The Cervical Vertebral Maturation (CVM)

Method for the Assessment of Optimal

Treatment Timing in Dentofacial Orthopedics
Tiziano Baccetti,*,† Lorenzo Franchi,*,† and James A. McNamara, Jr.†,‡,§

The present study introduces a further modified version of the Cervical Vertebral Maturation
(CVM) method for the detection of the peak in mandibular growth, based on the analysis of the
second through fourth cervical vertebrae in a single cephalogram. The morphology of the
bodies of the second (C2 – odontoid process), third (C3), and fourth (C4) cervical vertebrae
were analyzed in 6 consecutive cephalometric observations (T1 through T6) of 30 orthodon-
tically untreated subjects. Observations for each subject consisted of two consecutive
cephalograms comprising the interval of maximum mandibular growth (as assessed by
means of the maximum increment in total mandibular length, Condylion –Gnathion: Co-Gn),
together with two earlier consecutive cephalograms and two later consecutive cephalo-
grams. The analysis consisted of both visual and cephalometric appraisals of morphological
characteristics of the three cervical vertebrae. The construction of this new modified
version of the CVM method was based on the results of both ANOVA for repeated
measures with post hoc Scheffé’s test (P < 0.05) and discriminant analysis. The new
clinically improved CVM method is comprised of six maturational stages (cervical stage 1
through cervical stage 6, ie, CS1 through CS6). CS1 and CS2 are prepeak stages; the peak
in mandibular growth occurs between CS3 and CS4. CS6 is recorded at least 2 years after
the peak. The use of the CVM method enables the clinician to identify optimal timing for the
treatment of a series of dentoskeletal disharmonies in all three planes of space.
Semin Orthod 11:119 –129 © 2005 Elsevier Inc. All rights reserved.

I n the organization, differentiation, development, and

growth of any somatic structure, time plays a crucial role in
determining the final morphological and dimensional result.
ated growth that can contribute significantly to the correction
of skeletal imbalances in the individual patient. Cephalomet-
ric investigations on longitudinal samples have identified a
In orthodontics and dentofacial orthopedics, it is becoming pubertal spurt in mandibular growth that is characterized by
increasingly evident that the timing of the treatment onset wide individual variations in onset, duration, and rate.1-6 In-
may be as critical as the selection of the specific treatment dividual skeletal maturity can be assessed by means of several
protocol, as will be discussed below. By beginning a protocol biologic indicators: increase in body height1-3; skeletal mat-
at the individual patient’s optimal maturational stage, the uration of the hand and wrist7-10; dental development and
most favorable response with the least potential morbidity eruption8,11,12; menarche or voice changes9,13,14; and cervical
can be anticipated. vertebral maturation.15,16 The biologic indicators of skeletal
The issue of optimal timing for dentofacial orthopedics is maturity refer mainly to somatic changes at puberty, thus
linked intimately to the identification of periods of acceler- emphasizing the strict interactions between the development
of the craniofacial region and the modifications in other body
regions.
*Department of Orthodontics, University of Florence, Florence, Italy. The reliability and efficiency of a biologic indicator of skel-
†Department of Orthodontics and Pediatric Dentistry, School of Dentistry, etal maturity can be evaluated with respect to several funda-
University of Michigan, Ann Arbor, MI.
‡School of Medicine, University of Michigan, Ann Arbor, MI.
mental requisites.17 An “ideal” biologic indicator of individ-
§Center for Human Growth and Development, University of Michigan, Ann ual mandibular skeletal maturity should be characterized by
Arbor, MI. at least five features.
Address correspondence to Tiziano Baccetti, DDS, PhD, Università degli
Studi di Firenze, Via del Ponte di Mezzo, 46-48, 50127, Firenze, Italy. 1. Efficacy in detecting the peak in mandibular growth.
E-mail: [email protected] The method should present with a definite stage or

1073-8746/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. 119
doi:10.1053/j.sodo.2005.04.005
120 T. Baccetti, L. Franchi, and J.A. McNamara

