ORIGINAL ARTICLE

Phases of the dentition for the assessment

of skeletal maturity: A diagnostic
performance study
Lorenzo Franchi,a Tiziano Baccetti,a Laura De Toffol,b Antonella Polimeni,c and Paola Cozzad
Florence and Rome, Italy

Introduction: The aim of this study was to analyze the relationship between the circumpubertal phases of the
dentition (early mixed, intermediate mixed, late mixed, early permanent) and skeletal maturity as assessed by
means of the cervical vertebral maturation (CVM) method. Methods: The sample of 1000 subjects included
250 (125 boys, 125 girls) in each of the 4 dentition phases. Individual skeletal maturity was determined by
using the CVM method. The relationship between the skeletal maturity (stages in CVM) and the phases of the
dentition was evaluated statistically by means of indicators of diagnostic test performance. Results:
Prepubertal stage 1 (CS1) was the variable diagnosed in the early mixed and intermediate mixed dentitions;
pubertal stage 3 (CS3) was the variable diagnosed in the late mixed and early permanent dentitions.
Conclusions: The early mixed dentition phase showed a strong diagnostic value for the identification of
prepubertal skeletal maturity (CS1), whereas the intermediate mixed dentition phase had a low diagnostic
value for the same prepubertal stage. Neither the late mixed dentition nor the early permanent dentition
appeared to be a valid indicator for the onset of the pubertal growth spurt. (Am J Orthod Dentofacial Orthop
2008;133:395-400)

T
iming is a fundamental part of treatment plan-
ning in orthodontics, with special regard to
dentofacial orthopedics. Starting treatment in a
growing patient at the right time has demonstrated
significant favorable effects in the correction of dishar-
monies in the sagittal, transverse, and vertical planes.1-3
Optimal timing for treatment is different in the various
malocclusions. Recently, it was highlighted that treat-
ment protocols aimed to enhance or restrain maxillary
growth take advantage of treatment performed before
the adolescent growth spurt, whereas treatment regi-
mens aimed to enhance or restrain mandibular growth
produce greater effects when the pubertal growth spurt
is included in the treatment interval.3
The appraisal of a patient’s skeletal maturity is a
key factor for the application of the concept of treat-
a
Assistant professor, Department of Orthodontics, University of Florence,
Florence, Italy; Thomas M. Graber Visiting Scholar, Department of Orthodon-
tics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann
Arbor.
b
Fellow, Department of Orthodontics, University of Rome “Tor Vergata,”
Rome, Italy.
c
Professor and head, Department of Pediatric Dentistry, University of Rome
“La Sapienza,” Rome, Italy.
d
Professor and head, Department of Orthodontics, University of Rome “Tor
Vergata,” Rome, Italy.
Reprint requests to: Lorenzo Franchi, Università degli Studi di Firenze, Via del
Ponte di Mezzo, 46-48, 50127, Firenze, Italy; e-mail, l.franchi@odonto.unifi.it.
Submitted, December 2005; revised and accepted, February 2006.
0889-5406/$34.00
Copyright © 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.02.040
ment timing to clinical practice. Several biological
indicators of skeletal maturity have been used in many
studies in orthodontics: increases in statural height,4-10
hand and wrist maturation,11-17 cervical vertebral mat-
uration (CVM).18-22
In addition to these methods, the relationship be-
tween the development of the dentition and skeletal
maturation has been investigated. The studies refer
mainly to the correlations between the formation of
teeth (with special regard to the mandibular permanent
canines and second molars) and the onset of the
pubertal growth spurt.23-29 The results show much
variability in the concordance between stages of calci-
fication and eruption of teeth and skeletal maturation.
Correlations of tooth development with the peak in
mandibular growth are not reported in the literature,
whereas those with the peak in statural height are
generally weak (r ⫽ 0.03-0.42).28,29
On the other hand, the phases of the dentition
(deciduous, early and late mixed, permanent) have
often been used in investigations of the different
outcomes of treatment protocols at earlier vs later
stages of development. The effects of Class III treat-
ment have been analyzed in the deciduous vs the mixed
dentition30-33 and in the early vs the late mixed denti-
tion.34-36 Class II correction in the early mixed denti-
tion has been confronted with outcomes of treatment of
malocclusion in the late mixed dentition.37,38 No study,
395
396 Franchi et al
Fig 1. Schematic representation of the 6 stages of the CVM method. Reprinted from Baccetti et al3
with permission from Elsevier.
however, has described the relationship between the
phases of the dentition and skeletal maturation, despite
the role of skeletal maturity in treatment timing. This
information is needed both as an aid in clinical practice
and for the interpretation of the results of investigations
on timing of orthodontic treatment that use the dentition
stages as a categorization factor.
