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Effectiveness of CVM-Based Treatment Timing in Changing Facial Bone Size and Position in Class II Patients

Permanent Link: http://ufdc.ufl.edu/UFE0022206/00001

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Title: Effectiveness of CVM-Based Treatment Timing in Changing Facial Bone Size and Position in Class II Patients
Physical Description: 1 online resource (40 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: cervical, cvm, growth, maturation, predictor, skeletal, spurt, timing, treatment, vertebral
Dentistry -- Dissertations, Academic -- UF
Genre: Dental Sciences thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The purpose of this study was to evaluate skeletal differences in class II patients whose orthodontic therapy was begun during, or outside of, CVM stage 3. Retrospectively, all cephalometric radiographs for all subjects involved in the University of Florida Class II clinical trial were staged using the latest version of the CVM method. First, reliability testing was conducted. CVM, hand-wrist, age, and weight correlations with statural height were then made. Due to an inability to reliably place an individual in stage 3 at a single timepoint, and due to the stringent requirements of longitudinal data acquisition necessary for a growth study of this nature, relatively small sample sizes for the desired comparisons were acquired. Five sets of reliability tests, spanning 12 months time, were necessary to achieve acceptable standards of intra-examiner reliability. Several modifications to the existing method were necessary for reliable and consistent staging, including the addition of ?half-stages?, i.e. ?2.5? or ?3.5.? CVM stage 3 could be identified in only 28% of subjects, and often stage 3 lasted for more than one year. CVM stage correlated significantly with statural height at all timepoints before the end of Phase II, but it did not correlate better than hand-wrist or even age. Class II patients starting treatment in stages 2.5 or 3 did not show ultimate skeletal improvement over those starting treatment in a stage other than 2.5 or 3. Placing every individual in CVM stage 3 with consistency and accuracy is not possible. CVM may be useful in providing a general estimation of growth remaining, but it may not be any more accurate than an estimation based on age and sex. This fact aside, basing treatment timing decisions on CVM stage 3 does not seem to change the ultimate sizes or locations of facial bones in Class II patients.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis: Thesis (M.S.)--University of Florida, 2008.
Local: Adviser: Wheeler, Timothy T.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-05-31

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Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022206:00001

Permanent Link: http://ufdc.ufl.edu/UFE0022206/00001

Material Information

Title: Effectiveness of CVM-Based Treatment Timing in Changing Facial Bone Size and Position in Class II Patients
Physical Description: 1 online resource (40 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: cervical, cvm, growth, maturation, predictor, skeletal, spurt, timing, treatment, vertebral
Dentistry -- Dissertations, Academic -- UF
Genre: Dental Sciences thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The purpose of this study was to evaluate skeletal differences in class II patients whose orthodontic therapy was begun during, or outside of, CVM stage 3. Retrospectively, all cephalometric radiographs for all subjects involved in the University of Florida Class II clinical trial were staged using the latest version of the CVM method. First, reliability testing was conducted. CVM, hand-wrist, age, and weight correlations with statural height were then made. Due to an inability to reliably place an individual in stage 3 at a single timepoint, and due to the stringent requirements of longitudinal data acquisition necessary for a growth study of this nature, relatively small sample sizes for the desired comparisons were acquired. Five sets of reliability tests, spanning 12 months time, were necessary to achieve acceptable standards of intra-examiner reliability. Several modifications to the existing method were necessary for reliable and consistent staging, including the addition of ?half-stages?, i.e. ?2.5? or ?3.5.? CVM stage 3 could be identified in only 28% of subjects, and often stage 3 lasted for more than one year. CVM stage correlated significantly with statural height at all timepoints before the end of Phase II, but it did not correlate better than hand-wrist or even age. Class II patients starting treatment in stages 2.5 or 3 did not show ultimate skeletal improvement over those starting treatment in a stage other than 2.5 or 3. Placing every individual in CVM stage 3 with consistency and accuracy is not possible. CVM may be useful in providing a general estimation of growth remaining, but it may not be any more accurate than an estimation based on age and sex. This fact aside, basing treatment timing decisions on CVM stage 3 does not seem to change the ultimate sizes or locations of facial bones in Class II patients.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis: Thesis (M.S.)--University of Florida, 2008.
Local: Adviser: Wheeler, Timothy T.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-05-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022206:00001


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1 EFFECTIVENESS OF CVM-BASED TREA TMENT TIMING IN CHANGING FACIAL BONE SIZE AND POSITION IN CLASS II PATIENTS By JAMES DANIEL JONES A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2008

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2 2008 James Daniel Jones

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3 To Melanie, Daisy, and Isaac

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4 ACKNOWLEDGMENTS I thank m y family.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........6 LIST OF FIGURES.........................................................................................................................7 LIST OF ABBREVIATIONS.......................................................................................................... 8 ABSTRACT.....................................................................................................................................9 CHAP TER 1 INTRODUCTION..................................................................................................................11 Introductory Note....................................................................................................................11 Background.............................................................................................................................11 The Cervical Vertebral Maturation Method........................................................................... 14 Objective.................................................................................................................................15 2 MATERIALS AND METHODS........................................................................................... 16 Details of Clinical Trial Used For Data Collection ................................................................16 Calibration..............................................................................................................................17 Data Manipulation..................................................................................................................20 3 RESULTS...............................................................................................................................22 4 DISCUSSION.........................................................................................................................29 Ultimate..................................................................................................................... ..........29 The Ideal Experiment........................................................................................................... ..31 General Observations..............................................................................................................32 5 CONCLUSIONS.................................................................................................................... 35 LIST OF REFERENCES...............................................................................................................36 BIOGRAPHICAL SKETCH.........................................................................................................40

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6 LIST OF TABLES Table page 3-1 Correlations of various maturity indicators with statural height ....................................... 24