phase that coincides with the peak in mandibular Subjects and Methods
growth in the majority of subjects.
2. No need for additional x-ray exposure. The total sample (n ⫽ 706) that comprises the cephalometric
3. Ease in recording. files of the University of Michigan Elementary and Secondary
4. Consistency in the interpretation of the data. The inter- School Growth Study was evaluated.23 Due to the longitudi-
examiner error in the appraisal of the defined stages or nal nature and aim of the present investigation, subjects with
phases should be as low as possible. less than six consecutive annual cephalometric observations
5. Usefulness for the anticipation of the occurrence of the (n ⫽ 492) were excluded from the study. Total mandibular
peak. The method should present with a definable stage length (Co-Gn) was measured on the longitudinal sets of
or phase that occurs before the peak in mandibular lateral cephalograms for each of the 214 remaining subjects
growth in the majority of subjects. at yearly intervals. The lateral cephalograms were analyzed
by means of a digitizing tablet (Numonics, Lansdale, PA) and
The main features of the Cervical Vertebral Maturation digitizing software (Viewbox, version 3.0, D. Halazonetis,
(CVM) method as described previously by Franchi and co- Athens, Greece). The maximum increase in Co-Gn between
workers18 included: two consecutive annual cephalograms was used to define the
1. In nearly 95% of North American subjects, a growth peak in mandibular growth at puberty in the individual sub-
interval in CVM coincides with the pubertal peak in jects. Two consecutive cephalograms comprising the interval
both mandibular growth and body height. of maximum mandibular growth, together with two earlier
2. The cervical vertebrae are available on the lateral cepha- consecutive cephalograms and two later consecutive cepha-
logram that is used routinely for orthodontic diagnosis lograms, had to be available for each subject and were in-
and treatment planning. cluded in the study. This limited the investigation to 30 sub-
3. The appraisal of the shape of the cervical vertebrae is jects (18 males, 12 females).
straightforward. The morphology of the bodies of the second (C2 – odon-
4. The reproducibility of classifying CVM stages is high toid process), third (C3), and fourth (C4) cervical vertebrae
(⬎98% by trained examiners). were analyzed in the six consecutive annual observations (T1
5. The method is useful for the anticipation of the puber- through T6). The analysis consisted of both visual and ceph-
tal peak in mandibular growth. alometric appraisals of morphological characteristics of the
cervical vertebrae.
A subsequent study by our group19 provided a few im-
provements of the original CVM analysis to make the method Visual analysis. The morphology of the three cervical verte-
easier and applicable to the vast majority of patients: brae (C2, C3, C4) on the six consecutive cephalograms (T1
through T6) was evaluated by visual inspection. Two investi-
1. A more limited number of vertebral bodies was used to
gators (LF and TB) performed the appraisal independently.
perform the staging (as suggested by Hassel and
The percentage of interexaminer agreement was 96.7%. Two
Farman20). In particular, the method included only
those cervical vertebrae (C2, C3, and C4) that can be sets of variables were analyzed:
visualized when a protective radiation collar is worn by
the patient. 1. Presence or absence of a concavity at the lower border
2. Definitions of stages were not based on a comparative of the body of C2, C3, and C4; and
assessment of between-stage changes, so that stages can 2. Shape of the body of C3 and C4. Four basic shapes were
be identified easily on a single cephalogram. considered:
trapezoid (the superior border is tapered from posterior to
A series of investigations performed in different parts of the anterior);
world have confirmed the validity of the CVM method, rectangular horizontal (the heights of the posterior and
mostly by comparing it with the hand and wrist method. anterior borders are equal; the superior and inferior bor-
Pancherz and Szyska found that the cervical vertebral matu- ders are longer than the anterior and posterior borders);
ration method has level of reliability comparable to the hand squared (the posterior, superior, anterior, and inferior bor-
and wrist method.21 By replacing the hand-wrist method ders are equal); and
with the CVM method, an additional radiograph can be rectangular vertical (the posterior and anterior borders are
avoided, thus reducing the patient’s total radiation dose. longer than the superior and inferior borders).
Grave and Townsend also have confirmed the validity of the
CVM method in Australian aborigines.22 Cephalometric analysis. On the lateral cephalograms, the
The aim of the present article is to present a further mod- following points for the description of the morphologic char-
ified and refined version of the CVM method and its validity acteristics of the cervical vertebral bodies were traced and
for the appraisal of mandibular skeletal maturity in the indi- digitized (Fig 1):
vidual patient in light of the findings of recent studies in
which the CVM method has been used to assess optimal C2p, C2 m, C2a: the most posterior, the deepest, and the
timing for the treatment of malocclusions in the transverse, most anterior points on the lower border of the body of
sagittal, and vertical planes of space. C2.
The CVM method and treatment timing 121

border of C3 (distance from the line connecting C3lp

and C3la to the deepest point on the lower border of the
vertebra, C3 m).
C4Conc: a measure of the concavity depth at the lower
border of C4 (distance from the line connecting C4lp
and C4la to the deepest point on the lower border of the
vertebra, C4 m).
C3BAR: ratio between the length of the base (distance
C3lp-C3la) and the anterior height (distance C3ua-
C3la) of the body of C3.
C3PAR: ratio between the posterior (distance C3up-C3lp)
and anterior (distance C3ua-C3la) heights of the body of
C3.
C4BAR: ratio between the length of the base (distance
C4lp-C4la) and the anterior height (distance C4ua-
C4la) of the body of C4.
C4PAR: ratio between the posterior (distance C4up-C4lp)
and anterior (distance C4ua-C4la) heights of the body of
C4.

