J Gandhara Med Dent Sci

July - September 2026

ORIGINAL ARTICLE

How to cite this article

EVALUATION OF MIDPALATAL SUTURE MATURATION AND ITS CORRELATION WITH

MAXILLARY SECOND MOLAR MINERALIZATION IN GROWING INDIVIDUALS

Salka Urooj

, Ayesha Ikhar

, Sohrab Shaheed

Urooj S, Iftikhar A, Shaheed S.

Evaluation Of Midpalatal Suture

Maturation And Its Correlation With

Maxillary Second Molar

Mineralization In Growing

Individuals. J Gandhara Med Dent Sci.

2026;13(3):14-19.

Date of Submission: 17-12-2025

Date Revised: 05-06-2026

Date Acceptance: 08-06-2026

Associate Professor, Department of

Orthodontic, Rehman College of

Dentistry, Peshawar

Professor, Department of Orthodontic,

Rehman College of Dentistry, Peshawar

Correspondence

Salka Urooj,

Year Resident,

Department of Orthodontic, Rehman

College of Dentistry, Peshawar

+92-320 - 8010660

salka.urooj@rmi.edu.pk

ABSTRACT

OBJECTIVES

This study aimed to evaluate and correlate, using CBCT, the maturation

stages of the mid-palatal suture (MPS) and the mineralization stages of the

maxillary second molars in subjects to determine whether molar

mineralization can predict MPS maturation.

METHODOLOGY

This study (cross-sectional) was conducted on 33 participants (aged 10-18

years). MPS maturation was assessed according to Angelieri et al., and

second molar mineralization was evaluated using the Demirjian index from

CBCTs. Spearman's correlation was used to assess the relationship between

MPS maturation and second molar mineralization. Furthermore, partial

correlation analysis was conducted to assess the relationship between these

variables while controlling for age. Intra-examiner reliability was calculated

utilizing intraclass correlation coecients (ICC).

RESULTS

Intra-examiner reliability was high (ICC = 0.86). A signicant moderate

positive correlation was found between MPS maturation stages and second

molar mineralization (ρ = 0.479, p = 0.005). When analyzed by gender,

females showed a signicant moderate correlation (ρ = 0.522, p = 0.018),

whereas males showed a positive but non-signicant correlation (ρ = 0.402,

p = 0.173). Partial correlation analysis revealed a diminishing correlation

between MPS maturation and molar mineralization (ρ = 0.282, p = 0.117).

CONCLUSION

A moderate correlation was observed between second molar mineralization

and MPS maturation. However, the weakened correlation after adjustment

for age indicates that the relationship is largely age dependent. Therefore,

second molar mineralization may serve as a supporting indicator of MPS

maturation rather than a denitive predictor.

KEYWORDS: Mid-Palatal Suture Maturation (Mps), Demirjian Index,

Molar Mineralization, CBCT.

INTRODUCTION

Transverse maxillary deciency is a challenging

orthodontic problem with a prevalence of 8-22%.

can lead to complex issues such as posterior crossbite,

crowding, a V-shaped maxillary arch, a high and

narrow vaulted palate, airway constriction, changes in

tongue posture, and mouth breathing, all of which can

deleteriously impact muscular function and

esthetics.

2,3,4

Several treatment modalities exist for

correcting transverse maxillary deciency, which

primarily depend on the maturation stage of the mid-

palatal suture (MPS). MPS is an important anatomical

structure that undergoes several changes over time.

Initially described as broad and Y-shaped during

infancy by Melson, its morphology changes gradually,

eventually becoming fully interdigitated and

fused.

4,5

Various orthopedic interventions induce the

mid-palatal suture (MPS) separation, thereby

attempting to correct the transverse maxillary

deficiency and associated problems.

3,4,5,6,7

As the suture

progresses towards fusion, its resistance to opening

increases, diminishing response to skeletal expansion,

noticeably post-puberty.

8,9

Several methods are being

used for the evaluation of MPS, including 2D occlusal

radiographs and 3D CBCT. Occlusal radiographs are

considered inconclusive due to overlapping structures

and the risk of false interpretation, given their 2D

nature.

