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An Introduction to Orthodontics 3rd Edition Laura
Mitchell Digital Instant Download
Author(s): Laura Mitchell
ISBN(s): 9780198568124, 0198568126
Edition: 3
File Details: PDF, 45.82 MB
Year: 2007
Language: english
 • •

Laura Mitchell

THIRD EDITION

online
resource
centre
 • •

THIRD EDITION

Laura Mitchell
MDS, BDS, FDSRCPS (GiasgJ, FDSRCS (Eng), FGDP (UK),
D. Orth RCS (Eng), M. Orth RCS (Eng)
Luke's Hosp.tal Bradford
Consultant Orthot:l:mtlst, St.
Honorary Semor Climcol Lecturer. Leeds Dental Jnstitute. teeds

With contributions (r()m

Simon J. Littlewood
BDS. FOS(Orth) RCPS {Giasg), M Orth RCS (Edtn).
•

MOSt. FDSRCS {Eng)

Consultant OrthodontiSt, .)t Luke's Hospitaf. Bradford
Honorary Senior Clinical Lecturer. Leeds De.ntal JnstJtute, Leeds

Bridget Doubleday
PhD, M.Med.Sci., BDS. FDSRCPS tGiasg) M. Orth.
Consultant Odhodontlst and Honorary Semor Clinical Lecturer,
•

Glasgow Dental School. Glasgow

• Zararna L. Nelson-Moon
MSc. PhD, BDS. FOS Onn RCS (Eng), M. Orth RCS (Eng),
Consultant Orthodontist and Honorary Senior Climcal Lecturer,
• Leeds Dentallnstrcute. Leeds

OXFORD
•
UNIVERSITY l'RESS

..
OXFORD
VNlVERSITY PRESS

Great Clarendon Street. Oxford OX2 6DP

Oxford University Press is a department of the University of Oxford.
It furthers the University's objective of excellence in research. scholarship,
and education by publishing worldwide in
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Oxford is a registered trade mark of Oxford University Press

in the UK and in certain other countnes

Published in the United States

by Oxford Univers1ty Press Inc .. New York
©laura M1tchell. 2007

The moral rights of the authors have been asserted

Database ri ght Oxford University Press (maker)

This edition published 2007

First edition published 1996
Second edition published 2001

All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted, in any form or by any means.
without the prior permission in writing of Oxford University Press,
or as expressly permitted by law. or under terms agreed with the appropriate
reprographics rights orgar11zation. Enquiries concernmg reproduction
outside the scope of the above should be sent to the Rights Department.
Oxford Univers1ty Press. at the address above

You must not circulate this book in any other binding or cover
and you must impose the same condition on any acquirer

British Library Cata\oguing in Publication Data

Data avai !able

library of Congress Cataloging in Publication Data

Data available

Typeset by Graphicraft limited, Hong Kong

Printed in Great Bntain
ori acid· free paper by CPI Bath Ltd. Bath

ISBN 978-0-19-856812-4

1 3 5 7 9 10 8 6 4 2
Pre ace orthir"'"" e "'""ition
Bemg involved w1th the th1rd ed1t1on of a textbook suggests that the author 1s e1ther very old or needs to
consider other alternative hobbies. At t1mes 1t does feel as if the first is true. but I presently subscnbe to the
idea that given the rapid pace of change in any clintcal subject that in order to reflect current practice regular
revi sions of a text are a fact of life. In particular. in many countries the skill-mix m Orthodontics is changmg.
It is hoped that this new edition will appeal to thi� wider aud1ence.

I would like to ded1cate th1s ed1tion to N1gel E. Carter, who contributed to both the first and second edit1ons
of th1s book. Unfortunately, Nigel d1ed m 2005 H1s qu1et w1t and modesty 1S greatly mtssed.

I
J

I
..

Acknowle -ements __

Once again, I would like to express my gratitude to all those who have made positive comments about pre­
vious editions of this book. In addition, I would like to thank my co-authors for their expertise and support,
in particular Simon Littlewood. and I am sure they will join with m e in thanking all the staff that have helped
us along the way. I am also grateful to Christopher Hogg for his helpful comments regarding the Orthodontic
First Aid chapter.

The functional appliances illustrated in Chapter 19 were produced by the Senior Orthodontic te<:hnician at
St Lukes' Hospital Bradford, Nigel Jacques and are testament to his consistently good laboratory work.

I would like to thank the staff of Oxford University Press. in particular our previous editor Colin McDougall who
has been helpful and supportive throughout.

Finally, once again, I have to pay tribute to the support and encouragement of my husband without which.
this third edition would not have been possible.