Statistical analysis. The significance of the prevalence rates

for the morphologic characteristics of the cervical vertebrae
was evaluated at each observation time by means of the chi-
squared test with Yates’ correction (P ⬍ 0.05). Descriptive
statistics were obtained for total mandibular length and for
vertebral cephalometric measures at each of the six consecu-
tive observations (T1 through T6). The differences between
the mean values for all the computed variables at the six
consecutive stages were tested for significance by means of
ANOVA for repeated measurements with post hoc Scheffé’s
test (P ⬍ 0.05).
The cephalometric measurements of the bodies of the cer-
vical vertebrae at each interval between consecutive cephalo-
grams were analyzed by means of a multivariate statistical
Figure 1 Cephalometric landmarks for the quantitative analysis of approach, discriminant analysis, to identify those vertebral
the morphologic characteristics of the vertebral bodies of C2, C3, morphologic variables mostly accounting for the differences
and C4. between two consecutive observations. A stepwise variable
selection (forward selection procedure) was performed with
the goal of obtaining a model with the smallest set of signif-
C3up, C3ua: the most superior points of the posterior and icant cephalometric variables (F to enter and to remove ⫽ 4).
anterior borders of the body of C3. Finally, the classifying power of selected cephalometric vari-
C3lp, C3 m, C3la: the most posterior, the deepest, and the ables was tested. All statistical computations were performed
most anterior points on the lower border of the body of by means of computer software (SPSS for Windows, version
C3. 10.0.0, SPSS, Inc., Chicago, IL).
C4up, C4ua: the most superior points of the posterior and
anterior borders of the body of C4.
C4lp, C4 m, C4la: the most posterior, the deepest, and the Results
most anterior points on the lower border of the body of The findings of the visual analysis of the morphologic char-
C4. acteristics of cervical vertebrae (C2, C3, C4) are reported in
For the location of landmarks, the indications described by Table 1. The features of the examined vertebrae at the six
Hellsing were adopted partially.24 With the aid of these land- consecutive observations can be summarized as follows:
marks, the following measurements were performed:
T1. The lower border of C2 is flat in the vast majority of
C2Conc: a measure of the concavity depth at the lower subjects at this stage; a concavity is evident at the lower
border of C2 (distance from the line connecting C2p border of C2 in only 7% of the individuals examined, a per-
and C2a to the deepest point on the lower border of the centage that is not significant. The concavity is absent at the
vertebra, C2 m). lower borders of both C3 and C4 in 100% of the subjects. The
C3Conc: a measure of the concavity depth at the lower bodies of both C3 and C4 are trapezoid in shape.
 122 T. Baccetti, L. Franchi, and J.A. McNamara

T2. A concavity is present at the lower border of C2 in 80%

16 (53.3%) 14 (46.7%) 16 (53.3%) 14 (46.7%)

14 (46.7%) 16 (53.3%)
30 (100%)
30 (100%)

30 (100%)

30 (100%)
15 (50%)

15 (50%)
of the subjects. The observation at T2 is characterized also by

0 (0%)

0 (0%)

0 (0%)
No
the absence of a concavity at the lower borders of C3 (with
the nonsignificant exception of 7% of the subjects) and of C4.
T6

Both C3 and C4 still are trapezoid in shape, with the nonsig-

30 (100%)

30 (100%)

30 (100%)

15 (50%)

15 (50%)
nificant exceptions of 3% and 13% of the subjects showing

0 (0%)
0 (0%)

0 (0%)

14 (46.7%) 16 (53.3%) 0 (0%)

Yes

rectangular horizontal bodies for C3 and C4, respectively.

T3. A concavity is present at the lower border of C2 (100% of

the subjects) and of C3 (with the nonsignificant exception of
30 (100%)
30 (100%)

30 (100%)

30 (100%)
1 (3.3%)

26 (86.7%) 4 (13.3%) 29 (96.7%) 1 (3.3%)

18 (60%)

12 (40%)
0 (0%)

7% of the subjects). No concavity is present at the lower

No

border of C4 (with the nonsignificant exception of 10% of the

cases). The shape of both C3 and C4 may be either trapezoid
T5

or rectangular horizontal.
29 (96.7%)
30 (100%)

12 (40%)

18 (60%)
0 (0%)
0 (0%)

0 (0%)

0 (0%)
Yes

T4. This observation is characterized by the presence of a

concavity at the lower borders of C2, C3 (with the nonsignif-
icant exception of 7% of the cases), and C4 (with the nonsig-
30 (100%)
30 (100%)

30 (100%)
30 (100%)

30 (100%)

30 (100%)
2 (6.7%)

nificant exception of 13% of the cases). The bodies of both C3

0 (0%)

0 (0%)

0 (0%)
No

and C4 now are rectangular horizontal in shape (100% of the

subjects).
Table 1 Results of Qualitative Analysis of Cervical Vertebral Characteristics at the Six Consecutive Observations
T4

T5. A concavity is present at the lower borders of C2, C3

28 (93.3%)
30 (100%)

7 (23.3%) 23 (76.7%) 30 (100%)

30 (100%)

(with the nonsignificant exception of 3% of the cases), and

1 (3.3%) 23 (76.7%) 7 (23.3%) 0 (0%)
0 (0%)

0 (0%)
0 (0%)

0 (0%)

0 (0%)
Yes

C4 (with the nonsignificant exception of 3% of the cases).