Currently, CBCT is preferred, as it provides a

clear 3D view of the suture. In 2013, Angelieri et al.

proposed a method of individual evaluation of MPS

maturation using CBCT and determined ve

maturational stages (least to highly mineralized), g

5,10,11

Assessment of dental development is one of the

supportive indicators for predicting growth phases.

Generally, dental development can be evaluated at the

tooth-eruption or tooth-formation stages. Currently, the

Demirjian index is used in the literature for the

assessment of tooth mineralization and calcication,

among other methods.

The MPS maturation has

https://doi.org/10.37762/jgmds.13-3.839

J Gandhara Med Dent Sci

July - September 2026

been correlated with various parameters like

chronological age, hand-wrist x-rays

4, and cervical

maturation CVM.

3,10,13

Age is not a reliable parameter,

as reports show patients with no signs of fusion at ages

27, 32, 54, and even 71 years.

3,14,15

Recently, some

studies have been conducted to correlate dental age and

tooth mineralization with MPS maturation. In 2020,

Gao et al. investigated the correlation between MPS

and Demirjian dental age. Correlation of left lower

second molar and MPS had the highest Spearman

coecient (0.68), while that of left lower second

premolar and MPS was the second highest (0.64).

2023, Ńefeldaitė et al. evaluated mineralization of the

third molar and its correlation with MPS maturation. A

correlation (statistically signicant positive) was found

between the stages of third-molar mineralization and

mid-palatal suture maturation (ρ =0.814, P<0.01).

Another similar study was performed in India by

Munusamy et al. in 2023, results showed a positive

correlation between CVM Stage and MPS stage (ρ =

0.930), mandibular left second molar mineralization

stage and MPS stage (ρ = 0.757), and CVM stage and

mandibular left second molar mineralization stage (ρ =

0.760).

Some of these earlier correlation studies used

OPG, a 2D imaging tool, to assess the tooth, leading to

a preference for studying the lower second molar

because of potential structural overlap in the maxilla

that could impede accurate evaluation.

However, with

the utilization of CBCT, we can readily and accurately

examine the upper second molar, beneting from a

clearer 3D perspective. The maxillary second molar

was also selected because a previous study reported the

highest correlation coecient.

Therefore, the

objective of this study was to ascertain a correlation and

determine whether the mineralization stages of the

maxillary second molar could serve as a predictive

indicator for the maturation stages of MPS.

METHODOLOGY

This cross-sectional study included 33 participants, and

it was conducted at Rehman College of Dentistry

(RCD) after approval from the institutional Ethical

Review Committee (EC Ref No: RCD-23-03-170).

Informed consent was obtained from patients and

guardians for minors. The sample size was 33

participants. Based on a previously reported correlation

coecient of 0.68 between MPS maturation and dental

mineralization by Gao et al., a confidence level of 99%

and a statistical power of 90% were set, yielding a

minimum required sample size of 33 participants.

non-probability convenience sampling was employed.

The Age 10-18 (male/female) are coming to the

Radiology department of RCD for dental diagnostics.