Our aim in this investigation was to analyze the
diagnostic performance of the circumpubertal phases of
the dentition (early mixed, intermediate mixed, late
mixed, early permanent39,40) with respect to individual
skeletal maturity as assessed with the CVM method.3
MATERIAL AND METHODS
This large cross-sectional investigation included
1000 subjects (500 boys, 500 girls) from a parent
sample of 1600 subjects from the departments of
orthodontics of the universities of Florence and Rome
“Tor Vergata.” The exclusion criteria consisted of full
deciduous dentition, adult permanent dentition, cranio-
facial anomalies, cleft lip and palate, extensive caries,
early loss of deciduous teeth due to trauma or caries,
supernumerary teeth, tooth agenesis, and other tooth
anomalies. Dental casts, panoramic radiographs, and
lateral cephalograms of good quality were available for
all selected subjects.
The sample of 1000 subjects comprised 250 sub-
jects (125 boys, 125 girls) in each of the 4 dentition
phases, which were appraised by analyzing the dental
casts and the panoramic radiographs, and categorized
according to the following definitions.39,40
1. Early mixed dentition: shedding of the deciduous
incisors, eruption of the first permanent molars and
permanent incisors.
2. Intermediate mixed dentition: permanent incisors
and first molars fully erupted, presence of the
American Journal of Orthodontics and Dentofacial Orthopedics
March 2008
deciduous teeth in the buccal region (deciduous
canine, first molar, and second molar).
3. Late mixed dentition: shedding of the deciduous
canines and molars, eruption of the permanent
canines and premolars.
4. Early permanent dentition: presence of all perma-
nent teeth (possible presence of second molars;
absence of third molars).
Mean ages were 7.6 ⫾ 1.1 years for the early mixed
dentition group, 8.9 ⫾ 1.2 years for the intermedi-
ate mixed dentition group, 10.1 ⫾ 1.1 years for the late
mixed dentition, and 12.8 ⫾ 1.2 years for the early
mixed dentition group.
Appraisal of skeletal maturity
All subjects were analyzed with a reliable method
for the assessment of skeletal maturity. The recently
improved version of the CVM method was used on
lateral cephalograms.3 The 6 stages of CVM are illus-
trated in the Figure 1 and defined as follows.
Cervical stage 1 (CS1). The lower borders of the 3
vertebrae are flat. The bodies of both the third and
fourth cervical vertebrae (C3 and C4) are trapezoid-
shaped (the superior border of the vertebral body is
tapered from posterior to anterior). The peak in man-
dibular growth will occur not earlier than 2 years after
this stage.
Cervical stage 2 (CS2). The lower border of the
second cervical vertebra (C2) is concave. The bodies of
both C3 and C4 are still trapezoid-shaped. The peak in
mandibular growth will occur not earlier than 1 year
after this stage.
Cervical stage 3 (CS3). Concavities at the lower
borders of both C2 and C3 are present. The bodies of
C3 and C4 can be either trapezoid or rectangular
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 3
Table I. Prevalence of the CVM stages in the various dentition phases
CS1 CS2
Early mixed (n ⫽ 250) 241 (96.4%) 9 (3.6%)
Intermediate mixed (n ⫽ 250) 169 (67.6%) 71 (28.4%)
Late mixed (n ⫽ 250) 78 (31.2%) 61 (24.4%)
Early permanent (n ⫽ 250) 18 (7.2%) 47 (18.8%)
horizontal. The peak in mandibular growth will occur
within 1 year after this stage.
Cervical stage 4 (CS4). Concavities at the lower
borders of C2, C3, and C4 now are present. The bodies
of both C3 and C4 are rectangular horizontal. The peak
in mandibular growth occurred 1 or 2 years before this
stage.
Cervical stage 5 (CS5). The concavities at the lower
borders of C2, C3, and C4 still are present. At least 1 of
the bodies of C3 and C4 is square. If not square, the
body of the other cervical vertebra still is rectangular
horizontal. The peak in mandibular growth occurred
not later than 1 year before this stage.
Cervical stage 6 (CS6). The concavities at the lower
borders of C2, C3, and C4 still are evident. At least 1 of
the bodies of C3 and C4 is rectangular vertical. If not
rectangular vertical, the body of the other cervical
vertebra is square. The peak in mandibular growth
occurred not later than 2 years before this stage.
