thanks to Dr. Sowmiya B.D.S., tutor Department of

Orthodontics and Dentofacial Orthopedics, J.K.K. Natarajah Dental College for her

kind support and help throughout the completion of this study.

I am thankful to my batch mate Dr. M. R. Pandeeswaran for his support

and help throughout the study and the curriculum, and I also thank my juniors

Dr. P. Parthiban, Dr. E. Kiruthika, Dr. M. R. Silambu, Dr. N. Sanchana for

their support and help for the completion of the study.

I express my gratitude to Mrs. Sulakshana, Mrs. Krishnaveni,

Ms. Vinitha, the non- teaching faculty of our department for their help.

I am thankful to Dr. Bijivin Raj, M.D.S., (Statistics) for giving significance

to my study.

I would like to express my sincere gratitude to my husband

Dr. Hariharagugan. N for guiding me to choose the right path and supporting me

throughout the post-graduate curriculum and always.

I take this opportunity to express my gratitude and love to my Parents and

my in- laws and my sister without whom it would have been impossible to pursue

with the course and also for the sacrifices and for their underlying support

throughout my educational tenure. I would also like to thank them for their

everlasting support and encouragement to pursue my post-graduation in dentistry.

Above all I would like to thank my little son Pranav for his unconditional

love for me.

TABLE OF CONTENTS

S.

No. Description

Page

No.

1. INTRODUCTION 1

2. AIMS AND OBJECTIVES 6

3. REVIEW OF LITERATURE 7

4. MATERIALS AND METHODS 26

5. PHOTOGRAPHS 29

6. RESULTS 47

7. DISCUSSION 55

8. SUMMARY AND CONCLUSION 61

9. BIBLIOGRAPHY

10 ANNEXURES

11 LIST OF ABBREVIATIONS

ABSTRACT

Abstract

ABSTRACT

AIM: To evaluate the maturation stages of the midpalatal suture based on its

morphology, using Cone-Beam Computed Tomography in post-adolescents.

MATERIALS AND METHODS: The sample comprised of 120 patients,

63 female and 57 male, aged between 15 to 21 years. They had Cone-Beam

Computed Tomography images taken using DENSPLY SIRONA ORTHOPHOS

XG 3D and were exported and viewed using GALILEOS software, where axial

sections were obtained from the midpalatal suture for morphologic evaluation. The

examiners interpreted the images to establish the stage of sutural maturation of each

patient according to its morphologic characteristics in 5 maturational stages (A, B,

C, D, and E) given by Angelieri et al10

and Ladewig LM.11

RESULTS: The maturational stages most often observed in this study were

C, D, and E, (81%). In males, stage C was present in 38.2%; for females this

prevalence was 40.0%.

CONCLUSIONS: The high prevalence of stage C in the age group between

15 and 21 years may justify a good prognosis for rapid maxillary expansion in post -

adolescents.

KEY WORDS: mid palatal suture maturation, CBCT, rapid palatal

expansion,

INTRODUCTION

Introduction

1

INTRODUCTION

Growth is the biological process through which living matter gets enlarged in

size and development is the continuous progress from conception to maturation.

Growth is usually measured by their physical appearance such as height and weight

which are predetermined. Every individual has a different path in growth and

development, which are inherited genetically from their parents. The sequence of the

development is the same for all children, but the rate of development varies for

every individual in the laws of growth.

In the 4th

week of gestation, the development of the human face begins and is

completed by 6th

week. Development of the external face and the primary palate

takes place eventually in the 5th

and 6th

weeks of intrauterine life. The fusion of two

medial nasal processes with the maxillary processes forms the primary palate,

whereas between the 7th

and 8th

week of development the maxillary processes

outgrow as two palatal processes called the secondary palate. The fusion of the

primary and the secondary palate forms a definitive palate by the end of 12th

week.

The two palatal shelves found in close approximation are first covered by an

epithelial lining. This connective tissue of the palatal shelves first combines

resulting in fusion of the palatal shelves. The fusion of the palate doesn’t occur

uniformly. Initially, the mesial edge of the palatal processes fuse with the lower end

of the nasal septum, separating the two nasal cavities and oral cavities.

Ossification of palate occurs from the 8th week of gestation from the

single-center derived from the maxilla as an intramembranous type. The most

posterior part of the palate does not ossify, forming the soft palate. As sutures are

considered as the sites of the skeletal growth, the growth of the nasomaxillary

Introduction

2

complex is produced by the respective suture1 that is oblique in fashion. The growth

of the soft tissue carries maxilla in the downward and forward position. The tension

related to bone formation results in an increase in the overall size of the bones on

either side.

The breadth of the palate is equal to its length at birth, whereas the increase in

length is appreciated postnatally due to appositional growth in maxillary tuberosity

region and transverse maxillary-palatine suture. An increase in width of the palate is

by mid palatal sutural growth and appositional growth along lateral alveolar

margins. Remodeling of bones by apposition and resorption at sutures helps in the

preservation of the shape and dimension of bones during growth. By applying

controlled mechanical forces, we can do remodeling at the sutures. But in the

advanced stage, the suture lines obliterate due to calcification. So, the growth

modification procedures have to be carried out before the obliteration of the sutures.

The growth and development of the nasomaxillary complex are complex. The

posterior part of the sutural width is larger than the anterior part. In adolescence, the

obliteration starts but complete fusion occurs at the age of 20 years. A thorough

understanding of the principles and concepts of the nasomaxillary complex enables

us to understand the normal variations and plan the treatment meticulously.

The transverse discrepancy is one of the common malocclusion and some

etiological factors that influence this type of malocclusions are genetic factors, arch

length deficiencies, abnormal oral habits, posterior cross bite, dental crowding, and

abnormalities in tooth anatomy and eruption sequence.2 The increase in the

transverse dimension of the maxilla is achieved by employing rapid palatal

expansion, which has a long-term history in correcting the transverse discrepancy.

Introduction

3

This is an effective orthopedic approach for the expansion of the maxilla by opening

the mid palatal suture that separates the two halves of the maxilla and produces a

buccal movement of the posterior teeth and the alveolar process with the larger

magnitude of force and corrects the transverse maxillary deficiency. The exact time

for the treatment of posterior cross bite has been questioned, and it is not always

possible to achieve the opening of the palatal suture.3

Since rapid palatal expansion has been used as a treatment modality for

correcting the maxillary transverse discrepancy, many studies have been conducted

to know the dental and skeletal effects caused by RME and its stability after the

treatment. The advantages of RME are more significant in cases where increase in

the arch perimeter, which facilitates the correction of malocclusion without the need

for extraction in many patients.4 Also, obstructive apnea patients had reported an

improvement in the opening of the nasal pathway after RME.5

Rapid maxillary expansion is possible only if the mid palatal suture has not

been obliterated. In patients with fully obliterated mid palatal suture, surgical

expansion or surgically assisted expansion is recommended. The closure of bony

suture tends to increase with age, and the prognosis of RME cannot be predicted in

adults6.

Hence conventional RME is the treatment of choice in young patients.

Exaggerated inclination of the supporting posterior teeth and damage to the

periodontal tissues is encountered in adults, whose growth has been seized. For these

reasons, the proper diagnostic protocol is required for the evaluation of the mid-

palatal suture maturation and to classify the stages of maturation of mid-palate for

treatment purposes.