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7 LIST OF FIGURES Figure page 1-1 The CVM method............................................................................................................. .14 3-1 Calibration results........................................................................................................ ......22 3-2 Frequency of problems in the cephalograms not scored.................................................... 23 3-3 Average CVM stage at each timepoint.............................................................................. 23 3-5 Overall Johnston analysis comparisons............................................................................. 25 3-6 Johnston analysis comp arisons by treatm ent group........................................................... 27

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8 LIST OF ABBREVIATIONS CVM Cervical Vertebral Maturation

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9 Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science EFFECTIVENESS OF CVM-BASED TREA TMENT TIMING IN CHANGING FACIAL BONE SIZE AND POSITION IN CLASS II PATIENTS By James Daniel Jones May 2008 Chair: Timothy Wheeler Major: Dental Sciences The purpose of this study was to evaluate sk eletal differences in class II patients whose orthodontic therapy was begun durin g, or outside of, CVM stage 3. Retrospectively, all cephalometric radiographs for all subjects involve d in the University of Florida Class II clinical tria l were staged using the latest version of the CVM method. First, reliability testing was conducted. CVM, hand-wrist, age, and weight correlations with statural height were then made. Due to an inability to reliably place an individual in stage 3 at a single timepoint, and due to the stringe nt requirements of longitudinal data acquisition necessary for a growth study of this nature, relatively small sample sizes for the desired comparisons were acquired. Five sets of reliability tests, spanning 12 months time, were necessary to achieve acceptable standards of intra-examiner reliability. Several modifications to the existing method were necessary for reliable and consistent stagin g, including the addition of half-stages, i.e. .5 or .5. CVM stage 3 could be identified in only 28% of subj ects, and often stage 3 lasted for more than one year. CVM stage correlated significantly with statural height at all timepoints before the end of Phase II, but it did no t correlate better than hand-wrist or even age.

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10 Class II patients starting treatment in stages 2.5 or 3 did not show ultimate skeletal improvement over those starting treatment in a stage other than 2.5 or 3. Placing every individual in CVM stage 3 with consistency and accuracy is not possible. CVM may be useful in providing a general esti mation of growth remaining, but it may not be any more accurate than an estimation based on age and sex. This fact aside, basing treatment timing decisions on CVM stage 3 does not seem to change the ultimate sizes or locations of facial bones in Class II patients.

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11 CHAPTER 1 INTRODUCTION Introductory Note Because gro wth, relapse, and posturing (please see the discussion section for descriptions of these terms) can cloud a discussi on on the subject of changing the dimension or location of the mandible, the term ultimate will be used throughout this paper to describe what a bone would have looked like if no treatment would have taken place. This is a theoretical term because it assumes we know, for each individual, what the exact size, shape, and location of a bone would have been without treatment (and ther efore without relapse), after all growth was completed, and without posturing. For example, th e statement the ultimate size of the mandible was not changed, does not mean that the mandi ble did not change size (even significantly!) during the treatment time, but that its size was ultimately no different than it would have been without treatment. Background Many theories exist regarding an orthodon tists control over the ultim ate sizes and positions of the mandible and maxillary complex. Some believe we cannot, using any of our or thodontic apparatuses, change the ultimate size, shape, or position of the facial bones (particularly the mandible).1,2 Certain ones of our professi on, including those who subscrib e to the MEAW (Multiloop Edgewise ArchWire) philosophy, believe that the shape (as opposed to size), or configuration, of facial bones can be changed, even when the bones in question are not in an active growth phase. They claim that when an improper vertical dimension and an imprope r occlusal plane are addressed and corrected, proprioce ptive inputs and feedback m echanisms from occlusion can

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12 initiate remodeling in the mandible and temporal fossa, and bring about slight changes in the sutures and bones of the basicranium and nasomaxillary complex.3,4 Others believe that it is actually possible to move the articulation of the mandible (the temporal fossa) closer to the anterior of the maxillary complex (changing the location of the mandible).5 Some hold that one can change the ultimate size of the mandible by using various contraptions, if (and only if) these contraptions are used while the mandible is growing. For some proponents of the above theory, it is not necessary to treat during the greatest growth velocity, but simply while at least some growth is taking place. For example, these clinicians would expect to see a significant ultimate skeletal difference in patients treated before ages 16 (for girls) to 18 (for boys ), and those treated after 21 y ears of age (as there would be little to no growth taking place in most of th e adult individuals). They would not, however, expect to see an ultimate skelet al difference in patients treated at ages 9, those treated at ages 11, and those treated at ages 13, as all thes e groups are in growing stages of some kind.6 For others in the while bones are growing camp, it matters a great deal how much a patient grows (their intrinsic growth potential) during the time in treatment.7,8,9,10,11,12,13 During a time of low intrinsic growth (the amount that w ould be there with or w ithout treatment), they contend, the size of a bone could still be changed, but the net change would not be as large as if treatment had occurred during the period of greatest intrinsic growth. It is logical, then, that members of this school of thought would view the adolescent grow th spurt as a sort of holy grail, in which treatment carried out during this period will bring about the gr eatest change in a set amount of time.

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13 An inference can be made that if one subscribes to this philosophy, one must believe that the absolute greatest treatment effect would be seen if a patient were treated over the course of their entire growth period (up to 20 years). Five y ears of treatment (if it included the growth spurt) would yield greater change s than two years, and ten years of treatment would yield greater changes than five years, and so forth. From a skeletal standpoint only, the functional appliance two-phasers fall into this camp. Few of them would say that they are accomplishing more skeletal improvement in the first phase than in the second, circumpubertal phase. Instead, they feel they are simply gaining additional skeletal imp rovement (on top of what can be gained in the second phase) by adding more time in treatment during a life stage in which the patient is growing. It also happens that the typical first phas e (around 9 years of ag e) is a time when the permanent incisors have typically erupted (a nd can be easily aligned for esthetic purposes), and the permanent molars are in (these are wide ly recognized as good anchor units for a variety of appliances). Dentoalveolar class II correc tion can also take place during Phase I, which allows young people to have a decr eased overjet at an earlier age (a reason for performing Phase I treatment which has nothing to do with skeletal targeting). One division of this school of thought believes the mandibular and maxillary growth spurts coincide with the statural (long bones) growth spurt,14,15,16,17 while another divi sion is convinced that it does not.18,19,20,21,22 For those who believe it does not, it is obviously inconsequential to determine when the statural growth spurt will occur, but essential to find markers or predictors of the mandibular or maxillary growth spurt. The proponents of the CVM (Cervical Vertebral Maturation) method for determining optimal trea tment timing for Class II appliances are among this group.23,24,25,26,27,28

