1. Skeletal Maturity Indexes
Growth prediction

2. Outline

3. Outline
Growth prediction in Orthodontics
Skeletal Maturity Index
Hand-wrist radiographs
Greulich and Pyle (1959)
Fishman LH (1982)
Björk (1972) and Grave and Brown (1976)
Hagg and Tanranger method (1982)
Reviews of related studies
Cervical vertebra maturation
Hassel and Farman (1995)
Baccetti et al.(2005)
Reviews of related studies
Dental age
Reviews of related studies

4. Growth Prediction in
orthodontics
In orthodontic treatment planning, knowledge of
facial growth velocity and percentage of facial
growth remaining is very important for effective
growth modification interventions.
Assessment of skeletal maturation is essential in
planning individual orthodontic treatment because
of marked individual variations in timing, duration,
and intensity of pubertal growth.
Use of cervical vertebral maturation to determine skeletal age
Ricky W. K. Wong,a Hessa A. Alkhal,b and A. Bakr M. Rabiec
(Am J Orthod Dentofacial Orthop 2009;136:484.e1-484.e6)

5. Growth Prediction in orthodontics
Clinical decisions regarding
functional appliances or
orthognathic surgeries are
modulated by the patient’s
degree of physiological
maturity.

6. Growth Prediction in orthodontics
Many studies have shown an association between
peak velocity of facial growth and peak velocity
of statural growth during puberty (Bergerson EO.
1972; Singh J1 et al.1967; Fishman LS.1979)
Thompson G et al. (1974) demonstrated that the
pattern of mandibular growth coincides with body
height growth in adolescents

7. Growth Prediction in orthodontics
General skeletal maturity usually is used as an
indicator to predict timing of mandibular growth
velocity peak

8. Growth Prediction in orthodontics
chronological age alone is considered a poor
indicator of the level of skeletal maturity due to
significant individual growth variation (Roche AF.
1978.;Fishman LS 1979.)

9. Growth Prediction in orthodontics
Growth prediction can be assessed using physiological
parameters such as
Peak growth velocity in standing height
Pubertal markers ( voice change in male,menarche in
female etc. )
Dental development
Radiological analysis of skeletal maturation.
Hand-wrist radiographs
Lateral cephalometric radiographs assessment cervical
vertebral maturation

10. Growth Prediction in orthodontics
Secondary sexual characteristics and physical body
measurements , cannot be used to predict the timing
of maximum growth due to their retrospective nature
(Bjork A., Helm S. 1967)
Dental development indicators are not reliable
predictors of an individual’s stage of skeletal
development. (Demirjian A et al.,1985;Chertkow S.,
1980)

11. Skeletal Maturity Index
Hand-wrist radiographs
cervical vertebral maturation

12. Hand-wrist radiographs

13. Hand-wrist radiographs
The hand-wrist radiograph is
considered to be the most
standardized method of skeletal
maturation assessment ( Hassel
B,Farman AG,1995.;Gandini P et
al.2006)
Assessment based upon time
and the sequence of appearance
of the carpal bones and certain
ossification events

14. Hand-wrist radiographs
The ossification sequence and
timing of the skeletal maturity
within the hand-wrist area
show polymorphism and sexual
dimorphism. (Bowden BD
1976;Houston WJ 1980;Smith
RJ 1980;Garn SM et al 1966)
Hand-wrist radiograph of male
patient provide more valuable
information for orthodontic
treatment (Smith 1980)

15. Hand-wrist radiographs
The usual means by which to assess the hand-wrist
radiograph are
The comparison atlas of Greulich and Pyle (1959)
The processes that use specific indicators that
relate skeletal maturation to the pubertal growth
curve, such as the methods described by
Bjork (1972),
Fishman (1982),
Hagg and Taranger (1982)

16. Greulich and Pyle (1959)

17. Greulich and Pyle (1959)

18. Greulich and Pyle (1959)

19. Greulich and Pyle (1959)

20. Greulich and Pyle (1959)

21. Greulich and Pyle (1959)

22. Radiographic evaluation of Skeletal maturity
A clinically orient method based on Hand-wrist films
Leonard S. Fishman, Angle orthodontist Vol. 52,No.2,April 1982

23. Björk’s method of assessment
Bjork utilized certain anatomical sites located on
the phalanges, abductor sesamoid, carpal and
radius bone, which have predictable and consistent
time of onset of ossification.

