Original Article

The Cleft Palate-Craniofacial Journal

1-7
Circummaxillary Sutures in Patients With ª 2020, American Cleft Palate-
Craniofacial Association

Apert, Crouzon, and Pfeiffer Syndromes Article reuse guidelines:

sagepub.com/journals-permissions
DOI: 10.1177/1055665620947616
Compared to Nonsyndromic Children: journals.sagepub.com/home/cpc

Growth, Orthodontic, and Surgical

Implications

Maria Costanza Meazzini, DMD, MMSc1,2 , Federica Corradi, MD1,

Fabio Mazzoleni, MD1, Elena De Ponti, MD3, Muriel Maccagni, MD1,
Giorgio Novelli, MD1, and Alberto Bozzetti, MD1

Abstract
Objective: To evaluate patency of circummaxillary sutures in children with Apert, Crouzon, and Pfeiffer Syndromes and to compare
it to a nonsyndromic matched control group.
Design: Case–control study.
Setting: Tertiary care public hospital.
Materials and Methods: Thirty-eight computed tomography (CT) scans of patients affected by syndromic craniofacial synostosis
(13 patients with Apert syndrome, 20 patients with Crouzon syndrome, and 5 patients with Pfeiffer syndrome), average age 5 +
2.8 years, range 1.9 to 12 years, were compared to age- and sex-matched control CTs of 38 nonsyndromic children. Computed
tomography scans of the study group had to be performed prior to any midfacial surgery.
Main Outcome Measures: Midpalatal suture, zygomaticomaxillary sutures, and pterigomaxillary sutures were evaluated and scored.
Results: The syndromic group showed a significant earlier ossification of all sutures compared to the nonsyndromic group. Sig-
nificant differences were already present in early childhood and continued through adolescence.
Conclusions: Based on the differences in terms of maxillary sutural ossification identified, midfacial hypoplasia does not seem to be
only secondary to premature cranial base ossification, but also to primary synostosis of facial sutures, thus providing new insights
into the pathogenesis of midface deficiency in children with craniofacial-synostosis. Care should be taken when planning any
maxillary orthopedics, such as expansion or maxillary protraction, given the high frequency of early fusion of circummaxillary
sutures.

Keywords
Apert syndrome, craniofacial growth, craniofacial morphology, facial growth, maxilla, midfacial growth, orthodontics, orthog-
nathic surgery, orthopedic treatment, palatal development, synostosis