Fishman7

studied the skeletal maturation using carpal bones and evaluated the

Introduction

4

skeletal maturation using the Hand Wrist radiographs. He stated that variation in

maturation had been closely related to variation in the timing and magnitude of

growth, affirming that there was less correlation with the skeletal and chronological

age.

Melsen6 analyzed the growth of the palate from birth to 18 years of age and

found three different types of suture, in first stage the suture was short and broader,

Y- shaped in the second stage and more interdigitation seen in the third stage, but

not precise on the time of closure of the suture. Revelo and Fishman8 compared and

evaluated the fusion of mid palatal suture using occlusal radiograph and the skeletal

maturity indicator assessed using Hand-wrist radiograph. Even though the stages

correlated there was a disadvantage of superimposition of vomer and nasal structures

on the mid palatal suture.

Timms et al9

studied the rapid palatal expansion using the Cone-beam

computed tomography (CBCT). When compared with multi-slice medical computed

tomography, CBCT provides 3-dimensional images of maxillofacial structures

without superimposition of adjacent structures at relatively low cost, easy

accessibility, and low radiation exposure.

Angelieri et al10

and Ladewig NM11

conducted a Computed Tomographic

study and observed and evaluated the maturation of mid palatal suture stages using

standardized CBCT images in the axial plane. They identified and defined the five

stages of mid palatal suture maturation which helps in preventing the side effects

from the rapid maxillary expansion failure and unwanted surgically assisted rapid

maxillary expansion.

Grunheid et al12

conducted a study to predict the skeletal response of RME

Introduction

5

using the density ratio, cervical maturity indicator and chronological age, in which

the mid palatal suture density ratio was significant to assess the stages of maturation

whereas, other methods were insignificant leading to unwanted exposure to the

patient.

CBCT provides high dimensional accuracy and reliability for the non-invasive

evaluation of intermaxillary suture at a relatively low cost, precise, easy to access

with low radiation exposure when compared with multi-slice medical computed

tomography that lack anatomic superimposition.

The present study was to evaluate the mid palatal suture maturation stages using

Cone-Beam Computed Tomography in 120 samples of the Tamil Nadu population.

AIMS AND OBJECTIVE

Aim and Objective

6

AIM AND OBJECTIVE

AIM:

To evaluate the maturational stages of mid palatal suture ossification in post

adolescent in the age group of 15 to 21 years using Cone-Beam Computed

Tomography

OBJECTIVES:

1. To determine the ossification stages of mid palatal suture using cone beam

computed tomography.

2. To establish the gender differentiation regarding the maturation of mid palatal

suture.

REVIEW OF LITERATURE

Review of Literature

7

REVIEW OF LITERATURE

B. Melsen (1975)6

examined the growth activity of palate according to age in

the different regions. The tissue blocks removed from autopsies of thirty-three boys

and twenty-seven girls aged 0 to 18 years. The region selected was the medial part

of hard palate 1mm behind the incisors and the various growth activities were

determined from the histologic and micro radiographic examinations. The findings

showed that growth in length of the hard palate until the age of 13 to 15 was due to

growth in the transverse suture and apposition on the posterior margin of the palate,

after this age the sutural growth was found to cease, whereas the opposition seemed

to continue for some years and there was a change in the transverse suture

morphology during postnatal growth.

Bjork & V. Skieller (1975)13

conducted a study using implant method to

analyze the growth of the maxilla from profile and frontal (postero-anterior)

cephalometric radiographs in nine boys with normal primary occlusion. The

implants in the infrazygomatic crest were used, as a reference to identify the

proportion of sutural and appositional growth in height from profile radiographs and

the bilateral measurements in the frontal radiographs. The study suggests that the

contour of the anterior surface of the zygomatic process could be used as a reference

structure in growth analysis.

Maurits Persson and Birgit Thilander (1977)1

conducted a study on the

autopsy model of twenty- four persons with the age ranging from 15 to 35 years to

identify the incipient obliteration to the advancement of suture closure with the age

in the intermaxillary sutures. The stained sections quantified the degree of

obliteration by the use of the obliteration index. The result of the study was that


8

palatal sutures show less obliteration during the juvenile period, but a marked degree

of closure was rarely found until the third decade of life and the suture progress is

more towards the palatal side than in the nasal part.

Robert Wertz and Michael Dreskin (1977)14

conducted a study in the

deciduous, mixed, teen-age and in adult to provide a general statement of dental and

skeletal changes that result from suture opening. Fifty-six lateral and frontal

cephalometric roentgenograms were taken at four stages of treatment: before

treatment, at the completion of maxillary suture opening, at the removal of the

suture-opening appliance, and at the completion of active full orthodontic therapy.

The result showed that the Maxillary expansion was seen in all fifty-six cases with

no relapse in young adults but little orthopedic change in the older patients.

Fishman L (1979)7 studied the skeletal maturation using carpal bones and

evaluated the skeletal maturation using the Handwrist radiographs. He stated that

maturational variations have been closely related to the variations in the timing and

magnitude of growth. The methodology included the examination of groups as a

whole in relation to the specific individual maturational characteristics. The method

used four stages of bone maturation found at six anatomical sites located on the

thumb, third finger, fifth finger, and radius. He concluded that the Handwrist

radiograph were capable of providing accurate growth and maturational status to be

applied for Dentofacial orthopedics.

Leonard S. Fishman (1982)15

conducted a study for the evaluation of

skeletal maturation using the Hand Wrist radiographs. The methodology includes

examination of groups as a whole in relation to the specific individual maturational


9

characteristics. The four stages of bone maturation found at six anatomical sites

located on the thumb, third finger, fifth finger, and radius. He concluded that more

information on the study of skeletal maturation were required.

Richard A Kraut (1984)16

conducted a study to determine the standard

approach for surgically assisted RME. The study included 25 patients of surgically

assisted RME procedures performed in the three-year period. There were 14 females

and 11 males, who had a mean age of 24.78 years (range, 15-47 years), and 22.55

years (range, 17-32 years) respectively. They found that the there was successful rapid

maxillary expansion in 23 patients after Osteotomy of the lateral wall of the maxilla

combined with pterygomaxillary disjunction and midpalatal suture separation.

Donald W. Warren et al (1987)17

presented a study to assess the effects of

rapid maxillary expansion and surgical expansion on nasal airway size. The group

consisted of 16 subjects, who were divided into four groups - two control groups,

one rapid maxillary expansion group, one surgical expansion group. The results

demonstrated that both procedures improved the nasal airway.

B. Revelo (1990)18

determined the correlation between skeletal maturation and

closure or fusion of the midpalatal suture. Thirty-nine male patients and 45 female

patients occlusal radiograph of the upper jaw and a left hand-wrist radiograph were

taken for each patient. The total and partial anterio-posterior dimensions of

midpalatal suture were measured and recorded using Fishman's Skeletal Maturation

Indicators (SMI's). There was statistically significant correlation between

maturational development and initiation and progression of fusion of the midpalatal

suture with no significant sexual differences.


10

Omar Gabriel Da Silva et al (1991)19

evaluated the cephalometrical

skeletal changes induced by the rapid palatal expansion seen in the primary and the

mixed dentition periods and examined the anteroposterior and vertical alterations of

the apical base and the anchoring molar region alterations. The result based on the

cephalometric tracing showed that there was a significant change seen in the anterior

and downward displacement of maxilla along with the maxillary molars, which

significantly increases the vertical facial height.