'
-

•
Bri e cont ents
1 The rationale for orthodontic treatment 1

2 The aetiology and classification of malocclusion 7

3 Management of the developing dentition 15

4 Craniofacial growth, the cellular basis of tooth movement and anchorage

(Z. L. Nelson-Moon) 29

5 Orthodontic assessment 49

6 Cephalometrics 61

7 Treatment planning (S. J Littlewood) 73

8 Class I 89

9 Class II division 1 99

10 Class II division 2 111

11 Class Ill 121

12 Anterior open bite and posterior open bite 131

13 Crossbites 139

14 Canines 147

15 Planning anchorage (B. Doubleday) 157

16 Retention {5. J. Littlewood) 167

17 Removable appliances 177

18 189
•

Fixed appliances
19 Functional appliances (S. J Littlewood) 203

20 Adult orthodontics (5. J. Littlewood) 217

21 Orthodontics and orthognathic surgery (S. J. Littlewood) 227

22 Cleft lip and palate and other craniofacial anomalies 243

23 Or1hodontic first aid 255

Definitions 261

Index 263

....
 Detaile contents _

Preface for third edition v 5 Orthodontic assessment 49

.
Acknowledgements VI
5.1 Purpose and aims of an orthodontic assessment 50
5.2 Equipment 50
1 The rationale for orthodontic treatment 1 50
5.3 Patient's concerns

l 1.1 Definition 2 5.4 Dental history 52

1.2 Prevalence of malocclusion 2 5.5 Medical history 52

1.3 Need for treatment 2 5.6 Extra-oral examination 52

1.4 Demand for treatment 3 5.7 Intra-oral examination 56

1.5 The disadvantages and potential risks of 5.8 Radiographic examination 59

61
orthodontic treatment 4
1 .6 The effectiveness of treatment 5
6 Cephalometries

1. 7 The temporotnandibular joint and 6.1 The cephalostat 62

orthodontics 5 6.2 Indications for cephalometric evaluation 63
6.3 Evaluating a cephalometric radiograph 63
2 The aetiology and dassification of 6.4 Cephalometric analysis: generaI points 64
malocclusion 7 6.5 Commonly used cephalometric points and
reference lines 65
2.1 The aetiology of malocclusion 8
6.6 Anteroposterior skeletal pattern 66
2.2 Classifying malocclusion 8
6.7 Vertical skeletal pattern 6B
2.3 Commonly used classifications and indices 9
6.8 Incisor position 6B
2.4 Andrews· six keys 13
6.9 Soft tissue ana lysis 69

3 Management of the developing dentition 15 6.10 Assessing growth and treatment changes 70
6.11 Cephalometric errors 70
3.1 Normal dental development 16
3.2 Abnormalities of eruption and exfoliat1on 18 7 Treatment planning (S. J. Littlewood) 73
3.3 Mixed dentition problems 19
7.1 Introduction 74
3_4 Planned extraction of deciduous teeth 27
7.2 General objectives of orthodontic treatment 74
7.3 Forming an orthodontic problem list 74
4 Craniofacial growth, the cel1utar basis of
7.4 Aims of orthodontic treatment 76
tooth movement and anchorage
(Z. L Nelson�Moon) 29
7.5 Skeletal problems and treatment planning 77
7.6 Basic principles in orthodontic treatment planning 77
4.1 Introduction 30 7.7 Space analysis 78
4.2 Craniofacial embryology 30 7.8 Informed consent and the orthodontic
4.3 Mechanisms of bone growth 33 treatment plan 83
4.4 Postnatal craniofacial growth 34 7.9 Conclusions 83
Growth rotations
8
4.5
89
37
Craniofacial growth m the adult
4.6 39
Class I

4.7 Growth of the soft tissues 39 8.1 Aetiology 90

4.8 Control of craniofacia I growth 40 8.2 Crowding 90
4.9 Growth predictton 41 8.3 Spacing 93
4.10 Biology of tooth movement 41 8.4 Displaced teeth 96
4.11 Anchorage 45 8.5 Vertical discrepancies 97
4.12 Cellular events during root resorption 47 8.6 Transverse discrepancies 97
4 .13 Summary 47 8.7 Bimaxi IIary prod ination 97
 Detailed contents
J
9 Class II division 1 99 15 3 Types o f anchorage 160

9 1 Aettology 15.4 Reinforcmg anchorage 1 60

100
9.2 Occlusal features 15.5 Extra-oral anchorage and traction 162
102
9.3 Assessment of and treatment plannmg tn 15.6 Monitoring anchorage dunng treatment 164

Class II d1v1sion 1 malocc1us1ons 15.7 Common problems wtth anchorage 165

102
9.4 Early treatment 15 8 Summary 165
104

Retention (S. J Littlewood)

9.5 Management of an increased overjet assooated
16 167
with a Class I or mild Class II Skeletal pattern 106
9. 6 Management of an increased overjet associated 16.1 Introduction 168
with a moderate to severe Class II skeletal pattern 106 16.2 Definition of relapse 168
9.7 Retention 109 16.3 Aetiology of relapse 168
16.4 How common is relapse? 170
10 Class tl division 2 111 16.5 Informed consent and relapse 170
10.1 Aetiology 1 12 16.6 Retainers 170
10 2 Occlusal features 114 16.7 AdJunctive techniques used to reduce
10 3 Management 114 relapse 175
16.8 Conclusions about retention 175
11 Class Ill 121
17 Removable appliances 177
11.1 Aetiology 122
11.2 Occlusal features 122 17.1 Mode of act ion of removable appliances 178
11.3 Treatmentplanning in Class Ill malocclusions 123 17.2 Designing removable appliances 179
11.4 Treatment options 125 17.3 Active components 179
17.4 Retaining the appliance 180
12 Anterior open bite and posterior open bite 131 17.5 Baseplate 182
12.1 Definitions 132 17.6 Commonly used components and des1gns 183
12.2 Aetiology of anterior open bite 132 17.7 Fitting a removable appliance 185
12.3 Management of anterior open bite 134 17.8 Monitoring progress 185
12.4 Posterior open bite 136 17.9 Appliance repatrs 187