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14 The CVM method was originated by Dr. Lampar ski in a 1972 Masters thesis dissertation in Pittsburgh, Pennsylvania, and later published by OReilly and Yaniello in 1988.29 Though several modifications have been made over 35 years,30,31,32 it remains surprisingly unchanged from its original version. Since the inception of the met hod, a plethora of research has been conducted to show correlation between CVM and long bones (statural height),33 and hand-wrist maturation.14,15,34,35,36,37,38,39,40,41 These types of correlations gi ve us little to no information regarding the correlation or pred ictive capabilities of CVM with facial bones, which many believe to follow different growth patterns than other body bones (as previously referenced). Those who claim that CVM correlates well with mandibular growth,28,32,42 however, generally agree that when a patient is in stage 3, the p eak in mandibular growth will occur during the year following this time, and therefore treatment in a class II patient (for exam ple, with a functional appliance) should be initiated immediately. The Cervical Vertebral Maturation Method The currently proposed CVM m ethod32 for determining skeletal maturity is presented in Figure 1. Figure 1-1. The Cervical Vertebral Maturation method32 According to this system, at CVM stage 1, C2 C4 are flat, and C3 and C4 are trapezoid. At stage 2, there is a C2 concavity, and C3 and C4 are trapezoid. At stage 3, C2 and C3 have

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15 convavities, and C3 and C4 are either trapezoid or rectangular horizontal. At stage 4, C2, C3, and C4 all still have concavities, and C3 and C4 are both rectangular horizontal. At stage 5, C2, C3, and C4 have concavities, and C3 and C4 are both squared or one is r ectangular horizontal. Finally, at stage 6, C2, C3, and C4 all still have concavities, and C3 and C4 are either both rectangular vertical or one is squared.32 Concerning clinical relevance of the system, proponents of the method hold that at stage 1, the peak in mandibular growth w ill occur on average 2 years after this stage. At stage 2, the peak in mandibular growth will occur on average 1 y ear after this stage. At stage 3, the peak in mandibular growth will occur during the year after th is stage. At stage 4, the peak in mandibular growth has occurred within 1 or 2 years before this stage. At stage 5, the peak in mandibular growth has ended at least 1 year before this stag e. And at stage 6, the peak in mandibular growth has ended at least 2 years before this stage.32 Objective This study will inv estigate if treating a cla ss II occlusion in the ideal CVM stage will result in the mandible being signifi cantly larger or more anteriorly displaced than it would have been if no treatment would have taken place.

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16 CHAPTER 2 MATERIALS AND METHODS Details of Clinical Trial Used For Data Collection Cephalogram s and data from the Florida Class II clinical trial were used. This was a large, prospective trial in which 325 randomized Class II patients underwent eith er two-phase treatment with a bionator, two-phase treatment with a headgear/biteplane combination, or one postpubertal treatment phase (second phase only). For th e clinical portion of th e trial, 6303 third and fourth grade public school children from Alac hua County, Florida were screened. 1226 students qualified to participate in the study, and from these 325 were randomized and divided as previously described. The inclus ion criteria consisted of posi tive overbite and overjet, intact mixed dentition (>3 deciduous molars), bilateral (>1/2 cusp) Class II molar, all permanent first molars, less than 3 permanent canines or pr emolars present and good general health. The exclusion criteria includ ed the presence of periodontal problems or dental decay, unwillingness to be randomly assigned to treatment group and failure to sign informed consent. For the bionator and headgear/biteplane gr oups, half of the subjects were randomly assigned to six months of retention after Phas e I treatment. This consisted of wearing the bionator only at night or wearing the headgear/biteplane ever y other night. A nother six months after this retention peri od, all subjects were given the mo st appropriate orthodontic treatment (Phase II treatment). Fourth grade children were chosen because of the average age for pre-growth spurt Phase I treatment initiation of approximate ly ten years old, and because children in this age group are most likely to be in the appropriate dental condition for inclus ion in treatment (intact mixed dentition, all permanent first molars, and less than 3 permanent canines or premolars present). Treatment initiation time was therefore ba sed on chronologic and dental age.

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17 Phase II treatment was determined as follows : Orthodontic records at the end of Phase I treatment were made into videos and sent rando mly to orthodontists selected from the American Association of Orthodontists (AAO) directory. An average of four orthodontists reviewed and proposed treatment plans for each case. (A 72% overall agreement was found between the various orthodontists opinions on treatment need, approach, and extraction protocol.) Based on their responses, a consensus plan was formulated for Phase II, with treatment usually involving full fixed orthodontic appliances. All lateral cephalograms were made on a cepha lostat with a standard cathode-to-ear rod distance of 60 inches and an ear rod-to-film distance of 15 cm using Kodak Lanex X-D 600 speed film with X-O MATIC intensifying screens. These were exposed for 1 second at 80 kVP and 15 mA. Calibration For reliability testing, a set of approxim ately 100 cephalograms were staged once, then at least two weeks later were staged again. Five se ts of these reliability tests were necessary in order to achieve 97% relibility to within of a stage (achieved at the final set). In order to achieve 97% reliability, severa l modifications and additions to the current method (Baccetti, etc.) were necessary. Cephalograms were eliminated for darkness, blurriness, or anatomical superimpositions on necessary landmarks. The concavities at the lower bor ders of the vertebrae were m easured with a straight edge and a standard ABO ruler. If the concavity was greater than 1mm in depth, measured from a line through the posterior-inferior and anterior-inferior corners to th e point on the inferior border furthest perpendicularly from that line, th en a concavity was deemed to exist and the cephalogram was staged as such. If it was less th an 1mm in depth, the concavity was not scored.

