The Vomero-Premaxillary Suture - a Neglected Growth Site in Mid-Facial Development Of

The Vomero-Premaxillary Suture - A Neglected Growth Site in Mid-Facial Development of

Unilateral Cleft Lip and Palate Patients

HANS FRIEDE, ODONT. DR. Goteborg 33, Sweden

The growth capacity of the vomero-premaxillary suture (VPS) was analysed as this growth site, sometimes exposed during cleft surgery, is usually unrecognized in the patient's mid-facial development. Metallic implants were inserted on both sides of the suture in eight infants with unilateral cleft lip and palate at the time of the first surgery. The patients were _ followed roentgencephalometrically to the age of three years. Growth between the vomer and premaxilla was recorded in every case, with growth being especially marked during the first year of life. The horizontal increment of growth between the pins was greater than the vertical increment. On the basis of these findings, it was proposed that surgery which seriously impedes or stops growth in the VPS is likely to be an important factor in the etiology of the mid-facial retrusion that is sometimes seen in patients with unilateral cleft lip and palate.

Introduction suture in bilateral clefts can be extirpated, Facial growth studies of cleft lip and palate when a premaxillary set-back is performed, patients continue to yield divergent findings. without jeopardizing the patient's facial Differences are reported not only between growth. However, evidence of growth in the various treatment methods but also between VPS, at least during infancy, has recently studies utilizing the same technique. The ef- been presented not only in bilateral clefts fect of early bone grafting is a well-known (Pruzansky, 1971; Friede and Morgan, 1976), example of the latter. Only a few investiga- but also in nonclefts (Friede, 1975). Surgery tions have dealt with specific growth sites that which impairs growth in this suture in bilat- might be influenced by the different treat- eral cleft patients is, therefore, likely to lead ment procedures. Among these studies there to premaxillary retrusion (Friede, 1977). is a recent paper by Dahl (1977) that dem- In unilateral cleft lip and palate (UCLP) onstrated impeded sutural growth in the the pathological anatomy of the maxilla and width of the maxilla after surgery that in- its neighboring bones is more complex than cluded palato-vomerplasty. It has also been in the bilateral cleft condition (Figure 1). proposed that the sagittal growth of the max- Consequently, growth disturbances in the illary complex in the transverse palatine su- VPS have never been mentioned in the liter- ture and at the tuberosities may be restrained ature as a possible explanation for mid-facial by palatal scar tissue (Ross and Johnston, retrusion in unilateral cleft cases. The purpose 1972). of the present study was to investigate the In spite of Pruzansky's suggestion (1954) amount of growth taking place between the that the vomero-premaxillary suture (VPS) is vomer and premaxilla in UCLP patients. Ad- probably an important structure for mid-fa- ditionally, how does this compare with the cial development in bilateral cleft lip and growth in the VPS of bilateral clefts? palate, the VPS has received scanty recogni- Materials and Methods tion. This was demonstrated by the State-of- the-Art (Spriesterbach et al, 1973) which, re- The patients for this study were selected ferring to Burdi (1971), speculated that the from a series of infants with various craniofacial anomalies. Their facial growth was fol- Dr. Friede is affiliated with the Goteborg Craniofacial Center and Section of Jaw-Orthopaedics, Department of lowed by means of roentgencephalometry in Orthodontics, University of Goteborg, Sweden combination with metallic implants. From an 398 Friede, GROWTH OF THE VOMERO-PREMAXILLARY SUTURE 399

FIGURE 1. Infant with complete unilateral cleft lip and palate. (a) Intraoral view. (6) Specimen from an area indicated in (a) with the covering soft tissue removed. Note the distorted vomer and its rather wide articulation with the premaxilla in the anterior cleft area (arrow). P = premaxilla; M = maxilla; V = vomer. From Veau (1931)

initial group of 21 patients with UCLP, only eight proved to have stable pins in the region of the vomer and premaxilla at the age of three years. These children comprise the present sample. Five had complete unilateral cleft lips and palates, while the remaining three had soft tissue bridges (Simonart's band) across the unilateral clefts. At the time of the first operation, metallic implants were inserted on each side of the VPS. Cephalometric radiographs were taken after the first surgical 1. --- 2 mos procedure (lip adhesion and one-layered, 2.----- 9 -i- tilted vomer flap), after later surgical proce- 3-.24_”_ dures (push-back palatal closure followed by

final lip closure), at three years of age. A more 4.===- 40 -- / detailed description of the implant sites, FIGURE 2. The tracings of one patient from four different occasions oriented along the reference lines method of insertion, and follow-up has been NSLp and NSPp. The former line is constructed as a