Whole maxilla CBCTs with dentition, including second

molars, and high-quality CBCTs without artifacts were

included, whereas previous orthodontic treatment was

excluded. Patients with craniofacial conditions or

syndromes, CLP, and a history of trauma to the maxilla

were excluded. Participants were further categorized

into preadolescent and postadolescent groups based on

chronological age. Individuals aged 10-14 years were

classified as preadolescents and those aged 15-18 years

as postadolescents. The CBCT records of patients aged

10-18 years who came to the Radiology Department

were collected from RCD, Peshawar. These records

were taken using the CBCT scanner Carestream CS

9000 (Carestream Dental, Atlanta, GA) with the

following scanning parameters: 70 kVp, 10 mA, 10.8 s,

and a voxel size of 200µm. All CBCT volumes were

acquired with the patients in an upright posture, with

their heads in a natural head position, the mandible

fixed with a chin rest, and the Frankfort plane parallel

to the ground. For analysis, all collected CBCT data

were converted to DICOM (Digital Imaging and

Communications in Medicine) format and then

imported into CS 3D imaging v3.10.11 (Carestream

Dental, Atlanta, GA). The acquired images were

standardized and aligned such that the Frankfort

Horizontal Plane was parallel to the oor. With the CS

3D imaging v3.10.11(Carestream Dental, Atlanta, GA),

maxillary MPS were explored in the axial view of the

multiplanar reconstruction. The thickness of the

midsagittal cross-sectional slice was adjusted for better

visualization of the palate and suture. The stages of

MPS fusion were observed on these standardized

CBCT images in the axial plane, based on the method

provided by Angeileri et al. (Fig 1a(a-e).

5,10,11

The

maxillary second molar mineralization stages were

investigated according to the Demirjian index11 on

acquired CBCTs (Fig 1b).

Fig 1a. Mid palatal suture maturation stages(a-e) according to

Angeileri et al.

Evaluation of Midpalatal Suture Maturation and its C orrelation

J Gandhara Med Dent Sci

July - September 2026

Data were recorded and analyzed using SPSS version

25 (IBM Corp., Armonk, NY). For the quantitative

Figure 1b. Tooth mineralization stages(a-h) according to

Demirjian et al. (1973).

variable (age), means and standard deviations were

calculated. For all the qualitative variables (gender,

MPS maturation stages, index), frequencies were

calculated. Normality of the data was tested with the

Shapiro-Wilk test, and nonparametric tests were

applied. The correlation between the stages of

midpalatal suture maturation and the maxillary second-

molar mineralization was evaluated by Spearman's rank

correlation coecient (r) for the signicance of the

relationship. The signicance for all statistical tests was

set as p≤0.05. Furthermore, partial correlation analysis

was performed, controlling for age.

RESULTS

A single examiner evaluated all CBCT images. To

evaluate intra-examiner reliability, 10 CBCT scans

were randomly reassessed after a two-week interval.

Intraclass Correlation Coecient (ICC) analysis

demonstrated excellent agreement (ICC = 0.86). The

study included 33 participants, 13 (39.4%) male and 20

(60.6%) female, aged 10 to 18 years (mean age of 14.97

± 1.76 years). Analysis of suture maturation stages

revealed that most participants were in Stage E (n = 18,

54.5%), followed by Stage B (n = 10, 30.3%). Stages C

and D were less frequent, with 3 participants (9.1%)

and 2 participants (6.1%), respectively. Assessment of

second molar mineralization revealed that the majority

of participants were in Stage H (n = 19, 57.6%),

followed by Stage G (n = 7, 21.2%) and Stage F (n = 5,

15.2%). Only a small proportion were in the earlier

stages, with one participant (3.0%) in each of Stages D

and E. Spearman's correlation showed a signicant,

moderate positive correlation between second molar

mineralization and suture maturation stages (p = 0.005,

ρ = 0.479). This suggests that higher stages of second

molar mineralization are associated with more

advanced stages of suture maturation. Among male and

female participants, a moderate positive and statistically

insignificant correlation was observed between second

molar mineralization and suture maturation (ρ = 0.402,

p = 0.173) (Table 1), and a signicant moderate

positive and statistically signicant correlation was

found between second molar mineralization and suture

maturation (ρ = 0.522, p = 0.018), respectively (Table

2). Based on the age categorization, preadolescent

males exhibited early to intermediate suture stages (B-

E) and second molar stages ranging from D to G,

whereas females showed slightly more advanced stages,

reaching F-H. Among postadolescents, nearly all males

and females were in suture stage E and second molar

stage H, indicating complete skeletal and dental

maturation(Table 3). Overall, progression in second

molar mineralization corresponded closely with higher

suture maturation stages, particularly stage E, which

aligned with stage H, suggesting a positive association

between dental and skeletal maturation indicators

without controlling for age. Furthermore, partial

correlation analysis revealed that the correlation

between second molar mineralization and MPS

maturation diminished and lost statistical signicance

after adjusting for age (ρ = 0.282, p = 0.117). This

implies that age-related developmental alterations may

be partially responsible for the observed correlation

(Table 4). In the total sample (N = 33), gender showed

no signicant correlation with suture maturation,

second molar mineralization, or age (all p > 0.05).