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18 If it was exactly 1mm in depth, it was given a 0.5 rating. For example, if there was exactly a 1mm concavity at the lower border of C3, and no concavity at the lower border of C4, the cephalogram was labeled .5. If there was a concavity at C3 but not at C2, the cephalogram was scored as stage 3. If there were concavities at C3 and C4, but both were trapezoid in shape (not rectangular horizontal), the cephalogram was labeled stage 4. If there was a concavity at C4 but not C3 (with or without a c oncavity at C2), the shapes of C3 and C4 were assessed. If both were definite ly trapezoid and not rect angular horizontal, the concavity was not counted. If at least one was rectangular horizontal, th e concavity was counted, and the stage was assessed based on the sh ape of the one which was most mature. If there was no concavity at C4 but both C3 a nd C4 were squared or rectangular vertical, the concavity at C4 was assumed, and the cephalogr am was staged according to the shape of the vertebral body (of C3 and C4) which was most mature. The shapes of the vertebrae were measured with a standard millimeter ruler. Specifically, if the vertical dimension (from the anterior-infer ior corner to the anterior-superior corner) was less than the horizontal dimension (measured from the middle of the posterior border to the middle of the anterior border) minus 1mm, then the shape was determined to be rectangular horizontal. If the vertical dimension was greater than the horizontal dimension plus 1mm, then the shape was determined to be rectangular vertical. If they were within 1mm, the shape was determined to be square. When the vertebral bodies pres ented with a double border, the examiner generally used the most anterior line if it occurred in the posterior border, the most inferior line if in the posterior part of inferior border, the most superior line if in the anterior part of inferior border, and the

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19 most inferior line if in the anterior part of s uperior border. However, if both lines were of exactly equal distinctness and opacity, the cephal ogram was scored twice using the two different lines. If the cephalogram could have been labele d two different stages wh ich were greater than 1 stage apart, it was thrown out. Once stage 4 was reached, whichever verteb ral body (between C3 and C4) was farther along (more rectangular vertical) wa s used for staging, and the othe r not used. If the one used for staging had a double border, and assessments us ing both of the borders produced stages that were more than 1 stage apart (for example a nd ), the cephalogram was thrown out. If the assessed stages using both bor ders were within 1 stage. .5 numbers were used, giving staging possibilities of 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, and 6. In all staging, the assessor decided on the highest and the lowest possible stage that the cephalogram could be labeled. If those two num bers were off by 1, the average of the two was the score. If those two numbers were off by 0.5, the assessors best judgment was used to choose between the two numbers. If the two numbers were off by more than 1, the cephalogram was thrown out. After staging each cephalogram individually, every series of cephalograms from each individual subject was made to ascend numerically (in stage) with time. For example, if one timepoint was labeled stage 4 and the next tw o timepoints were labeled stage 3, the 4 was changed to 3 for the sake of chronology. If the stages, in order, were 3, 3, 4, 3, 4, 4, then the assessors best judgment was used to modify th e sequence for ascending order. (These rules were necessary 2% of the time). If there was a marked inconsistency in stage signs such that the assessor was unable to use the CVM method to score the cephalogram, it was eliminated.

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20 After the fifth calibration exercise using the above rules, the assessor rescored the cephalograms which he scored one time but did not score the ot her time in order to eliminate quality disagreements. The entire set of radiographs from all patients was then scored according to the new system. A general analysis of the distributi on of data (CVM stage over time) was made, and correlations of CVM, hand-wrist, age, and we ight with statural height were assessed. Data Manipulation In our study, only 3 subjects in the headgear group, 4 subjects in th e bionator group, and 5 subjects in the control group were assessed as CVM stage 3 at the first tim epoint (DC-1). If we included those who started as stages 2.5 and 3.5 also, more subjects could be included. However, our calibration exercises indicated that staging, at leas t for this examiner, could only be accurate to within 0.5 (not exact match). Th erefore, including subjects in stages 2.5 and 3.5 would in essence be including subjects who might well be in stage 2 or 4. After looking at the timepoint data available for these 12 patients, it was found that only 2 patients in each group could be found who had data at almost exactly the same length of time after the initial timepoint (which happened to be a range from 4 yrs 1 month to 4 yrs 3 months after timepoint 1). Co-Gn and Ar-Gn measurem ents and percentage increase in mandibular length data were obtained for thes e subjects, but this data will not be presented due to obvious sample size problems. The search was then expanded to include any subject whose treatment, whether Phase I headgear, Phase I bionator, or Phase II, was begun in either stage 2.5 or 3. (2.5 indicates a stage where either the concavity at C3 is 1mm but not more, or there is equal reason to believe the cephalogram should be staged as .) Seven subjects were found to be in either of these stages at the start of Phase II treatment, and 29 were found at the start of Phase I treatment (16

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21 bionator and 13 headgear). Johnstons cephalometric analysis43 was used to compare anterior displacement of maxilla relative to cranial base, anterior disp lacement of mandible relative to cranial base, and apical base cha nge (mandible relative to maxilla) from timepoint 1 to F (final) in two groups: those started in stages 2.5 or 3 (n=36), and those started in a stage other than 2.5 or 3 (n=81). In the same way, each individual treatment group (bionator, headgear, control) was divided into those started at the correct CVM stage (stages 2.5 or 3), and those started in any stage other than these.