Statistical analysis
The clinical records of the 1000 subjects were
analyzed as follows. An expert examiner (T.B.) ap-
praised the phases of the dentition on the dental casts
and the panoramic x-rays, and another examiner (L.F.)
appraised the CVM stages on the lateral cephalograms.
The examiner who evaluated the phases of the dentition
was blind as to CVM stages and vice versa. Percent
agreement and kappa statistics were calculated for the
evaluation of intraexaminer agreement. For the ap-
praisal of the CVM stages, agreement was 94.8% with
a kappa of 0.90; for the appraisal of the phases of the
dentition, agreement was 98.8% with a kappa of 0.98.
The prevalence of the CVM stages in the various
phases of the dentition was calculated. The relationship
between the skeletal maturity stages in the CVM
method and the phases of the dentition was evaluated
with measures of diagnostic performance41: sensitivity,
specificity, positive predictive value, and positive like-
lihood ratio. The positive predictive value of a test is
the probability that the patient has the condition (spe-
cific stage in skeletal maturation) when restricted to
patients who test positive (specific phase of the denti-
tion).41 The likelihood ratio incorporates both the
Franchi et al 397
CS3 CS4 CS5 CS6
0 (0%) 0 (0%) 0 (0%) 0 (0%)
10 (4%) 0 (0%) 0 (0%) 0 (0%)
90 (36%) 21 (8.4%) 0 (0%) 0 (0%)
76 (30.4%) 74 (29.6%) 27 (10.8%) 8 (3.2%)
sensitivity and the specificity of the test and provides a
direct estimate of how much a test result will change
the odds of having a condition. The likelihood ratio for
a positive result indicates how much the probability of
the condition (specific stage in skeletal maturation)
increases when a test is positive (specific phase of the
dentition).41 A likelihood ratio greater than 1 indicates
that the test result is associated with the disease,
whereas a result of 1 means absence of any diagnostic
performance. The further the likelihood ratios are from
1, the stronger the evidence for the presence or absence
of the condition (eg, a likelihood ratio of 2 means
minimal strength in the diagnostic performance of the
testing variable or method); likelihood ratios above 10
are considered to provide strong evidence to rule in
diagnosis in most circumstances.42 Variables to be
diagnosed (conditions) were defined on the basis of the
most prevalent CVM stage in the different phases of the
dentition.
RESULTS
The prevalence of the CVM stages in the various
phases of the dentition is given in Table I.
The diagnostic tests with the corresponding 95%
confidence intervals are shown in Table II. The early
mixed dentition phase showed high values in the
diagnostic tests for the prepubertal CS1 in skeletal
maturation (positive predictive value and positive like-
lihood ratio), whereas the intermediate mixed dentition
phase had low diagnostic scores for that stage. This
outcome indicates that a subject who tests positive (ie,
a subject in the early mixed dentition) has a high
probability to exhibit the condition that needs to be
diagnosed (CS1) (positive likelihood ratio ⫽ 26.14),
whereas the probability of CS1 stage is low if the
subject is in the intermediate mixed dentition (positive
likelihood ratio ⫽ 2.04).
The low scores for the positive predictive value and
the positive likelihood ratio for both the late mixed and
early permanent dentitions indicate that these phases
perform poorly in the diagnosis of the onset of the
pubertal growth spurt (CS3). In other words, a subject
who tests positive (ie, a subject in the late mixed or
early permanent dentition) has a low probability to have
398 Franchi et al
Table II. Diagnostic performance of the dentition phases in determining skeletal maturity
Early mixed Intermediate mixed
Variable diagnosed: CS1 Variable diagnosed: CS1
Diagnostic tests Value (95% CI) Value
Sensitivity 47.6% (46.2–48.5) 33.4%
Specificity 98.2% (96.7–99.0) 83.6%
Positive predictive value 96.4% (93.5–98.1) 67.6%
Positive likelihood ratio 26.14 (13.96–49.83) 2.04
the condition that needs to be diagnosed (CS3) (positive
likelihood ratios ⫽ 2.63 and 2.04 for the late mixed and
early permanent dentitions, respectively).
