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Abstract: The present study aimed to provide a 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 (odontoid
process, C2), third (C3), and fourth (C4) cervical vertebrae were analyzed in six consecutive cephalometric
observations (T1 through T6) of 30 orthodontically untreated subjects. Observations for each subject con-
sisted of two consecutive cephalograms comprising the interval of maximum mandibular growth (as as-
sessed by means of the maximum increment in total mandibular length, Co-Gn), together with two earlier
consecutive cephalograms and two later consecutive cephalograms. The analysis consisted of both visual
and cephalometric appraisals of morphological characteristics of the three cervical vertebrae. The construc-
tion of the new version of the CVM method was based on the results of both ANOVA for repeated
measures with post-hoc Scheffé’s test (P , .05) and discriminant analysis. The new CVM method presents
with five maturational stages (Cervical Vertebral Maturation Stage [CVMS] I through CVMS V, instead
of Cvs 1 through Cvs 6 in the former CVM method). The peak in mandibular growth occurs between
CVMS II and CVMS III, and it has not been reached without the attainment of both CVMS I and CVMS
II. CVMS V is recorded at least two years after the peak. The advantages of the new version of the CVM
method are that mandibular skeletal maturity can be appraised on a single cephalogram and through the
analysis of only the second, third, and fourth cervical vertebrae, which usually are visible even when a
protective radiation collar is worn. (Angle Orthod 2002;72:316–323.)
Key Words: Cervical vertebrae; Cephalometrics; Mandibular growth; Skeletal maturity; Maturational
indices
TABLE 1. Results of Qualitative Analysis of Cervical Vertebral (C2-C4) Characteristics at the Six Consecutive Observations (T1–T6)*
T1 T2
Yes No Yes No
Concavity at the lower border of C2 7 23 22 8
(23.3%) (76.7%) (73.3%) (26.7%)
Concavity at the lower border of C3 0 30 2 28
(0%) (100%) (6.7%) (93.3%)
Concavity at the lower border of C4 0 30 0 30
(0%) (100%) (0%) (100%)
C3 Shape: trapezoid 30 0 29 1
(100%) (0%) (96.7%) (3.3%)
C4 shape: trapezoid 30 0 26 4
(100%) (0%) 86.7% (13.3%)
C3 shape: rectangular horiz. 0 30 1 29
(0%) (100%) (3.3%) (96.7%)
C4 shape: rectangular horiz 0 30 4 26
(0%) (100%) (13.3%) (86.7%)
C3 shape: squared 0 30 0 30
(0%) (100%) (0%) (100%)
C4 shape: squared 0 30 0 30
(0%) (100%) (0%) (100%)
C3 shape: rectangular vert 0 30 0 30
(0%) (100%) (0%) (100%)
C4 shape: rectangular vert 0 30 0 30
(0%) (100%) (0%) (100%)
* Horiz indicates horizontal; and vert, vertical.
Table 1. Extended
T3 T4 T5 T6
Yes No Yes No Yes No Yes No
30 0 30 0 30 0 30 0
(100%) (0%) (100%) (0%) (100%) (0%) (100%) (0%)
28 2 28 2 29 1 30 0
(93.3%) (6.7%) (93.3%) (6.7%) (96.7%) (3.3%) (100%) (0%)
3 27 26 4 29 1 30 0
(10%) (90%) (86.7%) (13.3%) (96.7%) (3.3%) (100%) (0%)
23 7 0 30 0 30 0 30
(76.7%) (23.3%) (0%) (100%) (0%) (100%) (0%) (100%)
15 15 0 30 0 30 0 30
(50%) (50%) (0%) (100%) (0%) (100%) (0%) (100%)
7 23 30 0 12 18 0 30
(23.3%) (76.7%) (100%) (0%) (40%) (60%) (0%) (100%)
15 15 30 0 14 16 0 30
(50%) (50%) (100%) (0%) (46.7%) (53.3%) (0%) (100%)
0 30 0 30 18 12 15 15
(0%) (100%) (0%) (100%) (60%) (40%) (50%) (50%)
0 30 0 30 16 14 16 14
(0%) (100%) (0%) (100%) (53.3%) (46.7%) (53.3%) (46.7%)
0 30 0 30 0 30 15 15
(0%) (100%) (0%) (100%) (0%) (100%) (50%) (50%)
0 30 0 30 0 30 14 16
(0%) (100%) (0%) (100%) (0%) (100%) (46.7%) (53.3%)
Statistical analysis
The significance of the prevalence rates for the morpho-
logic characteristics of the cervical vertebrae was evaluated
at each observation time by means of Chi-square test with
Yates’ correction (P , .05). Descriptive statistics were ob-
tained for total mandibular length and for vertebral cepha-
lometric measures at each of the six consecutive observa-
FIGURE 2. Cephalometric landmarks for the quantitative analysis of tions (T1 through T6). The differences between the mean
the morphologic characteristics in the bodies of C2, C3, and C4. values for all the computed variables at the six consecutive
TABLE 2. Results of Quantitative Analysis: Descriptive Statistics and Statistical Comparisons (ANOVA for Repeated Measurements With post-
hoc Scheffe’s test) on the Measurements at the Six Consecutive Cephalometric Observations (T1-T6)*
T1 T2 T3
Mean SD SEM Mean SD SEM Mean SD SEM
Age (months) 104.67 15.12 2.76 116.40 14.84 2.71 128.73 14.99 2.74
Co-Gn (mm) 107.85 5.33 0.97 110.32 5.68 1.04 112.63 5.78 1.06
C2Conc (mm) 0.44 0.46 0.08 0.76 0.49 0.09 1.15† 0.44 0.08
C3Conc (mm) 0.01 0.41 0.07 0.36 0.49 0.09 0.95† 0.53 0.10
C4Conc (mm) 0.03 0.31 0.06 0.12 0.29 0.05 0.31 0.39 0.07
C3PAR (ratio) 1.35 0.15 0.03 1.26 0.16 0.03 1.16† 0.12 0.02
C3BAR (ratio) 1.85 0.24 0.04 1.77 0.23 0.04 1.61† 0.15 0.03
C4PAR (ratio) 1.34 0.13 0.02 1.25 0.14 0.03 1.15† 0.17 0.03
C4BAR (ratio) 1.83 0.25 0.05 0.71 0.22 0.04 1.59 0.21 0.04
* SD indicates standard deviation; and SE, standard error of mean.