Revelo and Fishman (1994)8 proposed individual assessment of the mid

palatal suture morphology with occlusal radiographs before RME therapy. The

quantitative description of ossification in the palatal suture is unreliable with

occlusal radiographs, as there was a superimposition of the vomer and other

structures on the suture area leading to misinterpretation of the fusion. Taken into

account these individual variations, newer techniques such as CT and CBCT

provided 3D and high- resolution images of the craniofacial structures aiding in

evaluating the suture maturation.

Marinho Del Santo et al (1998)20

analyzed the morphological features of

the mid-palatal suture in the anterior portion of the hard palate in human fetus by

light and scanning electron microscopy. The forty- eight human fetus obtained from

the necropsy of both male and female fetus from 4 to 9 months of intra-uterine life

were divided into three age groups, GI (16–23 weeks), GII (24–31 weeks) and GIII

(32–39 weeks). They concluded that the mid-palatal suture in GI fetus is rectilineal

in form and in GII and GIII fetus had a sinuous nature.


11

Tiziano Baccetti et al (2001)21

evaluated the short term and long term

treatment effects of Rapid Maxillary Expansion in 2 groups of subjects treated with

Haas appliance and outcomes were evaluated before and after the peak of skeletal

maturation and was assessed by the cervical vertebral maturation (CVM) method

with the sample size of 42 patients compared with the control sample of 20 patients.

Posteroanterior cephalograms were analyzed for the treated subjects at T1

(pretreatment), T2 (immediate post-expansion) and T3 (long-term observation), and

were available at T1 and at T3 for the controls. They concluded that RME treatment

with Hass appliance induces clinically significant and reproducible transverse

changes at the skeletal level before the peak and when performed after the pubertal

growth spurt there was a shift from skeletal level to dentoalveolar level.

Heinrich wehrbein and Faruk Yildizhan (2001)22

analysed the mid palatal

suture in young adults using occlusal radiographs based on the histological-

histomorphometric. Thirty radiological regions were obtained from 10 subjects with

the age group ranging from 18- 38 years and compared with the suture morphology,

mean sutural width, and degree of suture closure on stained sections. They

concluded that a radiologically visible mid palatal suture corresponds histologically

to a predominantly straight running oronasal suture, and a radiologically invisible

mid palatal suture was not the histological equivalent of a fused or closed suture.

Janusz Skrzat et al (2003)23

conduted a morphometric study to estimate the

contribution of the palatine bones and the horizontal plates of the maxilla to the

formation of the hard palate. The palatine sutures were investigated in 29 male and

33 female adult dry skulls belonging to the Anthropological Museum of the

Jagiellonian University. These led to a conclusion that the palatine process of the


12

maxilla and palatine bones dominate in the formation of the hard palate and the

length of the subsequent palatine sutures was almost equal in both sexes.

Britta Knaup et al (2004)24

analyzed the age-related morphological

differences in the human midpalatal suture by histomorphometrically and delineate

them in terms of local topography and also morphologically differentiate with the

mean sutural width (MSW) and the degree of obliteration (O) in the region of the

human midpalatal suture. It consists of a tissue blocks from the autopsy material of 22

subjects (19 male, 3 female) aged between 18 and 63 years. The result was that

ossification of the midpalatal suture is not a valid reason for the increased transversal

resistance encountered during rapid palatal expansion in younger subjects (≤25 years).

Altug Atac AT (2006)25

evaluated and compared the dental and skeletal

changes occurring during orthopedic rapid maxillary expansion (RME) and

surgically assisted RME during the active phase of treatment. The study was divided

into two groups. Group I- 10 patients (six males, four females; mean age, 15.51

years) received orthopedic RME and Group II- 10 patients (seven males, three

females; average age: 19.01 years) received surgically assisted RME (SARME) with

Hyrax-type expanders. Preexpansion and postexpansion lateral and posteroanterior

cephalograms were obtained for each patient. There was a statistically significant

difference between the SARME and RME groups were found but clinically, there is

no difference in patient response between the RME and SARME groups.

James A. McNamara (2006) 26

conducted a prospective clinical study of the

long-term effects of the expansion of acrylic splint RME appliance used in the early

mixed dentition and compared with non- treated patients. Significantly favorable


13

long-term results were produced in maxillary acrylic splint expander, mandibular

Schwarz. They concluded that RME alone or combined with removable mandibular

Schwarz appliance significantly increased arch width.

Heike Korbmacher et al (2007)27

used the micro-CT techniques to quantify

suture morphology three-dimensionally, and investigate its relation to age. The

morphology was evaluated using computed tomography of twenty-eight human

palatal specimens of age ranging from 14-71 years. Sutural morphology was

quantified and examined for age-dependent morphological characteristics. The

specimens were put into three age groups (< 25 years, 25 years to < 30 years, ≥ 30

years) based on obliteration index in the frontal plane, and suture length, linear

sutural distance, and interdigitation index in the horizontal plane, as well as bone

density (BV/TV [%]) in the sagittal plane. The quantification of micro CT concluded

that the obliteration was generally very low and interdigitation in horizontal plane

was independent of ages and the bone density in the sagittal plane was the only age

dependent parameter.

T. N’ Guyen et al (2007)28

conducted a study to determine the proportion of

mid palatal suture obliteration during adult life. One hundred (43 female and 57

male) patients with age group of 19 to 84 years old, whose CT Scan of the maxillary

sinus with no malformation and pathology of the face were included. The result of

the study showed that there was no correlation between mid palatal suture

obliteration and sex and the obliteration begins in the anterior and in the superior

part of the palate. The inferior part of the junction between the palatal processes is

the last part of the suture to be obliterated.


14

Daniela Gamba Garib et al (2007)29

studied the long-term effects of rapid

maxillary expansion via banded expanders in the sagittal and vertical planes for 25

subjects (11 male and 14 female) with the mean age of 13.5 years, which was

compared with 26 non-treated control groups. Three groups of subjects were

analyzed with lateral cephalograms taken at (i) before treatment (T1), (ii) at the end

of treatment (T2), and (iii) at 3 years post treatment (T3), comprising a 5-year

average time of observation. The result obtained was that the sagittal position of the

apical jaw bases and the facial vertical dimensions are not affected in the long term.

Brett J. Garrett et al (2008)30

conducted a quantitative study to evaluate the

skeletal expansion and alveolar tipping of the maxilla at the maxillary canine (C1),

first premolar (P1), second premolar (P2), and first molar (M1) after rapid maxillary

expansion (RME) by using Cone-Beam Computed Tomography. They also assessed

the transverse effects to the maxillary suture, nasal width, and maxillary sinus. Thirty

patients (17 boys, 13 girls; mean age, 13.8 ± 1.7 years) who required RME with Hyrax

appliances were studied. They compared the measurements before and after RME of

palatal and buccal maxillary widths, palatal alveolar angle, nasal width, nasal floor

width, and maxillary sinus width at C1, P1, P2, and M1. There was statistically

significant increase in nasal width and a decrease in maxillary sinus width after RME

but there was no statistically significant association of age with any parameter.

T N Guyen et al (2008)31

determined the status of mid-palatal suture using

occlusal radiographs and histological study in 20 human palates aged more than 70

years. He found that in all the subjects the mid palatalsuture was ossified in the

anterior thirds but not in the posterior third, which consisted of connective tissue.