DISCUSSION
Little is known about the relationship between the
onset of puberty and dental maturation. Some studies
showed that correlations between tooth mineralization
and other parameters of physical development are
generally low, whereas there is little more than slight
covariation between tooth eruption and the adolescent
growth spurt.23-29 Since no previous data are available
with regard to the correspondence between dentition
phases and skeletal maturation, we analyzed the rela-
tionship between the circumpubertal phases of the
dentition and skeletal maturity determined with a reli-
able indicator (the CVM method).3
The dentition phases include 4 developmental
stages identified on the basis of classical definitions by
Björk et al39 and van der Linden and Duterloo.40 The
early mixed dentition corresponds with shedding of the
deciduous incisors and eruption of the first permanent
molars and permanent incisors (first transitional period
of the dentition, according to van der Linden and
Duterloo40). In the intermediate mixed dentition, the
permanent incisors and first molars are fully erupted,
and deciduous teeth (canine, first molar, and second
molar) are present in the buccal region (intertransitional
period of the dentition, according to van der Linden and
Duterloo40). The late mixed dentition is characterized
by shedding of the deciduous canines and molars and
eruption of the permanent canines and premolars (sec-
ond transitional period of the dentition, according to
van der Linden and Duterloo40). In the early permanent
dentition, all teeth in the dental arches are permanent
(possible presence of second molars, absence of third
molars). Although phases of the dentition have often
been used in investigations of treatment timing in
dentofacial orthopedics,30-38 the literature lacks infor-
mation about the correspondence between dentition
phases and skeletal maturity in individual patients.
American Journal of Orthodontics and Dentofacial Orthopedics
March 2008
Phase of the dentition
Late mixed Early permanent
Variable diagnosed: CS3 Variable diagnosed: CS3
(95% CI) Value (95% CI) Value (95% CI)
(30.8–35.8) 51.1% (44.7–57.4) 43.2% (36.9–49.6)
(81.0–86.1) 80.6% (79.2–81.9) 78.9% (77.5–80.2)
(62.4–72.5) 36% (31.5–40.4) 30.4% (26–34.9)
(1.62–2.58) 2.63 (2.15–3.18) 2.04 (1.64–2.51)
Our findings demonstrate the usefulness of the early
mixed dentition phases for the identification of CS1, as
shown by the high scores of diagnostic performance
measures. In other terms, the developmental interval
characterized by shedding of the deciduous incisors and
eruption of the permanent incisors and the first molars
is a powerful indicator of the prepubertal stage of
skeletal maturity. Previous data suggest that this phase
might be the optimal time to start treatment protocols
aimed at altering orthopedically the maxilla (rapid
maxillary expansion, facemask treatment).3,21,34-36 Al-
though showing a low diagnostic value for the specific
CS1, the intermediate mixed dentition still showed that
96% of the subjects were at a prepubertal stage of
skeletal maturity (67.6% at CS1, 28.4% at CS2).
On the other hand, the phases of the dentition do not
appear to be useful for determining the onset of the
pubertal growth spurt (CS3). When permanent canines
or premolars are erupting (late mixed dentition), one
third of the subjects are at the onset of their pubertal
growth spurt, and about half still exhibit prepubertal
stage of skeletal maturity. Some— 8.4%—show post-
pubertal stage of skeletal maturity (CS4). Therefore, the
diagnostic performance of the late mixed dentition in
the identification of the onset of the pubertal growth
spurt is low. The early permanent dentition phase is not
a valid indicator of peak skeletal maturity, either. About
30% of growing subjects with early display of full
permanent dentition (except the third molars) can show
either the onset of the pubertal growth spurt (CS3) or a
postpeak stage of skeletal maturity (CS4). The relation-
ship between early permanent dentition and skeletal
maturity is so weak that 26% of the subjects are still at
the prepubertal stage of skeletal maturity, whereas 14%
of the subjects are already in CS5 or CS6.
Our results indicate that, when confronted with a
reliable indicator of skeletal maturity (such as the CVM
method), the dentition phases perform poorly in the
detection of the onset of the pubertal peak in skeletal
growth, which is a fundamental part of treatment
planning for protocols aimed at enhancing mandibular
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 3
growth.3-6,8-10,19 This study also provided interesting
data about the variability of chronologic age with
respect to the onset of the pubertal peak in skeletal
maturation. The age range at CS3 was from 8 years to
14 years 6 months. This wide variability emphasizes
once again that chronologic age has little value for the
appraisal of skeletal maturation, especially for the
identification of the pubertal growth spurt and, conse-
quently, for the evaluation of treatment timing in
dentofacial orthopedics.43
CONCLUSIONS
This study on the diagnostic performance of the
phases of the dentition as indicators of individual
skeletal maturity showed that the early mixed dentition
phase shows strong diagnostic value for the identifica-
tion of prepubertal skeletal maturity (CS1), whereas the
intermediate mixed dentition phase has poor diagnostic
value for that stage. Neither the late mixed dentition nor
the early permanent dentition is a valid indicator for the
onset of the pubertal growth spurt (CS3).
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