ORIGINAL ARTICLE

Midpalatal suture maturation in 11- to

15-year-olds: A cone-beam computed
tomographic study

bio Pinto Guedes, Ana Cla
Diego Luiz Tonello, Victor de Miranda Ladewig, Fa
udia de Castro Ferreira Conti,
Renata Rodrigues Almeida-Pedrin, and Leopoldino Capelozza-Filho
Bauru, S~ao Paulo, Brazil

Introduction: We used cone-beam computed tomography to evaluate the maturation stages of the midpalatal
sutures in children aged 11 to 15 years old. Maxillary expansion is successful for most patients in this age group,
so we sought to identify the status of suture maturation in these subjects to use as a comparison for the prognosis
of rapid maxillary expansion in older patients. Methods: Tomographic images in axial sections of the midpalatal
sutures from 84 children (40 boys, 44 girls; ages, 11-15 years) were classified using a scale denoting the matu-
ration stage of the midpalatal suture (A, B, C, D, and E). The chi-square test was applied to evaluate suture
stages by sex and age groups. Results: Stage A was observed in only one 11-year-old girl. Stage B was
present at all ages but was more prevalent in those less than 13 years of age. Stage C was the most
prevalent in all evaluated ages. Stages D and E showed low prevalence rates. There were higher
prevalences of the early stages of maturation in boys. Conclusions: The results of this study, which showed
dominant prevalence of stage C, suggest that conventional, nonsurgical rapid maxillary expansion performed
in patients over 15 years old is justified by a satisfactory prognosis when assessment of the sutural status indi-
cates stage C. (Am J Orthod Dentofacial Orthop 2017;152:42-8)