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22 CHAPTER 3 RESULTS As seen Figure 3-1, for calibration attem pts 1 and 3 the examiner used only whole numbers for staging (as the current method proposes). In bo th instances, inconsiste nt scoring of greater than or equal to 1 stage was seen one quarter of the time. This was decided to be unacceptable for later data interpreta tion. After the fifth calibration exercise the examiner rescored the quality disagreements (those which were marked cannot score one time, but scored the other). The results shown are after including the rescored da ta, and counting those not scored both times as exact matches. This brought the reliability of scoring w ithin .5 stages to an acceptable 97%. It is also important to remember that this acceptabl e level of calibration wa s only attained if the examiner could eliminate the cephalograms which were illegible (see calibration section of methods chapter). 0 10 20 30 40 50 60 70 80 90 100 1st2nd3rd4th5th exact match .5 stages off 1 or more offAttempt% Figure 3-1. Calibration results

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23 The total number of cephalograms staged fo r the calibration exercises was approximately 1200, and the total number of cephalograms stag ed for the study itself was 2470. Of those 2470, 530 (or 21%) were not scored due to one of the problems mentioned in the methods section. The problems encountered for those that were not scored and their fr equency are seen in Figure 3-2. 0 50 100 150 200 250 300 350 400 3-D Column 1 Blurry Superimpositions CVM system problem Dark Cut off Number Of Cephs Figure 3-2. Frequency of problems in the ce phalograms not scored (some cephalograms had more than one problem). The total number of cephalograms not scored was 530 out of 2470, or 21%. 0 1 2 3 4 5 6 13581012R1R3R5R7R9SS1SS3SS5 E CVM Stage Timepoint Figure 3-3. Average CVM stage at each timepoint, using data from as many subjects as possible at each timepoint

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24 As seen in Figure 3-3, a relatively smooth increase in CVM is seen over the early timepoints until R3, when CVM stage levels at around 5. Some timepoints had a greater number of radiographs than others. Timepoints 11 and 12 were particularly low, with n values of 4 and 1, respectively, and could account for the variation observed. Table 3-1. Correlations of various maturity indicators with statural height at various timepoints. Timepoint 1 is the beginning of Phase I treat ment, 3 is the end of Phase I treatment, 5 is an observation timepoint, 7 marks the begi nning of Phase II, a nd F is the end of Phase II. Hand-wrist radiographs were not exposed after timepoint 5. Stage represents CVM stage. indicates statis tical significance at the .01 level (Pearson Coefficients used) Timepoint 1 Timepoint 3 Timepoint 5 Timepoint 7 Timepoint F Stage/Height 0.45* 0.50* 0.47* 0.47* 0.13 H-W 1/Height 0.63* 0.65* 0.67* H-W 2/Height 0.48* 0.50* 0.48* Age/Height 0.52* 0.52* 0.51* 0.56* 0.46* Weight/Height 0.70* 0.69* 0.68* 0.59* 0.46* As seen in Table 3-1, CVM stage correlates significantly with statural height until timepoint F, at which point the co rrelation is not statistically si gnificant. However, at no time does CVM stage correlate better w ith height than any of the othe r maturity indicators, including age. In searching for CVM stage 3 in all patie nts, it was found that only 28% of the 276 patients in the study were scored stage 3 at leas t once along their entire timeline (timepoint 1 to their last retention timepoint). Of these, one third had more than one score of stage 3 along their timeline, and the average time span that they re mained in stage 3 was 14 months. The longest recorded period of time in stage 3 was 77 months.

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25 A B C Figure 3-5. Overall Johnston analysis43 comparisons from timepoint 1 (beginning of Phase 1) to timepoint F (end of Phase II) for patients w ho started treatment in the ideal stage (2.5) and those who started treatment out side of the ideal stage. p<.05, parametric (t-test) and non-parametric (Wilcoxon Rank Sum) tests. A) apical base change. B) maxillary skeletal change with respect to cranial base. C) mandibular skeletal change with respect to cranial base.

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26 As seen in Figure 3-5, the only significant finding was that the maxillary complex moved anteriorly more in the group which was started in stages 2.5 or 3 than in the other group. It should be noted that of the 36 subjects in the gr oup which started treatment in stages 2.5 or 3, seven were Phase II only patients. Phase II tr eatment was based on majority opinions from various AAO orthodontists. Therefore, some r eceived upper premolar extractions, a treatment plan in which the maxilla and mandible would lik ely receive far less Class II-type forces than most other class II treatment protocols. When data were examined by treatment group, mandibular skeletal change with respect to cranial base in the control group was the only measurement found to be significantly different between those whose treatment was started in stages 2.5 or 3 and those whose treatment was started in another stage (Figur e 6). However, this differenc e was only significant using a parametric test (t-test), and not using a non-pa rametric test (Wilcoxon Ra nk Sum test), a test which might be more appropriate given the sample sizes.

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27 0 1 2 3 4 5 6 7 8 9 Treatment started outside stage 2.5 or 3 Treatment started at stage 2.5 or 3BionatorHeadgearControlMandibularchange in mm from 1 to F (amount that mandible went forward relative to cranial base)* p <.05 t-test A Figure 3-6. Johnston analysis43 comparisons by treatment group from timepoint 1 (beginning of Phase 1) to timepoint F (end of Phase II) for patients who started treatment in the ideal stage (2.5) and those w ho started treatment outside of the ideal stage. p<.05, parametric (t-test) only. A) apical base change. B) maxillary skeletal change with respect to cranial base. C) mandibular skeletal change with respect to cranial base. 0 1 2 3 4 5 6 Treatment started outside stage 2.5 or 3 Treatment started at stage 2.5 or 3BionatorHeadgearControlMaxillary change in mm from 1 to F (amount that maxilla went forward relative to cranial base) B

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28 0 0.5 1 1.5 2 2.5 3 3.5 Treatment started outside stage 2.5 or 3 Treatment started at stage 2.5 or 3Apical base change in mm from 1 to F (amount that mandible went forward relative to maxilla)BionatorHeadgearControl C Figure 3-6. Continued

