Clinical and Investigative Orthodontics

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/todw21

Cervical vertebrae maturation assessment

as a predictive method for midpalatal suture
maturation stages in 11- to 14-year-olds:
retrospective study

Camila Novais Luz, Bruno de Paula Machado Pasqua, João Batista Paiva &
José Rino-Neto

To cite this article: Camila Novais Luz, Bruno de Paula Machado Pasqua, João Batista Paiva
& José Rino-Neto (2022) Cervical vertebrae maturation assessment as a predictive method
for midpalatal suture maturation stages in 11- to 14-year-olds: retrospective study, Clinical and
Investigative Orthodontics, 81:1, 43-49, DOI: 10.1080/13440241.2022.2042036

To link to this article: https://doi.org/10.1080/13440241.2022.2042036

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CLINICAL AND INVESTIGATIVE ORTHODONTICS
2022, VOL. 81, NO. 1, 43–49
https://doi.org/10.1080/13440241.2022.2042036

ORIGINAL ARTICLE

Cervical vertebrae maturation assessment as a predictive method for

midpalatal suture maturation stages in 11- to 14-year-olds: retrospective study
Camila Novais Luz , Bruno de Paula Machado Pasqua , João Batista Paiva and José Rino-Neto
Department of Orthodontics, School of Dentistry, University of São Paulo, São Paulo, Brazil

ABSTRACT ARTICLE HISTORY

Introduction: The treatment of transverse maxillary deficiency must be performed with the Received 12 August 2021
patient inside the growth phase, then, it is necessary to evaluate the patient’s skeletal matura­ Revised 12 December 2021
tion. There are two common methods: cervical vertebrae maturation (CVM) and midpalatal Accepted 3 February 2022
suture maturation (MSM). KEYWORDS
Objective: to evaluate and correlate the methods in patients aged from 11 to 14 years old, to Cervical vertebrae; growth;
investigate if CVM method can be predictive of the midpalatal suture maturation stage. cranial sutures; cone-beam
Methods: Forty-two CBCT scans and lateral cephalometric radiographs of children, aged computed tomography;
between 11 and 14 were analysed. The images were evaluated by two investigators. Kappa orthodontics
coefficient was calculated to estimate intra and inter-examiner agreement. Spearman correla­
tion test was performed to evaluate the correlation between methods, age and gender. To
evaluate the diagnostic performance of the CVM and MSM methods, the likelihood ratio (LHR
positive) was applied.
Results: MSM evaluation showed a strong correlation with the CVM evaluation (rs = 0.6916).
A high correlation between the methods were found for the male gender (rs = 0.7809). There
was no correlation between age and the maturation methods, considering both genders. The
CVM method presented a strong positive LHR with the MSM method (2.250), in the early stages;
nonetheless, in the more advanced stages there was a lower ratio (1.500).
Conclusions: The CVM method can be used as a predictor of the maturation stages of the
midpalatal suture in the early stages of maturity. In more advanced stages, the evaluation of
the palatal suture by tomography is suggested.

Introduction
Transverse maxillary deficiency can be associated with
several changes such as posterior crossbite; dental
crowding; occlusal disharmony; changes in tongue
posture and mouth breathing, producing significant
effects on muscle function and aesthetics [1]. The cor­
rection of this kind of malocclusion is achieved by
rapid maxillary expansion (RME), which consists of
separating the midpalatal suture, resulting in increased
transverse arch dimension and crossbite correction [2].
Nonetheless, it is not always possible to achieve the
rupture of this suture due to the interdigitation
increase [3–5]. Then, it was suggested by Melsen [3]
that the ideal age for RME would be at most 16 years
for females and 18 years for males. However, Persson
and Thinlander [6] identified a 71-year-old individual
with no signs of maturation. This indicates that suture
ossification is often not related to patient’s age [6],
which led to difficulties in Orthodontic diagnosis
of RME.
Midpalatal suture maturation assessment began to
be performed by means of occlusal radiographs [7].
A serious weakness of this method is the overlapping
of images that impair the visualization of the structures
in this region [8]. With the advancement of technology,
Cone-Beam Computed Tomography (CBCT) has
enabled three-dimensional evaluation of maxillofacial
structures. The assessment of palatal sutures using
CBCT showed a lower percentage of suture complete
ossification when compared to occlusal radiographs
[8], allowing orthodontists to perform more conserva­
tive treatments. Therefore, Angelieri et al. [9] proposed
a CBCT method for evaluating the midpalatal suture
maturation (MSM). This method is well-established in
the literature and has become one of the most impor­
tant and useful tools in the diagnosis of RME [10,11].
Despite its advantages and efficacy, MSM method
represents an increase in costs and radiation exposure.
Thus, the possibility of using another existing method to
evaluate bone maturation was considered. Since lateral
radiography is frequently requested prior to Orthodontic
treatment, the evaluation of bone maturation by means
of cervical vertebrae (CVM) [12,13] was investigated by
some authors as a predictive method to assess the
maturation of the midpalatal suture [14–18]. However,
the results presented by these studies were divergent