1
Department of Cranio-Maxillo-Facial Surgery, San Gerardo Hospital,
Introduction University of Milano-Bicocca, Monza, Italy
2
Department of Cranio-Maxillo-Facial Surgery, Smile House, Regional Centre
Syndromic craniosynostoses are characterized by the prema-
for CLP and Craniofacial Anomalies, Santi Paolo e Carlo Hospital, University
ture fusion of one or more of the calvarial sutures in association of Milan, Milan, Italy
with extracranial anomalies that define a distinct syndrome. 3
Medical Physics and Biostatistics Department, San Gerardo Hospital, Monza,
More than 180 genetic syndromes involve craniosynostosis Italy
(Kimonis et al., 2007), many of which demonstrate an autoso-
Corresponding Author:
mal dominant pattern of inheritance. Mutations in fibroblast Maria Costanza Meazzini, Department of Cranio-Maxillo-Facial Surgery, Santi
growth factor receptors (FGFRs) are the most common cause Paolo e Carlo Hospital, Milano and San Gerardo Hospital, Monza, Italy.
of syndromic craniosynostosis (Eswarakumar et al., 2005). The Email: cmeazzini@yahoo.it
2 The Cleft Palate-Craniofacial Journal XX(X)
mutation leads to the formation of a fibroblast growth factor
receptor 2 (FGFR2) which causes the premature closure of the
cranial sutures and sutures of the orbits (Bachler & Neubüser,
2001).
Crouzon, Apert, and Pfeiffer syndromes are the most
frequent syndromic craniosynostoses. These syndromes
present skull shape anomalies, exorbitism, hypertelorism,
and midface hypoplasia (Cohen & Kreiborg, 1996). The
prevalence of Apert syndrome is 6 to 15 in 1 000 000 births;
Pfeiffer syndrome has a prevalence of 1 in 100 000 births,
while Crouzon syndrome is more frequent, 16 in 100 000 000
births (Ko, 2016).
Midface deficiency in all 3 planes of space is a characteristic
feature, for which these syndromes are commonly defined as
craniofacial-synostosis (CFS) (Cohen & Kreiborg, 1996; Krei-
borg et al., 1999; Meazzini et al., 2005). The most common
clinical problems related to midfacial hypoplasia are ocular and
respiratory problems.
It is generally believed that growth of the maxillary complex
is reduced because of early fusion of the cranial base sutures,
while circummaxillary sutures are often believed to be still
patent. Therefore, many orthodontists attempt midfacial ortho-
pedics, as they would in nonsyndromic children, such as palatal
expansion or even maxillary protraction with a face mask.
Unfortunately, expansion in patients where sutures are not pat-
ent is generally ineffective and may lead to severe pain and
dental and periodontal damage (Graber & Vanarsdall, 1994,
Digregorio et al., 2019), as palatal expansion requires the
mechanical opening of maxillary and palatal sutures (Haas,
1965).
The purpose of this study was, thus, to evaluate the
patency of circummaxillary sutures in children with
Crouzon, Apert, and Pfeiffer syndromes and compare it to
a nonsyndromic control group, in order to have a better
understanding of maxillary growth impairment in CFS. In
addition, we propose a simplified method for a computed
tomography (CT)-based radiological classification of the
maturational stage of circummaxillary sutures. The study
was conducted according to the criteria set by the declara-
tion of Helsinki and the protocol was approved by the local
ethics committee.
Materials and Methods
A retrospective analysis on CT scans of syndromic patients and
healthy controls was carried out. A total of 38 syndromic young
patients were retrospectively collected. Inclusion criteria were
diagnosis of CFS, no previous midfacial surgery, and good
quality CT of all maxillary structures. The sample comprised
13 patients affected by Apert syndrome, 20 by Crouzon syn-
drome, and 5 by Pfeiffer syndrome; 20 were males, 18 were
females, aged from 1 year and 11 months to 12 years (mean age
5 years + 2.8). The control sample was extrapolated from the
archives of our Hospital and from SIRIO radiological diagnos-
tics and comprised 38 patients; 20 males, 18 females, aged
from 2 years and 5 months to 12 years and 9 months (mean
age 8 years + 3.3). In the control group the main indications
for CT were trauma or orthodontic treatment.
Computed tomography scans were carried out in different
hospitals and scanning parameters were not uniform, being a
retrospective study, but only high-quality cone beam CT
(CBCT) or traditional CT scans (width of each section  2
mm) were included. For each study axial, coronal, and sagittal
sections were available. Multiplanar reformations were per-
formed with softwares for surgical navigation and planning
when not previously present. Studies were visualized with soft-
wares provided by the producer or with Xero software (Agfa
HealthCare Corporation).
For each patient, 5 circummaxillary sutures were consid-
ered: zygomaticomaxillary suture (ZMS) bilaterally, pterigo-
maxillary suture (PMS) bilaterally, and midpalatal suture (MS).
Each suture was evaluated on 2 different planes. In particular,
the ZMS and the MS were analyzed on the axial and the coronal
plane; the PMS was evaluated on the axial and the sagittal
plane.
Classification Method
The radiological classification of maturational stages of the
ZMS and the MS was based on an adaptation of previous
studies (Angelieri et al., 2013; Angelieri et al., 2017).
- Stage 1: the suture appears like a continuous low-density
line in the middle, between 2 uniform high-density
lateral lines corresponding to the cortical bone. In this
stage, the suture may be considered open (Figure 1A
and B).
- Stage 2: the suture appears like a single uniform high-
density line with no or little interdigitation. In this
stage the suture may be considered still open (Figure
1C and D).
- Stage 3: the suture appears like a single scalloped high-
density line with interdigitation or like 2 thin scalloped
high-density lines with little low-density spaces in the
middle. In this stage, the suture is starting to close
(Figure 1E and F).
- Stage 4: the suture is no longer visible in many areas of
its original location and the parasutural bone appears
as completely reworked with increased bone density.
In this stage, the suture may be considered closed
(Figure 1G and H).
For the evaluation of the PMS, we needed to simplify this
classification, because of its complex anatomy. Therefore, only
stage 1 (Figure 2A), stage 2 (Figure 2B), and stage 4 (Figure
2C) were identified. Finally, we gave each suture a score
according to the maturational stage from 1 to 4.
Statistical Analysis
An interobserver analysis was carried out in order to assess the
reproducibility of our classification method. Three observers
(an expert maxillofacial surgeon, an expert orthodontist, and a
Meazzini et al 3

Figure 1. Computed tomography (CT) images of the median palatal suture (A) and the zygomaticomaxillary suture (B) at maturational stage 1 in
a nonsyndromic child; CT images of the median palatal suture (C) and the zygomaticomaxillary suture (D) at maturational stage 2 in a
nonsyndromic child; CT images of the median palatal suture (E) and the zygomaticomaxillary suture (F) at maturational stage 3 in a nonsyn-
dromic child; CT images of the median palatal suture (G) and the zygomaticomaxillary suture (H) at maturational stage 4 in a syndromic child.