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29 CHAPTER 4 DISCUSSION Ultimate In discussing the m anipulation of the mandibl e for the purpose of ma king it larger anteroposteriorly, or making it occupy a more anterior location with respect to the maxillary complex, it is important to completely remove four factors from the discussion. First, we must remove the teeth. This ma y seem obvious, but it is disconcerting how many studies aimed at discovering skeletal changes will present change s seen in the dentition. As difficult as it may be, overjet, mo lar/canine classification, and me sial/distal movement of teeth should not be mentioned. Second, we must remove growth. For the mo st part, any two orthodontists can agree on the average size, from Co to Gn, of a 12 year old mandible (Bolton norms and others). However, they often disagree on whether this particular mandible is ahead of the growth curve, behind it, or just about average. One orthodontist, therefore, will state that the mandible is of normal size and position (based on a certain am ount expected growth remaining), and the other will state that the mandible is of abnormal si ze and position (based on a different amount of expected growth remaining). Unfortunately for researchers in this field, the natural process by which a human mandible grows is to increase in antero-posterior size (as well other dimensions and shape changes), and to occupy a more anterior location with respect to the maxillary complex. Because these two changes are the exact changes orth odontists are trying to bring about, it is surprisingly difficult to look at a mandible which after two years of our treatment has grown larger and has come to occupy a more anterior location with respect to the maxillary complex, and say I did not change

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30 anything. In order for our treatment to have changed something, the mandibular size increase and location difference will need to be greater than that which would have happened anyway. Even more complicated is the fact that th ere is a time during adolescent growth, the adolescent growth spurt, in whic h bone growth occurs with a rela tively greater velo city than at other times. If the treatment we carry out happ ens to take place during this time, therefore, we are held to an even higher standard of demonstrat ing significant results than if it does not. This is because the mandible, during two years which in clude the adolescent growth spurt, should take on a significantly more favorable size and locatio n when compared to two years before or after this time, regardless of whether any treatment has taken place. Third, we must remove relapse, particularly with regards to functional appliances. It makes sense that a bone which has been disengaged from its joint socket for a period of a year will settle back into its housing, at least to some extent, after the dislodging force is removed. Therefore we cannot be satisfied in treatment results that are obtai ned from data taken immediately, or even soon after, appliance removal. Fourth, we must remove posturing. Again, th is applies mostly to functional appliance therapy. Although posturing should not affect si ze measurements obtained from a cephalogram, it will certainly affect clinical profile assessments and location measurements with respect to the maxillary complex or the cranial base. Agai n, it simply makes sense that someone whose mandible has been denied the ability to seat in its anatomical position for a period of a year or more will have adapted to the new, awkward way of opening and closing their jaw. During treatment, these individuals have been accomplishing rotational jaw movements not in the condylar fossa, but somewhere on the articula r eminence, a location usually reserved for translation. Their muscles have now been traine d on the involuntary level to accomplish opening

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31 and closing movements in this new position. Wh en given the chance to go back to a normal anatomical relationship, some time may be require d for the masticatory muscles to be re-trained. As explained in the note in the introduction section, these ar e the reasons for the need to use and define the term ultimate. The term ultimate is used throughout this paper to mean the exact size, shape, and location that a bone would assume if it were never treated (thereby removing external influences and relapse), after all growth was completed, and without posturing. The Ideal Experiment In order to explain our data m anipulation, a nd to put our study in proper perspective, a summary of the ideal experiment, which we were hoping to perform, will be presented. To determine whether or not CVM is a better predictor of the mandibular growth spurt than chronologic age, a large sa mple of longitudinal cephalometric data should be obtained, such as the Burlington, Bolton, or Michigan norms. Id eally, the records would extend out to 21 years, to make sure all growth has stopped (the Bolt on study goes to age 18). For each individual, the exact age of the beginnin g of the mandibular growth spurt (which may last up to two years) should be obtained. Next, the exact age at the beginning of CVM st age 3 should also be obtained. The ages of the subj ects selected in CVM stage 3 should ideally span a wide age range, in order to more distinctly divide the two comparison groups, age and CVM. The average age at which one would expect the mandibular growth spurt to begin (11 for girls, 13 for boys) should be compared with the actual beginning of each individuals growth spurt. Finally, the age at the beginning of CVM stage 3 should be compared with the actual beginning of each individuals growth spurt. An assessment could then be made regarding which method predicted the peak more accurately, age or CVM. Unfortunate ly, the data from this clinical trial was found to be insufficient in produci ng this kind of comparison. Indi viduals in the trial were all

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32 eventually treated, therefore there only exist control data (untr eated patients) for a period of about 4 years, when other subjects were unde rgoing Phase I treatment. In addition, missing data points for some patients and long timepoint intervals made for an inability to accurately chart mandibular growth (to determine the mandibular growth spurt). To determine whether or not treatment in stage 3 makes a difference in ultimate mandibular size, excellent long-term (and longitudinal) cephalometric data must again be used. This would require a large sample of patients treated exactly at CVM stage 3 with a consistent treatment protocol and whose final ma ndibular size (in adulthood) is known. Alternatively, if control group da ta only existed for a short pe riod, a time interval (such as 2 years) after the first sign of CV M stage 3, as long as all subjects had data at exactly that time (2 years), could be selected. For each individual in the control group, the mandibular length at the beginning of CVM stage 3 could be subtracted fro m the mandibular length exactly 2 years after that time. This amount could then be expressed as a percentage of original mandibular size at CVM stage 3 (to eliminate differences due to the s ubjects themselves being tall or small). This percentage would represent the average size in crease (without treatment) of a mandible from the beginning of the growth spurt (assuming CVM accurate ly predicts the growth spurt) to exactly two years after that. The same pe rcentage could be found in all the treated subjects, and then the two percentages could be compared to see if the treated subjects had a greater percent size increase than the untreated subjects. General Observations Unfortunately, as explained in the m ethods section, our study was unable to meet the above requirements for determining an individual s ultimate jaw bone size and position within the face. We can, however, make several obser vations regarding the CVM method as a growth assessor and predictor.

