COP 51

YRI
GHT
Virgilio F. Ferrario, MD
200
2 BY
Professor of Human Anatomy Three-dimensional hard tissue palatal size
QUI
NTE
Chiarella Sforza, MD
Professor of Human Anatomy
and shape: A 10-year longitudinal
SSE
NCE
Claudia Dellavia, DDS
evaluation in healthy adults
PUB
LIS Postgraduate Student
HIN
G Anna Colombo, DDS, PhD
CO, Research Assistant
A 10-year longitudinal evaluation of the
INC.
PRI Raffaella P. Ferrari, PhD morphology (size and shape) of hard tissue palate
NTI Postgraduate Student was performed in 6 female and 6 male healthy
NG adults (mean age at the second evaluation was 33
OF Functional Anatomy Research years, SD = 2.2). All subjects had a complete
THI Center (FARC)
S Laboratorio di Anatomia permanent dentition, including the second molars,
DO Funzionale dellApparato and were free from respiratory problems. Palatal
CU Stomatognatico (LAFAS) landmarks were digitized with a computerized 3D
ME Dipartimento di Anatomia
Umana Facolt di Medicina e instrument, and their coordi- nates were used to
NT
IS Chirurgia derive a mathematical model of palatal form.
RES and Facolt di Scienze Motorie Palatal shape (size-independent) was assessed by
Universit degli Studi di Milano,
TRI
Italy a fourth-grade poly- nomial in the sagittal and
CTE
frontal plane projections. Palatal dimen- sions in
D
TO Reprint requests: the frontal and sagittal planes were computed and
PER Dr Virgilio F. Ferrario compared between the 2 evaluations by paired
Dipartimento di Anatomia
SON
Umana via Mangiagalli 31
Student t tests. A great variability was observed,
AL
I-20133 Milan and no significant modifications in size were found
USE
ONL
Italy (P >
Fax: +39-0250315387
Y.N
E- mail: farc@unimi.it
.05 for all variables). No variations in shape were
O observed. Sex had no significant effect for any
PAR
T
variable (Student t for independent samples, P > .
OF 05). This study showed that in healthy subjects, hard
THI tissue palatal morphology does not seem to
S
change between the third and the fourth decades
ART
ICL of life. (Int J Adult Orthod Orthognath Surg 2002;17: 5158)
E
MAY
BER
EPR
OD
UCE
D
OR
TRA
NS The number of adult patients undergo- ing
MIT orthodontic treatment is increasing.1 To provide the
TED
IN best treatment, and to as- sess any possible relapse
ANY after therapy, an understanding of the normal
FOR modifica- tions of the craniofacial complex with
M aging is mandatory.2 Indeed, modifications in the
WIT Int J Adult Orthod Orthognath Surg Vol.
HO 17, No. 1, 2002 dimensions, shape, and arrangement of hard and soft
UT tissue craniofacial struc- tures can be detected even
WRI after the at- tainment of biologic maturity.214 Even if
TTE human permanent dentition (excluding the third
N
PER molars) completes its eruption by early
adolescence, 7 oral structures (both dental and
skeletal) still continue to mod- ify. As expected, the
changes occur at a slower rate than that observed
during the first 2 decades of life.2,710,15
Most studies analyzed longitudinal
modifications in dental arches, but the ac- tual
direction and magnitude of these modifications
are still debated. Indeed, re-
cent Bishara et al2,6 and Carter adulthood have been recently ana-
investig and McNamara10 found lyzed by Ferrario et al15 with a cross-
ations decrements in den- tal arch sec- tional design. In adolescent females,
perform widths with aging, Harris7 overall, palatal form (both size and
ed until and Bon- devik16 found that shape) ap- peared to have already
the fifth arch widths increased. attained adult char- acteristics; in males,
or sixth In contrast, quantitative some modifications be- tween
decade studies on the association adolescence and young adulthood were
of life between aging and measured for both linear and angular
reported palatal morphology are dimensions, and for palatal shape.15 Similar
oppo- scanty. Hard tissue palatal findings for palatal dimensions were
site dimensions between re- ported in a cross-sectional
results: adolescence and young investigation by Redman et al,17 who also
while found a significant
52 Ferrario et al

morphology of their hard-tissue palatal

size and shape after a 10-year interval.