† Statistically significant with respect to preceding observation.
stages were tested for significance by means of ANOVA with the nonsignificant exceptions of 3.3% and 13.3%
for repeated measurements with post-hoc Scheffé’s test (P of the subjects showing rectangular horizontal bodies
, .05). for C3 and C4, respectively.
The cephalometric measurements of the bodies of cer- T3. A concavity is present at the lower border of C2 (100%
vical vertebrae at each interval between consecutive ceph- of the subjects) and of C3 (with the nonsignificant ex-
alograms were analyzed by means of a multivariate statis- ception of 6.7% of the cases). No concavity is present
tical approach using a discriminant analysis to identify at the lower border of C4 (with the nonsignificant ex-
those vertebral morphologic variables mostly accounting ception of 10% of the cases). The shape of both C3
for the differences between two consecutive observations. and C4 may be either trapezoid or rectangular horizon-
A stepwise variable selection (forward selection procedure) tal.
was performed with the goal of obtaining a model with the T4. This observation is characterized by the presence of a
smallest set of significant cephalometric variables (F to en- concavity at the lower borders of C2, C3 (with the
ter and to remove 5 4). Finally, the classifying power of nonsignificant exception of 6.7% of the cases), and C4
selected cephalometric variables was tested. All statistical (with the nonsignificant exception of 13.3% of the cas-
computations were performed by means of computer soft- es). The bodies of both C3 and C4 now are rectangular
ware (SPSS for Windows, release 10.0.0, SPSS Inc, Chi- horizontal in shape (100% of the subjects).
cago, Ill). T5. A concavity is present at the lower borders of C2, C3
(with the nonsignificant exception of 3.3% of the cas-
RESULTS es), and C4 (with the nonsignificant exception of 3.3%
The findings of the visual analysis of the morphologic of the cases). The body of C3 is rectangular horizontal
characteristics of cervical vertebrae (C2, C3, C4) are re- in 40% of the cases and squared in the remaining sub-
ported in Table 1. The features of the examined vertebrae jects. The body of C4 is rectangular horizontal in
at the six consecutive observations can be summarized as 46.7% of the cases and squared in the remaining sub-
follows: jects.
T6. A concavity is present at the lower borders of all 3
T1. A concavity already is evident at the lower border of examined cervical vertebrae. The body of C3 is
C2 in 23.3% of the subjects. This percentage is signif- squared in 50% of the cases and rectangular vertical in
icant (Chi-square 5 5.82; P 5 .016). The concavity is the remaining 50% of the cases. The body of C4 is
absent at the lower borders of both C3 and C4 in 100% squared in 53.3% of the cases and rectangular vertical
of the subjects. The bodies of both C3 and C4 are in the remaining cases.
trapezoid in shape.
T2. A concavity is present at the lower border of C2 in Descriptive statistics for cephalometric measurements of
73.3% of the subjects. However, the prevalence rate of vertebral morphologic characteristics are reported in Table
subjects who do not show a concavity at the lower 2, together with the statistical comparisons between con-
border of C2 is significant (Chi-square 5 7.07; P 5 secutive observations. No significant differences for any of
.008). The observation at T2 is characterized by the the measurements were assessed between T1 and T2. The
absence of a concavity at the lower borders of C3 (with depth of the concavities at the lower borders of both the
the nonsignificant exception of 6.7% of the subjects) second (C2Conc) and the third (C3Conc) cervical vertebra
and of C4. Both C3 and C4 still are trapezoid in shape, was significantly greater at T3 when compared to T2. In the
TABLE 2. Extended
T4 T5 T6
Mean SD SEM Mean SD SEM Mean SD SEM
141.17 14.42 2.63 153.30 14.41 2.63 166.00 13.83 2.53
118.05† 5.83 1.06 119.63 5.91 1.08 121.77 5.93 1.08
1.58† 0.37 0.07 1.91 0.40 0.07 2.23 0.48 0.09
1.36 0.64 0.12 1.85 0.60 0.11 2.40† 0.68 0.12
1.07† 0.53 0.10 1.77† 0.60 0.11 2.28† 0.63 0.11
0.98† 0.08 0.01 0.98 0.06 0.01 0.99 0.06 0.01
1.39† 0.14 0.02 1.20† 0.15 0.03 1.03† 0.13 0.02
1.01† 0.06 0.01 1.008 0.07 0.01 0.97 0.05 0.01
1.36† 0.12 0.02 1.19† 0.18 0.03 1.04 0.12 0.02
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