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33 As a human grows, the bodies of the cervical vertebrae tend to become longer vertically, and cupping occurs on their inferior borders. From person to person, however, there is great variation in the markedness or depth of th e concavities throughout growth, the individual underlying shapes of the vert ebral bodies, and the sequence in which events such as shape changes in certain vertebrae take place. Because of this, it is extrem ely difficult to choose a certain step in the process which can be easily and consistently labeled, and which occurs at a certain point in growth (ideally, just prior to the mandibular growth spurt) in all individuals. The CVM method does seem to be reliable in giving a general idea of how much growth remains or has already taken place in an individual (it follo ws a general growth curv e relatively well), but it may not be any more reliable than an estimate based on sex and age. If the CVM method correlated better with the growth of the mandible than does the handwrist method, and if in add ition it contained a reliable predictor of the mandibular growth spurt, it would have the distinct advantage over ha nd-wrist of being assessed from a cephalogram, which would be convenient, and would eliminate the need for extra radi ation exposure to the patient. Perhaps it is reasoned that because ne ck bones are closer to the mandible (and other facial bones) than hand bones, they should correlate more similarl y in growth. (The cervical vertebrae do not have a more similar formationa l origin, i.e. intramembranous vs. endochondral, than do the bones of the hand and wrist.) Due to the stringent longitudinal requirements of a study investigating growth spurts, our experiment could not definitively state whether or not the CVM method matched or could predict ma ndibular growth. It is the authors opinion that neck bone growth, in the general popula tion, correlates with facial bone growth about as well as all other bones of the body (which, much of the time, is not very well). It is very possible, however,

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34 that in certain individuals, certain vertebral maturity indicato rs match (or precede) the peak in mandibular growth. If we assume that CVM stage 3 does immediately precede the mandibular growth spurt, then our investigation (though severely crippled from small sample sizes) does not show any indication that class II pa tients (treated in various ways) benefit from an ultimate mandibular size increase or anterior relocation. This would indicate (again, if CVM accurately predicts the mandibular growth spurt) that putting an anterior force on the mandible by way of the teeth does not change its ultimate size.

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35 CHAPTER 5 CONCLUSIONS Hum an cervical vertebral bodies, as they grow and mature, take on a more vertically rectangular shape, and show cupping at their inferior borders, when viewed from a lateral perspective. The process occurs gradually, howev er, and varies widely from person to person. It does not occur in distinct steps which can be easily followed in each individual, even with closely successive cephalograms. In early growth stages, CVM stage correlates highly with statural height (growth of long bones). However, at no time does it correlate mo re strongly than hand-wrist maturation or age. A specific marker in the cervi cal vertebrae which could accu rately predict a time when facial bones will undergo greater gr owth velocity was found to be elusive and highly variable among individuals. Many problems with legibility of cephalograms were found, making reliable CVM staging difficult. Class II patients with treatment starting in CV M stages 2.5 or 3 were not found to have any significant ultimate skeletal improvement over those with treatment starting in a stage other than stage 2.5 or 3.

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36 LIST OF REFERENCES 1. Tulloch JFC Proffit WR, Phillips C. Outcomes in a 2-phase randomised clinical trial of early Class II treatment. Am J Orthod Dentofacial Orthop 2004;125:657-667. 2. Dolce C, McGorray SP, Brazeau L, King GJ, Wheeler TT. Timing of Class II treatment: skeletal ch anges comparing 1-phase and 2-phase treatment. Am J Orthod Dentofacial Orthop 2007;132:481-9. 3. Slavicek R. The Masticatory Organ. 1s t ed. Ann Arbor, MI: Needham Press; 2002. 4. Sato S. A Treatment Approach to Malocclusi ons Under the Considera tion of Craniofacial Dynamics. 1st ed. Chicago, IL: Grace Printing Press; 2001. 5. Ruf S, Pancherz H. Temporomandibular joint remodeling in adolescents and young adults during Herbst treatment: A prospect ive longitudinal magnetic resonance imaging and cephalometric radiographic investig ation. Am J Orthod Dentofacial Orthop 1999;115:607-18. 6. Kluemper GT, Spalding PM. Realities of craniofacial growth modification. Atlas Oral Maxillofac Surg Clin North Am 2001;9:23-51. 7. Franchi L, Baccetti T, McNamara JA. Treatme nt and posttreatment effects of acrylic splint Herbst appliance therapy. Am J Orthod Dentofacial Orthop 1999;115:429-438. 8. Baccetti T, Franchi L, Toth LR. Treatment timing for Twin-block therapy. Am J Orthod Dentofacial Orthop 2000;118:159-170. 9. Faltin K, Faltin RM, Baccetti T. Long-te rm effectiveness and treatment timing for Bionator therapy. Angle Orthod 2003;73:221-230. 10. Gu Y, McNamara JA. Mandibular growth changes and cerv ical vertebral maturation: a cephalometric implant study. Angle Orthod 2007;77:947-53. 11. Bjrk A. Tim ing of interceptive orthodontic measures based on stages of maturation. Trans Eur Orthod Soc 1972;61:61-74. 12. Pancherz H, Hgg U. Dentofacial orthopedics in relation to somatic maturation: an analysis of 70 consecutive cases treated with the Herbst appliance. Am J Orthod 1985;88:273-87. 13. Von Bremen J, Pancherz H. Efficiency of ear ly and late class II division 1 treatment. Am J Orthod Dentofacial Orthop 2002;121:31-7. 14. Grave K, Townsend G. Hand-wrist and cervical vertebral maturation indicators: how can these events be used to time Class II treatments? Aust Or thod J 2003;19: 33-45.