24. Method of Björk (1972)
Skeletal maturation of each hand-wrist radiograph 9 stages
Stage 1 (PP2): Epiphysis of proximal phalanx of index finger (PP2) is
same width as diaphysis
Stage 2 (MP3): Epiphysis of middle phalanx of middle finger (MP3) is
same width as diaphysis
Stage 3 (Pisi-H1-R): Pisi, visible ossification of pisiform; H1: ossification
of the hamular process of the hamatum; R, same width of epiphysis
and diaphysis of radius
Stage 4 (S-H2): S, first mineralization of ulnar sesamoid bone of
metacarpophalangeal joint of hamatum; H2, progressive ossification of
hamular process of hamatum
Chronologic age and skeletal maturation of the cervical vertebrae and hand-wrist: Is there a relationship?
Tancan Uysal,a Sabri Ilhan Ramoglu,b Faruk Ayhan Basciftci,c and Zafer Saric, Kayseri and Konya, Turkey
(Am J Orthod Dentofacial Orthop 2006;130:622-8)

25. Method of Björk (1972)
Skeletal maturation of each hand-wrist radiograph 9 stages (method of
Björk and Grave and Brown)
Stage 5 (MP3cap-PP1cap-Rcap): Diaphysis is covered by cap-shaped
epiphysis; in MP3cap, process begins at middle phalanx of third finger; in
PP1cap, at proximal phalanx of thumb; in Rcap, at radius
Stage 6 (DP3u): Visible union of epiphysis and diaphysis at distal phalanx of
middle finger (DP3)
Stage 7 (PP3u): Visible union of epiphysis and diaphysis at proximal phalanx
of little finger (PP3)
Stage 8 (MP3u): Union of epiphysis and diaphysis at middle phalanx of middle
finger is clearly visible (MP3)
Stage 9 (Ru): Complete union of epiphysis and diaphysis of radius
Chronologic age and skeletal maturation of the cervical vertebrae and hand-wrist: Is there a relationship?
Tancan Uysal,a Sabri Ilhan Ramoglu,b Faruk Ayhan Basciftci,c and Zafer Saric, Kayseri and Konya, Turkey
(Am J Orthod Dentofacial Orthop 2006;130:622-8)

26. Method of Björk (1972)
Bjork 9 stages of skeletal maturation were reduced
to five intervals and ranked 1 to 5 according to
growth completion.
1.Growth preceeding acceleration = Bjork stage 1-3
2.Stage of growth acceleration = Bjork stage 4
3.Stage of peak growth = Bjork stage 5
4.Stage of growth deceleration = Bjork stage 6-7
5.Stage of growth completion = Bjork stage 8-9

27. Skeletal maturation determine
by cervical vertebrae
development.
Paloma San Roman et al.
European Journal of
Orthodontic 24 (2002) 303-311

28. Skeletal Maturation Assessment
(SMA) L.Fishman (1982)
Based on the observation of
ossification events localized in
the area of the finger
phalanges, carpal bone and
radius.
There is a close correlation
between sequence of hand-
wrist ossification and
mandibular growth status
Radiographic evaluation of Skeletal maturity
A clinically orient method based on Hand-wrist films
Leonard S. Fishman, Angle orthodontist Vol. 52,No.2,April 1982

29. Skeletal Maturation Assessment
(SMA) L.Fishman (1982)
Radiographic evaluation of Skeletal maturity
A clinically orient method based on Hand-wrist films
Leonard S. Fishman, Angle orthodontist Vol. 52,No.2,April 1982

30. Skeletal Maturation Assessment
(SMA) L.Fishman (1982)
SMI 1: The third finger proximal phalanx shows equal width of
epiphysis and diaphysis(PP3width)
SMI 2: Width of epiphysis equal to that of diaphysis in the middle
phalanx of third finger(MP3Width)
SMI 3: Width of epiphysis equal to that of diaphysis in the middle
phalanx of fifth finger (MP5Width)
SMI 4: Appearance of adductor sesamoid of the thumb (S)
Radiographic evaluation of Skeletal maturity
A clinically orient method based on Hand-wrist films
Leonard S. Fishman, Angle orthodontist Vol. 52,No.2,April 1982

31. Skeletal Maturation Assessment
(SMA) L.Fishman (1982)
SMI 5: Capping of epiphysis seen in distal phalanx of third
finger(DP3cap)
SMI 6: Capping of epiphysis seen in middle phalanx of third
finger(MP3cap)
SMI 7: Capping of epiphysis seen in middle phalanx of fifth
finger(MP5cap)
Radiographic evaluation of Skeletal maturity
A clinically orient method based on Hand-wrist films
Leonard S. Fishman, Angle orthodontist Vol. 52,No.2,April 1982

32. Skeletal Maturation Assessment
(SMA) L.Fishman (1982)
SMI 8: Fusion of epiphysis and diaphysis in the distal phalanx of
third finger(DP3fuse)
SMI 9: Fusion of epiphysis and diaphysis in proximal phalanx of
third finger (PP3fuse)
SMI 10: Fusion of epiphysis and diaphysis in middle phalanx of third
finger (MP3fuse)
SMI 11: Fusion of epiphysis and diaphysis seen in the radius (Rfuse)
Radiographic evaluation of Skeletal maturity
A clinically orient method based on Hand-wrist films
Leonard S. Fishman, Angle orthodontist Vol. 52,No.2,April 1982