Materials and
methods

Sample

Recently, a group of the subjects ana- lyzed 10 years ago returned to

the labora- tory for a longitudinal evaluation. The pres- ent study
analyzed the quantitative modifications in the three-dimensional

Fig 1 Digitized points on the stone cast of each

palate. IP= incisive papilla; RP= posterior-most raphe
point; 16, 26= right and left molar points; 15,
25= right and left second premolar points; 14,
24= right and left first premolar points; 13, 23=
right and left canine points; M = sagittal molar
point.

increment of palatal height in male

subjects after 18 years of age. No
recent data on palatal morphology after
the third decade of life can be found in
the literature.
Ten years ago, a group of healthy
young adults in their twenties was
analyzed in our laboratory.18 Among
the other assess- ments, an
impression of their dental arches was
taken, and the two-dimensional size
and shape characteristics of the
maxillary and mandibular arches were
analyzed. 18 Due to technological
limitations, no three- dimensional
assessments were performed, and no
evaluations of palatal morphology were
made.
Currently, technology provides three-di-
mensional digitizers that can be
directly used on dental casts to supply
the metric coordinates of selected
landmarks. The co- ordinates can be
used for any kind of mathematical
modeling. Optical devices,
electromechanical instruments, and
electromagnetic digitizers have all
been used to collect three-dimensional
data on the human palate in both normal
individu- als and patients with alterations
in cranio- facial structures, as recently
reviewed by Ferrario et al.15,19,20
 Int J Adult Orthod Orthognath Surg Vol. 17, No. 1, 2002
53 In years later, they were recalled for a
1989, a longitudinal evaluation. Among the
group other assessments,(standardized
of 45 facial pho- tographs, 3-dimensional facial
Caucas morphome- try, electromyography,
ian men electrokinesiogra- phy, alignate
and 38 impressions of the dental arches), on
Caucas both occasions their maxillary dental
ian arches were reproduced from algi- nate
women impressions cast in dental stone.
aged Among the respondents, 6 women
20 to and 6 men who still corresponded to the
27 inclu- sion criteria, and who still had a
years, sound dentition, were analyzed. The
all with 1989 casts of their maxillary arches were
sound judged to be of sufficient quality for the
dentitio three-dimensional assessment of palatal
ns, morphology.19
were All assessments were noninvasive
ana- and performed without procedures
lyzed in currently known to involve any present
our or future bi- ological damage. In both
laborat data collections, all subjects were
ory.18 previously informed about all the
Subject adopted procedures and gave their
s with a consent to the investigation. The study
previou protocol was approved by the local
s ethics committee.
history
of Digitization of
craniofa palates and
cial mathematical
trauma, equation
con-
genital
The method was derived from the
anomali
origi- nal description made by Ferrario et
es,
al.19 On each cast, the intersections of
surgery,
the palatal sulci of the right and left first
or
permanent molars (landmarks 16 and
orthodo
26 in Fig 1), pre-
ntics
molars (landmarks 15, 25, 14, 24), and
were
ca- nines (landmarks 13, 23) with the
not
gingival margin, the incisive papilla
include
(IP), and the most posterior limit of the
d in the
palatal raphe (RP) were identified and
sample.
marked. The intermolar 1626 line and
Ten
its perpendicular starting
 from IP were traced, and their 23
intersection point was marked as M. On distance,
the IP-M, 1626, 1525, 1424, and 13 mm)
23 lines, approxi- mately 12 to 20 nearly
equidistant points were then marked.
The x, y, and z coordi- nates of the
landmarks were obtained with an
electromagnetic three-dimensional digi- tizer
(3Draw, Polhemus, Colchester, VT) inter-
faced with a computer.13,19,20 The
digitization of landmarks was done by a
single operator. The files of the
coordinates were ob-
tained, and computer programs devised
and written by one of the authors were
used for all the following calculations.
A common orientation for all palates
was obtained by mathematically
setting the plane described by IP, 16,
and 26 as horizontal (X-axis,
corresponding to the 1626 line, right-
left; Y-axis, anterior-pos- terior; and Z-axis,
caudo-cranial). Actually, this plane is
tilted forward, but no assess- ment of
the spatial relationships between hard
tissue palate and craniofacial struc-
tures was performed. For each palate,
the following measurements were
obtained:

Sagittal plane:

Palatal length, horizontal projection

of the IP-M line (unit: mm)
Palatal slope, slope of the maximum
palatal height versus the horizontal
axis (degrees)
Maximum palatal height (mm)

Horizontal plane:

Angle between the IP-RP and the

IP-M lines (degrees)

Frontal plane:

Palatal width and maximum palatal

height at the first permanent molars
(1626 distance, mm)
Palatal width and maximum palatal
height at the second premolars (15
25 distance, mm)
Palatal width and maximum palatal
height at the first premolars (1424
distance, mm)
Palatal width and maximum
palatal height at the canines (13
 All coordinates were then standardized, in the frontal plane as computed using the rectangular
percentages of the intermolar distance 1626 (x coordinate), and in components of the angles.21 The
the sagittal plane as percentages of the horizontal projection of the significance of sex-related dif- ferences of
IP-M dis- tance (y coordinate). linear variables was quantified using
The curve of the palatal surface was fit- ted to a fourth-degree Student t tests for independent sam-
polynomial18,19: y = ax + bx2 + cx3 + dx4, separately for the sagittal ples, while differences of angular
and the frontal (4 curves corre- sponding to 1626, 1525, 14 variables were tested using Watson-
24, and 1323) plane projections of the three-di- mensional Williams test.21
standardized (ie, size-indepen- dent) coordinates of the digitized For each subject and variable, the
land- marks. In the frontal plane projection, the origin of axes was differ- ence between the second
set at 16, the X-axis cor- responded to the right-left transverse line, (present) and first (10 years ago)
and the Y-axis to its vertical perpendicular. In the sagittal plane measurement was cal- culated. The
projection, the origin of axes was set at IP, the X-axis corre- significance of the longitudi- nal
sponded to the horizontal projection of the IP-M distance, and the modifications was assessed by paired
Y-axis to its ver- tical perpendicular. The 4 coefficients of the Student t tests. In all cases, 2-tail tests
polynomial equation were computed using the least-square were used, with a level of significance set
method, and the correlation coefficient r of the curve was also at 5%.
assessed.18
Error of method
Statistical analyses
The intraoperator repeatability of
For each palatal measurement, descrip- tive statistics for the the measurements was assessed by
male and female groups in the 2 assessments (10 years ago and Ferrario et al19 using repeated tracings
the present) were calculated. Statistics for angular variables were (landmark
Table 1 Descriptive statistics of hard-tissue palatal size in 12 healthy
Northern Italians
Men (n = 6) Women (n = 6)
A B A B
Plane Measurement Mean SD Mean SD Mean SD Mean SD
Sagittal IP-M 28.52 2.08 28.96 2.62 29.83 0.84 30.34 2.42
Slope (deg) 30.29 0.77 29.75 0.96 26.89 1.45 26.04 1.13
Height 16.78 1.06 16.61 1.02 15.63 3.02 15.41 2.94
Horizontal Raphe (deg) 3.31 0.95 3.53 1.30 1.42 0.47 1.32 0.44
Frontal
1626 Width 37.40 3.01 37.42 3.27 34.29 2.42 34.36 2.75
Height 17.44 1.11 17.40 1.28 16.47 3.01 16.30 2.88
1525 Width 32.69 1.76 32.95 2.55 30.83 2.12 31.01 2.06
Height 14.57 2.25 15.12 1.91 15.44 2.96 15.24 3.26
1424 Width 27.13 1.92 27.23 2.21 27.18 1.65 27.12 1.74
Height 9.16 2.15 9.45 2.11 10.01 2.79 10.51 4.19
1323 Width 23.70 1.78 23.79 2.15 25.21 2.22 24.94 2.16
Height 3.33 1.04 3.34 1.00 3.45 2.20 3.81 1.99
All values are mm unless otherwise noted.
Assessment A = Men, mean age 22.4 years (SD 1.4); women, mean age 23.6 years
(SD 2.5). Assessment B = same patients 10 years later.
No significant sex differences, P > .05 (linear variables: Student t test for independent samples, 11 degrees of freedom; angles:
Wat- son-Williams test, 1, 10 degrees of freedom).