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37 15. Grave K, Townsend G. Cervical vertebral ma turation as a predicto r of the adolescent growth spurt. Aust Orthod J 2003;19: 25-32. 16. Hunter CJ. The correlation of facial growth with body height and sk eletal maturation at adolescence. Angle Orthod 1966;36:44-54. 17. Bergersen EO. The male adolescent growth s purt: its prediction and relation to skeletal maturation. Angle Orthod 1972;42:319-38. 18. Nanda RS. The rates of growth of several facial components measured from serial cephalometric roentgenograms. Am J Orthod 1955;41:658-73. 19. Burstone CJ. Process of maturation and growth prediction. Am J Orthod 1963;49:907-20. 20. Moore RN, Moyer BA, DuBois LM. Skeletal maturation and craniofacial growth. Am J Orthod Dentofacial Orthop 1990;98:33-40. 21. Bishara SE, Jamison JE, Peterson LC, DeKo ck WH. Longitudinal changes in standing height and mandibular parameters between the ages of 8 and 17 years. Am J Orthod 1981;80:115-35. 22. Mitani H, Sato K. Comparison of mandibular growth with other variables during puberty. Angle Orthod 1992;62:217-222. 23. Franchi L, Baccetti T, McNamara JA. Mandibular growth as related to cervical vertebral maturation and body height. Am J Or thod Dentofacial Orthop 2000;118:335-340. 24. Baccetti T, Franchi L, McNamara JA. An improved version of the cervical vertebral maturation (CVM) method for the assessmen t of mandibular growth. Angle Orthod 2002;72:316-323. 25. Baccetti T, Franchi L, McNamara JA. The cervical vertebral maturation (CVM) method for the Assessment of Optimal Treatment Timing in Dentofacial Orthopedics. Semin Orthod 2005;11:119-129. 26. Franchi L, Baccetti T, McNamara JA. Treatme nt and posttreatment effects of acrylic splint Herbst appliance therapy. Am J Orthod Dentofacial Orthop 1999;115:429-438. 27. Baccetti T, Franchi L, Toth LR. Treatment timing for Twin-block therapy. Am J Orthod Dentofacial Orthop 2000;118:159-170. 28. Faltin K, Faltin RM, Baccetti T. Long-te rm effectiveness and treatment timing for Bionator therapy. Angle Orthod 2003;73:221-230. 29. Lamparski, DG. Skeletal age assessment utilizing cervical vertebrae (dissertation). Pittsburgh, PA: The University of Pittsburgh 1972.

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38 30. Hassel B, Farman AG. Skeletal maturation ev aluation using cervical vertebrae. Am J Orthod Dentofacial Orthop 1995;107:58-66. 31. Chen F, Terada K, Hanada K. A new method of predicting mandibular length increment on the basis of cervical verteb rae. Angle Orthod 2004;74:630-634. 32. Baccetti T, Franchi L, McNamara JA. The cervical vertebral maturation (CVM) method for the Assessment of Optimal Treatment Timing in Dentofacial Orthopedics. Semin Orthod 2005;11:119-129. 33. Hellsing E. Cervical vertebral dimensions in 8-, 11-, and 15-year-old children. Acta Odontol Scand 1991;49:207-213. 34. San Roman P, Palma JC, Oteo MD, Nevado E. Skeletal maturation determined by cervical vertebrae developmen t. Eur J Orthod 2002;24:303-311. 35. Seedat AK, Forsberg CD. An evaluation of the third cervical vertebra (C3) as a growth indicator in Black subj ects. SADJ 2005;60:156, 158-60. 36. Caltabiano M, Leonardi R, Zaborra G. Evalua tion of cervical verteb rae for determination of skeletal age. Riv Ital Odontoiatr Infant 1990;1:15-20. 37. Mito T, Sato K, Mitani H. Cervical verteb ral bone age in girls. Am J Orthod Dentofacial Orthop 2002;122:380-385. 38. Mito T, Sato K, Mitani H. Predicting mandibul ar growth potential with cervical vertebral bone age. Am J Orthod Dent ofacial Orthop 2003;124:173-177. 39. Chen F, Terada K, Hanada K. A new method of predicting mandibular length increment on the basis of cervical verteb rae. Angle Orthod 2004;74:630-634. 40. Kucukkeles N, Acar A, Biren S, Arun T. Comparisons between cervical vertebrae and hand-wrist maturation for the as sessment of skeletal matu rity. J Clin Pediatr Dent 1999;24:47-52. 41. Chang HP, Liao CH, Yang YH, Chang HF, Chen KC. Correlation of cervical vertebra maturation with hand-wrist maturation in children. Kaohsiung J Med Sci 2001;17:29-35. 42. O'Reilly MT, Yanniello GJ. Mandibular grow th changes and maturation of cervical vertebrae--a longitudinal cephalome tric study. Angle Orthod 1988;58:179-184. 43. Johnston LJ. A comparative anal ysis of Class II treatments. In: P. Vig and K. Ribbens, Editors, Science and clinical judgment in orthodontics Monograph 19. Craniofacial Growth Series, Center for Human Growth and Development; University of Michigan, Ann Arbor 1986;1:103.

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39 44. Keeling SD, Wheeler TT, King GJ, Garvan CW Cohen DA, Cabassa S. Anteroposterior skeletal and dental changes after early Cla ss II treatment with bionators and headgear. Am J Orthod Dentofacial Orthop 1998;113:40-50.

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BIOGRAPHICAL SKETCH Jam es Daniel Jones was born in Geneva, Switzerland. Two years later, his family moved to Nantes, France, where he attended pu blic primary and middle schools. At age 13, he moved to Little Rock, Arkansas, only to move to Tuscaloosa, Alabama approximately 8 months later. After completing high school at Cent ral High in Tuscaloosa, he attended Harding University in Searcy, Arkansas, where he earned a B.A. in general studies. He then spent time in the Kaptagat area of Kenya, Africa as an Englis h teacher at a small, primitive boarding school. After recovering from life-threatening illnesses in Africa, and one year after university graduation, he entered dental school at the University of Alabama at Birmingham. His academic interests in mathematics, physics, and simple e ngineering coupled with his love for children and teenagers prompted him to pursue specialty training in orthodontics. After receiving his DMD in 2005, he entered the M.S. degree orthodontic program at the University of Florida in Gainesville, ultimately gaining his Masters degree in 2008. Daniel believes in balance in life. He prioritizes relationships over rules. He deeply values honesty and openness. In addition, he is concer ned that telling someone I was wrong for a specific action (not simply in general terms) is becoming a lost art in many adult populations. Getting outside and active usually puts Daniel in good spirits. His wife Melanie makes any room brighter when she steps into it, a nd he never knew how much he would love his children, Daisy (3 years old) and Isaac (7 months old).