33. Skeletal Maturation Assessment
(SMA) L.Fishman (1982)
Accelerating growth velocity period = SMI 1-4
High growth velocity period = SMI 4-7
Decelerating growth velocity period = SMI 7-11

34. Skeletal Maturation Assessment (SMA)
L.Fishman (1982)
PP3width appears approximately 3
years before the peak of pubertal
growth spurt(SMI 1)
Ossification of adductor sesamoid of
thumb (S) occurs shortly before or at
the beginning of the pubertal growth
spurt. (SMI 4)
The MP3cap stage marks the peak of
the pubertal growth.(SMI 6)
Mandibular Pubertal Growth Spurt Prediction. Part One: Method Based on the Hand-Wrist Radiographs
Antana S et al. Stomatologija, Baltic Dental and Maxillofacial Journal, 7:16-20, 2005

35. Skeletal Maturation Assessment (SMA)
L.Fishman (1982)
PP3width appears approximately 3
years before the peak of pubertal
growth spurt(SMI 1)
Ossification of adductor sesamoid of
thumb (S) occurs shortly before or at
the beginning of the pubertal growth
spurt. (SMI 4)
The MP3cap stage marks the peak of
the pubertal growth.(SMI 6)
Mandibular Pubertal Growth Spurt Prediction. Part One: Method Based on the Hand-Wrist Radiographs
Antana S et al. Stomatologija, Baltic Dental and Maxillofacial Journal, 7:16-20, 2005

36. Skeletal Maturation Assessment (SMA)
L.Fishman (1982)
PP3width appears approximately 3
years before the peak of pubertal
growth spurt(SMI 1)
Ossification of adductor sesamoid of
thumb (S) occurs shortly before or at
the beginning of the pubertal growth
spurt. (SMI 4)
The MP3cap stage marks the peak of
the pubertal growth.(SMI 6)
Mandibular Pubertal Growth Spurt Prediction. Part One: Method Based on the Hand-Wrist Radiographs
Antana S et al. Stomatologija, Baltic Dental and Maxillofacial Journal, 7:16-20, 2005

37. Skeletal Maturation Assessment (SMA)
L.Fishman (1982)
Union of epiphysis and diaphysis at
the distal phalanx of the middle
finger (DP3fusion) signify the end of
pubertal growth. (SMI 8)
Complete union of epiphysis and
diaphysis of the radius (R fusion)
indicate that skeletal growth is
finished. (SMI 11)
Mandibular Pubertal Growth Spurt Prediction. Part One: Method Based on the Hand-Wrist Radiographs
Antana S et al. Stomatologija, Baltic Dental and Maxillofacial Journal, 7:16-20, 2005

38. Skeletal Maturation Assessment (SMA)
L.Fishman (1982)
Union of epiphysis and diaphysis at
the distal phalanx of the middle
finger (DP3fusion) signify the end of
pubertal growth. (SMI 8)
Complete union of epiphysis and
diaphysis of the radius (R fusion)
indicate that skeletal growth is
finished. (SMI 11)
Mandibular Pubertal Growth Spurt Prediction. Part One: Method Based on the Hand-Wrist Radiographs
Antana S et al. Stomatologija, Baltic Dental and Maxillofacial Journal, 7:16-20, 2005

39. Hagg and Taranger Method(1982)
MP3 Ossification Stages: Hagg and Taranger Method
1. MP3-E stage: Epiphysis is 3/4 wide as diaphysis.
2. MP3-F stage: Start of the curve of pubertal growth spurt Epiphysis is as wide as
metaphysis. Radiolucent gap between epiphysis and metaphysis is wide.
3. MP3-FG stage: Acceleration of the curve of pubertal growth spurt.Distinct medial
and/or lateral border of epiphysis forms line of demarcation at right angle to distal
border.
4. MP3-G stage: Maximum point of pubertal growth spurt Sides of epiphysis have
thickened and cap its metaphysis, forming sharp distal edge on one or both sides.
Marked undulations in metaphysis give it “Cupid’s bow” appearance.
5. MP3-H stage: Deceleration of the curve of pubertal growth spurt.Fusion of epiphysis
and metaphysis begins. Radiolucent gap between epiphysis and metaphysic is narrower.
6. MP3-I stage: End of pubertal growth spurt Fusion of epiphysis and metaphysis
complete

40. Skeletal maturation evaluation using cervical vertebrae
Brent Hassel, BA, DDS, MS, and Allan G. Farman, BDS, PhD(odont), Dip ABOMR, EdS, MBA
(AMJ ORTHOD DENTOFAC ORTHOP 1995;107:58-66.)