CONTACT Camila Novais Luz camila.luz@usp.br Department of Orthodontics, School of Dentistry, University of São Paulo, Avenida Professor Lineu
Prestes, 2227, São Paulo/SP, Brazil, Zip 05508-000
Name for publication: Luz CNa; Pasqua BPMb; Paiva, JBc; Rino-Neto Jd.
© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-
nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or
built upon in any way.
44 C. N. LUZ ET AL.
[15,18], showing the need for further investigations.
Besides that, few studies have evaluated this prediction
specific for adolescence, which is a phase that brings us
doubts about the planning and diagnosis of RME [19].
Given this inconclusive condition, the purpose of
this retrospective study was to evaluate whether the
CVM method can be predictive of the stage of matura­
tion of the midpalatal suture (MSM) in patients aged
from 11 to 14 years old.
Methods
Study design
This descriptive and retrospective study was approved
by an Ethics Committee on Human Research of
University of São Paulo – School of Dentistry, with the
protocol number: 3.311.813. This study was also regis­
tered in the REBEC clinical trials (RBR-48g9q6).
The sample size calculation was performed for an RME
central study (a randomized clinical trial with Hybrid
hyrax. This device has a tooth-bone-support, which has
2 mini-implants in the anterior region of the maxilla,
indicated for patients aged between 10 and 15 years,
since during this period side effects already are expected
such as root resorption, reduction in cortical thickness
buccal of posterior teeth, and dental inclination [20].
Thus, the aim of this central study was to test the effi­
ciency of this device to justify its use, since it is a more
invasive procedure than devices conventional ones. The
sample calculation was based on the changes in bone
transverse dimensions observed through the interpreta­
tion of CBCT scans performed before and after rapid
maxillary treatment on a previous study [20], on the
coronal section, in the premolar and molar region. The
mean difference according to the literature was 3.33 mm
[20], with a standard deviation of 3.58 [mean of the
standard deviation of two groups]. Considering
a significance level of 0.05 and a type II error of 20%,
the minimum number of individuals per group was deter­
mined to be 19, using a bicaudal test. Considering
a sample loss of 10%, the final sample size was calculated
to be 42, with 21 patients in each group.
Patients aged 11–14 years were assessed for eligibility
in the trial of this central study between January and
July 2018. All participants included in the study fulfiled
the following inclusion criteria: transverse maxillary defi­
ciency, unilateral or bilateral posterior crossbite, presence
of maxillary first premolars (right and left), maxillary first
permanent molars (right and left). Patients with a history
of previous orthodontic treatment, presence of systemic
diseases, presence of congenital deformity, loss of per­
manent teeth, or agenesis were considered ineligible for
the study. All participants and their guardians were verb­
ally explained regarding the study and treatment
involved and a signed informed consent form was
obtained.
Thus, forty-two CBCT scans (used for mini-implant
planning) and forty-two lateral cephalometric radio­
graphs of patients aged between 11 and 14 years (fun­
damental exam for any orthodontic/orthopaedic
treatment), were evaluated. These exams were obtained
for treatment planning of all participants of the central
RME study. Both exams were performed with the
patients positioned with the orbital plane Frankfurt
planes parallel to the floor during the CBCT acquisition.
The tomography used was iCAT® with the following
settings: 120 kVp, 18 mA, exposure time of 8.9 seconds,
voxel size of 0.2 mm, and field of view (FOV) of
160x60mm. The CBCT scan area was limited to the max­
illary region for ethical reasons. The images were analysed
in Dolphin software (Dolphin 3D® version 11 premium,
Dolphin Imaging and Management Solutions,
Chatsworth, CA USA). Head position standardization of
the CBCT images in the software was made by the
arrangement of the palatal plane parallel to the floor
(Figure 1). For individuals with thicker palate, 2 axial sec­
tions were evaluated for identification and classification
of the suture. No adjustments were made to the contrast
or brightness of the images, and the evaluations were
performed in a dark room. Each image of the midpalatal
was enumerated in the software Dolphin to ensure
a blindly classification by 2 examiners, according to the
CVM method [9]: MSM stages from A to E were defined
[9]: stage A identified as 2 parallel high-density straight
lines, without or with slight interdigitation; stage B, 2 lines
gain a sinuous appearance at their margins, with inter­
digitation zones; stage C lines are well defined and over­
lapping; stage D suture begins to disappear, being
present only in the maxillary bone; stage E, midpalatal
suture fusion occurs throughout the maxilla, the suture is
no longer visible and looks similar to other regions of the
palate (Figure 2).
The lateral radiographs were obtained from the
Instrumentarium equipment (Kavo®) in the following spe­
cifications: 90 kvp, 12.5 mA and 14 seconds of exposure.
For the CVM evaluation, digital file of the radiography
(JPG format) was used. The images were organized in
a Power point presentation and enumerated. The CVM
method was used to check the cervical vertebrae matura­
tion based on the evaluation of C2, C3 and C4 vertebrae
(CS1, CS2, CS3, CS4, CS5, and CS6 stages) [13]. CS1 stage
has the lower edges of all three flat vertebrae (C2-C4), and
the C3 and C4 bodies have a trapezoidal shape. In the CS2
stage, a concavity is present at the lower edge of C2, and
the bodies of both C3 and C4 still have a trapezoidal
shape. In the CS3 stage, concavities on the lower edges
of C2 and C3 are present, and the bodies of C3 and C4 can
be trapezoidal or horizontal rectangular. On the CS4
stage, concavities on the lower edges of C2, C3 and C4
are present, with C3 and C4 bodies in horizontal rectan­
gular shape. On the CS5 stage, the concavities on the
lower edges of C2, C3 and C4 are present, and at least one
of the C3 and C4 vertebrae is square shaped. The other
 CLINICAL AND INVESTIGATIVE ORTHODONTICS 45