The body of C3 is rectangular horizontal in 40% of the cases
and squared in the remaining subjects. The body of C4 is
30 (100%)
30 (100%)

30 (100%)

30 (100%)
2 (6.7%)

27 (90%)

15 (50%)

15 (50%)

rectangular horizontal in 47% of the cases and squared in the

0 (0%)
No

remaining subjects.

T6. A concavity is present at the lower borders of all the three

T3

28 (93.3%) 28 (93.3%)

examined cervical vertebrae. The body of C3 is squared in

30 (100%)

3 (10%)

4 (13.3%) 15 (50%)

26 (86.7%) 15 (50%)
0 (0%)
0 (0%)

0 (0%)

0 (0%)
Yes

50% of the cases and rectangular vertical in the remaining

50% of the cases. The body of C4 is squared in 53% of the
cases and rectangular vertical in the remaining subjects.
Descriptive statistics for the cephalometric measurements
29 (96.7%)
30 (100%)

30 (100%)
30 (100%)

30 (100%)

30 (100%)
6 (20%)

of vertebral morphologic characteristics are reported in Table

No

2, together with the statistical comparisons between consec-

utive observations. No significant differences for any of the
T2

measurements were assessed between T1 and T2 with the

30 (100%) 0 (0%) 29 (96.7%)
30 (100%) 0 (0%) 26 (86.7%)

30 (100%) 4 (13.3%)
30 (100%) 2 (6.7%)

30 (100%) 1 (3.3%)
2 (6.7%) 28 (93.3%)24 (80%)
Yes

exception of a significant increase in the depth of the concav-

30 (100%) 0 (0%)

30 (100%) 0 (0%)
30 (100%) 0 (0%)

30 (100%) 0 (0%)

30 (100%) 0 (0%)

ity at the lower border of the second cervical vertebra

(C2Conc). The depth of the concavities at the lower borders
of both the second (C2Conc) and the third (C3Conc) cervical
vertebra is significantly greater at T3 when compared with T2.
No

In the transition from T2 to T3, the height of the anterior

border of both C3 and C4 increases significantly, thus lead-
T1

ing to significant decrements in the ratio between the heights

0 (0%)

0 (0%)

0 (0%)

0 (0%)
0 (0%)
0 (0%)

0 (0%)

0 (0%)
Yes

of the posterior and anterior borders of the vertebral bodies

(C3PAR and C4PAR).
At T4, the depth of the concavity at the lower border of C4
(C4Conc) becomes significantly greater than at T3. In the
Concavity at the lower

Concavity at the lower

Concavity at the lower

C3 shape: rectangular

C4 shape: rectangular

C3 shape: rectangular

C4 shape: rectangular
C3 shape: trapezoid
C4 shape: trapezoid

transition from T3 to T4, the height of the anterior borders of

C3 shape: squared
C4 shape: squared

both C3 and C4 increases significantly again, thus leading to

border of C2

border of C3

border of C4

significant decreases both in the ratio between the heights of

the posterior and anterior borders of the vertebral bodies
horiz.

horiz.

(C3PAR and C4PAR) and in the ratio between the length of

Vert.
vert.

the base and the anterior height of the vertebral bodies

(C3BAR and C4BAR). On average, C3PAR and C4PAR now
The CVM method and treatment timing 123

Table 2 Results of Quantitative Analysis: Descriptive Statistics and Statistical Comparisons (ANOVA for Repeated Measurements with Post Hoc Scheffe’s test) on the
have a ratio of approximately 1:1, an indication that both C3

2.53
1.08
0.09
0.12
0.11
0.01
0.02
0.01
0.02
SE
and C4 vertebral bodies are rectangular horizontal in shape.
T5 and T6 are characterized by decrements of the ratio

13.83
5.93
0.48
0.68
0.63
0.06
0.13
0.05
0.12
SD
between the length of the base and the anterior height of the
T6 vertebral bodies (C3BAR and C4BAR). The mean values for
these measurements indicate that the vertebral bodies be-