T
he etiology of some dental disharmonies, such as
crossbites and dental crowding, may be related
to transversal atresia of the maxillary bone. Rapid
maxillary expansion (RME) is routinely used in clinical
orthodontics for the correction of maxillary atresia.
These expander devices use heavy forces to promote
the rupture of the midpalatal suture (MPS). The subse-
quent regional formation of new bone corrects the
transverse maxillary deficiency, with a real increase in
bone size.1,2
Since the RME procedure has been applied for the
treatment of maxillary atresia, many studies have been
conducted to clarify its dental and skeletal effects.1-6
The advantages of RME are significant. It creates an
increased dental arch perimeter, which facilitates the
From the Department of Orthodontics, Sagrado Coraç~ao University, Bauru, S~ao
Paulo, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Renata Rodrigues Almeida-Pedrin, Department of
Orthodontics, Sagrado Coraç~ao University, 2-20 Leandro do Santos Martins st,
Bauru, S~ao Paulo 17017-900, Brazil; e-mail, repedrin@gmail.com.
Submitted, August 2016; revised and accepted, November 2016.
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2016.11.028
42
correction of malocclusions and avoids dental
extractions in many patients.7 In addition, some patients
report improvement in airflow after RME, although evi-
dence suggests that this is not likely to be a long-lasting
effect.8-10
RME is only possible in patients who do not have a
fully matured MPS, when the maxillary bones that
make up the palatal vault have not fused or are not inter-
digitated enough to impose a higher tensile strength to
rupture the MPS. In patients with a fully matured MPS,
surgical expansion or surgically assisted expansion is
recommended.7 A recent study has suggested that
when the suture is still present, RME with skeletal
anchorage support is a possibility.11
Since the literature states that closure of the bony su-
tures tends to increase with age, there are many doubts
about the prognosis of RME in patients who have
already stopped growing3,4,12; thus, conventional RME
is performed more often on young patients. The only
way to know whether RME could be performed on a
patient out of the growth phase was by trial and error,
which resulted in negative side effects when the
treatment was not successful.13 Therefore, it would be
a helpful if diagnostic imaging protocols and a means
to diagnose the maturation stage of MPS before RME
Tonello et al
Fig 1. CBCT images: A, the main screen of the InVivo5 program with axial, sagittal, and coronal views
and reference lines. Note in the sagittal view that the orange line is positioned through the center of the
hard palate. B, The axial view after corrected reference lines were positioned.
are available. This would allow the orthodontist to
establish a more accurate prognosis for older RME can-
didates or patients who have finished growing.
In this study, we aimed to determine the frequency of
MPS maturation stages in children aged 11 to 15 years
by using cone-beam computed tomography (CBCT).
Since this age group has demonstrated a favorable prog-
nosis with the RME procedure, we sought to identify the
bone maturation status of the MPS in these patients to
use as a comparison for RME prognosis in older patients.
See Supplemental Materials for a short video presenta-
tion about this study.
MATERIAL AND METHODS
This study was approved by the ethics committee in
research of Sagrado Coraç~ao University, Bauru, S~ao
Paulo, Brazil (protocol 1.302.307). For the evaluation
of the skeletal maturation stages of MPS, 84 CBCT scans
of children aged 11 to 15 years were chosen (40 boys, 44
girls). Inclusion criteria were age between 11 and
15 years and the availability of CBCT images. The exclu-
sion criteria were history of previous orthodontic treat-
ment or any appliance at the examination (previous
maxillary expansion as an early interceptive orthodontic
phase may affect suture status), cleft lip and palate, and
syndromic conditions. The CBCT scans were obtained
from a dental diagnostic imaging center. The primary
justification for the CBCT request was the diagnosis of
retained teeth.
All CBCT images used were obtained with the i-CAT
scanner (Imaging Sciences International, Hatfield, Pa),
adjusted to the following specifications: 8.9 to 30 sec-
onds, a field of view of at least 11 cm, and voxel size
of 0.2 to 0.3 mm. To standardize the position of the
American Journal of Orthodontics and Dentofacial Orthopedics
43
patients’ heads in the 3 planes of space, they were in-
structed to remain seated with their heads positioned
so that the Frankfort horizontal plane was parallel to
the ground and the median sagittal plane was perpen-
dicular to the ground. The CBCT images were acquired
with DICOM.
InVivoDental5 (Anatomage, San Jose, Calif) was used
to display the images.
First, in the multiplanar reconstruction screen, the
skull image was manipulated so that the vertical and
horizontal lines were overlaying the MPS in the axial
and frontal cuts (Fig 1).
In the sagittal section, the subject's jaw was manipu-
lated so that the horizontal reference line coincided with
the median region of the palate, which is the cancellous
bone between the upper and lower cortical bones. In the
axial CBCT section, the visualization and classification of
the skeletal maturation stage of the MPS were conduct-
ed according to the method of Angelieri et al12 (Fig 1).
For a curved palate, it was not possible to view the
MPS in 1 axial section; therefore, 2 axial sections were
made: 1 section was in the front and the other at the
rear of the palate (Fig 2). The skeletal maturation stages
of the MPS can be differentiated by using Table I and
Figure 3.
One examiner (D.L.T.) assessed all images and
selected the best axial image according to the method
of Angelieri et al.12 Subsequently, these images were
saved as JPEG files and arranged sequentially in a pre-
sentation (PowerPoint for Mac 2008; Microsoft, Red-
mond, Wash). The images were identified only by
numbers. Each patient was classified by the chief exam-
iner, who was blinded, using a computer with a high-
definition display in a dark room. This evaluation was
considered the main evaluation.
July 2017  Vol 152  Issue 1
44 Tonello et al

Fig 2. For subjects with a curved palate, 2 sagittal sections are needed, one for the anterior region and
the other for the posterior region. Both images should be considered for determining the maturation
stage.

measurement error was evaluated by kappa statistics,

Table I. Skeletal maturation stages of MPS description
Stage Description
A Relatively straight high-density line at the midline
B Scalloped high-density line at the midline
C Two parallel, scalloped, high-density lines close to each
other and separated in some
areas by small low-density
spaces
D Two scalloped, high-density lines at the midline on the
maxillary portion of the palate that cannot be
visualized in palatine bone
E It cannot be identified
To check the reliability of the MPS classification
method, the measurements of the images of the 84 sub-
jects were repeated by the examiner 15 days after the
main evaluation (intraexaminer error). To verify the in-
traexaminer error, the sample was also evaluated by a
second blinded examiner, an orthodontist (F.P.G.). The
and the results were interpreted with the method of
Landis and Koch14 (Table II).
Statistical analysis
Data were presented in tables by absolute (number)
and relative (percentage) frequencies. The chi-square
test was used to analyze the suture stages by sex and
age groups and to compare the data with those of Angel-
ieri et al.12 A significance level of 5% (P\0.05) was used.
All statistical procedures were conducted with Statistica
software (version 5.1; StatSoft, Tulsa, Okla).
RESULTS
Stage A (Fig 3, A) was observed in only 1 subject, an
11-year-old girl. Stage B (Fig 3, B) was present in all
ages; however, it was more prevalent in patients up to
13 years of age (11-year-olds, 30.8%; 12-year-olds,

July 2017  Vol 152  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Tonello et al 45

Fig 3. A, The suture is seen as a relatively straight radiopaque line, stage A; B, the suture appears as a
sinuous line of high density, stage B; C, 2 radiopaque, winding, and parallel lines are separated by
areas of low radiographic density, stage C; D, the palatine bones become more radiopaque, and the
suture is not visualized in this region, stage D (note that in the palatal area it is still possible to observe
2 parallel radiopaque lines); E, it is no longer possible to see the suture along the maxillary and palatine
bones, indicating suture fusion, stage E.