Figure 1. Standardization of head position in coronal, sagittal and axial slices.

Figure 2. CBCT assessment in the axial section for the evaluation of the midpalatal suture maturation (MSM), according Angelieri
et al, 2013. Note the changes from stages A to E, as described in the methodology.

vertebra is still horizontal rectangular. At the CS6 stage
the concavities on the lower edge of C2, C3 and C4 are
evident, and at least one of the C3 and C4 vertebrae is
vertical rectangular, the body of the other cervical verte­
bra is square (Figure 3).
All images of both methods were reclassified by
the 2 examiners 4 weeks after the first evaluation.
The weighted Kappa coefficient was performed for
the evaluation of intra and inter-examiner
agreement.
46 C. N. LUZ ET AL.

Figure 3. Maturation stages of the cervical vertebrae C2, C3 and C4, assessed by lateral radiography (CVM), according Baccetti et al,
2005. Note the anatomical changes from stages CS1 to CS6, as described in the methodology.

Statistical method Table 2. Midpalatal suture maturation distribution according

to age. N = 42.
The distribution and percentage of observed stages, MSM Female Male Total
age, and gender were calculated. The correlation Suture stage Age Age Age
between the methodologies, age and gender were A – 13.3 ± 1.6 13.3 ± 1.6
B 13.6 ± 1.6 13.2 ± 0.6 13.4 ± 1.2
performed using the Spearman correlation test. To C 12.7 ± 1.5 12.9 ± 1.7 12.3 ± 1.5
assess the degree of relationship between the meth­ D 13.5 ± 1.2 - 13.7 ± 1.2
ods, a diagnostic performance measurement was E 13.6 ± 1.3 13.5 ± 1.6 13.5 ± 1.2
Total 13.3 ± 1.3 13.3 ± 1.4 13.3 ± 1.3
used – the positive likelihood ratio (LHR). All statistical
– null value
tests of this paper were performed using Medcalc soft­
ware (version 19.1.3 – MedCalc Software® – Belgium).
The significance level of 5% was adopted.
Table 3. Cervical vertebral maturation stage distribution
according to age. N = 42.
CVM Female Male Total
Results Stage Age Age Age
CS1 – 13.4 ± 1.4 13.5 ± 1.2
The weighted Kappa coefficients for intra-operator CS2 12.1 ± 1 11.7 ± 1 11.9 ± 0.9
reliability for the CVM and MSM methods were 0.9461 CS3 – 12.9 ± 0.9 13.3 ± 1.2
CS4 13.6 ± 1.4 14.2 ± 1.2 13.8 ± 1.3
and 0.9115, respectively. For inter-examiner evalua­ CS5 – – 13.5 ± 1.4
tion, the Kappa coefficients for the CVM and MSM CS6 12.8 ± 1.5 – 12.8 ± 1.5
Total 13.3 ± 1.3 13.3 ± 1.4 13.3 ± 1.3
methods were 0.9325 and 0.9067, respectively. This
– null value
result indicates intra and inter-examiner reproducibil­
ity with ‘almost perfect’ agreement power according to