Significant moderate positive correlations were found

between suture maturation and second molar

mineralization (Spearman's ρ = 0.479, p = 0.005),

between age and suture maturation (ρ = 0.390, p =

0.025), and between second molar mineralization and

age (ρ = 0.447, p = 0.009). These results indicate that

both dental and skeletal maturation advance with

chronological age and are moderately associated with

each other.

Table 1: Distribution of the Mid-palatal Suture Maturation

Stages according to Second Molar Mineralization Stages in Males

(n = 13)

Mean

Age

(yrs)

SD Second

Molar

Mineraliza

tion Stage

MPS

Maturat

ion

Stage B

Total

D 00 01 00 00 01

E 00 00 00 00 00

F 01 00 01 00 02

G 02 00 00 01 03

12.0

–

13.0

14.5

16.5

–

0.0

0.5

0.7

00 05 07

Note: Spearman's rho = 0.402, p = 0.173 (statistically insignicant

positive correlation).

Evaluation of Midpalatal Suture Maturation and its C orrelation

J Gandhara Med Dent Sci

July - September 2026

Table 2: Distribution of the Mid-palatal Suture Maturation

Stages according to Second Molar Mineralization Stages in

Females (n = 20)

Table 3: Distribution According to Categories of Age

Age

Mean

(yrs)

Second Molar Mine

ralization Stage

Total

– D 00 00 00 00

– E 00 00 01 01

0.58 F 02 00 00 03

0.58 G 00 00 02 04

13.0

14.7

15.3

16.7

0.65

00 00

MPS Matura

tion Stage B

Categories of Age Gender Suture

Maturation

Second Molar

Mineralization

Total

D E F G H

Preadolescent

Male

B 00 01 01 02 04

C 00 01 00 00 01

D 01 00 00 00 01

E 00 00 02 00 02

Total 01 02 03 02 08

Female

B 01 02 01 04

C 01 00 00 01

D 01 00 01 02

E 00 01 03 04

Total 03 03 05 11

Postadolescent

Male

E 05 05

05 05

Female

B 00 01 01 02

C 01 00 00 01

E 00 00 06 06

Total

01 01

Table 4: Interpretation of Partial Correlation

Variables

Second molar mineralization ↔

MPS maturation (controlling for

age)

Partial Correlation (r)

-value

0.282 0.117

DISCUSSION

The maturation stage of the mid-palatal suture (MPS)

plays a pivotal role in determining successful outcomes

of rapid maxillary expansion (RME). MPS is the key

anatomical structure that enables transverse expansion

of the maxilla in growing individuals. This study aimed

to evaluate the correlation between the maturation stage

of MPS and the mineralization stage of the maxillary

second molar using cone-beam computed tomography

(CBCT) in growing patients. The results demonstrated a

statistically signicant, moderate positive correlation

between MPS maturation and second molar

mineralization stages, suggesting that higher levels of

molar mineralization are associated with more

advanced stages of suture maturation. These ndings

suggest that dental mineralization may provide

additional information regarding MPS maturation. MPS

can be assessed with an occlusal radiograph; however,

the two-dimensional nature of this imaging modality

can create challenges and limit diagnostic accuracy due

to the superimposition of the vomer and other nasal

structures. The classication of MPS maturation is

chosen for its demonstrated simplicity, accuracy, and

reproducibility.

To evaluate the mineralization stages

of maxillary second molars, the Demirjian index is

used, as it is simple and reproducible. Maxillary second

molars were assessed because existing literature focuses

on mandibular second molars, with limited research on

maxillary molars. The results of this study are

consistent with ndings of previous literature

demonstrating a relationship between dental and

skeletal maturation. Gao et al. (2020) reported a

positive correlation between Demirjian stages of the

mandibular second molar and MPS maturation.