identification) and digitizations of the similar, and no statistically significant

same casts. For each variable, the error
of the method (error percentage) was
calcu- lated as the percentage ratio
between the variance of the method
error (squared Dahlbergs error) and
the population vari- ance of that
measurement (squared stan- dard
deviation).19 For landmark identifica-
tion, the error percentage was always
less than 10% of the total biological
variance. For landmark digitization, the
error per- centage ranged between
1.76% and 8.26%.
Results
Table 1 reports the descriptive
statistics of all palatal measurements
performed in the 2 assessments (10
years ago and the present) separately
for men and women. Overall, male and
female values appeared
dif- ferences were found (P > .05 for all
vari- ables and in both assessments).
Interindividual differences between
the measurements taken in the third
(men, mean age 22.4 years, SD = 1.4;
women, mean age 23.6 years, SD =
2.5) and fourth (10-year follow-up)
decades of life ap- peared limited, the
largest being a 2.4-mm increment in
palatal sagittal length (IP-M distance) in
woman F048, and a 2.7-de- gree
decrement in raphe inclination in man
M051. Moreover, a large variability
was found, with almost the same
number of increments and decrements
in palatal dimensions. A notable
exception was ob- served for palatal
slope in the sagittal plane, where 8
out of 12 subjects had a smaller value
in the second assessment, with
differences ranging between 0.06
degrees and 2.63 degrees.
 Table 2 Descriptive statistics of 10-year
longitudinal modifications in
hard-tissue palatal size in 12 healthy
Northern Italians (sex pooled)
Plane Measurement Mean SD P
Sagittal IP-M 0.47 1.32 NS
Slope (deg) 0.70 0.37 .001
Height 0.21 0.37 NS
Horizontal Raphe (deg) 0.05 0.42 NS
Frontal
1626 Width 0.04 0.79 NS
Height 0.11 0.32 NS
1525 Width 0.14 0.86 NS
Height 0.22 0.97 NS
1424 Width 0.02 0.47 NS
Height 0.41 1.19 NS
1323 Width 0.09 0.63 NS
Height 0.19 0.67 NS
All values are mm unless otherwise noted.
A positive value indicates an increment in palatal dimension.
P = probability of a significant difference, Student t test for paired samples,
11 degrees of freedom.
NS = not significant (P > .05).