Landis and Koch [21]. Demographic distribution of the There was no correlation between age and suture
sample is presented in Table 1. The MSM results evaluation considering both genders (p = 0.9325). There
according to age and sex are presented in Table 2. was no correlation between age and CVM considering
The CVM assessment, according to age and sex, are females (p = 0.9253), males (p = 0.5084), and both gen­
presented in Table 3. ders (p = 0.3728). The agreement of the CVM stages with
The Spearman correlation coefficients are presented respect to the MSM stages are reported in Table 5.
in Table 4. It was observed that there was a strong The LHR positive ratios are presented in Table 6 and
correlation between MSM and CVM evaluations, con­ 7. A positive ratio was found between CS1 and stages
sidering the female gender (p = 0.0043), male gender A and B (1.5), and a strong relationship was found
(0.0002), and both sexes (p < 0.0001). The Spearman between CS2 and stage B (6.0). Stage C had a strong
correlation coefficient was stronger in males relationship with suture CS3 (3.833), and stages CS5
(rs = 0.7809). and CS6 strongly correlated with stage E (2.857).
The positive LHR index was also calculated consider­
Table 1. Age and gender distribution. N = 42. ing the initial growth stage (stages A and B compared to
Age (Years) Sex (%) stages CS1 and CS2), peak growth stage (stage
Female Male Total
C compared to stages CS3 and CS4) and the final stages
11 6 (66.7) 3 (33.3) 9
12 3 (50) 3 (50) 6 of bone maturation (stages D and E compared to stages
13 5 (50) 5 (50) 10 CS4 and CS6). A strong relationship was found between
14 11 (64.7) 6 (35.3) 17
Total 25 (59.9) 17 (40.1) 42
the early stages (2,250). For the more advanced stages,
Mean age (SD) 13.3 (1.4) 13.3(1.4) 13.3 (1.3) this ratio was lower, and at the peak growth stage this
SD: standard deviation ratio was less than 1.
 CLINICAL AND INVESTIGATIVE ORTHODONTICS 47

Table 4. Correlation coefficients (rs) and p-values (p) obtained using Spearman’s correlation test (5% significance level). N = 42.
Sex/Parameters CBCT CVM Age
Female/Male rs/p rs/p rs/p
CBCT – rs = 0.6916*/p < 0.0001**** rs = 0.0135/p = 0.9325
CVM rs = 0.6916/p < 0.0001**** – rs = −0.1411/p = 0.3728
Age rs = 0.0135/p = 0.9325 rs = −0.1411/ p = 0.3728 –
Female
CBCT – rs = 0.5504/p = 0.0043*** rs = 0.0352/p = 0.8674
CVM rs = 0.5504/p = 0.0043*** – rs 0.0198/p = 0.9253
Age rs = 0.0352/p = 0.8674 rs = - 0.0198/p = 0.9253 –
Male
CBCT – rs = 0.7809/p = 0.0002*** rs = 0.0665/p = 0.7997
CVM rs = 0.7809/p = 0.0002*** – rs = 0.1723/p = 0.5084
Age rs = 0.0665/p = 0.7997 rs = 0.1723/p = 0.5084 –
*P < .05; **P < .01; ***P < .001; ****P < .0001