13 Crossbites 139 18 Fixed appliances 189

13 1 Definttions
J
140 18.1 Principles of fixed appliances 190
'
13.2 Aet1ology 140 18.2 IndiCations for the use of fixed appliances 191
13.3 Types of crossb1te 141 18.3 Components of fixed appliances 192
13.4 Management 142 18.4 Treatment plannmg for fixed appliances 197
13.5 Clin1cal effectiveness 145 185 Practical procedures 197
18.6 Fixed appliance systems 198
14 Canines 147
18.7 Decalcification and fixed appliances 200
14.1 Facts and figures 148 18.8 Starting with fixed appliances 200
14 2 Normal development 148
14.3 Aet1ology of maxillary canine displacement 148 19 Functional appliances
14.4 Interception of d1splaced canines 149 (5. J. Littlewood) 203
14.5 Assessing maxillary canine positton 150 19.1 Definitton 204
14 6 Management of buccal displacement 151 19.2 History 204
14 7 Management of palatal displacement 152 19. 3 Overview 204
14.8 Resorptton 154 19.4 Timing of treatment 204
14 9 Transposttion 154 19.5 Types of malocclusion treated w1th functional
appliances 208

, 15 Planning anchorage (8. Doubleday)

15.1 What is anchorage and why is it important?

157

158
19.6 Types of functional appliance 208
1 9.7 Clinical management of functional appliances 214
15.1 Assessing anchorage requirements 158 19.8 How functional appliances work 215
 Detailed contents

20 Adult orthodontics (S. J. Littlewood) 217 22 Cleft lip and palate and other
craniofacial anomalies 243
20.1 Introduction 218
20.2 Speofic problems in a<iutt ortt'looontiC 22.1 P(evalence 244
treatment 218 22.2 Aet1ology 244

20.3 Orthodontics and periodontal disease 219 22.3 Classification 244

20.4 Orthodonttc treatment as an adjunct to 22.4 Problems in management 244

restorative work 219 22.5 Co-ordination of care 247

20.5 Aesthetic orthodof'ltic appliances 220 22.6 Management 247

22.7 Audit of cleft palate care 251
21 Orthodontics and orthognathic surgery 22.8 Other craniofacial anomalies 251
(S. J. 227
23
Littlewood)
j Orthodontic first aid 255
21 1 Introduction 228
23.1 Fixed appliance 256
21.2 Indications for treatment 228
23.2 Removable appliance 258
21.3 Objectives of combined orthodontics and
23.3 Functional appliance (see also problems
orthognathic surgery 228
related to removable appliances) 258
21 4 Diagnosis and treatment plan 228
23.4 Headgear 259
2 1 5 Planning 234
23.5 Miscellaneous 259
21 6 Common surgical procedures 236
21.7 Sequence of treatment 238 Definitions 261
21.8 Retention and relapse 241 Index 263

•
 •

Chapter contents
1.1 Definition 2

1.2 Prevalence of malocclusion 2

1.3 Need for treatment 2

1.3.1 Dental health 2
1 3.2 Psychosocial well-being 3
1.4 Demand for treatment 3
1 .5 The disadvantages and potential risks of
orthodontic treatment 4
1 .5.1 Root resorption 4
1.5.2 Loss of periodontal support 4
1 5.3 Decalcification 4

·1.5.4 Soft tissue damage 4

1.6 The effectiveness of treatment 5

1.7 The temporomandibular joint and
orthodontics 5
1.7.1 Orth odontic treatment as a contributorv factor in T MD 5
1.7.2 The role of orthodontic treatment 1n the prevention
and management of T MD 5

I Principal sources and further reading 6

_4t
 The rationale for orthodontic treatment

1 . 1 Defi n ition
Orthodontics is that branch of dentistry concerned with facial growth,
with development of the dentition and occlusion. and with the diagnosis,
intercept ion, and treatment of occlusal anomalies.

1 .2 Preva lence of malocclus ion

Numerous surveys have been condu cted to investigate the preva le nce
Table 1 .1 UK child dental health survey 2003.
•

of malocclusion. It should be remembered that the figures for a particu-

lar occlusal feature or dental anomaly will depend upon the size and
composition of the group studied (for example age and racial charac­
In the 12-year-old age band:
• , • � • 1 • • , • - 0 • • • • • • 0 • • • • • • • • • • • • • • • • • • • - • • • • • � • �-0 • • 0 • 0 • • 0 - 0 0 • 0 0 , • • • • y • • •

teristics), the cnteda used for assessment and the methods used by the
Children undergoing
examiners (for ex am ple whether radiographs were empl oyed). orthodontic treatment
It has been estimated that approximately 66 per cent of 12 -year-olds at the time of the survey B%

in the UK require some form of orthodontic intervention. and around

- 0 • • � - • • 0 • • • • • • 0 • 0 • • 0 • • • 0 • • • • � • 0 • 0 • • • • • • 0 • � • - - • • • • • • • � • • 0 • • • � • • • • • 0 • .. � •