2.40*
2.28*

1.03*
Mean
166.00
121.77
2.23

0.99

0.97
1.04
come progressively more squared in shape. At T6, one third of
the cases show a rectangular vertical shape of one or both C3
and C4 vertebral bodies.
2.63
1.08
0.07
0.11
0.11
0.01
0.03
0.01
0.03
Discriminant analysis revealed that the forming concavity
SE

at the lower border of C2 can account for 80% of the differ-

ences between T1 and T2. The depth of C3Conc becomes the
14.41
5.91
0.40
0.60
0.60
0.06
0.15
0.07
0.18
SD

discriminant variable between T2 and T3 with a classifying

T5

power of 75%. The difference in the posteroanterior ratio of

C3 (C3PAR) together with the depth of the concavity at the
1.77*

1.20*

1.19*
Mean
153.30
119.63
1.91
1.85

0.98

1.00

lower border of C4 (C4Conc) are the discriminant factors

between T3 and T4 (classifying power equal to 85%). C3PAR
in association with both the ratio between the length of the
2.63
1.06
0.07
0.12
0.10
0.01
0.02
0.01
0.02
SE

base and the anterior height of C3 (C3BAR) and C4Conc are

able to discriminate between T4 and T5 in 88% of the cases.
The ratios for C3 (C3BAR and C3PAR) together with the
14.42
5.83
0.37
0.64
0.53
0.08
0.14
0.06
0.12
SD

depth of the concavity at the lower border of C2 (C2Conc)

T4

are the discriminant variables between T5 and T6 in 80% of

the cases.
118.05*
1.58*

1.07*
0.98*
1.39*
1.01*
1.36*
Mean
141.17

1.36

Discussion
2.74
1.06
0.08
0.10
0.07
0.02
0.03
0.03
0.04
SE

The modifications in the size and shape of the cervical verte-

brae in growing subjects have gained increasing interest dur-
14.99
5.78
0.44
0.53
0.39
0.12
0.15
0.17
0.21

ing the past few decades as a biological indicator of individual

SD
T3

skeletal maturity. One of the main reasons for the increasing

popularity of the method is that the analysis of cervical ver-
1.15*
0.95*

1.16*
1.61*
1.15*

tebral maturation is performed on the lateral cephalogram, a

Mean
128.73
112.63

0.31

1.59

type of film used routinely in orthodontic diagnosis. The

objective of the present investigation was to provide a refine-
Measurements at the Six Consecutive Cephalometric Observations.

*Indicates statistical significance with respect to the preceding observation.

ment of the method through the definition of six stages (cer-

2.71
1.04
0.09
0.09
0.05
0.03
0.04
0.03
0.04
SE

vical stages 1 to 6) for a more practical application in dento-

facial orthopedics, and more specifically:
14.84
5.68
0.49
0.49
0.29
0.16
0.23
0.14
0.22
SD

a direct appraisal of the skeletal maturity of the mandible

T2

in relation to the morphological features of the cervical

vertebrae;
0.76*
Mean
116.40
110.32

0.36
0.12
1.26
1.77
1.25
0.71

an evaluation of the morphological features of the cervical

vertebral bodies restricted to those that are visible on the
lateral cephalogram even when a protective collar is
2.76
0.97
0.08
0.07
0.06
0.03
0.04
0.02
0.05
SE

worn, as originally proposed by Hassel and Farman20;

a definition of the cervical vertebral morphology at each
developmental stage that allows the clinician to apply
15.12
5.33
0.46
0.41
0.31
0.15
0.24
0.13
0.25
SD

the CVM method on the basis of the information derived

T1

from a single cephalogram. The assessment of individ-

ual stages in cervical vertebral maturation through the
104.67
107.85
0.44
0.01
0.03
1.35
1.85
1.34
1.83
Mean

comparative analysis of between-stage changes should

be avoided.
C2Conc (mm)
C3Conc (mm)
C4Conc (mm)

C3BAR (ratio)

C4BAR (ratio)
C3PAR (ratio)

C4PAR (ratio)

The anatomical features of the second (odontoid process),

Age (months)
Co-Gn (mm)

third, and fourth cervical vertebrae were evaluated here as

visualized on lateral cephalograms in a time interval ranging
on average from 2 years before to 2 years after the peak in
mandibular growth. The description of the consecutive
124 T. Baccetti, L. Franchi, and J.A. McNamara

Figure 2 Schematic representation of the stages of cervical vertebrae according to the newly modified method.

stages in vertebral development consisted of a noncompara- The peak in mandibular growth will occur during the year
tive definition of morphological characteristics at each obser- after this stage.
vation.
The findings of both the visual (qualitative) and cephalo- Cervical stage 4 (CS4, Fig 6). Concavities at the lower bor-
metric (quantitative) analyses revealed that a statistically sig- ders of C2, C3, and C4 now are present. The bodies of both
nificant discrimination can be made between the initial two C3 and C4 are rectangular horizontal in shape. The peak in
stages in cervical vertebral maturation only according to the mandibular growth has occurred within 1 or 2 years before
difference in depth of the concavity at the lower border of the this stage.
second cervical vertebra. A definite concavity at the lower
border of C2 is present in 80% of the subjects at cervical Cervical stage 5 (CS5, Fig 7). The concavities at the lower
stage 2. borders of C2, C3, and C4 still are present. At least one of the
The appearance of a visible concavity at the lower border of bodies of C3 and C4 is squared in shape. If not squared, the
the third cervical vertebra is the anatomic characteristic that body of the other cervical vertebra still is rectangular hori-
mostly accounts for the identification of the stage immedi- zontal. The peak in mandibular growth has ended at least 1
ately preceding the peak in mandibular growth (cervical year before this stage.
stage 3). The distinction among Cvs 4, Cvs 5, and Cvs 6 as
defined in the former CVM method is possible only by using
the shape of the bodies of C3 and/or C4 as a discriminant
factor.18