14 subjects (2 girls, 1 boy) who were 12 years old. Stage E

Table II. Kappa interpretation of Landis and Koch
also showed a higher prevalence in those aged 14
Kappa Strength of agreement (20%) and 15 (29.4%) years, except for 1 girl who was
\0.00 Poor 12 years old. In general, stages D and E also showed sim-
0.00-0.20 Slight ilarities between the sexes (Table III).
0.21-0.40 Fair
In the distribution between the sexes (Table IV), a
0.41-0.60 Moderate
0.61-0.80 Substantial higher prevalence of stage C was observed in boys
0.81-1.00 Almost perfect (42.5%), followed by stage B (30%). The prevalences
of stages D and E in boys were 12.5% and 15%, respec-
33.3%; 13-year-olds, 41.7%). The prevalence values in tively. In girls, stage C was the most prevalent (56.8%),
those aged 14 and 15 years were 6.7% and 11.8%, followed by stage B (20.5%). Stage D was observed in
respectively (Table III). 13.6% of the girls. Stages A (2.3%) and E (6.8%) had
Stage C (Fig 3, C) was the most prevalent in all ages the lowest prevalences.
included in our study (11-year-olds, 61.5%; 12-year-
olds, 51.9%; 13-year-olds, 50.0%; 14-year-olds, DISCUSSION
53.3%; 15-year-olds 35.3%). There were similar preva- The scientific literature supports performing RME in
lences between the sexes until the age of 13 years. At patients until adolescence. In most patients, the prog-
ages 13 and older, stage C was more prevalent in girls nosis is favorable with significant skeletal gains; howev-
(14-year-olds, 62.5% in girls, 42.9% in boys; 15-year- er, there are still many doubts about the prognosis in
olds, 66.7% in girls, 18.2% in boys) (Table III). patients outside the growth phase.5,6,13,15 The greater
Stages D (Fig 3, D) and E (Fig 3, E) were not present in the obliteration of the MPS, the lower the skeletal
any 11-year-old. Stage D was more prevalent in 14- and effects and the greater the dentoalveolar impact. This
15-year-olds (20% and 23.5%, respectively), except in 3 may be accompanied by side effects such as ulceration

American Journal of Orthodontics and Dentofacial Orthopedics July 2017  Vol 152  Issue 1
46 Tonello et al

Table III. Distribution of the maturational stages by age and sex

Stage

A B C D E

Age (y) Sex n % n % n % n % n % Total

11 F 1 10.0 3 30.0 6 60.0 0 0.0 0 0.0 10
M 0 0.0 1 33.3 2 66.7 0 0.0 0 0.0 3
F1M 1 7.7 4 30.8 8 61.5 0 0.0 0 0.0 13
12 F 0 0.0 6 33.3 9 50.0 2 11.1 1 5.6 18
M 0 0.0 3 33.3 5 55.6 1 11.1 0 0.0 9
F1M 0 0.0 9 33.3 14 51.9 3 11.1 1 3.7 27
13 F 0 0.0 0 0.0 1 50.0 1 50.0 0 0.0 2
M 0 0.0 5 50.0 5 50.0 0 0.0 0 0.0 10
F1M 0 0.0 5 41.7 6 50.0 1 8.3 0 0.0 12
14 F 0 0.0 0 0.0 5 62.5 2 25.0 1 12.5 8
M 0 0.0 1 14.3 3 42.9 1 14.3 2 28.6 7
F1M 0 0.0 1 6.7 8 53.3 3 20.0 3 20.0 15
15 F 0 0.0 0 0.0 4 66.7 1 16.7 1 16.7 6
M 0 0.0 2 18.2 2 18.2 3 27.3 4 36.4 11
F1M 0 0.0 2 11.8 6 35.3 4 23.5 5 29.4 17
11-13 F 1 3.3 9 30.0 16 53.3 3 10.0 1 3.3 30
M 0 0.0 9 40.9 12 54.5 1 4.5 0 0.0 22
F1M 1 1.9 18 34.6 28 53.8 4 7.7 1 1.9 52
14-15 F 0 0.0 0 0.0 9 64.3 3 21.4 2 14.3 14
M 0 0.0 3 16.7 5 27.8 4 22.2 6 33.3 18
F1M 0 0.0 3 9.4 14 43.8 7 21.9 8 25.0 32
11-15 F 1 2.3 9 20.5 25 56.8 6 13.6 3 6.8 44
M 0 0.0 12 30.0 17 42.5 5 12.5 6 15.0 40
F1M 1 1.2 21 25.0 42 50.0 11 13.1 9 10.7 84
F, Female; M, male.