Children not undergoing

33 per cent need complex treatment. The results of the recent survey
treatment - in need
of children in the United Kingdom is given in Table 1.1 . of treatment (IOTN dental
Now that a greater proportion of the popu lation are keeping their health component} 26%
teeth for longer, orthodontic treatment has an increasing adjunctive · · · · · • o • • · .. ._ • • • • , . .. . .. . . o o • · · · · · · · · · · · • • o • • · · · � O O' O O <r" • • · · · · · · · · • o o o o O o • • •

No orthodontic need
role prior to restorative work In addition, there 1s an increa�ing accept­
(NB includes children who
ability of orthodontic appliances with the effect that many adults who
have had treatment in past) 57%
did not have treatment during adolescence are now seeking treatment.

1 .3 Need for treatment

It is perhaps pertinent to begin this section by reminding the reader The decision to embark upon a course of treatment will be influenced
that malocclusion is one end of the spec t ru m of normal variation and is by the perceived benefits to the PatJent balanced against the risks of
not a disease. appli ancetherapy and the prognosis for achieving the aims of treatment
Ethically. no treatment should be embarked upon unless a demon­ successfully. In this chapter we consider each of these areas In turn,
strable benefit to the patient is feasible.In addition. the potential advant­ starting with the results of research into the possible benefits of ortho·
ages should be viewed in the light of possible risks and side-effects. dontic treatment upon dental health and psychological well-being_
jncluding failure to achieve the aims of treatment. Appraisal of these
factors is called risk-benefit analysis and. as in all branches of medicine 1.3 1 Dental health
and dentistry, needs to be considered before treatment is commenced
for an individual patient. In parallel, financial constraints coupled with Caries
the increasing costs of health care have led to an increased focus upon Research has failed to demonstrate a sign1ficant association between
the cost-benefit ratio of treatment Obviously the threshold for treat­ malocclusion and caries. whereas diet and the use of fluoride tooth·
ment and the amount of orthodontic int�rvention will differ between paste are correlated with caries experience. However, clinical experience
a system that is primarily funded by the state and one that is private or suggests that in susceptible children with a poor diet, malalignment
based on insurance schemes. may reduce the potential for natural tooth-cleansing and increase the
risk of decay.

Decision to treat Periodontal disease

depends upon The association between malocclusion and periodontal disease is weak,
as research has shown that individual motivation has more Impact than
Benefits oftreatment versus Risks
tooth alignment upon effective tooth brushing. Certainly, good tooth�
b rushers are motivated to brush around irregular teeth. whereas in the
lmpro.,led funcc;on Worsening ofdental health
(e. g. caries)
individual who brushes InfreQuently their poor pl aque control is clearly
Improved aesthetics Failure to achieve aims of of more importance. Nevertheless. it would seem logical that in the middle
treatment of this range that, Irregular teeth would hinder effective brushing. I naddi­
tlon. certain ocdusal anomalies may prejudice periodontal support.
 Demand for treatment

Crowding may lead to one or more teeth being squeezed buccally or T emporomandibu\ar io!nt dysfunction syndrome
lingually out of their investing bone, resulting in a reduction of periodontal This topic is cons idered in more detail i n Section 1.7.
support. This may also occur in a Class Ill malocclusion where the lower
incisors in cross-bite are pushed labially. contributing to gingival recession. •

Traumatic overbites can also lead to increased loss of periodontal sup· Those ocdusal anomalies for which there is evidence
port and therefore are another indication for orthodontic intervention. to suggest an adverse effect upon the longevity of
Finally, an increased dental awareness has been noted in patients the dentition, indicating that their correction would
following orthodontic treatment. and this may be of long-term benefit benefit long·term dental health
to oral health.
Increased over)et

Trauma to the anterior teeth Increased traumatic overbites

Any practitioner who treats children will confirm the association • Anterior crossbites (where causing a decrease i n labial
between increased overjet and trauma to the upper incisors. A recent periodontal support of affected lower incisors)
systematic review hasp rovided additiona I evidence for this association. • Unerupted impacted teeth (where there is a danger
This paper used a meta-analysis technique to synthesize the results of pathology)
from previous studies. Eleven studies were deemed to fit the reviewers'
Crossbites associated with mandibular displacement
criteria. The authors found that individuals with an overjet in excess
of 3 mm had more than doub\� the risk o'f injurv. The odds ratio for
traumatic injury was calculated to be 2.30 for overjets less than 3 mm.