Stages of Cervical Vertebral Maturation

The stages of cervical vertebral maturation in the modified
version of the method presented here are illustrated diagram-
matically in Fig 2. The six stages are defined as follows:

Cervical stage 1 (CS1, Fig 3). The lower borders of all the
three vertebrae (C2-C4) are flat. The bodies of both C3 and
C4 are trapezoid in shape (the superior border of the verte-
bral body is tapered from posterior to anterior). The peak in
mandibular growth will occur on average 2 years after this
stage.

Cervical stage 2 (CS2, Fig 4). A concavity is present at the

lower border of C2 (in four of five cases, with the remaining
subjects still showing a cervical stage 1). The bodies of both
C3 and C4 are still trapezoid in shape. The peak in mandib-
ular growth will occur on average 1 year after this stage.

Cervical stage 3 (CS3, Fig 5). Concavities at the lower bor-

ders of both C2 and C3 are present. The bodies of C3 and C4
may be either trapezoid or rectangular horizontal in shape. Figure 3 Cervical stage 1 (CS1): two clinical examples.
The CVM method and treatment timing 125

Figure 6 Cervical stage 4 (CS4): two clinical examples.

Figure 4 Cervical stage 2 (CS2): two clinical examples. Application to Dentofacial Orthopedics
The clinical application of the method to dentofacial ortho-
pedics becomes relevant for those treatment protocols that
benefit from the inclusion of the period of accelerated man-
Cervical stage 6 (CS6, Fig 8). The concavities at the lower dibular growth. CVM method can be useful as a maturational
borders of C2, C3, and C4 still are evident. At least one of the index to detect the optimal time to start treatment of man-
bodies of C3 and C4 is rectangular vertical in shape. If not dibular deficiencies by means of functional jaw orthope-
rectangular vertical, the body of the other cervical vertebra is dics.25,26 It has been demonstrated that the effectiveness of
squared. The peak in mandibular growth has ended at least 2 functional treatment of Class II skeletal disharmony depends
years before this stage. strongly on the biological responsiveness of the condylar car-
tilage, which in turn is related to the growth rate of the man-
dible.27

Figure 5 Cervical stage 3 (CS3): two clinical examples. Figure 7 Cervical stage 5 (CS5): two clinical examples.
126 T. Baccetti, L. Franchi, and J.A. McNamara

mandibular length
Pubertal Class II Treatment (treatment includes the pubertal peak in

Net increase in

over untreated
controls
mm
mm
mm
mm
mm
mm
mm
ⴙ3.6
ⴙ3.0
ⴙ2.4
ⴙ2.7
ⴙ4.7
ⴙ3.9
ⴙ4.3

*The appraisal of treatment timing in individual studies was based upon chronologic age, hand and wrist, or CVM method. All data are short-term and refer to controlled studies.
The Effect of Treatment Timing on Supplementary Elongation of the Mandible in Class II Treatment

mandibular growth)

Class II elastics

Acrylic Herbst
Appliance

Twin-block

Twin-block

Bionator
FR-2

FR-2
Baccetti and Franchi, 200126
Lund and Sandler, 199836
198528
Petrovic et al., 199429

Baccetti et al., 200025

Figure 8 Cervical stage 6 (CS6): two clinical examples.

Franchi et al., 199937

Faltin et al., 200335

Study
McNamara et al.,
When CS1 or CS2 are diagnosed in the individual patient
with mandibular deficiency, the clinician can wait at least one
additional year for a radiographic reevaluation aimed to start
treatment with a functional appliance. The appearance of a
definite concavity at the lower border of C2 indicates that the
Table 3 Analysis of the Literature Regarding Treatment Timing for Class II Malocclusion*

growth spurt is approaching, that is, that the year of the peak
will start approximately 1 year after this stage. CS3 represents
mandibular length
Pre-Pubertal Class II Treatment (treatment ends before the pubertal

the ideal stage to begin functional jaw orthopedics, as the

Net increase in

over untreated

peak in mandibular growth will occur within the year after

controls
mm
mm
mm
mm
mm
mm
mm
mm
mm
mm
this observation. In the sample examined here, total mandib-
ular length exhibited an average increase of 5.4 mm in the
ⴙ1.2
ⴙ1.0
ⴙ1.4
ⴙ0.4
ⴙ1.8
ⴙ1.0
ⴙ0.9
ⴙ0.5
ⴙ1.6
ⴙ0.8
year following CS3, a significantly greater increment when
compared with the growth interval from CS1 to CS2 (about
2.5 mm), from CS2 to CS3 (again about 2.5 mm), and to the
postpeak between-stage intervals (1.6 mm and 2.1 mm for
peak in mandibular growth)

the intervals from CS4 to CS5 and from CS5 to CS6, respec-
tively).
Class II elastics
Appliance