Table IV. Distribution and comparison of the maturational stages in 11- to 15-year-old subjects by sex
Stage

A B C D E

Sex n % n % n % n % n % Total
Female 1 2.3 9 20.5 25 56.8 6 13.6 3 6.8 44
Male 0 0.0 12 30.0 17 42.5 5 12.5 6 15.0 40
Chi-square test: P 5 0.425, not significant.

of the mucosa, gingival recession, marked labial
inclination of the supporting teeth, and pain and
discomfort.13,16,17 Therefore, due to the lack of a
reliable parameter to evaluate the possibility of
opening the sutures, many professionals opt for
surgically assisted maxillary expansion in adult
patients, even though it is more costly and may cause
some morbidities.17 Since the degree of maturation of
the MPS varies in adults, it would be useful to improve
the diagnosis through accurate images and protocols,
which would enable the orthodontist to make a person-
alized prognosis for these potential RME patients.4
In this study, we used the protocol of Angelieri et al12
to classify MPS based on CBCT scans. Our study included
many subjects concentrated in the restricted age range
at which RME shows clinical indications for good results.
These results can contribute to create a prognostic
parameter for comparison with patients above the age
of growth.
All stages were observed in the sample we examined.
There was a higher prevalence of stages A, B, and C at
younger ages. The prevalence of the more advanced
stages of maturation (D and E) proportionally increased
with increasing age, particularly at ages 14 and 15 years.
The results showed that the more advanced stages (C,
D, and E), were more prevalent in girls (77.2%) (Table III).
In the younger ages (11-13 years) (Table III), at which
clinical success would be theoretically achieved, 13.3%