15

This showed a correlation with the masticatory forces acting on the maxillary bones

during the entire life.

Kimberly F. Christie et al (2010)32

examined the transverse response of the

maxilla to rapid palatal expansion (RPE) using cone-beam computed tomography

(CBCT). They included twenty-four children (average age, 9.9 years) who had RPE

treatment with a bonded expander. CBCT images of pretreatment orthodontic records

(T1) and immediately after expansion (T2) were taken. The width of the nasal cavity

at the level of the maxillary first permanent molar and second deciduous molar (or

second premolar), the width of the maxillary basal bone, and the width of the

midpalatal suture at the level of the second deciduous molar (or the second premolar),

the first deciduous molar (or first premolar), and the deciduous canine (or permanent

canine) at T1 and T2 and also the amount of tipping for both the maxillary right and

left first permanent molars was measured. The conclusion was that after RPE,

significant increases in the transverse dimensions of the nasal cavity, the maxillary

basal bone, and the midpalatal suture opening occurred and a significant buccal

tipping occurred on both maxillary first molars.

Lorenzo Franchi et al (2010)33

evaluated and assessed the density of the

midpalatal suture using low- dose computed tomography (CT). The study sample of

17 prepubertal subjects (mean age of 11.2 years) with constricted maxillary arches

and unilateral or bilateral posterior crossbite. Multi-slice low-dose CT scans were

taken before rapid maxillary expansion (RME) (T0), at the end of active expansion

(T1), and after a retention period of 6 months (T2). On axial CT scanned images, 4

regions of interest (ROIs) were placed and density was measured. There was a

significant decrease in sutural density and effective opening of the midpalatal suture.


16

Manish Thadani et al (2010)34

evaluated and compared the ossification of

the mid palatal suture using cross-sectional maxillary occlusal radiograph and cone

beam computed tomography scan of hard palate in the axial direction. The samples

of 21 subjects with transverse maxillary deficiency were divided into two groups.

Group I – growing patients of age ranging from 8.1 to 16.1 years and Group II – post

adolescent and young adult ranging from 16.1 to 25 years. The percentage of

ossification was in correlation with cervical vertebral maturation and mid palatal

suture maturation stages in group I subjects and group II was with the chronological

age. There was a statistically less significance in the ossification of mid palatal

suture when compared with the cross- sectional maxillary occlusal radiograph.

Giampieteo Farronato et al (2011)35

conducted a reterospective study to

evaluate and compare the skeletal, vertical and sagittal effects of the Hyrax expander

in 183 patients (91 males, 92 females ) with mean age of 8.7 years with bilateral

crossbite and maxillary hypoplasia. They were divided into three groups of 65

skeletal Class I, 55 skeletal Class II and 63 skeletal Class III. There was a

statistically significant change in the vertical dimensions in class III patients,

whereas there were no statistically significant changes seen in sagittal dimensions in

Class I and class II patients where the maxilla and the mandible moved forward.

Susanne Fricke-Zech et al (2012)36

conducted a study to determine the

midpalatal sutural width radiographically with a flat-panel volume computed

tomography (fpVCT) in a porcine model. The palate specimens from five young

(aged 12–18 weeks) and five old (aged 128– 208 weeks) Sus scrofa domestica,

German land race were used. All imaging was performed with the fpVCT prototype,

which comprised two flat-panel x-ray detectors based on amorphous silicon. There


17

was a significant difference in the suture anatomy observed between the younger

and the older animals, with a higher interdigitation and smaller suture width in the

old age group, and also the bony structures appear to be more compact in the older

group.

Sung-Tae Yang et al (2013)37

evaluated the three dimensional (3D)

longitudinal changes in the palatal vault from 6 to 14 years of age. The sample of 50

subjects (25 girls and 25 boys) virtual casts was constructed using 3D laser scanning

and reconstruction software. The reference gingival plane was constructed with the

12-quadrisectional points between the most gingival points of the palatal

dentogingival junctions from the canine to the first molar to measure the palatal

heights. They concluded that there was a significant annual increase in palatal height

in all of the variables, but there was no significance in the sexual dimorphism.

Fernanda Angelieri et al (2013)10

conducted a CBCT study among 140

subjects (ages, 5.6-58.4 years) to evaluate the maturation of mid palatal suture and

the stages of fusion of the midpalatal suture were described from the cross-sectional

images in the axial plane. They identified and defined the five stages of mid palatal

suture maturation in which Stages A and B were observed up to 13 years of age,

whereas stage C was noted from 11 to 17 years. Fusion of the palatine (stage D) and

maxillary (stage E) were observed after 11 years only in girls and this method helps

to avoid the side effects of RME failure or unnecessary surgically assisted RME for

late adolescents and young adults.

Yoon Chang et al (2013)38

conducted a prospective study to assess the

dimensional changes of the upper airway after rapid maxillary expansion using


18

CBCT. 14 orthodontic patients (mean age, 12.9 years; range, 9.7-16 years) with

posterior crossbite and constricted maxilla were treated with rapid maxillary

expansion. The sagittal, cross-sectional areas and volumetric changes in the retro

palatal and retroglossal airway before and after rapid maxillary expansion were

assessed using cone- beam computed tomography scans. The transverse expansions

by rapid maxillary expansion were assessed between the midpalatal alveolar bone

plates at the maxillary first molar and first premolar levels were assessed. They

concluded that only the cross-sectional area of the upper airway at the posterior

nasal spine to basion level significantly increased after rapid maxillary expansion.

Jessica L. Woller et al (2014)39

conducted a retrospective study to quantify

and evaluate the effects of rapid maxillary expansion (RME) on the maxillary

complex in growing patients who were treated with a tooth-borne rapid maxillary

expander (Hyrax). Mean age of subjects at the first imaging appointment was 12.3 ±

2.6 (8.3 to 17.8 years) and the second CBCT image was taken on an average of 22.8

± 5 days after. The changes of the alveolar bone and maxillary sutures following

rapid maxillary expansion were measured using the Dolphin 3-D software with

consistent landmark identification. The treatment results showed significant

displacement of the circummaxillary sutures and midpalatal sutures in growing

children in all three planes of space.

Young-Jae Kim et al (2014)40

Conducted a study to determine the

relationships between cephalometric measurements and cone-beam computed

tomography-based measurements of the palatal bone thickness. Palatal bone

thicknesses were measured anteroposteriorly from thirty sets of cone-beam

computed tomography images and lateral cephalograms between the first and second


19

premolars and the first and second molars using both imaging methods, and also

laterally from 1.5 mm off-center to 10 mm off- center in the cone-beam computed

tomography images. There were no statistically significant differences for 5-mm off-

center measurements when compared with the cephalometric measurements in all

anteroposterior areas.


conducted a study to analyze the

correlation between the cervical vertical maturation (CVM) and mid palatal suture

maturation stages among 142 subjects containing 84 female and 58 males with mean

age of 14.8 years. They concluded that CVM stages can be used to assess the

maturation of the mid palatal suture in the post pubertal period and it helps in

deciding whether to go for conventional RME or surgically assisted RME.

