J. Anat. (1971), 108, 1. pp.

31-41 31
With 12 figures
Printed in Great Britain

The development, structure and growth pattern of the

human mid-palatal suture
R. A. LATHAM
Institute of Child Health, Alder Hey Children's Hospital,
Liverpool L12 2AP
(Received 22 January 1970)
INTRODUCTION
A knowledge of the normal development and function of the mid-palatal suture in
man is particularly important in the study and treatment of cleft lip and palate. But,
despite the interest shown in this and other aspects of the suture in the past, little, as
yet, is known about it.
Some observations on its development and growth in experimental animals have
been reported (Pritchard, Scott & Girgis, 1956; Linder-Aronson & Larsson, 1965).
In man, consideration has been given mainly to the question of when this suture
ceases to be a growth site (Scott, 1956).
This paper presents an account of the initial formation and subsequent develop-
ment of the premaxillary and maxillary parts of the mid-palatal suture based on the
histological examination of a series of human specimens. Particular attention has
been given to the histological evidence for when bone deposition in the suture
normally ceases.
MATERIAL AND METHODS
Twenty-eight specimens of the mid-palatal suture representing an age range from
6 weeks in embryonic life to 15 years in postnatal life were studied (Table 1). Foetal
specimens were aged, where possible, according to crown-rump measurements and
body weight with reference to Streeter's data (Streeter, 1920). Tissues were fixed in
10 0 formalin, decalcified in 7 0 formic acid and embedded in paraffin wax. Most
sections were cut on a rotary microtome set at 10 ,tm, and stained by the Masson
trichrome method and with either Van Gieson's stain or haematoxylin and eosin.
The entire suture of the small foetal specimens was serially sectioned throughout its
length. In the case of the larger, postnatal palates an attempt was made to obtain
sections of both the interpremaxillary and intermaxillary parts.

RESULTS
Development
Premaxillary part. From an examination of embryos 41 and 47 d old respectively,
it appeared that the interpremaxillary suture developed very soon after the appearance
of the premaxillary ossification centres. Sections of the 41 d embryo (H419) showed
32 R. A. LATHAM

Table 1. Ages offoetal specimens (estimated) and post-mortem material

Prenatal Postnatal
Age Specimen no. Age Specimen no.
Days Months
39 H 376 2 H 937
41 H 419 6 H 614
47 H 340 14 H 936
49 H 273 Years
Weeks 2 H 942
8 H 563 3 H 938
9 H 274 4 H1106
10 H 762 5 H 475
10 H 555 6 H 1042
10 H 769 8 H 628
10-5 H 275 11 H 615
12 H 1163 15 H 448
14 H 345
19 H1162
26 H 1071
30 H 424
Full term H 625
Full term H1164 N= 28.

Fig. 1. Drawing of palate of 47 d human embryo, after removal of lower jaw, showing relative
development of primary palate (premaxillary region) and secondary palate (maxillary region).
Guide lines 1 and 2 show location of sections illustrated in Figs. 2 and 3 respectively.

small, and presumably recently formed, premaxillary ossification centres, and a

condensation of mesenchyme at the site of the presumptive interpremaxillary suture.
A well-established interpremaxillary suture was found in the 47 d embryo (H 340);
cells in the sutural soft tissues were orientated transversely between the bone margins,
 Development of the mid-palatal suture 33
and in the middle zone they were longitudinally orientated and came mainly from the
inserting septopremaxillary ligament (Figs. 1, 2). It therefore appeared that the inter-
premaxillary part of the mid-palatal suture formed at about 45 d.
Maxillary part. The secondary palate, in which the maxillary and palatine parts of
the mid-palatal suture form, was still rudimentary at 47 d (Figs. 1, 3). After fusion of

..4 ~~~~~~~~~~~~~~~~~~p

,-I.- :S^_t. ;'

_ _ _ _
'09i
_ _ _ *
4 ~~~~~~~~42 1.'~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~?
#4~OW

4 . E i

>,
* . +.a; ,- ,E ,' ll
-L i - a

Fig. 2. Early interpremaxillary suture in a coronal section corresponding to level 1 in Fig, 1,