presented elsewhere (Friede et al., 1977). Dis- parallel and the latter as a perpendicular to the nasion- tances between the pins and certain reference sella line through the posterior implant (Ip). The anterior points and lines were measured directly on implant (Ia) and the reference points:sella (s), the ante- the cephalograms (magnification: 11 per cent) rior nasal spine (sp) and pterygomaxillare (pm) are also indicated. on two separate occasions, and the mean value

was used in the analysis. The reference points line NSLp was constructed as a parallel and

and the method of superimposition of the the NSPp line as a perpendicular to the na-

tracings were the same as described earlier sion-sella line through the posterior implant

(Friede and Morgan, 1976). The reference (Ip) (Figure 2).

400 Cleft Palate Journal, October 1978, Vol. 15 No. 4

j . L.J. d’ s wd. -. _..._.°_._._.__7. poy 40 \

1.---- 2 mos 2.---~-10 -!-

4 , --- 38 -1-

* 8+ us 1. ---- 4 mos 1. ----_ 5 mos

2,-----~ 7 -I- 2,------1 -!!- 3. seee JP8

4, ---- 36 -I!- Cust 4 , ---: -- 37 -I- we

FIGURE 3. All patients' tracings superimposed on the posterior implants for analysis of growth between the pins in the vomer (Ip) and premaxilla (Ia).

Friede, GROWTH OF THE VOMERO-PREMAXILLARY SUTURE 401

Results The growth between the vomer and the Growth between the vomer and premaxilla premaxillary reference points of the present was recorded in every case (Figure 3; Table patients compared rather well with the mea- 1). The distance between the implants in- surements of the bilateral cleft patients pre- creased especially during the first year of life viously followed until the age of three years but also during the third year. The period (Friede & Morgan, 1976) (Table 1). Unfor- studied was characterized by a greater hori- tunately, the remainder of the reported bilat- zontal than vertical increment of growth be- eral cleft patients were studied for shorter tween the pins (Table 2). periods. However, if correspondingly short in- Two of the patients (J.E. and K.S.-J.) con- tervals had been used for the present patients, stituted exceptions. In the former case (J.E.), the resemblance in growth between the two the anterior implant had been placed some- cleft categories is obvious. what low, that is, in the alveolar process of the premaxilla, and was, therefore, displaced Discussion inferiorly within the premaxilla during alveo- It is a well-known fact that the study of lar growth. However, if sp had been used as pathological conditions contributes to the un- the anterior reference point, the patient's derstanding of the normal. Furthermore, measurements hardly differed from those of anomalies make certain investigations possi- the main group. In the other patient (K.S.-]J.), ble which, for practical reasons, are impossible the posterior pin had probably been inserted to carry out on non-affected individuals. This into the body of the sphenoid bone. The is exemplified by the present study where the increase in distance between the implants, unilateral cleft lip and palate allowed inser- therefore, included growth not only between tion of metallic implants in the nasal septum. the vomer and premaxilla but also between The growth pattern demonstrated for the the vomer and sphenoid bone. This is sup- vomer and premaxilla cannot be taken for ported by the fact that the pm-point displayed granted as true in detail for all cleft types. a greater descent than in other cases. Further- Yet, in some of them, the main growth prin- more, the s-point, located within the sphen- ciples may be the same as illustrated by the oid, moved only minimally on superimposi- resemblance between the measurements of the tion of the tracings. UCLP cases and the limited data on bilateral

TABLE 1. Results of growth analysis of unilateral cleft lip and palate (UCLP) patients for the whole period studied. The increase in distance between the posterior implant (Ip) and the anterior landmarks (Ia and sp) is obvious in all cases. For comparison, data from an earlier study of bilateral cleft lip and palate (BCLP) are included. No correction for magnification (11 per cent).

