The Cervical
Vertebral
Maturation
method
Tiziano Baccetti, DDS, PhD
Department of Orthodontics,
The University of Florence, Italy,
and
“T.M. Graber Visiting Scholar”
Department of Orthodontics and Pediatric Dentistry
The University of Michigan
The Cervical
Vertebral
Maturation
method
Tiziano Baccetti, DDS, PhD
Department of Orthodontics,
The University of Florence, Italy,
and
“T.M. Graber Visiting Scholar”
Department of Orthodontics and Pediatric Dentistry
The University of Michigan
Craniofacial growth is an individual phenomenon
Craniofacial growth rate is not linear during development
Treatment Outcomes Treatment Timing
Hunter, 1966
•
Need for biologic indicators of
“mandibular
skeletal maturity”
Limitations of Other Biologic Indicators of Skeletal Maturity
•
Increase in statural height
Nanda, 1955; Hunter, 1966
limitation: 3 consecutive standardized recordings are
needed
•
Skeletal maturation of the hand and wrist
Greulich and Pyle, 1959; Hägg et al., 1987
limitation: additional x-ray exposure
•
Dental development and eruption
Hellman, 1923; Lewis and Garn, 1960
limitation: no significant correlations with mandibular growth
•
Menarche and voice changes
Tanner, 1962
limitation: these events are post-pubertal in 90% of the subjects
Biological Indicator of Skeletal Maturity
Peak in
Mandibular
Growth
CS 1
CS 3
CS 4
CS 5
CS 6
The Cervical Vertebral Maturation (CVM) Method for
the Assessment of Optimal Treatment Timing in
Dentofacial Orthopedics
Tiziano Baccetti, DDS, PhD, Lorenzo Franchi, DDS, PhD, and James A. McNamara Jr, DDS, PhD
(Seminars in Orthodontics
2005;11:119-129)
CS 2
VISUAL ANALYSIS
C2
C3
C4
Presence of a concavity at the
lower border of the vertebral
bodies of C2, C3, and C4
Shape of the vertebral
bodies
of C3 and C4:
trapezoid
rectangular
horizontal
squared
rectangular vertical
CS 1
The peak interval will start not earlier than 2 years after this stage
Peak in
mandibular
growth
one year
-1 y
-2 ys
+1 y
+2 ys
•All lower borders are flat (7% may show a concavity)
•C3 and C4 are trapezoid in shape
CS 2
The peak interval will start 1 year after this stage
Peak in
mandibular
growth
one year
-1 y
-2 ys
+1 y
+2 ys
•The lower border of C2 shows a concavity (80% of the subjects)
•C3 and C4 are trapezoid in shape
CS 3
The peak interval starts at this stage
Peak in
mandibular
growth
one year
-1 y
-2 ys
+1 y
+2 ys
•The lower borders of C2 and C3 may show a concavity
•C3 or C4 may be trapezoid/rectangular horizontal in shape
CS 4
The peak interval ends at this stage
(or it has ended during the year before this stage)
Peak in
mandibular
growth
one year
-1 y
-2 ys
+1 y
+2 ys
•All lower borders show concavities
•C3 and C4 are rectangular horizontal in shape
CS 5
The peak interval ended one year before this stage
Peak in
mandibular
growth
one year
-1 y
-2 ys
+1 y
+2 ys
•All lower borders show concavities
•At least one of the bodies of C3 and C4
is squared in shape
CS 6
The peak interval ended at least two years before this stage
Peak in
mandibular
growth
one year
-1 y
-2 ys
+1 y
+2 ys
•All lower borders show concavities
•At least one of the bodies of C3 and C4
is rectangular vertical in shape
GUIDELINES FOR IDENTIFICATION OF CERVICAL STAGES
IN “UNCERTAIN” CASES
The minimal depth of a concavity at the lower border
of the cervical vertebral body must be 0.8 mm,
in order to consider that concavity in the classification
of stages.
If the depth of the concavity is smaller than 0.8 mm,
DO NOT CONSIDER the concavity
(if undecided whether the stage is an earlier or
later stage, choose the earlier one)
GUIDELINES FOR IDENTIFICATION OF CERVICAL STAGES
IN “UNCERTAIN” CASES
“SPIKES” that are detached from the lower border
of the body of the cervical vertebrae (more frequently
in the anterior portion)
=
DO NOT CONSIDER
when deciding upon
the presence or absence of a concavity
(if undecided whether the stage is an earlier or
later stage, choose the earlier one)
GUIDELINES FOR IDENTIFICATION OF CERVICAL STAGES
IN “UNCERTAIN” CASES
When the shape of either CS 3 or CS4, or
BOTH is
TRAPEZOID
the stage is earlier than stage CS 4
(CS 1, CS 2, or CS 3)
GUIDELINES FOR IDENTIFICATION OF CERVICAL STAGES
IN “UNCERTAIN” CASES
“SPIKES” that are an elongation of the supero-
posterior corner of the body of the cervical
vertebrae (C3 and/or C4)
=
CONSIDER
in the CLASSIFICATION OF SHAPE
=
TRAPEZOID
(the stage is earlier than stage CS 4)
GUIDELINES FOR IDENTIFICATION OF CERVICAL STAGES
IN “UNCERTAIN” CASES
CS 5 is identified when:
- C3 is still rectangular horizontal and C4 is
squared
- C3 is squared and C4 is still rectangular
horizontal
- both C3 and C4 are squared
GUIDELINES FOR IDENTIFICATION OF CERVICAL STAGES
IN “UNCERTAIN” CASES
CS 6 is identified when:
- C3 is still squared and C4 is rectangular
vertical
- C3 is rectangular vertical and C4 is still
squared
- both C3 and C4 are rectangular vertical
What is the accuracy of the CVM method in the
identification of the pubertal peak in mandibular
growth with respect to chronologic age ?
Error for the CVM method : ± 6 months
Error for chronologic age:
Females: ± 1 ys 6 mos
Males: ± 2 ys
years
1,000 Subjects
CS1
CS2
CS3
CS4
CS5
CS6
Early Mixed
(N=250)
241
(96.4%
)
9
(3.6%)
0
(0%)
0
(0%)
0
(0%)
0
(0%)
Intermediate
Mixed
(N=250)
169
(67.6%
)
71
(28.4%
)
10
(4%)
0
(0%)
0
(0%)
0
(0%)
Late Mixed
(N=250)
78
(31.2%
)
61
(24.4%
)
90
(36%)
21
(8.4%)
0
(0%)
0
(0%)
Early Permanent
(N=250)
18
(7.2%)
47
(18.8%
)
76
(30.4%
)
74
(29.6%
)
27
(10.8%
)
8
(3.2%)
Early Mixed
Intermediate Mixed
Pr
e-
Pu
be
rt
al
!!
!
The clinical
impact of the CVM
method
Planning the orthodontic treatment in the individual patient
Establishing the time for long-term appraisal of treatment outcomes
Establishing completion of growth (orthognathic surgery; implants; etc.)
Matching/comparing control subjects to treated subjects
Cervical Vertebral
Maturation
-trial-
Case N. 1
CS 2
Case N. 2
CS 3
Case N. 3
CS 1
Case N. 4
CS 4
Case N. 5
CS 6
Case N. 6
CS 2
Case N. 7
CS 5
Case N. 8
CS 6
Case N. 9
CS 3
Case N. 10
CS 4