This document summarizes methods for evaluating skeletal maturation using cervical vertebrae on lateral cephalograms. It describes six stages of cervical vertebral maturation as defined by Lamparski, Hassel and Farman, Baccetti et al. Evaluating the shapes and concavities of C2-C4 can assess skeletal age and timing of growth spurts for orthodontic treatment planning. Quantitative analysis of landmarks on C2-C4 is also used to measure vertebral morphology objectively.

1. SKELETAL MATURATION
EVALUATION USING
CERVICAL VERTEBRAE
SUPERVISED BY :
PROF .MAHER FOUDA
PREPARED BY : SAMAR MOSTAFA

2. • Orthodontic diagnosis and treatment planning of growth
children must involve growth prediction.
• The pubertal growth spurt is considered to be an
advantageous period for certain types of orthodontic
treatment and should be taken into account together
with orthodontic treatment planning.
• Because of the wide individual variation in the timing of
the pubertal growth spurt , chronological age is an
unreliable guide for assessment of children development
status.
• Other parameter, such as growth velocity , secondry sex
changes,

3. • dental development and skeletal ossification , have proven to
be more accurate.
• The standard method to evaluate skeletal maturity has ben
the use of hand-wrist radiograph ,matching the overall
pattern of the subject`s maturation to a set of reference
patterns , available in an atlas.
• Skeletal maturation is generally determined by evaluating
either the stage of ossification of bones of the hand and wrist
, due to the large number of different types of bone available
in these areas , or the ossification onset on the ulnar
sesamoid.
• However taking additional radiograph ,the cervical vertebrae

4. CERVICAL VERTEBRAL MATURATION (CVM)
METHODS
Skeletal maturation has been assessed using the shapes of
the cervical vertebrae , and these have been used to
estimate skeletal age.
Several workers have indicated this to be a superior
alternative to the hand and wrist method.
This method evaluates the first six 4 or 5 vertebrae,
excluding the atlas, and distinguishes 5 or 6 maturational
stages based on the change in the height-width-ratio of

5. LATERAL
CEPHALOGRAM

6. • A –LAMPARSKI (1972)
• Lamparski described a method to assess skeletal age
using maturational changes of the cervical vertebrae .
• A series os 6 standards resulted for each sex ,one for
each age (10-15 years):
• Stage 1 (Age 10):All inferior borders of the bodies are
flat.The superior borders are strongly tapered from
posterior to anterior.
• Stage 2 (Age 11):A concavity has developed in the
inferior border of the second cervical vertebrae .The
anterior vertebral height of the bodies have increased.

7. • Stage 3 (Age 12): A concavity has developed in the
inferior border of the third vertebrae.
• Stage 4(Age 13): All cervical bodies from C3 to C6are
rectangular in shape ,a concavity has developed on the
fourth vertebrae. Concavities on C5 and C6 are just
beginning to form.
• Stage 5 (Age 14): The bodies are nearly square in shape,
and the spaces between the bodies are visibly smaller,
concavity of the lower border of all cervical bodies is well
defined at this stage.
• Stage 6 (Age 15): All cervical bodies have increased in

8. LAMPARSKI`S METHOD

9. • B-HASSEL AND FARMAN (1995)
• Hassel and Farman stated that skeletal maturation is a
continuous process and modified LAMPARSKI`s method.
They defined six categories of CVM:
• CATEGORY 1:was called Initiation :at this stage inferior
borders of C2,C3andC4 are flat. The vertebrae are wedge
shaped ,and the superior vertebral borders are tapered
from posterior to anterior.
• CATEGORY2:Acceleration :concavities are developing in
the inferior borders of C2 and C3 .The inferior border of
C4is flat .The bodies of C3andC4 are nearly rectangular

10. CATEGORY3:Transition :distinct concavities are seen in the
inferior borders of C2and C3 .A concavity begins to
develop in the inferior border of C4.The bodies of C3 and
C4 are rectangular in shape.
CATEGORY 4 :Deceleration ;is characterized by distinct
concavities are seen in the inferior borders of
C2,C3andC4.The vertebral bodies of C3and C4are
becoming more square in shape.
CATEGORY 5:Maturation,more accentuated concavities are
seen in the inferior borders of C2.C3 and C4.Thebodies of
C3 and C4are nearly square in shape.
CATEGORY 6 Completion: Growth is considered to be

11. • Deep concavities are seen in the inferior border of
C2,C3andC4.The bodies of C3and C4 are square.