1.3.2 Psychosocial well�being

Ovenet is a greater contributory factor in girls than boys even though
traumatic injuries are more common in boys. Other studies have shown
that the risk is greater in patients with incompetent lips. While it is accepted that dentofacial anomalies and severe malocd us ion
do have a negative effect on the pyschological well-being and self·
Masticatory funct1on esteem of the individual, the impact of more minor occlusal problems
Patients with anterior open bites (AOB) and those with markedly is more variable and is modified by socia I and cultural factors. Resea rch
increased or reverse overjets often complain or difficulty with eating, has shown that an unattractive dentofacial appearance does have
particularly when incising food. Classically patients with AOB complain a negative effect on the expectations of teachers and employers.
that they have to avoid sandwiches conta i n ing lettuce or cucumber. However. in this respect. background facia I appearance would appear
to have more impact than dental appearance.
Speech A patient's perception of the impact of dental variation upon his
The soft tis�ues show remarkable adaptation to the changes that occur or her self-image, is subject to enormous diversity and is modified by
during the transition between the primary and mixed dentitions. and cultural and racial influences. Therefore, some individuals are unaware
when the incisors have been lost owing to trauma or disease. In the of marked malocclusions. whilst others complain bitterly about very
main, speech is little affected by ma locc lusi on. and correction of an minor i rregu Ia rities.
occlusal anomaly has little effect upon abnormal speech. However, if a The dental hea lth component of the Index of Orthodontic T reatment
patient cannot attain contact between the incisors anteriorly, this may Need was developed to try and quantify the impact of a particular
contribute to the production of a lisp (i nterdental sigmatism). malocclusion upon long-term dental health. The index also comprises
an aesthetic element which is an attempt to quantify the aesthetic
Tooth impaction handicap that a particular arrangement of the teeth poses for a patient.
Unerupted teeth may rarely cause pathology. Unerupted impacted Both aspects of this index are discussed in more deta II in Chapter 2_
teeth. for example maxillary canines, may cause resorption of the The psychosocial benefits of treatment are however countered
roots of adjacent teeth. Dentigerous cyst formation can occur around to a degree by the visibility of appl iances during treatment and their
unerupted third molars or cani ne teeth. Supernumerary teeth may also effect upon the self-esteem of the individua I. I n other words a child
give rise to problems. most importantly where their presence prevents who is being teased about their teeth will probably also be teased
normal eruption of an associated permanent tooth or teeth. about braces.

1 .4 Demand for treatm ent

After working with the general public for a short period of time, it • females
can readily be appreciated that demand for treatment does not neces­ • higher socio-economic families/groups
sarily reflect need for treatment. Some patients are very aware of mild
• in areas which have a smaner population to orthodontist ratio,
rotations of the upper incisors. whilst others are blithely unaware
presumably because appl iances become more accepted
of markedly increased overjets. It has been demonstrated that aware­
ness of tooth alignment and malocclusion, and willi ngness to undergo One interesting example of the latter has been observed in countries
orthodontic treatment are greater i n the following groups: where provision of orthodontic treatment is mainly p rivatelyfunded, for
 •

The rationale for orthodontic treatment

example. the USA. as orthodontic appliances are now perceived as a pressures place considerable s train upon the limited resources of
'status symbol'. state-funded systems of care. As it appears likely that the demand
With the increasing dental awareness shown by the public and the for treatment will continue to escalate. some form of rationing of
increased acceptability of appliances. the demand for treatment state-funded treatmer1t is inevitable and is already operating in some
is increasing rapidly, particularly among the adult population who countries. In Sweden for example, the contribution made by the state
may not have had ready access to or1hodontic treatment as children. towards the cost of treatment is based upon need for treatment
In addition, increa�ed dental awareness also means that patients as determined by the Swedish Health Board's \ndex (see IOTN in
are seeking a higher standard of treatment result. These combined Chapter 2).

1 .5 The d i sadvantages and potential risks of orthodontic treatment

like any other branch of medicine or dentistry, orthodontic treatment appliances. This normally reduces or resolves following removal of the
is not without potential risks (see Table 1.2). appliance. but some apical migration of periodontal attachment and
alveolar bony support is usual during a 2·year course of orthodontic
1�5.1 Root resorption '/!'
treatment. In most patients this is minimal. but if oral hygiene is poor,
,J. ,.._
_
•

(, ......,....
.
particularly in an individual susceptible to periodontal disease. more
marked loss may occur.
It is now accepted that some root resorption is inevitable as a con·
sequence of tooth movement. On average. during the course of a con­
Removable appliances may also be associated with gingival inflam­
••
ventional 2-year fixed-appliance treatment around 1 mm of root length
will be lost. However. this mean masks a w\de range of �ndividual vari a
mation. particularly of the palatal tissues, in the presence of poor oral
­

hygiene.
tion. as some patients appear to be more susceptible and undergo
more marked root resorption. Evidence would suggest a genetic basis in
1.5.3 Decalcification
these cases. Radiographic signs which are associated wlth an increased
risk include shortened roots with evidence of previous root resorption, Caries or decalcification occurs when a cariogenic plaque occurs in
pipette-shaped or blunted roots, and teeth which have previously association with a high-sugar diet. The presence of a fixed appliance
suffered an episode of trauma. In addition. more resorption is seen in predisposes to plaque accumu la tio n as tooth cleaning around the com·
..
cases where extensive movement of root apices has been undertaken. ponents of the appliance is more difficult. Decalcification during treat·
ment with fixed appliances is a real risk, with a reported prevalence of
1 5.2 Loss of periodontal support
.. between 2 and 96 per cent (see Chapter 18, Section 18.7), Although
there is evidence to show that the lesions regress following removal of
As a result of reduced access for cleansing, an increase in gingival
the appliance, patients may stiU be �eft with permanent 'scarrrng' oft he
inflammation is commonly seen following the placement of fixed
enameiFig. 1.1.