41. Conclusion
MP3cap
MP3width S
Ru

42. Conclusion
MP3cap
MP3width S
Ru

43. Conclusion
MP3cap
MP3width S
Ru

44. Conclusion
MP3cap
MP3width S
Ru

45. Use of Skeletal Maturation Based on Hand-Wrist Radiographic Analysis
as a Predictor of Facial Growth: A Systematic Review
Carlos Flores-Mir, DDS, MSc, Cert Orth, PhDa; Brian Nebbe, BDS, Mdent, FFD(SA)Ortho, PhDb; Paul W. Major, DDS, MSc, MRCD(c)
The purpose of this systematic review was to evaluate the predictive value of hand-
wrist radiographic assessment of skeletal maturity in estimating facial growth
timing and velocity.
A search of PubMed, Medline, Cochrane Database of Systematic Reviews, Embase,
Web of Sciences, and Lilacs
16 articles that met the following inclusion criteria:
use of hand-wrist radiographs for skeletal maturation determination
facial growth evaluated through cephalometric radiographs
and cross-sectional or longitudinal studies.
Five articles were rejected because of major methodological issues. Most of the
remaining articles had small sample size, and there was no report of randomization
or method error.
Angle Orthod 2004;74:118–124.

46. USE OF SKELETAL MATURATION BASED ON HAND-WRIST RADIOGRAPHIC ANALYSIS
AS A PREDICTOR OF FACIAL GROWTH: A SYSTEMATIC REVIEW
CARLOS FLORES-MIR, DDS, MSC, CERT ORTH, PHDA; BRIAN NEBBE, BDS, MDENT, FFD(SA)ORTHO, PHDB; PAUL W. MAJOR, DDS, MSC, MRCD(C)
Angle Orthod 2004;74:118–124.

47. USE OF SKELETAL MATURATION BASED ON HAND-WRIST RADIOGRAPHIC ANALYSIS
AS A PREDICTOR OF FACIAL GROWTH: A SYSTEMATIC REVIEW
CARLOS FLORES-MIR, DDS, MSC, CERT ORTH, PHDA; BRIAN NEBBE, BDS, MDENT, FFD(SA)ORTHO, PHDB; PAUL W. MAJOR, DDS, MSC, MRCD(C)
Skeletal maturity determined by hand-wrist
radiographic analysis was well related to overall facial
growth velocity.
Maxillary and mandibular growth velocities were
related to skeletal maturity, but their relationship was
less robust than that for overall facial growth.
Angle Orthod 2004;74:118–124.

48. Reliability of growth prediction with hand–wrist radiographs
Damian Verma, Timo Peltomäki and Andreas Jäger
The aim of this study was to investigate the validity of
hand–wrist radiographic analysis in estimating the amount of
remaining craniofacial growth.
The material and method
cephalograms of 22 males and 27 females with a Class I
malocclusion.
The median age of the females at the beginning (T1) was
11 years 10 months and at the end (T2) of treatment 14
years 7 months
The median age of the males at the beginning (T1) was
12 years 6 months and at the end (T2) of treatment 15
years 3 months, respectively.
European Journal of Orthodontics 31 (2009) 438–442

49. Reliability of growth prediction with hand–wrist radiographs
Damian Verma, Timo Peltomäki and Andreas Jäger
The results showed a highly significant correlation between
statural growth increases and growth prediction assessed from the
hand–wrist radiographs (females: r = 0.68; males: r = 0.7).
Concerning craniofacial structures, the increase in mandibular
corpus (Go-Gn) showed the highest correlation with growth
prediction (females: r = 0.21; males: r = 0.52), but this association
would not allow a reliable growth prediction.
There was no significant correlation between growth increases of
the cranial base, the maxilla, the ramus, and the effective length
of the mandible (Co-Gn) and growth prediction assessed with the
help of hand–wrist radiographs.
European Journal of Orthodontics 31 (2009) 438–442

50. Reliability of growth prediction with hand–wrist radiographs
Damian Verma, Timo Peltomäki and Andreas Jäger
As each patient has an individual growth pattern and different
craniofacial structures show individual growth potential, it is
questionable if quantitative craniofacial growth prediction with
the help of hand–wrist radiographs is reliable.
However, in an individual case for the assessment of the timing
of the growth process, a hand–wrist radiograph can contribute
to treatment planning.
European Journal of Orthodontics 31 (2009) 438–442

51. Cervical Vertebral Maturation method(CVM)
The cervical vertebral maturation method has proved effective in
assessing the adolescent growth peak both in body height and
mandibular size.
Hellsing (1991) found significant correlation between height and
length of the cervical vertebral bodies and statural height.
Mitani and Sato (1992) reported changes in the cervical vertebrae
correlated significantly with increases in mandibular size.
Mappes et al (1992) indicated that predominant ethnic origin,
climate, nutrition, socioeconomic level, and urbanization are
causative factors of these racial variations.