12. • BACCETTI,FRANCHI AND MCNAMARA
(2000,2002)
• Franchi et AL adopted Lamparski`s original method for
the appraisal of skeletal age in 34 subjects.
• They confirmed the validity of CVM stages as a biologic
indicator for the appraisal of mandibular and skeletal
maturity on the basis of a single cephalometric
observation and without additional x-ray exposure.
• Baccetti and co-workers reported five-maturational
stage method CVMS1 through CVMS V instead of cvs 1
through cvs 6 (Franchi et Al,2000) in an effort to provide

13. • They conclude that five maturation stage method is
useful when skeletal maturity is assessed on a single
cephalogram and when only the second through fourth
cervical vertebrae are visible.
• CVMS 1:the lower borders of all the three vertebrae are
flat , with possible exception of a concavity at the lower
border of C2. Bodies of C3 and C4 are trapezoid in shape
with the superior border tapered from posterior to
anterior .The peak of mandibular growth will occur not
earlier than one year after this stage.
• CVMS 2:Concavities at the lower borders of both C2 and

14. • The peak of mandibular growth will occur within one
year after this stage.
• CVMS 3 :concavities at the lower border of C2,C3and
C4are present
• C3and C4 are rectangular horizontal in shape. The peak
of mandibular growth has occurred within one or two
years before this stage.
• CVMS 4: concavities at lower borders of C2,C3 and C4
still are present ,and at least one of the bodies of C3and
C4is squared in shape. The peak of mandibular growth
has occurred no later than one year before this stage.

15. CVMS 5:the concavities at the lower borders of C2,C3 and
C4 are still evident . At least one of the bodies of C3 and
C4 is rectangular vertical in shape .The peak in
mandibular growth has occurred no later than two years
before this stage.

16. • In 2002 ,the authors described a quantitative analysis to
evaluate the morphology of the three cervical vertebrae
(C2,C3andC4).
• Modified reference points described by HELLSING
(1991)were adopted partially for the location of
landmarks to measure the concavity of the lower border
of C2,C3and C4 .
• The points for description of the morphologic characters
of the vertebral bodies were described as follow:
• C2p,C3m,C2a : the most posterior ,the deepest and the
most anterior points on the lower border of C2.
• C3up,C3ua: the most superior points of the posterior

17. • C3lp ,C3m,C3la:the most posterior and anterior borders
of the body of C3.
• C4up, C4ua :the most superior points of the posterior
and anterior borders of the body of C4.
• C4lp,C4m,C4la:the most posterior ,the deepest and the
most anterior point on the lower border of the body of
C4.
• C2conc :a measure of the concavity depth at the lower
border of C2,distance connecting C2p and C2a to the
deepest point on the lower border of the vertebrae,C2m.
• C3conc: a measure of concavity depth at the lower
border of C3,distance from the line connecting C3lp and

18. • Point on the lower border of the vertebrae ,C3m.
• 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
vertebrae ,C4m.
• C3BAR:ratio between the length of the base (distance
C3lp to C3la )and the anterior height (distance C3ua to
C3la )of the body.
• C3PAR: ratio between the posterior (distance C3up to
C3lp ) and anterior (distance C3ua to C3la)heights of the
body of C3.

19. • C4PAR: ratio between the posterior (distance C4up to
C4lp)and anterior(distance C4ua to C4la )
• heights of the body of C4

20. BACCETI ,FRANCHI AND MCNAMARA
In 2005the authors introduced a further refinement with a
six-stage method to assess cervical vertebral maturation
(CVM) .
Initial bottom border of all the vertebrae is flat. gradually,
starting from top to bottom ,a concavity appears and
simultaneously the shape of C3and C4 vertebrae changes
from a trapezium to a rectangle ,a square ,till a standing
rectangle

21. STAGE 1:lower border of all cervical vertebrae is flat
The shape of C3and C4 vertebrae is similar to a
rectangular trapezium, there are minimum 2 or more
years lhg
left to the beginning of maximum pubertal
growth.

22. • STAGE CS2: A concavity appears on the lower border of
C2( over or equal to 0.8 mm) the lower border in C3and
C4 vertebrae is flat.
• The shape of C3and C4 vertebrae
is similar to a rectangular trapezium.
There is about 1 year left to the
beginning of maximum pubertal
growth.

23. • STAGE CS3 :The lower border of C3 vertebrae becomes
concave (concavity of C2 is over or equal to 0.8), the
shape of C3and C4 vertebrae are the same ,rectangular
Horizontal or trapezoid .
It is the beginning of maximum pubertal
growth.

24. • STAGE CS4:All vertebrae have a concavity on the lower
border ,the shapes of the vertebrae turn into a
rectangular .
• It is the end of maximum pubertal
growth.

25. • STAGE CS5: The concavity on the lower border
and the shape of C3 and C4 changes into a
square .It has been about a year
since maximum pubertal growth.

26. • STAGE CS6: There is a concavity on the lower borders
and the proportion of the length of the borders of C3
and C4 changes
• The vertical borders become longer
than the horizontal one
There have been 2 years or more since
maximum pubertal growth.

28. THANK YOU