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Background: The absence/presence of the mid-palatal suture in patients with cleft lip and palate has never been well investigated, although this is essential for the rapid palatal expansion and maxillary growth modification. The aim of this study was to test the hypothesis that the mid-palatal suture is present in patients with unilateral complete cleft lip and palate (UCLP). Methods: Twenty-three consecutive growing patients with UCLP who received cone beam computed tomography (CBCT) and maxillary growth modification at the bone age of cervical vertebral maturation stage 2 (CVS2) from 2007-2013 were included. For each patient, the CBCT axial sections right before the treatment were examined for the prevalence of presence, extent of suture in maxilla, and maturation of mid-palatal suture at the basal and alveolar bone levels. The data were analysed statistically. Results: The prevalence of presence of mid-palatal suture was 100.00% at the basal-bone levels but decreased significantly (p<0.001) to 60.87% at the alveolar levels. The incidence of late stage suture maturation was 86.96% at the basal-bone levels and decreased significantly (p<0.001) to 14.29% at the alveolar levels when the mid-palatal suture is present. The extent of suture in the maxilla was 72.00±20.52% at the basal-bone levels and decreased significantly (p<0.001) to 28.54±27.00% at the alveolar levels. Conclusions: Although the mid-palatal suture in patients with UCLP is present, it fades away sharply and matures gradually from the basal bone down to the alveolar bone level of maxilla at the bone age of CVS2. (1156) Sherif E Zahra and Hanady M Samih E.D.J. Vol. 63, No. 2 Although studies report on different sequence and timing of treatment in patients with cleft lip and palate (CLP), almost all treatment protocols include some types of expansion of the maxillary dental arch. In complete UCLP, the mid-palatal suture has an abnormal position lateral to the midline and the segment on the cleft side has no sutural connection with the maxilla on the non-cleft side. Some studies were conducted to either expand the maxilla before 9-11 or after alveolar bone grafting12,13. Most of these studies relied on the fact that the maxillary opening was demonstrated clinically by the diastema between the maxillary central incisors, which reveals splitting of the maxillary processes in the premaxillary mid-palatal suture. It has been postulated that since the alveolar cleft crosses the region corresponding to the tooth bud of the maxillary lateral incisor, thus not interfering with the possible formation of an intermaxillary suture (mid-palatal suture) at the region of the premaxilla 14. Therefore, there may be a mid-palatal suture in the premaxilla of patients with complete alveolar clefts. Although there is no agreement regarding the existence of the premaxillary suture in human beings, studies showing the nonexistence of a totally independent premaxillary suture have described the ‘‘incisive fissure’’15, 16. The incisive suture is located in the anterior region of the premaxilla and originated embryologically from the primary palate 17 The mid-palatal suture has been described as an end-to-end type of suture18, 19 with characteristic changes in its morphology during growth20, 21,22, 23. In the infantile period, it has been reported that the midpalatal suture is broad and Y-shaped in its frontal sections23, 24, however in patients with cleft lip and palate, the palatal suture system is disturbed25 From the above mentioned, it shows that only anecdotic case reports and limited clinical radiographic studies where published discussing expansion in complete UCLP patients however the question of whether the mid-palatal suture is present or absent in patients with cleft remains controversial. To our knowledge, the absence or presence of the mid-palatal suture in patients with cleft lip and palate has never been well investigated, although this is essential for the treatment of maxillary growth modification in cleft patients. The objective of the present study is to conduct a pilot study to test the null hypothesis that there is no mid-palatal suture in patient with unilateral complete cleft lip and palate patients. PATIENTS AND METHODS This was a retrospective clinical cohort study and was approved by the Suez canal university research ethical committee. Twenty-three consecutive growing patients with complete unilateral complete cleft lip and palate who received cone beam computed tomography (CBCT) and maxillary growth modification for their maxillary hypoplasia at cervical vertebral maturation stage 2 (CVS2) from 2007-2013 were included. For each patient, the CBCT images were obtained with i-CAT cone-beam 3-dimensional imaging system (Imaging Sciences International, Hatfield, Pa, USA). Image evaluation was performed using i-CAT vision system. All images were evaluated by one trained examiner in a darkened room with a high definition monitor after a memory washout period of at least 4 weeks. Evaluation of the absence/presence of the midpalatal suture The CBCT images right before the maxillary growth modification of all the patients were oriented so that the palatal plane in the sagittal sections, the plane between the right and left supraorbital margins in the coronal sections, and the plane between the right and left ptyregoid plates in the axial plane are parallel to the floor. The axial sections were then examined for the presence/absence of the mid-palatal suture at the levels of 3 mm below the anterior nasal spine (3mm-below-ANS) (Figure 1), root-apex (Figure 2), middle-third (Figure 3), and coronal-third of the root of right maxillary incisor ABSENCE OR PRESENCE OF MID-PALATAL SUTURE IN UCLP (1157) Fig. (1) (Left)Sagittal and (Right) axial sections at the level of 3 mm below ANS, showing mid-palatal suture Fig. (2) (Left) Sagittal and (Right) axial sections at the level of root apex, showing mid-palatal suture Fig. (3) (Left) Sagittal and (Right) axial sections at the level of root middle third, showing mid-palatal suture. (1158) Sherif E Zahra and Hanady M Samih E.D.J. Vol. 63, No. 2 The presence of suture was defined as visible observation of a lined-suture or/and a spacedsuture on the CBCT images no matter the length is. The absence of suture was defined as no visible observation of a lined/spaced suture on the CBCT images. A lined-suture is a straight/scalloped highdensity suture line on the CBCT image, which represents the early stage suture maturation 26 and a spaced-suture is a two parallel, straight/scalloped, high-density lines separated by small low-density spaces on the CBCT image, which represents the late stage suture maturation 26. The following 5 measurements were measured: 1. Prevalence of presence of suture (%): It is the ratio of cases number with presence of suture/ total cases number multiplied by 100 %. 2. Prevalence of absence of suture (%): It is the ratio of cases number with absence of suture/ total cases number multiplied by 100 %. 3. Incidence of lined-suture (%): It is the ratio of cases number with lined-suture/cases number with presence of suture multiplied by 100 %. 4. Incidence of spaced-suture (%): It is the ratio of cases number with spaced-suture/cases number with presence of suture multiplied by 100 %. 5. Suture length index (%): It is the ratio of suture length/maxillary bone length multiplied by 100 %. The suture length is the perpendicular length of mid-palatal suture, and the maxillary bone length is the median perpendicular distance between the most anterior and posterior points of the bone revealed on the examined axial section. This was for the evaluation of the extent of mid-palatal suture in maxilla. Statistical analysis Post-hoc power analysis was performed using the prevalence of presence of suture as the primary outcome, since there is no published data in literature for priori-power analysis. Repeated measurements of five randomly selected cases at two different times were performed for the intra-examiner error by using the Dahlberg’s formula 27. The measurements were analysed statistically for the differences among the 4 different bone levels with the Friedman’s test, and the Wilcoxon signedrank test for the pair-wise comparisons between any 2 different bone levels when the Friedman’s test revealed significant difference. The multiple pairwise comparisons were adjusted by the Bonferroni’s correction. The level of significance was set at p ≤ 0.05.

ABSENCE OR PRESENCE OF MID-PALATAL SUTURE IN PATIENTS WITH COMPLETE UNILATERAL CLEFT LIP AND PALATE, (A RETROSPECTIVE STUDY)