Table 5. CVM stages distribution according MSM stages. aged from 11 to 14 years old, since few articles have
N = 42. related both methodologies and the results are not yet
MSM stages clear [14–18].
CVM The MSM method results (Table 2) indicate that most
Stages A B C D E
patients, about 30% of the total sample, had stage
F M F M F M F M F M
CS1 3 3 1 C maturation of the midpalatal suture, with a mean
CS2 2 1 1 1 age of 12.3 years (± 1.5). Of that total, 61.5% were
CS3 1 1 1 3
CS4 2 3 1 1 1 2 2 female. Tonello et al. [19] obtained similar results, show­
CS5 3 2 2 ing a higher prevalence of stage C maturation in a total
CS6 1 1 3
of 50% of patients, with a higher prevalence in females
(56.8%), corroborating the present study. Stage B had
a percentage of 23.8% of the total sample, equally dis­
Table 6. Positive LHRs for CVM method stages for the diag­ tributed between the genders. Stage D was observed in
nosis of MSM. N = 42. approximately 17% of the total number of participants,
MSM stages
85.7% being female and only one male participant
CVM Stage A B C D E
CS1 1,5 1,5 – 0,333 – (14.3%). For stage E, the prevalence was 19.1% of the
CS2 – 6,0 2,7 – – total sample, 75% female and 25% male (Table 2). These
CS3 0,767 1,533 3,833 – –
CS4 – 0,8 2,0 0,8 2,0 results corroborate previous researches [18,19], where
CS5/ CS6 – – 2,0 1,333 2,857 stages D and E were more frequent in females. Jimenez
– null value
et al. [11] obtained similar results, with a sample com­
posed by participants aged between 10 and 25 years, in
which a total of 70% of the women in the sample with
Table 7. Diagnostic performance parameters of initial matura­
suture maturation in stages D and E were found; and
tion (CS1 and CS2 to identify suture stages A and B), peak 17% of the sample of individuals between 21 and
growth phase (CS3 and CS4 to identify stage C of the mid­ 25 years of age had stages A, B or C. Reinforcing the
palatal suture), and advanced stage maturation (stages CS5 randomness between maturation stages and age. The
and CS6 to identify stages D and E of the midpalatal suture). data obtained suggest that female individuals have
Vertebrae Vertebrae Vertebrae more advanced maturation of the midpalatal suture.
stages CS1 stages CS3 stages CS5
e CS2. e CS4. e CS6 When considering the distribution of the stages in the
Diagnosed Diagnosed Diagnosed 14-year age group, we found female subjects in both
stages A and stages C of stages D and
B of the suture. the suture E of the suture. stages A and E. This suggests that if the diagnosis of
Likelihood ratio – LHR 2,250 (0,709 to 0.477 (0,231 1,500 (0.534 to RME is only age-based, there is a risk of causing greater
Value (IC 95%) 7,141) to 0,985) 4,214) dental effects than skeletal, leading to an unfavourable
Diagnostic test – 64,3% 53,8% 53,3%
Sensitivity prognosis [6]. In the present paper, it was observed
Diagnostic test – 70% 70% 44,4% a percentage of 19.1% of patients in stage E of midpa­
Specificity
latal suture maturation, with a mean age of 13.5 ± 1.2. In
these cases, according Angelieri [6], SARPE would be
a more effective treatment. However, age should also
Discussion
be considered, contradicting the surgery. Therefore,
In the present study, the relation between CVM and devices with skeletal anchorage with miniscrews
MSM methods was evaluated with the aim to deter­ would be interesting, with the aim of realize RME with
mine whether the CVM can be predictive of the less dental side effects and more skeletal effects by non-
maturation stage of the midpalatal suture in patients invasive procedures [22,23].
48 C. N. LUZ ET AL.
CVM method results (Tables 3), showed that
28.5% of the patients presented CS4 stage, consid­
ering the total sample. These data are similar to
those presented by Perinetti et al. [24], in which
the CS4 stage was more prevalent in individuals
aged between 11 and 16 years. As well as found
by Gorucu-Coskuner [18], in which 62% of the sam­
ple presented CS4 stage of vertebral maturation.
The same pattern was observed in MSM evaluation,
where female individuals present a more advanced
stage of maturation. Stages CS1 and CS5 had
a prevalence of 16.7% and a mean age of
13.5 years (Table 3). It is noticeable that with the
same mean age we can find simultaneously
advanced and initial stages of cervical vertebrae
maturation. It indicates that there is no relationship
between vertebrae maturation and chronological
age. Similar results were found by Perinetti et al
[24]., in which patients aged 11.0 years ± 1.2 had
CS2, CS3, and CS4 maturation stages. Distribution of
CVM stages was different between the sexes. In
males, skeletal maturation was observed later com­
pared to females, because 6 males (14% of the total