Mennatallah Ihab Mosleh et al (2015)42

conducted a CBCT study to

evaluated and compared the dentoskeletal changes concurrent with 4-point bone-

borne and tooth-borne rapid maxillary expanders in growing children. The 20 girls

with the age ranging from 12 ± 0.6 years with posterior crossbite were divided into

two groups; one group was treated with a tooth-borne maxillary hyrax expander

(TBME), and those in the other group were treated with the bone-borne maxillary

hyrax expander (BBME). The result showed significant skeletal changes in BBME

group, whereas the TBME group produced more dental expansion, and a greater

increase in nasal width.

Björk & V. Skieller L.D.S (2016)43

conducted a study to assess the growth

of the maxilla, implant method from profile and frontal (postero-anterior)

cephalometric radiographs in nine boys with normal primary occlusion. The


20

measurements on frontal radiographs between bilateral implants proved that the

growth in the median suture was greater posteriorly than anteriorly, and there was

rotation of maxilla in the transverse plane in relation to each other and a high

correlation in the sutural growth in the medium suture, while the increase in the bi-

canine width was lesser. The forward drift of the dental arch led to a reduction in

incisor spacing.

Gueutier et al (2016)44

conducted a study to evaluate the accuracy of

Multislice Computed Tomography (MSCT) in the detection of resistance areas on

the midpalatal suture (MPS). Maxillary bones were obtained from the ten fresh

corpses, age ranging from 70-86 years with the mean age of 79.4 year. Three

radiological regions of interest (ROI) were identified in the MPS and were classified

into ‘‘open’’ (group 1) or ‘‘closed’’ (group 2). The 30 ROI were then histologically

analyzed based on the mean suture width (MSW), obliteration index (OI) and

interdigitation index (Ii). There was a statistically significant difference between the

2 groups was found for the MSW and concluded that MSCT can be used for the

evaluation of the width of the MPS.

Hong-Ik Jang et al (2016)45

conducted a study to determine the maturation

of the midpalatal suture and identify the morphology on cone-beam computed

tomography (CBCT) images and its relationships with other developmental age

indices. The morphology and fusion of the midpalatal suture were additionally

investigated on coronal cross-sectional planar images and volume-rendered images.

Bone age was evaluated using the hand and wrist method (HWM) and cervical

vertebrae method (CVM); dental age (Hellman’s index), sex, and chronological age

were also assessed. The result reveals that the above mentioned assessment methods


21

of maturation suggests a strong correlations and high association for assessing

maturation of the midpalatal suture.

Kyoung Ho Kwak et al (2016)46

evaluated the midpalatal suture maturation

by fractal analysis. 131 subjects (69 men and 62 women) with a mean age of 24.1 ±

5.9 and 25.2 ± 5.9 years respectively and aged over 18 years underwent cone-beam

computed tomography. Correlations between maturation stage and fractal

dimensions were calculated using Spearman’s correlation coefficient. The result was

that there was strong negative correlation between fractal dimension and midpalatal

suture maturation.

Poorsattar KB Mir et al (2016)47

examined the two dentulous adult patients

of 49-year-old male and 54-year-old female with the help of CBCT images. It

showed an in-ossified suture in anterior 2/3 of midpalatal region. The study

concluded that the RME treatment was based on the timing of mid-palatal suture

ossification as a chronologic-related phenomenon and masticatory force

transmission, which various from one individual to another and also showed

difference in the ossification on the anterior two-third and posterior one-third of the

hard palate due to the effect of the masticatory forces.

Thorsten Grunheid et al (2017)48

conducted a study to determine the

midpalatal suture maturity, and the midpalatal suture density ratio, based on the

novel measurement method to predict the skeletal response to RME. 30 patients

(aged, 12.9 ± 2.1 years) were assessed before treatment for the midpalatal suture

density ratio, chronologic age, cervical vertebral maturation, and the stages of

midpalatal suture maturation of patients who underwent RME treatment. Cone-beam


22

computed tomography scans were used to determine the proportions of expansion

achieved at the greater palatine foramina, the nasal cavity, and the infraorbital

foramina. They concluded that the midpalatal suture density ratio alone could be a

useful clinical predictor of the skeletal response to RME.

Juliana da. S. Pereira et al (2017)49

conducted a randomized clinical trial to

identify the dental, dentoalveolar and skeletal changes occurring after the rapid

maxillary expansion treatment (RME) for 21 patients (mean age of 8.43 years) and

Slow maxillary expansion (SME) treatment for 16 patients (mean age of 8.70 years)

using Haas type expander. All the patients were taken CBCT before installation (T1)

and after installation (T2). There was a change in the intermolar width using RME

which was only showed the skeletal change, SME showed the dentoalveolar

changes.

Sina Haghanifar et al (2017)50

conducted a CBCT study of the maxilla to

evaluate the morphology and the maturation stage of the suture and its degree of

ossification in an axial cross- sectional slice at 1mm intervals in 144 Iranian subjects

(72 males, 72 females) with an age range from 10 to 70 years. They observed six

stages of development and also the ossification process occurred in the posterior to

anterior direction and stated that there was a significant relationship between aging

and degree of ossification.

Diego Luiz Tonello et al (2017)51

evaluated the maturation of the mid palatal

suture using CBCT of 84 children (40 boys, 44 girls) from the age of 11-15 years were

classified using the maturation stages (A, B, C, D, and E). The bone maturation status

of the mid palatal suture in these patients was used as a comparison for RME


23

prognosis in older patients. The result obtained was that non-surgical rapid maxillary

expansion could be performed in patients over 15 years of age.


evaluated the mid palatal suture

maturation using CBCT scans from 78 subjects, in which 64 female and 14 male,

age range from 18 to 66 years. The central cross-sectional axial slice in the superior–

inferior dimension of the palate was verified for midpalatal suture maturation using

methods validated previously. The majority of the adults presented stage D i.e. a

fused midpalatal suture in the palatine and/or maxillary bones. They concluded that

there were no significance in sex and chronological age of the maturational stages of

the midpalatal suture.

Zahra Dalili Kajan et al (2018)53

conducted a cross sectional study using

CBCT to determine the mid palatal suture opening depth and to assess its effect on the

zygomaticomaxillary suture (ZMS). 167 CBCT of 90 females and 77 males, were

selected with patients aged 7–25 years (mean age: 16.04 ± 5.17 years) were selected.

The mean percentage of the depth of MPS opening at anterior, middle, and posterior

regions in the coronal and closure status of ZMS in axial views were determined. A

significant difference was observed in the middle and posterior regions, where the

MPS closure starts from the posterior region and was different in different age group,

whereas the ZMS in younger people is usually open on both sides.

Hande Gorucu-Coskuner et al (2018)54

conducted a study to evaluate the

stages of midpalatal suture (MPS) maturation, and to determine the correlation

between the stage of MPS maturation, and age and cervical vertebral maturation

(CVM). Cone-beam computed tomography (CBCT) scans of 50 patients (29 female


24

and 21 male; mean age, 19.79 ± 4.09 years) were evaluated. The axial sections of

CBCT images were evaluated for MPS maturation and was classified as A, B, C, D,

or E. The stages of CVM were classified using sagittal sections of the CBCT

images. The result of the study concludes that there was no significant correlation

between chronological age and maturation of MPS and between the stages of CVM

and maturation of MPS.