Similarly, Munusamy et al. (2023) observed signicant

positive correlations between the mandibular second

molar, cervical vertebral maturation (CVM), and MPS

stage, reinforcing the potential of using dental

mineralization as a predictor of suture development.

Likewise, Ńefeldaitė et al. (2023) found a stronger

correlation between third molar mineralization and

MPS maturation.

Another study by Booth et al. in

2024 showed a weak correlation between MPS and

third molar mineralization, since many people have

congenitally missing third molars.

Interestingly, the

current study's ndings showed that chronological age

was not a reliable predictor of MPS maturation or molar

mineralization, as age correlations were weak and

statistically insignicant among males. However, when

both genders were analyzed collectively, signicant

moderate correlations emerged between suture

maturation and age and between second molar

mineralization and age. These results align with

previous studies reporting considerable individual

variation in MPS fusion timing, with some individuals

showing open sutures beyond age 30.

3,14,15

This

underscores the inadequacy of chronological age as a

standalone indicator for clinical decision-making in

maxillary expansion therapy. Further partial correlation

analysis, controlling for age, indicated that age-related

developmental changes may partially explain the

observed relationship between second molar

mineralization and MPS maturation. Therefore, dental

mineralization should be considered a supportive

indicator rather than an independent predictor of MPS

maturation. Gender dierences were also observed in

our study: females exhibited a signicant moderate

correlation between second molar mineralization and

MPS maturation, while the correlation among males,

although positive, was not statistically signicant,

possibly due to the small sample size. This may reect

the generally earlier onset of skeletal and dental

maturation in females compared to males, consistent

with ndings from other studies. The present outcomes

of our study may reinforce the notion that dental

development can serve as an auxiliary indicator of

Evaluation of Midpalatal Suture Maturation and its C orrelation

J Gandhara Med Dent Sci

July - September 2026

skeletal maturity when evaluating candidates for

maxillary expansion. Since the success of conventional

rapid maxillary expansion (RME) depends on the

degree of MPS fusion, assessing second molar

mineralization on routine CBCT (limited FOV) or

panoramic radiographs may provide a low-radiation,

accessible screening tool. Patients in earlier

mineralization stages are more likely to show less

advanced suture maturation; however, treatment

decisions should not be based solely on dental

mineralization.

LIMITATIONS

Nonetheless, the study's cross-sectional design limits

causal inference, and its relatively small sample size

limits generalizability. Another limitation of this study

was the uneven distribution of MPS maturation stages,

with the majority of participants in stages B and E and

no subjects in stage A. This may have aected the

strength of observed correlations and could limit

generalizability across the complete spectrum of MPS

maturation. Variations in molar mineralization timing

across populations and individual genetic factors should

also be considered. Future multicenter studies with

larger, age-stratified samples are recommended to

rene predictive thresholds and to explore the

quantitative aspects of suture density and bone

thickness in three dimensions.

CONCLUSIONS

A moderate positive correlation was observed between

MPS maturation and maxillary second molar

mineralization, suggesting that molar mineralization

stages may provide some useful information regarding

MPS maturation status. However, after controlling for

age, the correlation weakened and lost statistical

significance, suggesting that age may substantially

inuence both MPS maturation and dental

mineralization. Therefore, although second molar

mineralization may serve as an adjunctive indicator of

MPS maturation, it should not be used as a sole

predictor for clinical decision-making.

CONFLICT OF INTEREST: None

FUNDING SOURCES: None

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Evaluation of Midpalatal Suture Maturation and its C orrelation

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AUTHORS CONTRIBUTION

The authors accept responsibility for all aspects of the work

and will ensure that any concerns regarding the accuracy or

integrity of any part are properly investigated and resolved.

Salka Urooj

Concept & Design; Data Acquisition;

Critical

Revision; Supervision;

Final Approval

Ayesha Iftikhar

Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Critical Revision; Final Approval

Sohrab Shaheed

Concept & Design; Data Acquisition;

Drafting Manuscript; Critical Revision; Supervision; Final

Approval

Evaluation of Midpalatal Suture Maturation and its C orrelation