Case Interval (mos) Increase in distance (mm)

Ip-Ia Ip-sp UCLP BCLP* UCLP BCLP* UCLP BCLP* UCLP BCLP*

L.J. 1 - 37 8.0 9.0 J.E. 1 - 37 13.5 12.0 D.A-F. 2 -> 38 10.0 10.5 J.B. 2 -> 40 8.5 11.0 T.G. 3 -> 36 9.0 7.0 3 - 37 13.0 14.5 AK. 4 - 36 8.0 10.0 L.O. 3 - 37 8.5 8.5 D.A. 2 - 5 - 1.0 P.H. 2 - 13 4.5 6.5 M.N. 2 - 18 5.0 6.0 A.O. 3 -> 19 - 8.5 L-O.J. 7 -> 36 6.5 11.5

* Friede and Morgan, 1976 402 ~ Cleft Palate Journal, October 1978, Vol. 15 No. 4

cleft lip and palate patients. How the amount of growth between the vomer and premax-

illa/maxilla found in the present study com- the

1.5 1.5 1.0

3.0 3.0 2.0 2.5 4.5 pare to growth in nonclefts can only be spec- NSPp-s ulated on. Probably no marked differences

through existed for our patients because the mean position of their anterior maxilla, as measured

cephalometrically relative to the cranial base,

planes

5.5

6.0 5.0 8.0 9.0 9.5 9.5 0.0 did not differ statistically from noncleft stan-

NSLp-s dards at the age of three years (81.9° com-

(NSPp) pared to 82.8°). Possible rotationships between the premaxilla/maxilla, the vomer, and

the skull during growth corresponding to the vertical

1.0 1.0 0.0 0.0 rotations of the jaws in nonclefts relative to

-1.0 -0.5 -0.5 -0.5

and the anterior cranial base (Bjork & Skieller, NSPp-pm 1972) could not be established. Only one or

two implants had been inserted in the pre- (NSLp) maxilla and vomer, and an analysis of rota-

tional movements, studied in all planes, would

(mm) 1.5

2.0 2.9

5.0 3.0 9.5 4.0

4.5 have necessitated at least three stable refer- NSLp-pm

horizontal ence points in each segment (Rune et al., distance

the 1975). in to Growth of the noncleft nasal septum from birth to adulthood has recently been analysed

7.0

9.5 9.0

6.5

11.5 10.0

11.0 11.0 histologically (Melsen, 1977). Sutural growth

relative Difference NSPp-sp was noted between the vomer and maxilla up

to puberty. As the direction of displacement points of bones during growth is difficult to evaluate by histologic technique, the author did not 1.5 3.0 3.0 5.0 5.0 6.5 11.5

-0.5 mention any sliding movement between the reference NSLp-sp septum and the premaxilla/maxilla similar to that found in UCLP patients in the present

study (Figure 4). Melsen speculated, however, different

that the vomer might be displaced anteriorly

the

7.0

9.0

8.0 8.0

8.0 in relation to the perpendicular plate of the

11.5 10.5

cent). and

NSPp-IA ethmoid bone. Yet, both a sliding movement per

pin between the vomer and the ethmoid bone and (11 between the vomer and premaxilla/maxilla,

as demonstrated herein, is quite likely to occur anterior

3.5 3.0 3.0 4.0 0.0 10.5 11.0 to allow the pronounced forward growth of

-0.5 the

NSL the maxillary complex relative to the cranial magnification base which takes place during development

(e.g. Bjork & Skieller, 1977). for

between In a UCLP patient, the VPS, which contin-

37 36

37 36 37

38 40

(mos) ues posteriorly into the vomeromaxillary su-

- -> -

- ->» -> ->

growth ture, is very close to the surgical field and is

2 2 3 4 correction

of sometimes exposed during the cleft operation. Interval

No Consequently, the demonstrated translocation movements might be affected to a greater

Analysis or lesser degree by different surgical tech- implant.

2. niques. A bone graft across the suture(s) is Case able to block the growth completely, but even a soft tissue closure of the cleft might influence

L.O AK

L.J. D.A-F. K.S-J.

T.G.

posterior J.E.

J.B. TABLE Friede, GROWTH OF THE VOMERO-PREMAXILLARY SUTURE 403

University of Goteborg, Sweden Address: Faculty of Odontology Fack S-400 33 Goteborg 33, Sweden