Giuseppina Laganà et al (2018)55

conducted a retrospective study to assess

the morphological shape variations of the palatal vault by means of Geometric

Morphometric Method (GMM). 75 subjects (39 females, 36 males; mean age: 8.5 ±

0.8 years) of the Open Bite Group (OBG) was compared with a Control Group (CG)

of 46 prepubertal subjects presenting normal occlusion (24 females, 22 males; mean

age of 8.3 ± 1.7 years). Landmarks and semi landmarks on the lateral cephalograms

were digitalized on the maxillary dental casts. There was a significant morphological

change in transverse and vertical dimensions with OBG palates presented with a

significant constriction of the maxillary arch when compared with control group.

Rosalia Leonardi et al (2018)56

measured and compared the semi palatal

widths with the median sagittal plane between crossbite and non-crossbite sides and

also to investigate and compare palatal morphology and shape between the two

palatal halves. A study sample (SS) of 35 subjects with mean age of 9.2 ± 0.8 years

were diagnosed with functional crossbite, and a control sample (CS) of 35 subjects

with mean age 9.4 ± 0.9 years without crossbite were selected. They analysed the

digital models to assess palatal dimension size and symmetry by measuring linear

distances between primary canines (D1) and first molars (D2) to the median palatine

plane and the 3D deviation between the two specular models of the palatal vault for


25

each patient. The result was that the semi-palatal widths on the cossbite side were

smaller than on the non-crossbite side and in control groups.

Natalia Maria Vieira Barbosa et al (2019)57

conducted a study to assess

reliability and reproducibility of the individual assessment of midpalatal suture

maturation in computed tomography among orthodontists and radiologists. Sixty

axial slices from cone-beam computed tomography and multi-slice CT scans of

patients aged between 11 and 21 years old (33 females and 27 males) were selected.

Two groups of examiners were established for the investigation of reliability and

reproducibility of the method. This was a statistically significant method for

individual assessment of midpalatal suture maturation.

MATERIALS AND METHOD

Materials and Methods

26

MATERIALS AND METHODS

Sources of samples:

Total of 120 samples in the age group of 15 to 21 years, for whom CBCT of

mid palatal region of maxilla were taken using DENTSPLY SIRONA

ORTHOPHOS XG 3D of version 126677 (Fig. 1) and analyzed for ossification

using GALILEOS SOFTWARE 1.7 (Fig. 2). The study is based on the evaluation,

which was approved by the Institutional ethical committee.

Inclusion criteria:

1. Patients within the age group of 15 years to 21 years.

2. Patients with any Angle’s class of malocclusion.

Exclusion criteria:

1. Syndromic patients

2. Patients with cleft lip and palate

3. Patients with previous orthodontic treatment.

4. Presence of noise on the CBCT images or blurred images.

5. Patients with previous orthognathic surgery.

6. Patients with skeletal deformity.

Steps involved in CBCT imaging:

The CBCT images were obtained from the same DENSPLY SIRONA

ORTHOPHOS XG 3D scanner for all the patients. To obtain the CBCT image in a

standardized way, each patient was positioned in a natural head position during the

scanning process and instructed to bite in a maximum intercuspation. The obtained

images were analysed using GALILEOS software. The following steps were followed

for determining and analyzing the maturational stages of the midpalatal suture.


27

1. Specifications of CBCT: The CBCT used for this study has the following

specifications;

i) Field of view- 22 x 16 cm

ii) Exposure time- 14.4 secs

iii) kV(p)- 85

iv) mA - 5

2. Head orientation: Natural head position in all 3 planes of space was oriented

and corrected if malpositioned. The cursor of the image analysis software was

positioned at the patient's midsagittal plane in the axial view to obtain the final

images.

3. Standardization: In the sagittal plane, the horizontal position of the palate is

obtained using midsagittal cross-sectional slice. The central cross-sectional slice in

the superoinferior dimension (i.e., from the nasal to the oral surface) was used for

classification of the maturational stage of the midpalatal suture. In patients with a

curved palate, 2 images were taken, one in which the sagittal plane line passes

through the suture in the most posterior region and a second one with the cursor

passing in the most anterior region. Both the images were used to evaluate the

maturation stage.

4. Method of assessment: The CBCT images obtained from all the samples have

been assessed for the classification of midpalatal suture maturation; all axial central

cross-sectional slices were arranged by the investigator in a PowerPoint

presentation. No adjustments in contrast or brightness of these images were

undertaken. All images of the midpalatal suture were classified blindly by the

examiner according to the maturational stages described by Angelieri et al10

.


28

CLASSIFICATION OF MID PALATAL SUTURE ACCORDING TO

ANGELIERI ET AL AND LADEWIG ET AL (Fig. 3)

Stage A - The suture is seen as a relatively straight radiopaque line

Stage B - The suture appears as a sinuous line of high density

Stage C - Two radiopaque suture lines winding, and parallel to each other separated

by areas of low radiographic density

Stage D - The palatine bones become more radiopaque, and the suture is not seen in

this area, but it is still possible to observe the 2 parallel radiopaque lines

Stage E - Complete fusion of palatal bones of maxilla

PHOTOGRAPHS

Photographs

29

Figure 1 : DENSPLY SIRONA ORTHOPHOS XG 3D - VERSION 126677

Photographs

30

Figure 2 : GALILEOS CBCT VIWER 1.7

Photographs

31

Figure 3 : CLASSIFICATION OF MATURATIONAL STAGES

Photographs

32

Photographs

33

Photographs

34

Photographs

35

Photographs

36

Photographs

37

Photographs

38

Photographs

39

Photographs

40

Photographs

41

Photographs

42

Photographs

43

Photographs

44

Photographs

45

Photographs

46

RESULTS

Results

47

RESULTS

TABLE 1. EVALUATION AND ASSESSMENT OF MID PALATAL SUTURE

BASED ON AGE AND GENDER

AGE IN

YEARS STAGE A (%) STAGE B (%) STAGE C (%) STAGE D (%) STAGE E (%)