July 2017  Vol 152  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Tonello et al
of the girls were in palatal maturation stages D and E,
whereas the boys in the same age group accounted for
only 4.5%. These results are consistent with the results
of Angelieri et al,12 who observed a lack of male patients
in the same age group in stages D and E and a female
prevalence of 25%. Since these results showed that sex
is a direct influencing factor, they corroborate the asser-
tion that predicting the prognosis from chronologic age
is uncertain. It is likely that this variable becomes more
relevant at older ages, when there is more uncertainty
if individualized diagnostic methods are not applied.
Stage A, typically a stage of childhood, was found
only in an 11-year old child in our study; this is consis-
tent with the results of Angelieri et al.12 Stages B and C,
found in younger patients, corroborate with the histo-
logic findings of Melsen and Melsen,18 which describe
the tortuous path of MPS development during the juve-
nile stage, with the formation of “bone islands”
throughout the suture. These “bone islands” can be
seen in the tomographic images of subjects in stage C,
who made up 50% of our study sample.
In the age group of 11 to 13 years, it was observed
that the unfused stages (A, B, and C) were seen in
90.3% of the subjects; this is similar to the 85.41% in
the study by Angelieri et al.12 However, they observed
a higher prevalence of stage B (58.33%) in this age
group; in our study, there was a higher prevalence of
stage C (53.84%). Subjects in stage B comprised
34.61% of the sample between 11 and 13 years of age
(Table III).
RME is successful in almost all patients, and skeletal
gains are greater and more stable in those who have not
peaked in their pubertal growth.5,15 Since 90.3% of
patients under 13 years of age are in stage C, this led
us to believe that being in stage A, B, or C provides a
good prognosis for patients who need RME. However,
some factors, responsible for the resistance to
maxillary transverse expansion, other than the stage of
MPS maturity, can also influence the success of RME,
such as bone density,19 fusion of the zygomaticotempo-
ral, zygomaticofrontal, and zygomaticomaxillary su-
tures.7,18-22 In this context, resistance at the pterygoid
plates has also been mentioned in a previous surgically
assisted RME study, although performing pterygoid
detachment did not influence the buccal tipping of the
maxillary molars.22 Since stage C is still the most preva-
lent in patients between 13 and 15 years of age, this
study justifies routinely using conventional RME in
this age group.
Authors of studies have claimed that the prognosis
for RME becomes worse as the patient ages.1-6,13,15 It
has been suggested that this poor prognosis is mainly
due to the gradual obliteration of MPS with age.3,13
American Journal of Orthodontics and Dentofacial Orthopedics
47
Our results confirm these authors’ findings; stages D
and E were found in more subjects who were 14 and
15 years old compared with younger ages (Table III). In
stage D patients, skeletal growth likely occurs in the
anterior maxillary area, whereas the dentoalveolar effect
only occurs in the regions of the premolars and molars.
In such cases, patients would be best treated with surgi-
cally assisted expansion. Our results showed a low prev-
alence of stage D in subjects from 11 to 15 years (13.1%)
of age, with equal distribution between the sexes (6 girls,
5 boys) (Tables III and IV). In the study by Angelieri
et al,12 a progressively higher prevalence of stage D
was observed as the age of the group increased.
In patients aged 11 to 13 years, in whom any ortho-
dontist would expect clinical success from RME, we
found that approximately 7.7% of them in this study
were in stage D. This may suggest the clinical possibility
of success with RME in subjects with that same degree of
maturation. The prognosis is not as favorable as the pre-
vious stages, but perhaps it is enough to prevent surgi-
cally assisted palatal expansion in patients of advanced
age, in whom higher prevalences of stages D and E are
expected. A study of prevalence confirming the greater
distribution of the last stages in patients who have
already peaked in their pubertal growth would be neces-
sary, as well as a clinical study, to validate this hypothe-
sis.
Stage E was found in 10.7% of the sample popula-
tion, and almost all subjects (8 of 9) were 14 or 15 years
of age, with the exception of 1 girl (age, 12 years) in
whom stage E was found (Table III). In our study, stage
E was the most prevalent in boys, and Angelieri et al12
found that stage E was only present in male patients
older than 18 years. Revelo and Fishman,23 in a radio-
graphic study, evaluated the degree of MPS closure
and found no statistically significant differences be-
tween the sexes. However, other studies have shown
that bone maturation begins earlier in girls.24,25
An interesting finding was that the vast majority of
subjects in various stages (7 of 9 subjects) had a thinner
palate, compared with the rest of the study sample. This
can be clearly seen in the frontal CBCT slices. Angelieri
et al12 mentioned that patients with a thinner palate
are usually classified as stage E because the upper and
lower cortical bones are close. This leads one to question
whether conventional RME would really be unfeasible
for them because a thin palate is less resistant to the
heavy forces exerted by the expander.
The prevalences of the earlier stages (A and B) were
greater in the boys (30%) than in the girls (22.8%). These
values were expected, since skeletal maturation begins
earlier in girls.24,26 It is also possible that boys would
have a better chance of obtaining satisfactory results
July 2017  Vol 152  Issue 1
48
from RME, compared with girls of a similar age. Thus,
tomographic evaluation to evaluate the stitching
stenosis stage before an attempt to conduct RME after
the growth phase is recommended.
Our findings pointed out to a paradigm shift in the
treatment of maxillary transversal deficiency. For older
patients (over 15 years), CBCT scans to verify the suture
stages can change clinical protocol; if stage C is
observed, a conventional RME procedure would have a
good prognosis.
Clinical studies are welcome to test the veracity of
this proposed diagnostic method in subjects in postpu-
bertal growth and should consider variations in the
thickness of the MPS and include evaluation of circum-
maxillary sutures.
CONCLUSIONS
RME is a clinically successful procedure in most
young patients with prevalence of stages A, B, and C.
These results, which showed 76.2% of the sample in
those stages, suggest that conventional, nonsurgical
RME performed in patients over 15 years old is justified
by a satisfactory prognosis when assessment of the su-
tural status indicates stage C.
SUPPLEMENTARY DATA
Supplementary data related to this article can be
found online at http://dx.doi.org/10.1016/j.ajodo.2016.
11.028.
REFERENCES
1. Haas AJ. The treatment of maxillary deficiency by opening the
midpalatal suture. Angle Orthod 1965;35:200-17.
2. Haas AJ. Rapid expansion of the maxillary dental arch and nasal
cavity by opening the midpalatal suture. Angle Orthod 1961;31:
73-90.
3. Melsen B. Palatal growth studied on human autopsy material. A
histologic microradiographic study. Am J Orthod 1975;68:42-54.
4. Persson M, Thilander B. Palatal suture closure in man from 15 to
35 years of age. Am J Orthod 1977;72:42-52.
5. Wertz R, Dreskin M. Midpalatal suture opening: a normative study.
Am J Orthod 1977;71:367-81.
6. Bell RA. A review of maxillary expansion in relation to rate of
expansion and patient's age. Am J Orthod 1982;81:32-7.
7. Silva Filho OG, Magro AC, Capelozza Filho L. Early treatment of the
Class III malocclusion with rapid maxillary expansion and maxillary
protraction. Am J Orthod Dentofacial Orthop 1998;113:196-203.
8. Warren DW, Hershey HG, Turvey TA, Hinton VA, Hairfield WM. The
nasal airway following maxillary expansion. Am J Orthod Dentofa-
cial Orthop 1987;91:111-6.
July 2017  Vol 152  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Tonello et al
9. Ramires T, Maia RA, Barone JR. Alteraç~oes da cavidade nasal e do
padr~ao respirat