47 d human embryo (H 340). Transversely orientated cells are present in the upper sutural area,
longitudinally coursing cells predominate in the lower middle zone. S, nasal septum; P, pre-
maxillary bone. Masson.
Fig. 3. Embryonic palatal processes at horizontal approaching stage in a more posterior section
corresponding to level 2 in Fig. 1, 47 d (H340). Hard palate formation is still rudimentary
compared with skeletal development in primary palate seen in Fig. 2. Masson.
Fig. 4. Newly formed intermaxillary suture (M) in a horizontal section through palate of 12 week
foetus (H 1163). The boundaries of the other two parts of mid-palatal suture; interpremaxillary
(P) and interpalatine (Pal), are also shown. Masson.
3 A NA I08
34 R. A. LATHAM
 Development of the mid-palatal suture 35
the embryonic palatal processes (between 47 and 54 d) a further 5 weeks elapsed
before the horizontal processes of the maxillary bones extended to the midline where
sutural union could occur. The first indication of sutural formation was at 10 weeks
when the superior uniting layer of fibre bundles developed across the midline in close
proximity to the vomer's periosteum. Epithelial fusion remnants, on the oral aspect,
appeared to have a retarding effect upon sutural development. A definitive inter-
maxillary suture was established at 12 weeks (Fig. 4).
Structure
Premaxillary part. In early foetal life the interpremaxillary suture was typically
wide with pronounced transverse bundles of fibres connecting the two bones.
Anteriorly it was rather dominated by the septopremaxillary ligament whose fibre
bundles inserted mainly on to the anterior nasal spine, but some fibre bundles
continued into the sutural tissues; in an older foetal specimen (H424) the orientation
of the bony trabeculae at the sutural border suggested that they had been drawn out in
conformity to the direction of these inserting fibres (Latham, 1970). In transverse
sections these bony trabeculae appeared as interlocking bony processes which trans-
formed the interpremaxillary suture into one of the serrate type (Fig. 7). However,
the inferior part of the suture within the alveolar process remained straight.
During development the vomer extended forwards between the inferior border of
the nasal septum and the premaxillary bone (Fig. 7); its forward progress was pre-
sumably stopped by the septopremaxillary ligament.
Maxillary part. The intermaxillary suture extended from the incisive canal to the
transverse palato-maxillary suture posteriorly. It was much narrower than the inter-
premaxillary suture, less than half as wide at 14 weeks, and its sutural cells and fibres
ran along the suture, parallel to the bone margins. The marked structural difference
between the maxillary and premaxillary parts of the mid-palatal suture is shown in
Figs. 5 and 6.
The vomer at first lay across the upper part of the intermaxillary suture, with its
periosteum blending with the upper transverse fibre bundles of the suture (Fig. 6).
Then, beginning at about 20 weeks, the vomer progressively grew into the inter-

Fig. 5. Coronal section through interpremaxillary suture, 14 week foetus (H 345) showing greater
width and transversely coursing fibre bundles contrasting with structure of intermaxillary part of
same specimen in Fig. 6. Masson.
Fig. 6. Coronal section through intermaxillary suture, same specimen (H 345) at almost twice the
magnification of Fig. 5. Suture is narrower and intervening cells are orientated longitudinally.
Masson.
Fig. 7. Coronal section through interpremaxillary suture at full term (H 625) showing interlock-
ing serrate structure in upper part and straight lower part between tooth germs of permanent
central incisors (PI). The vomer (V) shows immediately inferior to nasal septum (NS). Masson.
Fig. 8. Intermaxillary suture of same specimen (H 625) 'Y '-shaped due to invagination by vomer
(V). Oblique maxillary trabeculae (OT) appear to result from slower rate of bone deposition in
maxillo-vomeral than in intermaxillary part of suture. Masson.
Fig. 9. Intermaxillary suture, 6 months postnatal (H614). The most striking feature is inferior
remodelling growth mechanism: resorption-superiorly on nasal surface where periosteum has
lifted, inferior endosteal surface where osteoclasts are numerous; deposition-inferiorly on
periosteal palatal and superior endosteal surfaces Note medullary excavation of bones. Masson.
3-2
36 R. A. LATHAM
maxillary joint, reaching a maximum involvement at full term when the sutur
presented a 'Y'-shaped cross-section (Fig. 8). At this time the maxillary palata
processes articulated more with the vomer than with each other.