Treatment Timing for Class II Malocclusion

Twin-block

Twin-block

An emerging fundamental concept underlying Class II cor-

Bionator
Bionator

Bionator

rection is that this type of intervention should be undertaken

when the likelihood for a maximum growth response is high,
FR-2

FR-2
FR-2
FR-2

that is, during the circumpubertal growth period. A series of

short-term studies has demonstrated statistically and clini-
cally significant correction of the Class II dentoskeletal rela-
Baccetti and Franchi, 200126

tionships when either functional appliances or fixed appli-

ances in combination with Class II elastics are used during
De Almeida et al., 200232
198528

the circumpubertal period (Table 3). When Class II maloc-

Petrovic et al., 199429

Baccetti et al., 200025

O’Brien et al., 200334

Keeling et al., 199831
Tulloch et al., 199730

Janson et al., 200333

clusion is treated too early (therapy starting at CS1 and com-

Faltin et al., 200335
Study
McNamara et al.,

pleted before the interval of peak velocity in mandibular

growth, ie, before CS3), the net difference in supplementary
growth of the mandible (expressed cephalometrically by the
measurement Co-Pg or Co-Gn) in the treated samples versus
untreated controls ranges between 0.4 mm and 1.8 mm (Ta-
ble 3). On the contrary, when intervention in a Class II pa-
The CVM method and treatment timing 127

tient includes the CS3-CS4 interval (growth spurt), the net Treatment Timing for Transverse Maxillary Deficiency
supplementary growth of the mandible in treated samples The issue of treatment timing for maxillary expansion aimed
versus untreated controls ranges from 2.4 mm to 4.7 mm to correct transverse maxillary deficiency has been addressed
(Table 3). The data reported in Table 3 suggest also that in in the past by Melsen44 and by Wertz and Dreskin.45 Melsen
Class II patients, the timing of therapeutic intervention has a used autopsy material to examine histologically the matura-
greater impact on supplementary elongation of the mandible tion of the midpalatal suture at different developmental
than does the type of appliance used. stages.44 In the infantile stage (up to 10 years of age), the
The only long-term study that deals with the evaluation of suture was broad and smooth, whereas in the juvenile stage
the role of treatment timing in Class II correction35 revealed (from 10 to 13 years) it had developed in a more typical
that the use of a Bionator followed by fixed appliances in squamous suture with overlapping sections. Finally, during
contrast with untreated Class II controls is able to induce a the adolescent stage (13 and 14 years of age) the suture was
supplementary elongation of the mandible of less than 2 mm wavier with increased interdigitation. From these histological
when the functional appliance is used before the peak in data, the inference is that patients who show an advanced
mandibular growth, and of about 5 mm when the growth stage of skeletal maturation at the midpalatal suture may have
spurt is included in the treatment interval. These results pos- difficulty in undergoing orthopedic maxillary expansion.
sess significance not only at the statistical level, but also at the Clinical support for the histologic findings by Melsen44 is
clinical level, as the correction of a full cusp Class II molar derived from the results of a study by Wertz and Dreskin45
relationship to Class I represents a 5 to 6 mm sagittal correc- who noted greater and more stable orthopedic changes in
tion at the level of the occlusal plane. young patients (under the age of 12 years). Either group of
researchers, however, did not use any biological indicator of
Treatment Timing for Class III Malocclusions skeletal maturity to define “early” versus “late” treatment.
Early treatment of Class III disharmony has been advocated The use of the CVM method has been applied recently to
for a long time.38 The clinical understanding that Class III the estimate of the effects of different treatment timing on the
malocclusion is established early in life and that it is not a correction of transverse maxillary deficiency.46 A sample of
self-correcting disharmony has led to the recommendation of 42 patients was compared with a control sample of 20 sub-
intervention as early as in the deciduous dentition. Cephalo- jects. Posteroanterior cephalograms were analyzed for each of
metric and morphometric investigations using Class III un- the treated subjects at T1 (pretreatment), T2 (immediate pos-
treated controls have demonstrated that treatment of Class III texpansion), and T3 (long-term observation); films were
malocclusion by means of efficient protocols (eg, maxillary available at T1 and at T3 for the controls. The mean age at T1
expansion and protraction) is more effective in the early than was 11 years and 10 months for both the treated and the
in the late mixed dentition.39-41 control groups. The mean ages at T3 also were comparable
Until recently, however, information about the possible (20 years 6 months for the treated group, and 17 years 8
role of treatment timing on long-term changes after active months for the control group). Following rapid maxillary
therapy for Class III malocclusion was not available in the expansion and retention (2 months on average), fixed stan-
literature.42 At a postpubertal observation (CS5 or CS6), dard edgewise appliances were placed. The study included
when active growth of the craniofacial skeleton is completed transverse measurements on dentoalveolar structures, max-
for the most part, Class III subjects treated with a rapid max- illary and mandibular bases, and other craniofacial regions
illary expander and a facial mask well before the growth spurt (nasal, zygomatic, orbital, and cranial).
(CS1) present with different long-term changes with respect Treated and control samples were divided into two groups
to Class III subjects treated at a later stage, that is, at the peak according to individual skeletal maturation as evaluated by
in mandibular growth (CS3). Prepubertal orthopedic treat- the CVM method. The early treated and early control groups
ment of Class III malocclusion is effective both in the maxilla consisted of subjects who had not reached the pubertal peak
(which shows a supplementary growth of about 2 mm over in skeletal growth velocity at T1 (CS1 through CS3), whereas
Class III untreated controls) and in the mandible (restriction the late-treated and late control groups were comprised of
in growth of about 3.5 mm over controls), whereas treatment subjects during or slightly after the peak at T1 (CS4 through
of Class III malocclusion at puberty is effective at the man- CS6). The group treated before the pubertal peak showed
dibular level only (restriction in growth of about 4.5 mm over significantly greater short-term increases in the width of the
controls).42 nasal cavities. In the long-term, increments in maxillary skel-
The findings in the maxilla have a biological explanation in etal width, maxillary intermolar width, lateronasal width,
the physiology of the circummaxillary sutures, which are and latero-orbitale width were significantly greater in the
more amenable to orthopedic intervention during the early early-treated group when compared with the corresponding
stages, whereas they become more heavily interdigitated control group. The late-treated group exhibited significant
around puberty.43 On the other hand, the possibility of re- increases in lateronasal width and in maxillary and mandib-
stricting mandibular growth both before and during puberty ular intermolar widths. The use of the CVM method demon-
gives the clinician the chance of resuming facemask therapy strated that rapid maxillary expansion before the peak in
at a later time when correction of Class III relationships is skeletal growth velocity is able to induce more pronounced
only partial after the prepubertal intervention. transverse craniofacial changes at the skeletal level. Treat-
128 T. Baccetti, L. Franchi, and J.A. McNamara