52. Cervical Vertebral Maturation method(CVM)
The cervical vertebral maturation method has proved effective
in assessing the adolescent growth peak both in body height
and mandibular size.
Hassel and Farman (1995) and Garcia-Fernandez et al (1998)
found high correlations between cervical vertebral
maturation and the skeletal maturation of the hand-wrist.
Franchi and coworkers (2000) confirmed the validity of six
CVM stages as a biologic indicator for both mandibular and
somatic skeletal maturity in 24 growing untreated subjects

53. Cervical Vertebral Maturation method (CVM)
Lamparski (1972) created method analyzed size and shape
changes in the bodies of five cervical vertebrae (from the
second one through the sixth).
Thereafter, several cervical vertebral maturation (CVM)
methods were proposed, and some modifications were made
and improvements achieved.

54. Cervical Vertebral Maturation method(CVM)
Hassel and Farman (1995) compiled a new index of CVM,
evaluated the second, third, and fourth cervical vertebrae.
Baccetti et al (2002) devised new CVM method,comprised of
five maturationa stage (CVMS I through CVMS V instead of
Cvs 1 through Cvs 6 in the former CVM method)
Baccetti et al (2005) present a further modified and refined
version of the CVM method

55. Hassel and Farman(1995)
Six stages in evaluation of cervical vertebrae maturation according to method of Hassel and Farman(1995)
I.Initiation stage (CVMI 1) Very significant amount of adolescent growth expected C2, C3, and C4
inferior vertebral body borders are flat Superior vertebral borders are tapered posterior to anterior
II. Acceleration stage (CVMI 2) Significant amount of adolescent growth expected Concavities
developing in lower borders of C2 and C3 Lower border of C4 vertebral body is flat C3 and C4 are more
rectangular in shape
III.! Transition stage (CVMI 3) Moderate amount of adolescent growth expected Distinct concavities
in lower borders of C2 and C3 C4 developing concavity in lower border of body C3 and C4 are
rectangular in shape
IV. Deceleration stage (CVMI 4) Small amount of adolescent growth expected Distinct concavities in
lower borders of C2, C3, and C4 C3 and C4 are nearly square in shape
V. Maturation stage (CVMI 5) Insignificant amount of adolescent growth expected Accentuated
concavities of inferior verte- bral body borders of C2, C3, and C4 C3 and C4 are square in shape
VI. Completion stage (CVMI 6) Adolescent growth is completed Deep concavities are present for
inferior vertebral body borders of C2, C3, and C4 C3 and C4 heights are greater than widths

56. Hassel and Farman(1995)
I.Initiation stage (CVMI 1) Very significant
amount of adolescent growth expected
C2, C3, and C4 inferior vertebral body
borders are flat Superior vertebral
borders are tapered posterior to
anterior
II. Acceleration stage (CVMI 2) Significant
amount of adolescent growth expected
Concavities developing in lower borders
of C2 and C3 Lower border of C4
vertebral body is flat C3 and C4 are
more rectangular in shape

57. Hassel and Farman(1995)
III.! Transition stage (CVMI 3) Moderate
amount of adolescent growth expected
Distinct concavities in lower borders of C2
and C3 C4 developing concavity in lower
border of body C3 and C4 are rectangular
in shape
IV. Deceleration stage (CVMI 4) Small amount
of adolescent growth expected
Distinct concavities in lower borders of
C2, C3, and C4 C3 and C4 are nearly
square in shape

58. Hassel and Farman(1995)
V. Maturation stage (CVMI 5) Insignificant
amount of adolescent growth expected
Accentuated concavities of inferior
vertebral body borders of C2, C3, and
C4 C3 and C4 are square in shape
VI. Completion stage (CVMI 6) Adolescent
growth is completed
Deep concavities are present for
inferior vertebral body borders of C2,
C3, and C4 C3 and C4 heights are
greater than widths

59. Hassel and Farman

60. Baccetti et al 2002
An Improved Version of the Cervical Vertebral Maturation (CVM) Method for
the Assessment of Mandibular Growth (Angle Orthod 2002;72:316–323.)