F,
Fig. 10. Intermaxillary sutural margin 14 months postnatal (H936), coronal section, at higher
magnification to show localized deposition of endosteal bone (EB) on sutural bone (SB). Osteo-
genesis at sutural surface (S) is either very slow or has ceased. Masson.
Fig. 11. Intermaxillary suture at 3 years (H 938). Suture is more extensive vertically, narrower and
more fibrous. Sutural growth has ceased but pattern of superior bone resorption and inferior
deposition is still present. Van Gieson.
 Development of the mid-palatal suture 37
Whether this vomeral encroachment was due to pressure from the nasal septum or
to an inductive influence by the intermaxillary suture was not clear. The vomer also
reached its greatest relative size at birth; thereafter it became progressively thinner
due to bilateral resorption.
In the immediate postnatal period the fine cancellous bone of the palate was
replaced by bone having a cortex and medullary spaces, and the medial ends of the
palatal processes gradually thickened (Figs. 9, 11). During the first 2 years the inferior

(A)
' .Ii,i |_________ ___________

(B)

(C)

Fig. 12. Diagram illustrating the changing growth pattern and structure of intermaxillary suture.
Shaded areas represent bone deposition, dots represent resorption. (A) Simple marginal exten-
sion (sutural growth) characteristic of early foetal life until about 16 weeks. See Figs. 5 and 6.
(B) The 'Y '-shaped suture of late foetal life resulting from vomeral invagination, sutural growth
is directed infero-medially and mechanism of nasal resorption and oral deposition becomes
increasingly active. See Figs. 8 and 9. (C) After 1-2 years in postnatal life when sutural growth
has ceased, growth activity now confined to palatal surface in association with nasal resorption.
Vomer becomes thinner and less invaginated into suture.

cortical layer remained cancellous in nature, due to the rapid deposition of bone on
its oral surface; the intermaxillary suture increased markedly in height and became
narrower; and the sutural bone margins tended to become parallel and to be formed
by continuous cortical bone.
At 3 years, and in all older specimens, compact cortical bone and clear medullary
spaces, confined to the thickened medial area, were characteristic. The intervening
sutural tissue was mainly fibrous and the fibre bundles coursed parallel to the bone
margins (Fig. 11).
38 R. A. LATHAM

Growth
Associated with the changing structure of the intermaxillary suture during develop-
ment corresponding changes in its growth pattern were observed. Three stages could
be identified (Fig. 12): (i) sutural growth; (ii) sutural and remodelling growth;
(iii) remodelling growth only.
(i) Sutural growth. As the horizontal processes of the maxillary bones approached
the midline, bone deposition occurred mainly on their medial edges. Later this
pattern was continued as sutural growth, in association with growth in width of the
facial skeleton (Fig. 12A). The sutural cambial layers were typically cell dense and
produced a highly cellular, woven bone (Fig. 6). Additional evidence of this sutural
growth was seen in the premaxillary region: the lateral movement of the bony
palatal processes with respect to the nasal septum brought bone to bear against the
paraseptal cartilages and here some remodelling of the bone by resorption was
observed.
(ii) Sutural and remodelling growth. At about 16 weeks osteoclasts appeared on the
free nasal aspect of the maxillary palatal bone and, in association with the obvious
picture of osteogenesis on the oral aspect, remodelling inferiorly of the palatal bone
as a whole commenced. It was soon after this time that the vomeral intrusion began.
Meanwhile sutural bone deposition continued.
The medial border of the maxillary process now presented two sutural surfaces in
different planes, and, from the evidence of their bone structure, having different
growth rates-growth being slower in the maxillo-vomeral part than in the inter-
maxillary part. The bone therefore tended to form in trabeculae parallel to the slower
growing surface. These trabeculae in turn were being remodelled infero-medially by
resorption on their nasal surface and bone deposition on the intermaxillary surface,
The sutural surface of the vomer was also depository in character (Fig. 8).
After birth the mechanism of palatal remodelling inferiorly predominated, and was
particularly in evidence at 6 months (Fig. 9). The cross-sectional form of the suture
now changed to a 'T' shape, the maxillo-vomeral part becoming more aligned with
the nasal floor and becoming, like it, a resorptive surface. Appearances suggested
that separational growth at the suture was slowing down and that the rate of re-
modelling inferiorly had increased.
(iii) Remodelling growth only. The onset of this stage was marked by the slowing
and cessation of sutural growth, the thinning of the vomer and increasing height of
the suture (Figs. 11, 12 C).
Sutural growth evidently ceased between the ages of 1 and 2 years. This was
indicated by a change in growth pattern of the bone forming the sutural margin.
When bone had been actively deposited on the sutural margin, a corresponding
resorption occurred on the adjacent medullary surface (Fig. 9). When sutural growth
ceased, the medullary resorptive surface changed to a depository one, giving rise to
lamellae of the endosteal bone on the sutural plate. At first endosteal bone formation
was localized to small trabeculae or ridges protruding into the medullary space, as
was seen at 14 months (Fig. 10), but in the next older specimen of 26 months (H 942)
endosteal bone extended more evenly along the sutural area. The number of sutural
osteoblasts was also reduced.
 Development of the mid-palatal suture 39
In all older specimens, viz. at 3, 4, 5, 6, 8, 11 and 15 years, no indication of sutural
growth was found. The resorptive-depository pattern of inferior palatal remodelling
was recognised in each case, but little inference was possible about its rate of activity.

