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