References Bjork, A. and SxiEtuER, V., Facial development and tooth eruption, An implant study at the age of puberty, Am. J. Orthod., 62, 339-383, 1972. Bjork, A. and SxirruEr, V., Growth of the maxilla in three dimensions as revealed radiographically by the implant method, Br. J. Orthod., 4, 53-64, 1977. Burp1, A. R., The premaxillary-vomerine junction: An anatomic viewpoint, Cleft Palate J., 8, 364-370, 1971. DanL, E., Transverse maxillary growth in combined cleft FIGURE 4. Suggested mode of growth of the mid- lip and palate, A longitudinal roentgencephalometric facial structures from infancy to the third year of life. study by the implant method, Third Int Congr Cleft The tracings in this example (patient D.A-F.) are oriented Palate, Toronto, Abstract no 51, 1977. along the nasion-sella line and superimposed on the sella FriEpE, H., A histological and enzyme-histochemical and the two implants. Note the pronounced horizontal study of growth sites of the premaxilla in human translocation of the premaxilla/maxilla relative to the foetuses and neonates, Arch. Oral. Biol., 20, 809-814, vomer during the growth period studied. 1975. H., Studies on facial morphology and growth in bilateral cleft lip and palate, University of Goteborg, Sweden, Thesis, 1977. movements between vomer and premaxilla/ Frigpe, H. and Jonanson, B., A follow-up study of cleft children treated with primary bone grafting, Scand. J. maxilla to a variable extent. If the sliding is Plast. Reconstr. Surg., 8, 88-103, 1974. severely impaired, the result might not only FriEpr, H. and Morcan, P., Growth of the vomero- be marked maxillary retrusion but also poor premaxillary suture in children with bilateral cleft lip descent of the premaxillary area, as reported and palate. A histological and roentgencephalometric by Graber (1964) and Friede and Johanson study, Scand. J. Plast. Reconstr. Surg., 10, 45-55, 1976. (1974). Frirpe, H., Jonanson, B., AnrcrEnN, J., and THi1tanDeER, B., Metallic implants as growth markers in infants with It is questionable whether the bone grafting craniofacial anomalies, Acta Odontol. Scand., 35, method which unites the maxillary segments 265-273, 1977. along the whole bony cleft (e.g. Johanson and GraBER, T.M., A study of craniofacial growth and devel- Ohlsson, 1961) would ever have been intro- opment in the cleft palate child from birth to six years of age, In Hotz, R. (ed), Early Treatment of Cleft Lip duced with knowledge of the mid-facial and Palate. Berne: Huber, 30-43, 1964. growth pattern presently demonstrated. It is Her1Qquist, R. and T., Influence of infant perios- also tempting to state that those cleft palate teoplasty on facial growth and dental occlusion in teams advocating bone grafting in the area of complete unilateral cleft lip and palate from age 5 to the alveolar process only (Rosenstein, 1977) 8, Third Int Congr Cleft Palate, Toronto, Abstract no 80, 1977. were more successful because the sliding Joranson, B. and Ontsson, A., Bone grafting and dental growth of the maxilla was less affected by orthopaedics in primary and secondary cases of cleft their method. How much the bone formation lip and palate, Acte Chir. Scand., 122, 112-124, 1961. from the periosteoplasty method (Skoog, B., Histological analysis of the postnatal development of the nasal septum, Angle Orthod., 47, 83-96, 1965) influences facial development has not 1977. yet been definitively determined (Hellquist Pruzansxy, S., The role of the orthodontist in a cleft & Skoog, 1977), but mucoperiosteal flaps are palate team, Plast. Reconstr. Surg., 14, 10-29, 1954. no doubt raised close to or over the VPS. As Pruzansky, S., The growth of the premaxillary-vomerine indicated by the present investigation, this complex in bilateral cleft lip and palate, Tandlaege- bladet, 75, 1157-1169, 1971. suture appears to play an important role in RosEnstTEIN, SW., An interim cephalometric evaluation the postnatal growth of the mid-face in UCLP of one technique utilizing orthodontic and primary patients. bone grafting procedures, Third Int Congr Cleft Palate, Hans Friede, Odont Dr Toronto, Abstract no 109, 1977. Ross, R. B. and Jounston, M.C., Cleft Lip and Palate. Goteborg Craniofacial Center and Baltimore: Williams & Wilkins Co, 158-206, 1972. Section of Jaw-Orthopaedics, Runr, B., SarNAs, K-V. and SEivik, G., Analysis of Department of Orthodontics, motion of skeletal segments following surgical-ortho- 404 Cleft Palate Journal, October 1978, Vol. 15 No. 4 _

dontic correction of maxillary retrusion, Dentomaxillofac. Horowitz, S.L., Mc Wirrtams, B. J. ParapisE, J.L. Radiol., 4, 90-94, 1975. and Ranpart, P., Clinical research in cleft lip and Srkooc, T., The use of periosteal flaps in the repair of palate: The State of the art, Cleft Palate J., 10, 113-165, clefts of the primary palate, Cleft Palate J., 2, 332-339, 1973. . 1965. Vrauv, V., Division Palatine. Paris: Masson et Cie, 23-49, SpriestrerBaceH, D.C., Dickson, D.R., FrasER, F.C., 1931.