61. 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 aim of the present article is
to present a further modified and refined version
of the CVM method and
its validity for the appraisal of mandibular skeletal
maturity in the individual patient in light of the
findings of recent studies in which the CVM
method has been used to assess optimal timing
for the treatment of malocclusions in the
transverse, sagittal, and vertical planes of space.
Semin Orthod 11:119–129 © 2005

62. 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.
Subjects and Methods
The total 30 sujects (18 males, 12 females) that comprises the cephalometric files of the University of
Michigan Elementary and Secondary School Growth Study was evaluated.
Total mandibular length (Co-Gn) was measured on the longitudinal sets of lateral cephalograms
The maximum increase in Co-Gn between two consecutive annual cephalograms was used to define the
peak in mandibular growth at puberty in the individual subjects. Two consecutive cephalograms comprising
the interval of maximum mandibular growth, together with two earlier consecutive cephalograms and two
later consecutive cephalograms,
The morphology of the bodies of the second (C2 odontoid process), third (C3), and fourth (C4) cervical
vertebrae were analyzed in the six consecutive annual observations (T1 through T6). The analysis consisted
of both visual and cephalometric appraisals of morphological characteristics of the cervical vertebrae.
Semin Orthod 11:119–129 © 2005

63. 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.
Semin Orthod 11:119–129 © 2005

64. Baccetti et al 2005
Cervical stage 1
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 vertebral body is
tapered from posterior to
anterior).
The peak in mandibular growth will
occur on average 2 years after this
stage.

65. Baccetti et al 2005
Cervical stage 2
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 mandibular growth
will occur on average 1 year after
this stage.

66. Baccetti et al 2005
Cervical stage 3
Concavities at the lower borders
of both C2 and C3 are present.
The bodies of C3 and C4 may be
either trapezoid or rectangular
horizontal in shape.
The peak in mandibular growth
will occur during the year after
this stage.

67. Baccetti et al 2005
Cervical stage 4
Concavities at the lower borders
of C2, C3, and C4 now are
present.
The bodies of both C3 and C4
are rectangular horizontal in
shape.
The peak in mandibular growth
has occurred within 1 or 2 years
before this stage.

68. Baccetti et al 2005
Cervical stage 5
The concavities at the lower
borders of C2, C3, and C4 still
are present.
At least one of the bodies of C3
and C4 is squared in shape. If not
squared, the body of the other
cervical vertebra still is
rectangular horizontal.
The peak in mandibular growth
has ended at least 1 year before
this stage.

69. Baccetti et al 2005
Cervical stage 6
The concavities at the lower
borders of C2, C3, and C4
still are evident.
At least one of the bodies
of C3 and C4 is rectangular
vertical in shape. If not
rectangular vertical, the
body of the other cervical
vertebra is squared.
The peak in mandibular
growth has ended at least 2
years before this stage.

70. Baccetti et al 2005
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. Semin
Orthod 11:119–129 © 2005

71. 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.
Semin Orthod 11:119–129 © 2005

72. 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.
Application to Dentofacial Orthopedics
1. Class II treatment is most effective when it includes the peak
in mandibular growth (CS3)
2. Class III treatment with maxillary expansion and protraction
is effective when performed before the peak (CS1 or CS2),
whereas it is effective in the mandible during both prepubertal
and pubertal stages;
3. skeletal effects of rapid maxillary expansion for the correction
of transverse maxillary deficiency are greater at prepubertal
stages(CS1-CS3),
4. deficiency of mandibular ramus height : the peak in mandibular
growth (CS3).
Semin Orthod 11:119–129 © 2005

73. Cervical vertebral maturation as a biologic indicator of skeletal maturity
A systematic review
Rodrigo Ce ́sar Santiagoa; Luiz Felipe de Miranda Costaa; Robert Willer Farinazzo Vitralb; Marcelo Reis
Fragac; Ana Maria Bolognesed; Lucianne Cople Maiae
(Angle Orthod. 0000;00:000–000.)

74. Cervical vertebral maturation as a biologic indicator of skeletal maturity
A systematic review
Rodrigo Ce ́sar Santiagoa; Luiz Felipe de Miranda Costaa; Robert Willer Farinazzo Vitralb; Marcelo Reis
Fragac; Ana Maria Bolognesed; Lucianne Cople Maiae
There was a moderate to high reproducibility of the CVM
method
Although some studies indicate that the CVM method
shows good correlation with the HWM method, with
considerable levels of reproducibility
These parameters are not good enough for determining the
validity of the CVM method. Furthermore, these
conclusions were based on six articles, which points to a
low level of evidence, and
The biggest question remains unanswered: How reliable is
CVM staging for predicting the pubertal spurt?
(Angle Orthod. 0000;00:000–000.)