M F M F M F M F M F

15 30 16.7 30 33.4 40 50.1 0 0 0 0

16 25.0 14.3 25.0 14.3 50 42.9 0 28.6 0 0

17 16.7 0 16.7 33.3 50.1 33.3 16.7 33.3 0 0

18 0 0 14.3 0 57.2 66.7 14.3 22.2 14.3 11.1

19 0 0 12.5 0 24.0 57.2 37.5 28.6 25.3 14.3

20 0 0 0 0 22.2 23.1 44.4 38.5 33.6 38.5

21 0 0 0 0 23.1 5.6 38.5 39.2 38.5 56

15-21 10.2 4.4 14.1 11.6 38.2 40 21.6 27.2 16 17.1

TOTAL 7.3 12.8 40.0 24.4 16.6

Results

48

TABLE 2. FREQUENCY AND DISTRIBUTION OF MID PALATAL SUTURE

MATURATION STAGES IN MALE AND FEMALE SUBJECTS

AGE IN

YEARS

STAGE A STAGE B STAGE C STAGE D STAGE E TOTAL

M F M F M F M F M F M F

15 3 1 3 2 4 3 0 0 0 0 10 6

16 1 1 1 1 2 3 0 2 0 0 4 7

17 1 0 1 1 3 1 1 1 0 0 6 3

18 0 0 1 0 4 6 1 2 1 1 7 9

19 0 0 1 0 2 4 3 2 2 1 8 7

20 0 0 0 0 2 3 4 5 3 5 9 13

21 0 0 0 0 3 1 5 7 5 10 13 18

15-21 5 2 7 4 20 21 14 19 11 17 57 63

Results

49


MATURATION STAGES IN MALE AND FEMALE SUBJECTS IN 3 AGE GROUPS

AGE IN

YEARS

STAGE

A

STAGE

B

STAGE

C

STAGE

D

STAGE

E TOTAL

M F M F M F M F M F M F

15-17 5 2 5 4 9 7 1 3 0 0 20 16

18-19 0 0 2 0 6 10 4 4 3 2 15 16

20-21 0 0 0 0 5 4 9 12 8 15 22 31


MATURATION STAGES IN MALE AND FEMALE SUBJECTS IN 3 AGE GROUPS

AGE IN

YEARS

STAGE

A

STAGE

B

STAGE

C

STAGE

D

STAGE

E TOTAL

M + F M + F M + F M + F M + F M + F

15-17 7 9 16 4 0 36

18-19 0 2 16 8 5 31

20-21 0 0 9 21 23 53

STAGES OF MATURATION OF MID PALATAL SU

3

1 1

0 0 0 0

STAGE A

Fre

qu

ency

Distribution and assessment of mid palatal

maturational satges in male subjects

15

AGE IN YEARS

50

STAGES OF MATURATION OF MID PALATAL SU

3

4

0

1

2

0

1

3

11

4

11

2

3

0

2

4

0

3

5

STAGE B STAGE C STAGE D


maturational satges in male subjects

16 17 18 19 20

Results

STAGES OF MATURATION OF MID PALATAL SUTURE

0 0 0

1

2

3

5

STAGE E


21


1 1

0 0 0 0 0

STAGE A

Fre

qu

ency


maturational stage in female subjects

AGE IN YEARS

51


2

3

0

1

3

2

1 1 1

0

6

2

0

4

2

0

3

5

0

1

7

STAGE B STAGE C STAGE D


maturational stage in female subjects

15 16 17 18 19 20 21

Results


0 0 0

1 1

5

10

STAGE E


Results

52


10.2

14.1

38.2

21.6

16

4.4

11.6

40

27.2

17.1

STAGE A STAGE B STAGE C STAGE D STAGE E

Fre

qu

ency

MALE

FEMALE

Distribution and assessment of mid palatal suture maturational stages

in Tamil Nadu population

Results

53

Table 1 represents the assessment of maturation stages of mid palatal suture

based on the age and gender. The common maturational stage in the study sample

was stage C (40%), followed by stage D (24.4%) and stage E (16.6%) irrespective of

gender. Whereas, stage A (7.3%), is the least prevalent among all the stages,

followed by stage B (12.8%).

When the values are tabulated, irrespective of gender stage C depicts the

common stage. In that nearly half of the female sample (40%), maturation stages C

is observed, whereas in males it is 38.2% is observed.

Table 2 represents the frequency and distribution of the mid palatal suture

maturation stages in male and female. At, 15 years of age, stage A is seen in 3 males

and one in female. 10 females and 5 males of 21 years have the highest frequency.

In the age group between 20-21 years, there is absence of stage A and B in both

males and stage A in females.

Table 3 and table 4 shows the frequency between 3 age groups, like

(i) 15-17, (ii) 18-19 and (iii) 20-21. Stage C is more prevalent in 15-17 and 18-19

years, where as in 20-21, stage E is more prevalent.

Graph I represents the assessment and distribution of the maturational stages

among males.

Results

54

Graph II represents the assessment and distribution of the maturational stages

among females.

Graph III, represents the comparisons between the males and females, which

shows the higher prevalence of stage C, followed by stage D and E.

The obtained results reveal that both male and female had higher prevalence

of maturation in stage C, with frequency higher in females than males.

DISCUSSION

Discussion

55

DISCUSSION

The major etiological factors for transverse malocclusions are genetic

factors, arch length deficiencies, abnormal oral habits, dental crowding, and

abnormalities in tooth anatomy and eruption sequence.

Rapid maxillary skeletal expansion is a widely accepted treatment modality

for correcting the transverse maxillary deficiency. The expansion is achieved by

opening the mid palatal suture (i.e. the two halves of the palatine processes of the

maxilla), which also opens the nasal cartilage and circummaxillary sutures,

including the frontonasal, zygomaticomaxillary, intermaxillary, midpalatal, sphenoid

and transpalatal sutures in growing children. The type and duration of the RME

appliance, optimal time and choice of the suitable candidate in the treatment of the

maxillary expansion is very important due to the effects of RME on the craniofacial

structures.

The effects of RME are completely based on the maturation level of the mid

palatal suture. According to the literature review, the closure of the mid palatal

suture is from 14-15 years in females and 15-16 years for males.9

In growing

children the Rapid palatal expansion is successful as the sutures are not closed,

whereas in adults surgically assisted RME is the alternative treatment for correction

of the transverse maxillary deficiency.15, 25

The morphological status of the mid palatal suture cannot be correlated with

the chronological age because the skeletal growth has periods of acceleration and

maturation. Since chronological age is unreliable particularly in young adults, many

skeletal maturity indicator methods such as Handwrist method, and the cervical

Discussion

56

vertebral maturation (CVM) method are used.15

The obliteration of the suture for an individual at the same age at different

suture site varies.1 Many authors like, Bjork and Skiller,

13 Singer R et al

58 and Todd

et al59

had identified and concluded the time of obliteration of the sutures ranges

from early childhood to the third decade of life.

Melsen B6 had conducted a histological study on palatal growth using

human autopsy material and determined the three stages of palatal growth and

examined the growth activity of palate at different regions. The region selected was

the medial part of hard palate 1mm behind the incisors. The various growth

activities were determined from the histologic and micro radiographic examinations

and found that there was growth in length of the hard palate and apposition on the

posterior margin of the palate until the age between 13 and 15 years. But apposition

continued even after some years and the sutural growth was found to cease later and

changes in transverse suture morphology can be noted in postnatal growth.

Fishman L7 Studied the skeletal maturation using carpal bones and

evaluated the skeletal maturation using the Hand Wrist radiographs. He stated that

maturational variations have been closely related to the variations in the timing and

magnitude of growth. The methodology includes the examination of groups as a

whole in relation to the specific individual maturational characteristics. The method

uses four stages of bone maturation found at six anatomical sites located on the

thumb, third finger, fifth finger, and radius. He concluded that more information and

study of skeletal maturation are required, and also stated that there was less

correlation with the skeletal and chronological ages.

Discussion

57

Revelo and Fishman8

proposed individual assessment of the mid palatal

suture morphology with occlusal radiographs before RME therapy. The quantitative

description of ossification in the palatal suture is unreliable with occlusal

radiographs due to superimposition of the vomer and other structures of the on the

suture area leading to misinterpretation of suture fusion. Taken into account these

individual variations, newer techniques such as CT and CBCT provided 3D and

high-resolution images of craniofacial structures aiding in evaluating the suture

maturation.

In the histologic investigations by Persson M et al1 and Weherbein H et al,

22

only the frontal sections of the midpalatal suture were analyzed, failing in

evaluation of the whole palate. In other studies by Knaup et al24

and Korbmacher

et al,27

the palatal specimens between the incisive foramen and the posterior spine of

the hard palate were evaluated; whereas the variations of fusion at different areas of

the palate were not evaluated.