1.5.4 S oft tissue damage

Table 1.2 Potential risks of orthodontic treatment Traumatic ulceration can occur during treatment with both fixed and
removable appliances. although it is more commonly seen in association

Problem Avoidance/Management of risk

o o o o • 't 1 � o o o o .··, • ' o • " • oro , f/ f o • o o o o o o I o o o o o o o 0 ., • o o o o • " • • 0 1 o o o o o o ,. o o o ,o • o j o o

Decalcification Dietary advice. imp rove oral hygiene. increase

availability of fluoride

Abandon treatment
• 0 0 • • • • 0 • • • � • • • • • • - • 0 , 0 • • • � 0 • 0 • .. • • • • • • • � � • • • • • ' •

� 0 � • f • � • • � 0 • • • 0 • • • • • • • • • • • • • • • • • • - w • - • • • • • • • , • • • • • • • • • , • • • • • • • • • , • • � • • ,

Periodontal Improve oral hygiene. Avoid moving teeth

attachment IQSS QUt Qf alveQlar bone
· · · · · · · · · ·· · · · · · · · · · · · · · � · · · · · · · · · · · · · · · · · · · · · · --· · · · · · 1 · · · · · · , · · � · · · · · ·

Root resorption Avoid treatment in patients with resorbed.

blunted, or pipette-shaped roots
. . .. . . . . . . . . . � . . ... . . .. .
. . .. . . ..
- . ' . . . -· . . .. . . . . . . , . .. . , . . . . .. - . . ' . . .. . .

Loss of vitality If history of previous trauma to incisors.

counsel patient
"- • • • • '- • • • • • • • • • • • • r • � o • • • • • • • • • • • • • • • • • • · • • • • i • • • • • • • • • • • • • • • • • • r • • • • • •

Relapse Avoidance of unstable tooth positions at end of

treatment
. . . . .
' .. .. . .
... . .. . .. . . .. .... .... .. .. .. .. . .... ... . .. . .

Retention
Fig. 1.1 Decalcification.
 The temporomandibular joint and orthodontics

with the former as a removable appliance which is uncomfortable is which have undergone a previous episode of trauma appear to be
usually removed. Over-enthusiastic apical movement can lead to particularly susceptible, probably because the pulpal tissues are
a reduction in blood supply to the pulp and even pulpal death. Teeth already compromised.

1 .6 The effectiveness of treatment

The decision to embark upon orthodontic treatment must also consider The likelihood that orthodontic treatment will benefit a patient is
the effectiveness of appliance therapy in correcting the malocclusion increased if the malocclusion is severe. the patient is well-motivated
of the individual concerned. This has several aspects. and appliance therapy is planned and carried out by an experienced
orthodontist. The likelihood of gain is reduced if the malocclusion is
• Are the tootn movements planned atta\nable? This is considered mild and treatment is undertaken by an inexperienced operator.
in more detail i n Chapter 7 but, i n brief. tooth movement is only ; ' In essence, i t may be better not to embark on treatment at all. rather
feasible within the constraints of the skeletal and growth patterns
than run the risk of failing to achieve a worthwhile improvement.
of the individual patient. The wrong treatment plan, or failure to anti­
cipate adverse growth changes. will reduce the chances of success.
Table 1.3 Fai lure to achieve treatment objectives
In addition, the probable stability of the completed treatment needs
to be considered. If a stable result is not possible, do the benefits
) - -
Operator factors Patient factors
.. conferred byproceedrngjustify prolonged rete ntion. or the possibil ity • • • • • • • • 0 • • • 0 • 0 • • 0 0 • • • 0 • • • • • • • • • • • • • 0 - 0 • • • • • • • • 0 • 0 • 0 • • • • • 0 • • • • • • - • • • •

of relapse?
" /"
Errors of diagnosis
,
Poor oral hygiene

• There is a wealth of evidence to show that orthodontic treatment is

• • • • • • � • • ' • • • • • • • • • • • 0 • • • • • • 0 • • • • • • •� • 4 • 0 • • • 0 • • • 0 • • • • • • • • 0 0 • • • • • • • • • • •

Errors of treatment planning Failure to wear appliances

more likely to achieve a pleasing and successful result if fixed appli­ • • • • • • • • • • • • • � • • • • • • • • • • • • • • • • • • • 0 • • • • • 0 • • • - • • • • • • • • • • • - • • • - • • 0 � • • - • • • •

-
ances are used. and if the operator has had some postgraduate Anchorage loss Repeated appliance breakages
training in orthodontics.
• • • • • • • • • • • • • • • • • • • • • • • • 0 • • • • • • • • • • • • • 0 • • • • • • • • • • • • • • • • 0 • • - • 0 • • • 0 • • • • •

Technique errors Failed appointments

• Patient co-operation.