Figure 2. Computed tomography (CT) images of maturational stages 1 (A), 2 (B), and 4 (C) of the pterigomaxillary suture in a nonsyndromic
child (stage 1 and 2) and in a syndromic child (stage 4).

maxillofacial surgery resident) did individually a single-
blinded evaluation on 5 CT scans of syndromic patients and
5 CT scans of healthy controls and weighted k coefficient was
calculated. The agreement was defined according to the scale
of Landis and Koch.
In addition, an intraexaminer analysis was performed. The
second examination was made after 6 months and an intraclass
correlation coefficient was chosen for the statistical correlation.
As concerns the statistical analysis both syndromic and con-
trol patients were divided into 4 age groups (1-3, 4-6, 7-9, and
10-12 years) and for each suture the highest stage was consid-
ered. Mean maturational stage with standard deviation was
calculated for each group and data were organized in histo-
grams and line graphs. Maturational stages between syndromic
and nonsyndromic patients were compared with an indepen-
dent Student t test. The percent of open sutures (stage 1 and 2)
in syndromic patients was calculated for each type of suture
analyzed, in all groups of age.
Given the presence of multiple comparisons and the
increased risk of type I error, a Benjamini-Hochberg correction
was carried out and the adjusted P value was set at .029.
Statistical analysis was carried out with Stata version 10 soft-
ware (StataCorp 2007; Stata Statistical Software: Release 10:
StataCorp LP).
Results
The weighted k values, for interexaminer reproducibility of the
identification of the maturational stages of the ZMS, demon-
strated good agreement with average weighted k coefficient of
0.86 (95% CI: 0.74-1.00), almost perfect agreement with aver-
age weighted k coefficient of 0.91 (95% CI: 0.84-1.00) for the
MS and relatively good agreement with average weighted k
coefficients of 0.71 (95% CI: 0.64-1.00) for the PMS.
A sensitivity power analysis (used when the sample size is
predetermined by study constraints) was run for the indepen-
dent sample t tests, determining the size effect found with the
sample we had (Cohen d). Observed power was calculated,
given the sample size reached, setting a (type I error) at
0.029 and calculating the population size effect for each test
(Cohen, 1988). The observed power of each test was between
0.93 and 0.99 (Table 1).
4 The Cleft Palate-Craniofacial Journal XX(X)

Table 1. Mean and Standard Deviation (SD) of Maturational Stages of the ZMS, MS, and PMS in Syndromic Patients and in the Control Group.a

Control patients Syndromic patients

N ¼38 Sutures (mean + SD) (mean + SD) P value Cohen d (Effect size) Observed power
1-3 Years 10 ZMS 1.6 + 0.55 2.3 + 0.48 .031 1.35 0.96
MS 1.4 + 0.55 3.1 + 0.88 .001 2.32 0.99
PMS 1.8 + 0.45 3.3 + 1.16 .016 1.70 0.94
4-6 Years 11 ZMS 1.7 + 0.48 2.36 + 0.67 .018 1.13 0.91
MS 1.6 + 0.52 3.55 + 0.82 .000 2.83 0.99
PMS 1.9 + 0.32 3.64 + 0.81 .000 2.82 0.99
7-9 Years 9 ZMS 1.67 + 0.65 2.71 + 0.95 .030 1.28 0.92
MS 2.17 + 0.83 3.86 + 0.38 .000 2.60 0.99
PMS 1.92 + 0.29 3.43 + 0.98 .000 2.10 0.97
10-12 Years 8 ZMS 2.71 + 0.76 3.57 + 0.53 .010 1.30 0.93
MS 2.71 + 0.76 3.86 + 0.38 .003 1.91 0.94
PMS 2.57 + 0.78 3.71 + 0.76 .018 1.30 0.93
Abbreviations: MS, midpalatal suture; PMS, pterigomaxillary suture; SD, standard deviation; ZMS, zygomatico maxillary suture.
a
P values of the independent samples t test was set at 0.028 after Benjamini-Hochberg correction. Given the small size of the samples; Cohen d effect size
coefficient was calculated and relative observed powers were listed.