Chracanovic BR, Custodio AL60

believed that skeletal maturation and

closure of the suture in females occurred earlier than males, this is consistent with

the results of the present study but N’ Guyen et al (2007),28

found there was no

relationship between gender and the closure of the midpalatal suture.

N’Guyen et al (2008)

31 carried out a study on 20 patients over 70 years of

age and reported that the midpalatal suture is the only suture that might not close

completely even in the older age. Poorsattar et al47

also came with the same result

as of N’Guyen et al31

that there were some cases with incomplete ossification of the

sutures that were observed even at the age of 40 years.

Discussion

58

Baccetti T et al21

has performed the CVM method on lateral cephalograms,

which avoids the need for an additional radiograph. The results indicated that the

correlation of the mid palatal suture ossification with the CVM stage I. This method

had demonstrated reliability and reproducibility for evaluating the pubertal peak of

growth and further maturation in skeletal growth but failed to specify the gender

difference. Krobmacher et al27

analyzed 28 patients using 30 micro-CT from 14 to

17 years of age, which showed no significant relationship between age and closure

of the suture.

Many authors conducted a study on rapid maxillary expansion using

Computed Tomography. However, very few studies utilized CBCT as a diagnostic

tool for the evaluation of the ossification of various sutures in the craniofacial

complex. In orthodontics, many studies had promoted the use of CT and CBCT for

the diagnostic procedures like localization of impacted teeth, amount of root

resorption, study of cleft palate, site planning for orthodontic implants, assessment

of maxillary movements during RME therapy, the position of condyle in the glenoid

fossa of the temperomandibular joint, 3D modeling, finite analysis, etc.

The identification of the midpalatal sutural stage with CBCT images is a

reliable method for the prediction of the treatment outcome with RME without the

overlay of the vomer and other external structures of the nose that occur when a 2-

dimensional occlusal radiograph is used for diagnosis.10,22

Angelieri et al (2013)10

identified and defined the five stages of mid palatal

suture maturation in the CBCT study among 140 subjects (ages, 5.6-58.4 years) and

the stages of fusion of the midpalatal suture were described from the cross-sectional

images in the axial plane. In which Stages A and B were observed up to 13 years of

Discussion

59

age, whereas stage C was noted from 11 to 17 years. Fusion of the palatine (stage D)

and maxillary (stage E) were observed after 11 years only in girls.

Angelieri et al10

proposed 5 maturational stages of the midpalatal suture:

stage A - straight high-density sutural line, with no or little interdigitation; stage B-

high density sutural line with scalloped appearance; stage C - two parallel,

scalloped, high-density lines are separated by small low-density spaces; stage D - no

evidence of suture with complete fusion in the palatine bone; and stage E - fusion

completed in the anterior maxilla.

Hande Gorucu-Coskuner et al (2018)54

conducted a CBCT study of 50

patients (29 female and 21 male; mean age, 19.79 ± 4.09 years). The axial sections

of CBCT images were evaluated for Midpalatal Suture maturation and was classified

as A, B, C, D, or E. The stages of CVM were classified using sagittal sections of the

CBCT images, showed that there was no significant correlation seen between

chronological age, stages of CVM and maturation of Midpalatal Suture.

The current CBCT study has been done with 120 subjects with 57 males and

63 females subjects with the age range of 15 to 21 years. The cross-sectional view of

the mid palatal suture in the axial view has been used for classification purposes.

The classification has been done based on the Angelieri et al10

classification.

The study relied on the methodology used by Angelieri et al10

and Ladewig

et al11

and restricted the age of the sample to 16 and 20 years to determine the frequency

of subjects over 15 years of age. The method is more relevant as the patients in this age

group would be treated successfully with RME.

Discussion

60

The stages C, D, and E were most commonly observed in the study, which

was similar to the results of Angelieri et al10

and Ladewig et al,11

whose study had

a prevalence of 89% in stages C, D and E with subjects over 14 years of age.

In both males and females the stage C is more prevalent (38.2% and 40%

respectively), followed by stage D (24.4%) and E (16.6%). However, in nearly half

of the female sample (44.2%), maturation stages D and E were observed, whereas in

males only 37.6% were observed. Likewise, in the study by Angelieri et al,10

the

sample of female subjects had a higher prevalence of stages D and E (37.2%)

compared with the male sample (27.7%). These findings may suggest that female

patients have an advanced maturational status compared with male patients that is

consistent with the study done by Chracanovic BR, Custodio AL.60

The maturational stages most observed in subjects between 15 and 21 years

were C, D and E, respectively, with the high prevalence of stage C. The result shows

that the stage C may justify a good prognosis for RME in post-adolescents.

SUMMARY AND CONCLUSION

Summary and Conclusion

61

SUMMARY AND CONCLUSION

The study was conducted to evaluate the maturation stages of midpalatal

suture ossification in post-adolescents using CBCT. The study consisted of 120

samples of age between 15 to 21 years. CBCT data involving mid palatal suture

were taken using DENSPLY SIRONA ORTHOPHOS XG 3D software. Ossification

stages were examined using GALILEOS CBCT VIEWER. The obtained images

were compared to the stages given by Angelieri et al10

and the images were

assigned to each stage they belong to. The results show that the Stage C was more

prevalent, irrespective of gender followed by stage D & E.

In both males and females the stage C is more prevalent (38.2% and 40%

respectively), followed by stage D (24.4%) and E (16.6%). However, in nearly half

of the female sample (44.2%), maturation stages D and E were observed, whereas in

males only 37.6% were observed. These findings may suggest that female patients

have an advanced maturational status compared with male patients.

Assessment of skeletal maturity has always been a challenge with common

use of handwrist and lateral cephalograms. CBCT is a more advanced and

predictable diagnostic aid, which provides valuable information in determining the

predictable prognosis for patient requiring arch expansion.

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Annexures

LIST OF FIGURES

Fig. No. Description Page No.

1. DENTSPLY SIRONA ORTHOPHOS XG 3D –

VERSION 126677 29

2. GALILEOS CBCT VIWER 1.7 30

3. CLASSIFICATION OF MATURATIONAL STAGES 31

Annexures

LIST OF TABLES

Table

No. Description

Page

No.

1. EVALUATION AND ASSESSMENT OF MID PALATAL

SUTURE BASED ON AGE AND GENDER 47

2.

FREQUENCY AND DISTRIBUTION OF MID PALATAL

SUTURE MATURATION STAGES IN MALE AND FEMALE

SUBJECTS

48

3.



SUBJECTS IN 3 AGE GROUPS

49

4.



SUBJECTS IN 3 AGE GROUPS

49

Annexures

LIST OF GRAPHS

Graph No. Description Page No.

1.

DISTRIBUTION AND ASSESSMENT OF MID

PALATAL MATURATIONAL SATGE IN MALE

SUBJECTS

50

2.


PALATAL MATURATIONAL STAGE IN

FEMALE SUBJECTS

51

3.


PALATAL SUTURE MATURATIONAL STAGE

IN TAMILNADU POPULATION

52

Annexures

LIST OF ABBREVIATIONS

CBCT Cone-beam computed tomography

CT Computed tomography

RME Rapid maxillary expansion

SME Slow maxillary expansion

CVM Cervical vertebral maturation

SMI Skeletal maturity indicator

ROI Region of interest

MSW Mean sutural width

Documents

EVALUATION OF MATURATION STAGES OF THE MID PALATAL …