DISCUSSION
The timing of the development of the mid-palatal suture is of interest for two
reasons. First, the interpremaxillary suture establishes a skeletal bridge across the
embryonic primitive palate from the earliest possible time. Growth tensions appear
to be present in the face between the fifth and the seventh week as it rapidly develops.
The forward growing nasal septum is thought to act as a primary force not only in
the formation of the early facial profile, but also in the development of the bones of
the upper jaw and their soft tissues by means of its connexions with them (Scott,
1953; Latham, 1970). If this is so, early formation of the interpremaxillary suture
would be necessary to support the primary palatal region and to ensure equal loading
of each side of the face to the growing septum. It is noteworthy that the interpre-
maxillary suture is the first of all the cranial sutures to develop. Disruption of the
primary palate, as when a developmental cleft occurs, is quickly followed by widening
of the cleft and facial asymmetry (Latham, 1969).
Secondly, while the embryonic secondary palate was formed in the eighth week
(fusion commencing at about 47 d), it was not wholly supported by bone until the
twelfth week. It follows that for fully 5 weeks prior to this time union of the maxillary
bones across the midline was effected solely in the primary palate by the inter-
premaxillary suture. The scope that this provides for malformation in the event of
primary palatal failure but successful secondary palate formation is considerable.
This explains why facial deformity accompanying a unilateral cleft of the primary
palate only (cleft lip) is frequently as severe as when the cleft affects both the primary
and secondary palatal regions (cleft lip and palate).
The structural differences between the premaxillary and maxillary parts of the
mid-palatal suture in foetal life may be simply a reflexion of their different times of
development or they may have been due to the effect of a tension across the suture
anteriorly and a slight pressure posteriorly. It is possible that the forward pull of the
growing cartilaginous nasal septum upon the premaxillary region caused a tension
across the anterior part of the suture where interlocking spurs of bone later formed,
and that there was an associated tendency for the maxillae to be pressed together
posteriorly to make a simple end to end joint.
The method for detecting cessation of sutural growth appeared to be reasonably
reliable. It was not so much a subjective matter as the observation of an end point,
when endosteal resorption of bone gave way to endosteal deposition. The finding, on
histological evidence, of cessation between one to two years agrees with that of Scott
(1956) who thought it doubtful whether any growth occurred after the first year. The
question of when growth normally ceases at the mid-palatal suture is an important
one in relation to the timing of surgery for the closure of cleft palate. Until recently
in some centres, operations were delayed until six years of age to avoid interference
with growth centres of the palate, but to the detriment of speech development. The
present findings support the view that early closure of the hard palate (between 1 and
40 R. A. LATHAM
2 years of age) will not interfere materially with growth in palatal width normally
occurring in the mid-palatal suture.
The mid-palatal region is occasionally marked on its oral aspect by a bony ridge or
smooth eminence (torus palatinus). While this is of interest mainly when a full upper
denture is to be fitted, an explanation is suggested by the changes normally occurring
in the mid-palatal suture. With the invagination of the vomer it appeared that the
original sites of sutural growth were displaced inferiorly (Fig. 12B).
The sutural osteogenic cells would have already been in the process of blending with
those of the adjacent palatal periosteum inferiorly, which was developing as a zone