Syndromic patients aged 1 to 3 years (n ¼ 10) had a mean
maturational stage of the ZMS of 2.3 + 0.48, while in the
control group the mean was 1.6 + 0.55 (ns). The mean stage
of MS was 3.1 + 0.88, while in the control it was 1.4 + 0.55
(value ¼ .001). Pterigomaxillary suture was 3.3 + 1.16, while
the control group was 1.8 + 0.45 (P ¼ .016). Syndromic
patients aged 4 to 6 years (n ¼ 11) had a mean maturational
stage of the ZMS of 2.36 + 0.67, while in the control group the
mean was 1.7 + 0.48 (P ¼ .018). Midpalatal suture was 3.55
+ 0.82, while the control group was 1.6 + 0.52 (P ¼ .000).
Pterigomaxillary suture was 3.8 + 0.6, while the control group
was 1.9 + 0.32 (P ¼ .000).
Syndromic patients aged 7 to 9 years (n ¼ 9) had a mean
maturational stage of the ZMS of 2.7 + 0.95, while in the
control group the mean was 1.67 + 0.65 (ns). Midpalatal
suture was 3.86 + 0.38, while the control group was 2.17 +
0.83 (P ¼ .000). Pterigomaxillary suture was 3.43 + 0.98,
while the control group was 1.92 + 0.29 (P ¼ .000).
Syndromic patients aged 10 to 12 years (n ¼ 8) old had a
mean maturational stage of the ZMS of 3.57 + 0.53, while in
the control group the mean was 2.71 + 0.76 (P ¼ .010). Mid-
palatal suture was 3.86 + 0.38, while in the control group the
mean was 2.71 + 0.76 (P ¼ .003). Pterigomaxillary suture was
3.71 + 0.76, while the control group was 2.57 + 0.78 (P ¼
.018).
Taking into consideration the whole sample of syndromic (n
¼ 38) and nonsyndromic patients, the difference between the
groups, without age separation, was significant for all sutures (
P ¼ .000). A visual representation of the progressive ossifica-
tion of each suture in every age-group is given in Figure 3A-D.
In every age-group, the mean maturational stage of each
suture was compared. In syndromic patients aged 1 to 3 years,
the ZMS were open (stage 1 and 2) in 70% of cases, MS and
PMS in 30%. In syndromic patients aged 4 to 6 years, the ZMS
were open (stage 1 and 2) in 64% of cases, the MS in 18%, and
the PMS in 9%. In syndromic patients aged 7 to 9 years the
ZMS were open (stage 1 and 2) in 40% of cases, the MS and the
PMS were fused in all patients. In syndromic patients aged 10
to 12 years all sutures were fused.
Discussion
To the best of our knowledge this is the first study describing
the patency of the circummaxillary sutures with CTs in grow-
ing patients affected by Crouzon, Apert, and Pfeiffer
syndromes.
The results of this study show that, not only calvarial and
cranial base sutures are prematurely closed but also circum-
maxillary sutures. Samples are not large, given the prevalence
of CFS and the need for high-quality CT scans, nevertheless,
power of the study was high.
There are several theories on the etiology of midface hypo-
plasia in craniosynostosis. Until recently, the most held theory
was that premature ossification of the cranial base secondarily
induced midfacial hypoplasia (Rosenberg et al., 1997; Eswar-
akumar et al., 2005). But is maxillary retrusion truly only due to
cranial base synostosis? Kreiborg et al. (1999) suggested that,
maybe, also early lack of sutural growth of the maxilla and an
abnormal remodeling pattern result in a maxilla that is small in
3 planes of space. No actual study was ever carried out; there-
fore, no evidence was given for these statements. Meazzini
et al. (2005), in nonoperated patients, reported no horizontal
growth of the maxilla after age 7, therefore, after the age in
which in nonsyndromic patients the cranial base component of
maxillary growth is significantly reduced, suggesting that cra-
nial base might not be the only cause of maxillary growth
impairment, though again, no imaging of the sutures was
provided.
Interestingly, in mouse models (Purushothaman et al.,
2011), premature synostosis of the premaxillary-maxillary,
nasal-frontal, and maxillary-palatine sutures were shown.
These were detected in the absence of premature ossification
Meazzini et al 5