1 .7 The temporomandibular joint and orthodontics

The aetiology and management of temporomandibular joint dysfunc­ the development of TMD are predominantly of the viewpoint {based
tion syndrome (TMO) have awused considerable controversy in all on the authors' opinion) and case report type. In contrast. controlled
branches ofdentistry. The debate has been particularly heated regarding longitudinal studies have indicated a trend towards a lower incidence
the role of orthodontics. with some authors claiming that orthodontic of the symptoms of TMD among post-orthodontic patients compared
treatment can cause TMD, whilst at the same time others have advo­ with matched groups of untreated patients.
cated appliance therapy in the management of the condition. V� ,The consensus view is that orthodontic treatment. either alone or in
There are a number of factors that have contributed to the con­ combination with extractions, does not 'cause' TMD.
fusion surrounding TMD. The objective view is that TMD comprises a
group of related disorders of multifactorial aetiology. Psychological. 17 ., The rofe of orthodontic treatment in
hormonal, genetic, traumatic. and occlusal factors have all been the prevention and management of TMD
implicated. I t is accepted that parafunctional activity, for example
Some authors maintain that minor occlusal imperfections lead to
bruxism. can contribute to muscle pain and spasm. Success has been
abnormal paths of closure and/or bruxism, which then result in the
claimed for a wide assortment of treatment modalities. reflecting
development ofT MD. If this were the case. then g1ven the high incid­
both the multifactorial aetiology and the seiHmiting nature of the
ence of malocclusion in the population (50-75 per cent), one would
condition. Given this i t is wise to try irreversible approaches in the first
expect a higher prevalence of TMD than the reported 10 per cent A
instance. The reader is directed to look at two recent Cochrane reviews
number of carefully controlled longitudinal studies have been carried
(see further reading) on the use of stabilization splints and occlusal
out in North America. and these have found no relationship between
adjustment.
the signs and symptoms of TMD and the p(esence of non-functional

1 7.1 Orthodontic treatment as a contributory occl usa I contacts or mandibular displacements. Howeve r. other studies
have found a small but statistically significant association between TMD
factor in TMD
and some types of malocclusion including Class II skeletal pattern
A survey of the literature reveals that those articles claiming that (especially associated with a retrusive mandible); Class Ill; anterior
orthodontic treatment (with or without extractions) can contribute to open bite; cross bite and asymmetry. Further well-designed studies are
•
 The rationale for orthodontic treatment

required to delineate the aetiology of 1MD in more detail, bearing in patient for a comprehensive as sessment and specialist management
mind that this term probabty comprises a range of related disorders. before embar\<ing on orthodontic treatment.
A review of the current literature would indiCate that orthodontic
treatment does not 'cure' TMD. It is important to advise patients. par­ Key points
ticularly those who present reporting TMD symptoms, of this and to
The decision to undertake orthodontic treatment or n ot
note t his in their records.
is essentially a risk-berrefit analysis where the perceived
Whilst current evidence indicates that orthodontic treatment is not
benefits in commencing treatment at that time outweigh
a contributory factor and also does not cure the TMD, it is advisable to
the p ot en tia\ risks.
carry out a TMD screen for all potential orthodontic patients. At the
very least this !>hOuld include questioning patients about symptoms: an If there is any uncertainty as to whethe r the patient will
examination of the temporomandibular joint and associated muscles co-operate and/or benefit from treatment, then it is

and recording the range of oPening and movement (see Chapter 5). If advisable not to proceed at that time.

signs or symptoms of TMD are found then it may be wise to refer the

•
•

AI-Ani,M. Z., Davies. S. J. Gray, R. J.M., Sloan. P .. and Glenny, A.M. Murray. A.M. (1989). Discontinuation of orthodontic treatment
(2005). Stablisation splint therapy for temporomandibular pain a study of the contributing factors. British Journal ofOrthodanlics,
dysfunction syndrome. Cochrane Database of Systemic Reviews . 16, 1� 7.

Nguyen, Q. V. Bezemer, P. D., Habets, Land Prahl·Andersen. B. (1999).

2004, Issue 1.

American Journal of Orthodontics and Dento{(}CJol Orthopedic s , 101(1).

.

A systematic review of the relationship between overjet size and

(1992�. traumatic dental in juries Euro!JeOn Joumaf o( Orthodontic>. 21,
.

This is a special issue dedicated to the results of several studies set up 503-15.
bY the Ameriun Association of Orthodontists to investigate the link
Office for National Statisti(.s (2004). Children's dental health in the United
Kingdom 2003. Office for National Statistics, London.
between <lrthodontk treatment and the temporomandibular ioint..
Jt is essential reading for an those invofved in dentistry.
Shaw. W. C .. O'Brien, K.D., Richmond. S., and Brook, P. (1991). Quality
Chestnutt. I. G Burden, D. J., Steele, J. G.. Pitts, N. B., Nuttall, N,M., and
Morris. A J. (2006). The orthodontic condition of children in the United
control in orthodontics: risk/benefit considerations. British Dental
.•

Kingdom. 2003. Brilish Dental Journal, zoo. 609-12.