of rapid surface deposition. Then as resistance to lateral palatal growth increased the
sutural osteogenic cells might have been extruded on to the oral surface. Thus it
appears possible that the formation of a median bony ridge could result from removal
of cells with growth potential from their intra-sutural position on to the inferior
sutural borders where the existing growth process might be augmented.
It might be expected that the lowering of the hard palate by resorption of the nasal
floor would result in the formation of a median nasal ridge on the superior aspect of
the horizontal processes of the maxillae where these articulate with the vomer. It was
found, however, that the resorptive area of the nasal floor extended medially as far as
the intermaxillary suture (Fig. 9), so that no part of the nasal bony surface was
excluded from the resorptive process. The possible exception was in the interpre-
maxillary region where the septopremaxillary ligament maintained a tight connexion
between the cartilaginous nasal septum and the underlying bone; here the nasal
crest was a characteristic feature (Fig. 7). The formation of a nasal crest, in general,
should not be regarded as a criterion of activity of the remodelling mechanism for
palatal descent.
The fact that the mid-palatal suture can be widened and the palate expanded by
orthodontic appliances after the age of 10 years is probably more a reflexion of its
special character in being only in part a tension resisting joint and in having deep,
relatively flat, opposing surfaces which would appear to be adapted to resist inter-
mittent medial pressures. It appears that at no time after the cessation of sutural
growth does synostosis take place in the mid-palatal suture. Possibly the range of
masticatory movements characteristic of man, causing constant slight movement of
the bones, is one of the factors involved.
SUMMARY
The development, structure and growth pattern of the human mid-palatal suture
were studied using 28 specimens ranging in age from 6 weeks in embryonic life to 15
years. The interpremaxillary part was formed at about 45 days and the intermaxillary
part at about 12 weeks. The different developmental structures of the intermaxillary
suture were associated with three different patterns of growth: (1) an initial, purely
sutural type of growth until 16 weeks in foetal life; (2) sutural growth combined
with inferior remodelling of the entire palate, from 16 weeks until about 1-2 years of
age when sutural growth ceased; (3) continued inferior palatal remodelling (including
the sutural area) without sutural growth. The change on the endosteal side of the
sutural bony plate from a resorptive to a depository surface provided a criterion for
the cessation of sutural growth.
 Development of the mid-palatal suture 41
The author thanks Drs E. G. Hall, M. J. Bouton, R. M. Rawcliffe, R. E. Rewell
and D. A. Stanley for their co-operation in obtaining post-mortem material. Grateful
acknowledgement is also made to Mrs Patricia Harris for the histotechnical work, to
Messrs J. S. Bailie and K. Walters for photomicrography, to Miss Hazel Carline for
drawing Fig. 1 and to Miss K. D. Maclean and Mrs W. Wethered for typing the
manuscript.
REFERENCES
LATHAM, R. A. (1969). The pathogenesis of the skeletal deformity associated with unilateral cleft lip and
palate. Cleft Palate J. 6, 404-414.
LATHAM, R. A. (1970). Maxillary development and growth: the septopremaxillary ligament. J. Anat.
107, 471-478.
LINDER-ARONSON, S. & LARSSON, K. S. (1965) Postnatal growth of the median palatine suture. Trans.
Eur. orthod. Soc. 79-85.
PRITCHARD, J. J., SCOTT, J. H. & GIRGIs, F. G. (1956). The structure and development of cranial and
facial sutures. J. Anat. 90, 73-86.
SCOTT, J. H. (1953). The cartilage of the nasal septum. Brit. dent. J. 95, 37-43.
SCOTT, J. H. (1956). Growth at facial sutures. Am7r. J. Orthod. 42, 381-387.
STREETER, G. L. (1920). Weight, sitting height, head size, foot length and menstrual age of the human
embryo. Contr. Emnbryol. 11, 143-170.