Figure 3. Histograms representing the average maturational stage of the ZMS, the MS, and the PMS sutures in nonsyndromic patients (black
columns) and in syndromic patients (grey columns) aged 1 to 3 (A); histograms representing the average maturational stage of the ZMS, the MS,
and the PMS sutures in nonsyndromic patients (black columns) and in syndromic patients (grey columns) aged 4 to 6 (B); histograms
representing the average maturational stage of the ZMS, the MS, and the PMS sutures in nonsyndromic patients (black columns) and in
syndromic patients (grey columns) aged 7 to 9 (C); histograms representing the average maturational stage of the ZMS, the MS, and the PMS
sutures in nonsyndromic patients (black columns) and in syndromic patients (grey columns) aged 10 to 12 (D). MS indicates midpalatal suture;
PMS, pterigomaxillary suture; ZMS zygomaticomaxillary suture.

of the cranial base. Therefore, midfacial hypoplasia does not
seem to be secondary to premature cranial base ossification, but
rather primary synostosis of facial sutures, thus providing new
insights into the pathogenesis of midface deficiency in humans
with CFS.
Other studies demonstrated high levels of FGFR1-2 expres-
sion during midfacial membranous ossification in human and
mouse embryonic tissue, also suggesting that FGFR1-2 muta-
tions directly affect midfacial embryonic tissue outgrowth
(Bachler & Neubüser, 2001; Britto et al, 2001), indicating that
abnormalities of intramembranous bone ossification, such as
decreased bone formation or increased apoptosis, not only
affect the calvarial bones, as has been previously described,
but also involve the facial skeleton.
Growth modification of the maxilla is highly dependent on
the level of maturation of the circummaxillary sutures. Histo-
logical examination of nonsyndromic human autopsy material
demonstrated similar maturational stages of the transverse
palatine and pterygopalatine sutures during the infantile, juve-
nile, and adolescent growth stages (Melsen & Melsen, 1982).
These sutures show an increasing interdigitation and complex-
ity from the infantile through the adolescent stages, with com-
plete fusion of the sutures in the adult. Recently, Angelieri et al.
(2017) described a method of classification of the MS and ZMS
maturational stages on CBCT images that can be useful for late
adolescent and young adult patients in whom the efficacy of
orthodontic rapid maxillary expansion (RME) is unpredictable.
In our study, according to clinical implications, we consid-
ered appropriate to simplify Angelieri’s classification method
by reducing the number of scores. Specifically, Angelieri’s
classification identifies 2 different stages (stages B and C) to
describe the phase during which sutures are closing. Therefore,
given that Angelieri’s stages B and C are often detectable in the
same suture and at the same time, we chose to unify these 2
stages under the name of stage 3. Stages D and E were unified
into stage 4, because, clinically, even if the suture is only
partially closed (stage D of Angelieri’s classification corre-
sponds to the closure of the palatine part of the MS or of the
inferior part of the ZMS, while stage E describes the final
phase, when the suture is no longer visible) and surgically
assisted palatal expansion would be required. We needed to
add stage 1, an earlier stage, not present in Angelieri’s classi-
fication, given the much younger age of our samples. Stage 1
was characterized by a wider suture. For the PMS, considering
it’s anatomical and histological complexity, only 3 stages were
identified. Nevertheless, PMS assessment reliability was the
lowest (k coefficient ¼ 0.71).
Before starting with CT evaluation, observers were trained
using sample images of each radiological stage of sutural
maturation. Common mistakes in which a nontrained operator
might incur, are, as an example, not distinguishing the vomer
insertion, which looks like a single high-density line as a suture
in stage 2, from the suture itself.
As can be clearly seen from the histograms (Figure 3A-D),
at the same age, the 3 circummaxillary sutures were at a more
advanced stage in syndromic patients, in comparison with the
control group. In every age-group, in syndromic patients, the
MS and the PMS were at a more advanced stage of maturation
6 The Cleft Palate-Craniofacial Journal XX(X)
in comparison with the ZMS and more so, before 9 years
of age.
Rapid maxillary expansion is often unsuccessful in the gen-
eral population after 15 years (Angelieri et al., 2013). Angelieri
et al found closed MS in girls older than 11 years and in boys
older than 14 years. On dry human skulls, the pterygomaxillary
sutural area at 6.5 years of age was found to be linear with
evidence of a gap between the pterygoid process of the sphe-
noid bone and the maxillary tuberosity. In contrast, the anat-