75. Cervical vertebrae maturation method morphologic criteria: Poor
reproducibility
Trenton S. Nestman,Steven D. Marshall, Fang Qian, Nathan Holton,Robert G. Franciscus, and Thomas
E. Southardf Brighton, Colo, and Iowa City, Iowa
The weakness of the CVM method
Difficulty in classifying the vertebral bodies of C3 and
C4 as trapezoidal, rectangular horizontal, square, or
rectangular vertical.
This led to the overall poor reproducibility of the CVM
method and our inability to support its use as a strict
clinical guideline for the timing of orthodontic
treatment.
(Am J Orthod Dentofacial Orthop 2011;140:182-8)

76. Validity and reliability of a method for assessment of
cervical vertebral maturation
Xiao-Guang Zhaoa; Jiuxiang Linb; Jiu-Hui Jiangc; Qingzhu Wanga; Sut Hong NGa
The reliability of the CVM method was strong interobserver
agreement and substantial intraobserver agreement.
The percent of Interobserver agreement was below 50% at
both times. Percent intraobserver agreement varied widely
among observers (range, 40.7%–79.1%).
The validity of the CVM method was moderate agreement
between the gold standard and observer staging at the initial
time.
Percent agreement, especially at cervical stage 3, left much to
be desired.
The CVM method should be used with other growth indicators in
the evaluation of skeletal maturation.
(Angle Orthod. 2012;82:229–234.)

77. Validity and reliability of a method for assessment of
cervical vertebral maturation
Xiao-Guang Zhaoa; Jiuxiang Linb; Jiu-Hui Jiangc; Qingzhu Wanga; Sut Hong NGa
The accuracy and reproducibility of the CVM method leave much
to be desired. Factors that affect them are listed as follows.
1) The ‘‘measurements’’ are purely subjective.
It is difficult to define and identify the gradual appearance of
the concavity in the inferior border of the vertebral bodies.
The difference between horizontally rectangular, square, and
vertically rectangular shapes depends on the researcher’s
arbitrary decision
(Angle Orthod. 2012;82:229–234.)

78. Validity and reliability of a method for assessment of
cervical vertebral maturation
Xiao-Guang Zhaoa; Jiuxiang Linb; Jiu-Hui Jiangc; Qingzhu Wanga; Sut Hong NGa
The accuracy and reproducibility of the CVM method leave much to
be desired. Factors that affect them are listed as follows.
2) The shapes of cervical vertebrae show marked variation from subject
to subject.
Sometimes the shape and inferior borders of C2–C4 cannot fulfill
the definition of a cervical stage at the same time.
Furthermore, The shapes of C3 and C4 bodies were still
horizontally rectangular in some adult patients
(Angle Orthod. 2012;82:229–234.)

79. Validity and reliability of a method for assessment of
cervical vertebral maturation
Xiao-Guang Zhaoa; Jiuxiang Linb; Jiu-Hui Jiangc; Qingzhu Wanga; Sut Hong NGa
The accuracy and reproducibility of the CVM method leave much
to be desired. Factors that affect them are listed as follows.
3) Could the mandibular growth rate be taken as a reference to
establish the CVM method ?
Controversy about the relationship between facial (mandibular) growth
and general bodily growth continues
(Angle Orthod. 2012;82:229–234.)

80. Dental maturation
Tooth emergence, dental maturity detected through
radiographic methods has been investigated as a marker
of skeletal maturity
Tooth emergence has been investigated as a marker of
skeletal maturity; however, this has been shown to be
poorly correlated with individual skeletal maturity (Bjork
and Helm, 1967; Hagg and Taranger, 1982; Franchi et al.,
2008).

81. Dental maturity VS Skeletal maturity
Dental maturity detected through radiographic methods appears
to be highly related to skeletal maturity (Sierra, 1987; Coutinho
et al., 1993; Krailassiri et al., 2002; Uysal et al., 2004; Basaran et
al., 2007).
The maturity of several mandibular teeth, excluding the third
molar, has been reported to be correlated with the skeletal
maturation phases, with correlation coefficients of 0.63–0.81
(Sierra, 1987), 0.56–0.69 (Krailassiri et al., 2002), 060–0.91
(Basaran et al., 2007), and 0.63–0.84 (Uysal et al., 2004).

82. Dental maturity VS Skeletal maturity
In contrast, one study failed to show significant
correlations between dental maturation and other
indices of skeletal maturation (Demirjian et al.,
1985). However, this last study recorded dental
maturity as 90 per cent of development of the whole
dentition rather than using individual tooth maturity.

83. Dental Calcification Stages Using Demirjian Index
(DI)
Stage A Calcification of single occlusal points
A without fusion of different calcifications
Stage B Fusion of mineralization points; the
B contour of the occlusal surface is recognizable
Stage C Enamel formation has been completed
C at the occlusal surface, and dentin formation
has commenced The pulp chamber is curved,and
no pulp horns are visible
D Stage D Crown formation has been completed to
the level of the cementoenamel junction Root
formation has commenced. The pulp horns are
beginning to differentiate, but the walls of the

84. Dental Calcification Stages Using Demirjian Index
(DI)
Stage E The root length remains shorter than the crown
height. The walls of the pulp chamber are straight, and the
E pulp horns have become more differentiated than in the
previous stage. In molars, the radicular bifurcation has
commenced to calcify.
F Stage F The walls of the pulp chamber now form an
isosceles triangle, and the root length is equal to or
greater than the crown height. In molars, the bifurcation
has developed sufficiently to give the roots a distinct form
G
Stage G The walls of the root canal are now parallel, but
the apical end is partially open. In molars, only the distal
root is rated.
H
Stage H The root apex is completely closed (distal root in
molars). The periodontal membrane surrounding the root
and apex is uniform in width throughout..