sample) were classified in the CS1 maturation stage,
without signs of maturation in C1 and C2. In
females, only one participant presented CS1 stage.
On the other hand, it was observed that approxi­
mately 12% of the total sample presented the max­
imum stage of cervical CS6 maturation, all of them
were female (Table 3).
Spearman’s correlation results (Table 4) showed
a strong correlation between CVM and MSM meth­
ods (rs = 0.6916), corroborating to previous studies
[14–16]. Gao & Yan Gu [25] also corroborate with
these results; however, the method of evaluation
of the midpalatal suture used was not the same of
this study. On the other hand, Chutasripanich [17]
found a weak correlation between these bone
maturation methods. Following the data presented
in Table 4, a higher correlation coefficient was
found between the methods in males
(rs = 0.7809) compared with females (rs = 0.6916).
This discrete difference between genders was also
previously reported [25].
The LHR positive ratio was positive between the
methods in the initial stages of CVM and weakest in
advanced stages (Tables 6 and 7). Thus, it is possi­
ble to state that the more advanced the cervical
vertebrae maturation, the lower is the relation
between the methods, corroborating previous stu­
dies [14,16]. Then, it is possible to speculate that
CVM method is a reliable diagnostic option to pre­
dict the maturation of the midpalatal suture in early
stages of maturation. However, in advanced stages,
it is suggested to evaluate the midpalatal suture by
CBCT (MSM).
There was no correlation between CVM and MSM
methods to age. These results corroborate a previous
study [17]. Conflicting results were observed by Jang
et al. [15]; nonetheless, in this study the age of individuals
varied between 8 and 20 years. Similarly, Lee [16] found
a positive correlation between age and CVM and MSM
methods, diverging from the present study; however, this
study sample consisted of patients aged between 7 and
15 years. It is believed that this positive correlation
between age and skeletal maturation indicates that the
higher the chronological age of the patient, the more
advanced is his skeletal maturation. Nevertheless, in the
present study the age range was small (patients aged 11–
14 years), resulting in a weak correlation. This suggests
that when a specific age is considered, the stage of
maturation has great variation [26]. Therefore, it is recom­
mended that age cannot be considered a factor of choice
for RME diagnosis.
Analysing the results obtained, it is speculated that
CVM method is an effective predictive option for the
maturation of midpalatal suture. Nevertheless, it is indi­
cated that in advanced stages of cervical vertebrae
maturation the MSM assessment be performed [14,16].
In cases of young patients with advanced maturational
stages, expansion by means of conventional ERM would
no longer be indicated, as it would cause greater dental
than skeletal effects. Tooth-bone-borne appliances
should be considered in these cases [22,23].
These methods are tools used to complement the
diagnosis for the therapeutic decision, other biological
factors such as dental age, body growth, signs of puberty,
menarche, changes in voice, are also extremely impor­
tant, especially in cases where we notice a discrepancy
with chronological age and skeletal maturation.
Further investigations are required to validate the CVM
method as a predictive diagnostic option for the matura­
tion of the midpalatal suture. To obtain more consistent
results, it is suggested to increase the sample size, with
a similar distribution between genders, of a wider age
range, and with a longitudinal follow-up of patients.
Conclusion
- Both methods showed no correlation with chronolo­
gical age.
- Cervical vertebrae maturation has a strong correla­
tion to midpalatal suture maturation method.
- CVM method can be a predictive of midpalatal
suture maturation in the initial maturation stages
(CS1 and CS2 as predictive of stages A and B).
- In advanced CVM stages, it is suggested the CBCT
evaluation of the midpalatal suture maturation for RME
planning and diagnosis.
- Further research might explore the validation of the
CVM method as a predictor of midpalatal suture
maturation.

Disclosure statement
No potential conflict of interest was reported by the
author(s).
ORCID
Camila Novais Luz http://orcid.org/0000-0002-4811-1653
Bruno de Paula Machado Pasqua http://orcid.org/0000-
0002-0890-6179
Ethical approval statement
This study was approved by an Ethics Committee on Human
Research of University of São Paulo – School of Dentistry,
with the protocol number: 3.311.813. This study was also
registered in the REBEC clinical trials (RBR-48g9q6).
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