The document discusses the cervical vertebral maturation (CVM) method as a critical biological indicator for assessing optimal treatment timing in dentofacial orthopedics. It highlights the importance of targeting therapeutic interventions around peak growth periods to achieve better outcomes for various malocclusions, with specific guidelines on staging and treatment implications. Furthermore, it illustrates the differential effectiveness of treatments based on developmental stages, emphasizing the significance of timing in relation to skeletal growth patterns.

1. Umm Al-Qura University Dr. Reham Al-Haratani

2. The Cervical Vertebral Maturation (CVM) Method for the Assessment of Optimal Treatment Timing in Dentofacial Orthopedics Done by: Reham Al-haratani

3. The timing of the treatment onset may be as critical as the selection of the specific treatment protocol The issue of optimal timing for dentofacial orthopedics is linked intimately to the identification of periods of accelerated growth that can contribute significantly to the correction of skeletal imbalances in the individual patient. Individual skeletal maturity can be assessed by means of several biologic indicators : * increase in body height * skeletal maturation of the hand and wrist * dental development and eruption * menarche or voice changes * cervical vertebral maturation Introduction: “ Timing is the fourth dimension in orthodontics (transverse, sagittal , vertical )”

4. The reliability and efficiency of a biologic indicator can be evaluated with respect to several fundamental requisites: 1. Efficacy in detecting the peak in mandibular growth. 2. No need for additional x-ray exposure. 3. Ease in recording. 4. Consistency in the interpretation of the data. 5. Usefulness for the anticipation of the occurrence of the peak.

5. The main features of the Cervical Vertebral Maturation (CVM) method: * The cervical vertebrae are available on the lateral cephalogram that is used routinely for orthodontic diagnosis and treatment planning. * The estimation of the shape of the cervical vertebrae is straightforward * The reproducibility of classifying CVM stages is high * The method is useful for the anticipation of the pubertal peak in mandibular growth. * A limited number of vertebral bodies is used to perform the staging C2, C3, and C4

6. Two sets of variables are analyzed: 1. Presence or absence of a concavity at the lower border of the body of C2, C3, and C4 2. Shape of the body of C3 and C4. Four basic shapes: trapezoid : least mature rectangular horizontal squared rectangular vertical : typical of the adult life

7. Stages of Cervical Vertebral Maturation: 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 peak in mandibular growth will occur on average 2 years after this stage.. Cervical stage 2: A concavity is present at the lower border of C2 , the absence of a concavity at the lower borders of C3 and of C4. 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. Cervical stage 3: The door to the peak 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. Discriminate factor C3 with a lower concavity C4 is not.. The peak in mandibular growth will occur during the year after this stage. The amount of elongation of the mandible is greater than the 2 yrs before and the yrs after puberty. Analyzed in six consecutive annual observations:

8. 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. The main characteristic: concavity at lower border of C4 + The peak interval ends at this stage or has ended. 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, others are rectangular horizontal. The peak in mandibular growth (growth spurt) has ended at least 1 year before this stage. 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, others are squared The peak in mandibular growth has ended at least 2 years before this stage. CS6 Shows you the timing that you should send a patient to orthognathic surgery ,there’s an exception for CIII.. CS6 is not an indicator for growth ceasing in a CIII pt.

10. Guidelines for identification of cervical stages in uncertain cases: 1. Linear measurement from the tangent of the lower borders.. A real concavity is .8mm at least … if the depth of the concavity is smaller than .8mm do not consider the concavity .. If undecided whether the stage is an earlier or later stage,, choose the earlier one.. E.g. C2 than C3.. 2. Measuring angular instead of linear measurements 3. Do not consider the “spikes” or white lines on the lower anterior borders..

11. 4. But do consider the spikes in the upper posterior region = meaning that its trapezoidal 5. Whenever the shape of either C3 or C4 or both is trapezoidal, the stage is pre-pubertal

12. Application to Dentofacial Orthopedics Treatment Timing for Class II Malocclusion Intervention should be undertaken when the likelihood for a maximum growth response is high, that is, during the circumpubertal growth period. When Class II malocclusion is treated too early (therapy starting at CS1 and completed before the interval of peak velocity in mandibular growth, i.e., before CS3), the net difference in supplementary growth of the mandible ranges between 0.4 mm and 1.8 mm . On the contrary, when intervention in a Class II patient includes the CS3-CS4 interval (growth spurt), the net supplementary growth of the mandible ranges from 2.4 mm to 4.7 mm .. The data reported also that in Class II patients, the timing of therapeutic intervention has a greater impact on supplementary elongation of the mandible than does the type of appliance used.. .