orio ap

os expans~ao maxilar. Rev Bras Otorrinolarin-
gol 2008;74:763-9.
10. Baratieri C, Alves M Jr, Souza MM, Ara

ujo MT, Maia LC. Does rapid
maxillary expansion have long-term effects on airway dimensions
and breathing? Am J Orthod Dentofacial Orthop 2011;140:
146-56.
11. Lee KJ, Park YC, Park JY, Hwang WS. Miniscrew-assisted nonsur-
gical palatal expansion before orthognathic surgery for a patient
with severe mandibular prognathism. Am J Orthod Dentofacial Or-
thop 2010;137:830-9.
12. Angelieri F, Cevidanes LH, Franchi L, Gonçalves JR,
Benavides E, McNamara JA Jr. Midpalatal suture maturation:
classification method for individual assessment before rapid
maxillary expansion. Am J Orthod Dentofacial Orthop 2013;
144:759-69.
13. Capelozza Filho L, Cardoso Neto J, da Silva Filho OG, Ursi WJ.
Non-surgically assisted rapid maxillary expansion in adults. Int J
Adult Orthodon Orthognath Surg 1996;11:57-66: discussion,
67-70.
14. Landis JR, Koch GG. The measurement of observer agreement for
categorical data. Biometrics 1977;33:159-74.
15. Baccetti T, Franchi L, Cameron CG, McNamara JA Jr. Treatment
timing for rapid maxillary expansion. Angle Orthod 2001;71:
343-50.
16. Bishara SE, Staley RN. Maxillary expansion: clinical implications.
Am J Orthod Dentofacial Orthop 1987;91:3-14.
17. Northway WM, Meade JB Jr. Surgically assisted rapid maxillary
expansion: a comparison of technique, response, and stability.
Angle Orthod 1997;67:309-20.
18. Melsen B, Melsen F. The postnatal development of the palatomax-
illary region studied on human autopsy material. Am J Orthod
1982;82:329-42.
19. Korbmacher H, Schilling A, P€ uschel K, Amling M, Kahl-Nieke B.
Age-dependent three-dimensional microcomputed tomography
analysis of the human midpalatal suture. J Orofac Orthop 2007;
68:364-76.
20. Knaup B, Yildizhan F, Wehrbein H. Age-related changes in the
midpalatal suture. A histomorphometric study. J Orofac Orthop
2004;65:467-74.
21. Jafari A, Shetty KS, Kumar M. Study of stress distribution and
displacement of various craniofacial structures following applica-
tion of transverse orthopedic forces: a three-dimensional FEM
study. Angle Orthod 2003;73:12-20.
22. Magnusson A, Bjerklin K, Nilsson P, Marcusson A. Surgically assis-
ted rapid maxillary expansion: long-term stability. Eur J Orthod
2009;31:142-9.
23. Revelo B, Fishman LS. Maturational evaluation of ossification of
the midpalatal suture. Am J Orthod Dentofacial Orthop 1994;
105:288-92.
24. Fishman LS. Radiographic evaluation of skeletal maturation. A
clinically oriented method based on hand-wrist films. Angle Or-
thod 1982;52:88-112.
25. Bj€ork A. Sutural growth of the upper face studied by the implant
method. Acta Odontol Scand 1966;24:109-27.
26. Fishman LS. Chronological versus skeletal age, an evaluation of
craniofacial growth. Angle Orthod 1979;49:181-9.