85. Eruption of the maxillary canines in relation to skeletal maturity
This study was to assess the relationship between the eruption of the permanent maxillary canines
and skeletal maturity in subjects with different skeletal relationships in the sagittal and vertical
planes.
Methods: A sample of 152 subjects (63 boys, 89 girls) with erupting permanent maxillary canines
was analyzed. On the lateral cephalograms, the stage of cervical vertebral maturation was assessed.
The subjects were divided into
prepeak (before the pubertal growth spurt, cervical stage [CS]1 and CS2)
peak (during the pubertal growth spurt, CS3 and CS4)
postpeak (after the pubertal growth spurt, CS5 and CS6) groups.
Skeletal relationships in the sagittal and vertical planes were evaluated, and relationships to timing
of canine eruption were tested statistically
Tiziano Baccetti, Lorenzo Franchi, Simona De Lisa, and Veronica Giuntini
(Am J Orthod Dentofacial Orthop 2008;133:748-51)

86. Eruption of the maxillary canines in relation to
skeletal maturity
Eruption of the permanent maxillary canine can occur
at any stage in skeletal maturation before the end the
pubertal growth spurt (CS1-CS4).
A post- pubertal stage (CS5 or CS6) without an
erupted maxillary canine indicates delayed canine
eruption and suggests canine impaction.
Eruption of the permanent maxillary canine occurs
more frequently in the prepubertal stages of skeletal
development in subjects with increased vertical
skeletal relationships.
Tiziano Baccetti, Lorenzo Franchi, Simona De Lisa, and Veronica Giuntini
(Am J Orthod Dentofacial Orthop 2008;133:748-51)

87. Relationships Between Dental Calcification Stages and
Skeletal Maturity Indicators in Thai Individuals
the canine stage F may represent the MP3width
stage evaluating the onset of the accelerating
growth period.
The second molar stage E for female subjects,
coinciding with the S stage
the second molar stage G for male subjects,
coinciding with the MP3cap stage, were indicative
of a very high rate of growth acceleration.
Suleekorn Krailassiri, DDS; Niwat Anuwongnukroh, DDS, MSD; Surachai
Dechkunakorn, DDS, D Ortho (Angle Orthod 2002;72:155–166.)

88. Relationships Between Dental Calcification Stages and
Skeletal Maturity Indicators in Thai Individuals
This suggests that tooth calcification stages
from panoramic radiographs might be clinically
useful as a maturity indicator of the pubertal
growth period
However, further study is recommended in a
larger sample size, and future studies should
address development of the canines and second
molars
Suleekorn Krailassiri, DDS; Niwat Anuwongnukroh, DDS, MSD; Surachai
Dechkunakorn, DDS, D Ortho (Angle Orthod 2002;72:155–166.)

89. Conclusion
No single method of assessing maturity level has
been shown to be effective and accurate in all
patients.
The hand-wrist radiograph is considered to be
the most standardized method of skeletal
maturation assessment
Additonal radiation exposure to the patient should
be concern
In an individual case, for the assessment of the
timing of growth process, hand-wrist radiograph
can contribute for treatment plan

90. Conclusion
The accuracy of predicting growth may be
improved if other parameters (morphologic,
biological, or genetic indicators), in addition to
hand-wrist radiographic evaluation are used.
Sato K, Mito T, Mitani H. An accurate method of predicting man-
dibular growth potential based on bone maturity. Am J Orthod
Dentofacial Orthop. 2001;120:286–293.

91. Conclusion
Validity and reliability of CVM method : still
controversy
The CVM method should be used with other growth
indicator in the evaluation of skeletal maturation
So do dental maturity index

93. If you look for the peak of growth

94. If you look for the peak of growth
MP3cap

95. If you look for the peak of growth
MP3cap

96. If you look for the peak of growth
MP3cap

97. If you look for the peak of growth

98. If you look for the peak of growth
CS 3

99. If you look for the peak of growth

100. If you look for the peak of growth

101. If you look for the peak of growth

102. If you look for the peak of growth
2nd molar stage G
(Male)

103. If you look for the peak of growth
2nd molar stage G
(Male)

104. If you look for the peak of growth
2nd molar stage G
(Male)

105. If you look for the peak of growth

106. If you look for the peak of growth
2nd molar stage
E(Female) : S stage

107. If you look for the peak of growth
2nd molar stage
E(Female) : S stage

109. Thank you