omy of this region changes dramatically by 12 years of age,
when the 2 bony surfaces are more interdigitated (Melsen,
1972; Melsen & Melsen, 1982).
According to our study, in healthy children, stage 3 was
already found at 9 years of age. In syndromic patients, the
closure of the circummaxillary sutures starts earlier. Midpalatal
suture and PMS were found in stage 4 already at 4 years of age
(only 18% and 9% of the sutures, respectively, were found
radiologically open between 4 and 6 years, none after 7 years).
The ZMS was found open in 64% of cases between 4 and 6
years, in 40% between 7 and 9 years, no sutures were found to
be radiologically open between 10 and 12 years of age.
Clinically at stage 3 an attempt at orthopedic expansion of
the maxilla seems to be still advisable in some syndromic
patients, although, an exact clinical correlation with each
maturational stage as seen on a CT is not available at this time
and clinical–radiological correlation will probably become eas-
ier with the gradual improvement of CT quality.
Rapid maxillary expansion was first introduced by Angell in
1860. It was then popularized in the mid-1960s (Haas, 1965).
Rapid maxillary expansion appears to involve an ample portion
of the craniofacial complex, as the maxilla is associated with 10
bones in the face and head (Melsen, 1972). The introduction of
3-dimensional CT imaging allowed to evaluate quantitatively
the extent of disarticulation of these sutures in young ortho-
dontic patients following treatment with RME (Garrett et al.,
2008; Leonardi et al., 2011). Many investigators have pointed
out that RME results in complex changes in the craniofacial
structures. Timms (1980) showed that the maxilla and the pala-
tine bones moved apart, along with the pterygoid processes of
the sphenoid bone. Jafari et al. (2003) in a 3D study on a finite
element model of a human skull showed an expansive force at
the intermaxillary suture, but also high forces on various struc-
tures on the craniofacial complex, particularly the sphenoid and
zygomatic bones.
Separation of the palatal bone from the pterygoid process is
relatively easy to obtain only in infantile and early mixed den-
tition skulls. Attempted disarticulation in the late juvenile and
adolescent periods was always accompanied by fracture of the
greatly interdigitated osseous surfaces and if performed in
adults it induced periodontal damage (Melsen & Melsen,
1982).
In general, in nonsyndromic children, orthodontic expansion
of the maxilla is almost always carried out between 6 and 12
years of age, when sutures are still completely patent. Although
there is a lack of validated correlation between clinical
response and CT imaging, nevertheless, in syndromic patients,
we recommend CT evaluation of the maturational stage of
circummaxillary sutures. Already at age 4 to 6 years only sel-
dom in CFS patients, sutures were found to be radiologically
open. Therefore, treatment through orthodontic expansion
should be evaluated with extreme care. RPE in a patient with
fused sutures may be a risk for the teeth and for the periodontal
support (Digregorio et al., 2019). Furthermore, syndromic chil-
dren have extremely severe dental crowding, which ideally
would need early expansion or maxillary protraction with
anchorage on the deciduous dentition. In the presence of closed
sutures, the strain on the deciduous teeth may cause either early
loss, with resulting mesial movement of permanent molars and
worsening of dental crowding, or ankylosis and subsequent
impaction of the permanent premolars (Meazzini et al.,
2011). Therefore, an orthodontic treatment carried out on a
child affected by CFS needs to be complemented by a profound
knowledge of the biological mechanisms which lead to the
facial defect and extreme clinical circumspection.
Conclusion
This study proposes a classification method for the assessment
of maturational stages of circummaxillary sutures, which
seems reproducible and based on easily accessible CT
examinations.
In consideration of the early radiological apparent fusion of
circummaxillary sutures in syndromic patients, in most of these
patients, orthopedic treatment on the maxilla should be carried
out with great prudence. Computed tomography scans might
help the clinical decision between exclusive orthodontic treat-
ment or surgically assisted expansion in syndromic children,
although further development in CT accuracy will improve our
ability to correlate clinical prognosis with CT imaging.
Acknowledgments
The authors thank Dr Dario Lanzani, SIRIO Radiology, for the help in
collecting control CT scans. Part of the data in this article were used as
the MD thesis of Dr Margherita Lisciandrano.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Maria Costanza Meazzini, DMD, MMSc https://orcid.org/0000-
0001-9596-570X
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