Men and women appeared to palatal

change with a similar pattern, and curves
descriptive sta- tistics for the age- obtained
related variations were computed after from the
pooling the sexes ( Table 2). The dental casts
significance of the differences was of
tested by Student t test for paired
sam- ples, and all values except
palatal slope were not significantly
different from 0. In- deed, the mean
variation in palatal slope was very limited
(0.7 degrees).
Palatal shape independently from
size in both the sagittal and frontal
planes (ca- nine, premolar, and molar
areas) was well reconstructed by the
fourth-degree poly- nomials, with
coefficients of correlation r ranging
between 0.91 and 0.99. In all sub- jects,
the curves from 10 years ago and the
current curves appeared well superimpos-
able, without any detectable difference.
As an example, the size-independent
woman F020 and of man M004 are shown in Figs 2 and 3.
Discussion
Hard and soft tissue facial dimensions continue to increase
even after the third decade of life, as reported both in longitu-
dinal2,5,8,9,11,14 and cross-sectional studies.3,12 Most investigations
analyzed the charac- teristics of dental arches in this time span, but
no study measured palatal morphol- ogy, apart from a cross-
sectional assess- ment of palatal surface
area.3
Published data on human palate are
lim- ited to the first 3 decades of life, and
were performed only with cross-
sectional de- signs. 15,17 In adolescent
females, overall, hard tissue palatal
form appeared to have already attained
adult characteristics; in males, some
modifications (size increments
Fig 2 Palatal shape independent from size in woman F020. A = cast
taken at 26.8 years of age; B = cast taken 10 years later. Upper panel
= sagittal plane projection; lower panel = frontal plane projection. X-
axis unit = per- cent of 1626 distance; Y-axis unit = percent of IP-M
distance. Green = molar points; red = second premolar points; blue =
first premolar points; gray = canine points.
Fig 3 Palatal shape independent from size in man M004. A = cast
taken at 21.3 years of age; B = cast taken 10 years later. Upper panel
= sagittal plane projection; lower panel = frontal plane projection. X-
axis unit = per- cent of 1626 distance; Y-axis unit = percent of IP-M
distance. Green = molar points; red = second premolar points; blue =
first premolar points; gray = canine points.
and shape variations) between
adoles- cence and young adulthood
(up to the third decade of life) were
found.15,17 In con- trast, the palatal area
did not modify after adolescence.3
In the present study, a longitudinal
eval- uation assessed the changes in hard
tissue palatal size and shape between
20 and 30 years of age in healthy,
normal men and women. Unfortunately,
the analyzed sam- ple was very limited
(12 subjects), and all the following
considerations should be taken with
caution. Overall, a large in-
terindividual variability in the
modification of dental arch dimensions
was found, with both increments and
decrements, so that no mean difference
was larger than 0.5 mm (Table 2).
It is difficult to compare the present
findings to literature reports,
because quantitative investigations
of normal palatal size and shape are
uncommon. As
recently reviewed by Ferrario et al,19,20
the main shortcoming seems to be
technical: Direct techniques, in which
several stan- dardized landmarks are
used as endpoints for caliper
measurements, are time-con- suming
and prone to error. Indirect analy- ses,
with the use of two-dimensional pro-
jections (radiographs, photographs,
or photocopies), are insufficient for
the palate. Only three-dimensional
computer- ized analyses can correctly
assess palatal morphology.19,22 Both
surface-based and landmark-based
methods have been used. Indeed, most
surface-based approaches are time-
consuming, requiring several scans
for each cast, and while they seem best
suited for the analysis of selected pa-
tients (for instance, cleft-palate
children), they are of difficult application
for a wide- scale collection of data.
The major limitation of landmark-
based methods seems to be the
reduced number
of digitized landmarks, which No
approxi- mates the analyzed structure significant
neglecting most information.15,19 In the sexual
present inves- tigation, a modification to differences
the original pro- tocol devised by were found
Ferrario et al19 was intro- duced, and in the
palatal morphology was analyzed present
also in the canine and premolar areas, study, but
thus supplying a better approxima- tion the limited
of the size and shape characteristics
(Figs 2 and 3).
The present data can be partly com-
pared to data collected on dental
arches. For instance, a large
interindividual vari- ability was also
reported by Bondevik16 in his 10-year
longitudinal follow-up of the dental
arches of Norwegian women and men
between the third and the fourth
decades of life. Indeed, the mean
differ- ences found by Bondevik16 in
maxillary in- termolar width (the only
measurement comparable to the
present ones) were, on average, 0.3 mm
in both sexes, a value sim- ilar to those
found in the current study ( Table 2).
But, while the Norwegian differ- ence
was statistically significant, in the
present investigation neither palatal
size (sagittal and frontal plane depth,
widths, and heights) nor palatal shape
(size-inde- pendent mathematical
reconstruction of the sagittal and frontal
plane morphology) appeared to change
significantly in the analyzed time span (
Table 2; Figs 2 and 3). Only palatal
slope in the sagittal plane yielded a
statistically significant differ- ence,
but the mean variation measured was
so small (a decrement of 0.7 de-
grees) to be of limited anatomical and
clinical significance.
Carter and McNamara10 also found
sig- nificant longitudinal decrements in
maxil- lary depth measured at the first
molars and in maxillary intercanine
width (lingual sur- face), while no
significant variations were found for
interpremolar and intermolar lin- gual
widths. Indeed, their follow-up period
was much longer, with a first
assessment at 17 years of age, and a
second examination at 48 years. The
mean differences in maxil- lary
intercanine width were about 1 mm in
females and 1.4 mm in males, while
maxil- lary depth measured at the first
molars de- creased about 1.1 mm in both
sexes.
 number of subjects do not allow any con- clusions to be drawn, and
the sexual dimor- phism in dental and hard tissue palatal di- References
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