13. The Effect of Treatment Timing on Supplementary Elongation of the Mandible in Class II Treatment THE RED TABLE

14. THE GREEN TABLE Note: for a twin-block to work, the vertical opening should be at least 7mm

15. Treatment Timing for Class III Malocclusions Treatment of Class III malocclusion by means of efficient protocols (e.g., maxillary expansion and protraction ) is more effective in the early than in the late mixed dentition At a post pubertal observation (CS5 or CS6), when active growth of the craniofacial skeleton is completed for the most part, Class III subjects treated with a rapid maxillary expander and a facial mask well before the growth spurt (CS1) present with different long-term changes with respect to Class III subjects treated at a later stage, that is, at the peak in mandibular growth (CS3). Prepubertal orthopedic treatment of Class III malocclusion is effective both in the maxilla (which shows a supplementary growth of about 2 mm ) and in the mandible (restriction in growth of about 3.5mm ), Note: early treatment in CIII cases counteracts the tendency of the maxilla to show deficiency. Whereas treatment of Class III malocclusion at puberty is effective at the mandibular level only (restriction in growth of about 4.5mm)

16. Treatment Timing for Transverse Maxillary Deficiency The use of the CVM method demonstrated that rapid maxillary expansion before the peak in skeletal growth velocity is able to induce more pronounced transverse craniofacial changes at the skeletal level Treatment changes are more dentoalveolar in nature when expansion is performed during or after the peak.

17. The key indicator for maxillary transverse deficiency is by an analysis .. * Distance between the central fossae of the upper 1 st molars.. * Compare this measurement with the distance between the tips of the distobuccal cusps of the lower 1 st molars.. Measurement 1 – Measurement 2 = transverse discrepancy is ZERO for a normal occlusion because the tips must articulate together. If the no. is in (-) transverse problem (maxilla is narrow) E.g. . 40mm – 44mm = - 4 mm TD So if you know that the TD is 4mm.. beneficial because it lets you know how many days u need to expand.. And with 30% of relapse that usually occurs,, you need 8 days more For example if you activated .2 / day you need 20 days + 8 = 28 days..

18. Treatment Timing for Increased Vertical Dimension One of the goals of orthopedic treatment in subjects with increased vertical dimension is the control of the vertical growth of the mandibular ramus A significantly more favorable effect can be obtained when treatment is performed at CS3 , that is, at the peak in mandibular growth , when compared with treatment performed at an earlier maturational stage (CS1).

19. The application of the CVM method has revealed that: 1. Class II treatment is most effective when it includes the peak in mandibular growth; CS3 – CS 4 and Cl III ttt to restrict mandibular growth 2. Class III treatment with maxillary expansion and protraction is effective in the maxilla only when it is performed before the peak (CS1 or CS2). 3. Skeletal effects of rapid maxillary expansion for the correction of transverse maxillary deficiency are greater at prepubertal stages ,( CS1-CS2 ) while pubertal or post pubertal use of the rapid maxillary expander entails more dentoalveolar effects 4. Deficiency of mandibular ramus height can be enhanced significantly in subjects with increased vertical facial dimension when orthopedic treatment is performed at the peak in mandibular growth (CS3). To summarize, effects of therapies aimed to enhance/restrict mandibular growth appear to be of greater magnitude at the circumpubertal period during which the growth spurt occurs in comparison to earlier intervention, while effects of therapies aimed to alter the maxilla orthopedically (maxillary protraction/maxillary expansion) are greater at prepubertal stages

20. Growth of The Maxilla: Prepubertal CS1- CS2 Midpalatal and Pterygomaxillary Sutures Active Pubertal CS3-CS4 Postpubertal CS5-CS6 ossified

21. Growth of The Mandible : Prepubertal CS1- CS2 Condylar growth decelerated Pubertal CS3-CS4 Condylar growth Accelerated Window of oppurtunity Postpubertal CS5-CS6 decelerated