ment changes are more dentoalveolar in nature when expan- effective in the mandible during both prepubertal and
sion is performed during or after the peak. pubertal stages;
3. skeletal effects of rapid maxillary expansion for the cor-
Treatment Timing for Increased Vertical Dimension
rection of transverse maxillary deficiency are greater at
The CVM method also has been applied to the appraisal of
prepubertal stages, while pubertal or postpubertal use
ideal treatment timing for a specific therapeutic protocol for
of the rapid maxillary expander entails more dentoal-
the correction of vertical excess of the face by means of a
veolar effects; and
bonded rapid maxillary expander in association with a verti-
4. deficiency of mandibular ramus height can be en-
cal-pull chincup. One of the goals of orthopedic treatment in
hanced significantly in subjects with increased vertical
subjects with increased vertical dimension is the control of
facial dimension when orthopedic treatment is per-
the vertical growth of the mandibular ramus (expressed
formed at the peak in mandibular growth (CS3).
cephalometrically by the measure Co-Go). Available short-
term data from our research group show that a significantly
To summarize, effects of therapies aimed to enhance/re-
more favorable effect can be obtained when treatment is per-
strict mandibular growth appear to be of greater magnitude at
formed at CS3, that is, at the peak in mandibular growth,
the circumpubertal period during which the growth spurt
when compared with treatment performed at an earlier mat-
occurs in comparison to earlier intervention, while effects of
urational stage (CS1). No significant increase in ramal height
is observed in hyperdivergent subjects treated at CS1, therapies aimed to alter the maxilla orthopedically (maxillary
whereas a significant increase of about 2 mm more than in protraction/maxillary expansion) are greater at prepubertal
untreated controls is recorded in hyperdivergent subjects stages.
who receive orthopedic treatment at CS3. The CVM method can be helpful for the assessment of
completion of active growth in studies dealing with the long-
term effects of orthodontic/orthopedic treatment strategies.
Final Remarks Similarly, the method can be used to identify clinically the
The CVM method is comprised of six maturational stages adequate time for intervention in subjects who need surgery
(cervical stage 1 through cervical stage 6, CS1-CS6), with the for the late correction of facial disharmonies.
peak in mandibular growth occurring between CS3 and CS4. Due to its practical applications, the CVM method appears
The pubertal peak has not been reached without the attain- to be a powerful diagnostic tool. The implementation of the
ment of both CS1 and CS2. In particular, the detection of CS2 method in orthodontic decision making allows for an im-
indicates that the growth spurt is approaching, and it will provement of treatment outcomes by combining effective
start at CS3, which is approximately 1 year after CS2. Active and efficient protocols with optimal treatment timing.
growth is virtually completed when the CS6 is attained.
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