Journal, 170. 33-7.
A rather pessimtstic view of Otthodontks.
Davies. S. J.. Gray, R. M. J., Sandler. P. J.. and O'Brien. K. D. (2001).
Orthodontics and oc clusion. British Dental Journal. 191, 539-49.
Turb\lt E. A, Richmond. S., and Wright. J.l. (1999). A clos�r look at GD5
This tont)�e artide \s part of a series of articles on otdusion.
orthodontics in England and Wales 1: Factors influencing effectiveness.
British DentaiJournal, 187, 211-16.
It contains an example of an articulatory e,camination.

Egermark, 1.. Magnusson. T .. and Carlsson. G.£. (2003). A 20-year follow­

Wheeler. T. T.. McGorray. S. P., Yurkiewicz, L., Keeling, S.D .. and
King, G. J. ( 1994). Orthodontic treatment demand and need in third
up of signs and symptoms oftemporomandibular disorders in subjects
and fourth grade schoolchildren. Amencan Journal of Or th odon t;cs
with and without orthodontic treatment in childhood. Angle
and Dentofaciaf Orthopedics, 106.22-33.
Orthodontist, 73. 10 9-15.
Contains a good d'scussion on the need and demand for
A fong-term cohort Study which found no statistkafly-signiflcant
treatment.
difference in TMD signs and symptoms between subjects with or
without previous experience of orthodontic treatment.

Hoi mes, A (19 92). The subjective need and demand for orthodontic
treatment. British Journal of Orthodontics. i 9. 287-91.

Koh, H. and Robinson, P. G. {2004} Occlusat adjustment for treating References for this chapter can also be found at www:oxfordtextbooks.co�uk/
i
and preventing temporomandibular joint disorders. The Cochrane orc/m itchell3e. Where possible. these are presented as actve links which
Database of Syste mi c Reviews. 2003, ls�ue 1. direct you to an electronic version of the work to help facilitate onward
study. If you are a subscriber to that work (either individually or through
Luther, F. { 1998). Orthodontics and the TMJ: Where are we now? Angle an institution). and depending on your level of access. you may be able to
Orthodontist. 68. 2 95-318. peruse an abst(aCt or the full article i� available. We hope yoo find thi>
An authoritative review of the literature on this subject. feature helpful towards assignments and literature searches.
 1

• •

Chapter contents
• 2.1 The aetiology of malocclusion 8

2.2 Classifying malocclusion 8

2.2.1 Qualitative assessment of malocclusion 8

2.2.2 Quantitative assessment of malocclusion 9

2.3 Commonly used classifications and indices 9

2.3.1 Angle's classification 9
2.3.2 British Standards Institute classification 9
2.3.3 Summers occlusal index 10
2.3.4 Index of Orthodontic Treatment Need (IOTN) 10
2.3.5 Peer Assessment Rating (PAR) 12
2.3.6 Index of Complexity Outcome and Need (ICON) 12

2.4 Andrews' six keys 13

Principal sources and further reading 13

 The aetiology and classification of malocclusion

2.1 The aeti ology of malocclusion

The aetiology of malocclusion is a fascinating subject about which there inclt�ding the lips are by necessity attached to the underlying skeletal
is still much to elucidate and understand. At a basic level, malocclu­ framework, their effect is also mediated by the skeletal pattern.
sion can occur as a result of genetically determined factors, which are Crowding is extremely common in Caucasians, affecting approx­
inherited, or environmental factors. or more commonly a combination imately two-thirds of the population. As was mentioned above, the
of both inherited and environmental factors acting together. For example, size of the jaws and teeth are mainly genetically determined; however,
failure of eruption of an upper central incisor may arise as a result environmental factors, for example premature deciduous tooth loss,
of dilaceration following an episode of trauma during the deciduous can precipitate or exacerbate crowding. In evolutionary terms both jaw
dentition which led to intrusion of the primary predecessor - an example size and tooth size appear to be reducing. However, crowding is much
of environmental aetiology. Failure of eruption of an upper central more prevalent in modern populations than it was in prehistoric times.
incisor can also occur as a result of the presence of a supernumerary It has been postulated that this is due to the introduction of a less abra­
tooth - a scenario which questioning may reveal also affected the sive diet, so that less interproximal tooth wear occurs during the li(etime
patient's parent. suggesting an inherited problem. However. if in the of an individual. However, this is not the whole story, as a change from
latter example caries (an environmental factor) has led to early loss of a rural to an urban life-style can also apparently lead to an increase
many of the deciduous teeth, then forward drift of the first permanent in crowding after about two generations. .1 W I
molar teeth may also lead to superimposition of the additional problem Although this discussion may at first seem rather theoretical, the aeti­
of crowding. ology of malocclusion is a vigorously pebated_subject. This is because if
While it is relatively straightforward to trace the inheritance of syn­ one believes that the basis of malocclusion is genetically determined,
dromes such as cleft lip and palate (see Chapter 22), it is more difficult then it follows that orthodontics is limited in what it can achieve.
to determine the aetiology of features which are in essence part of However, the opposite viewpoint is that every individual has the poten­
normal variation, and the picture is further complicated by the com­ tial for ideal occlusion and that orthodontic intervention is required
pensatory mechanisms that exist. Evidence for the role o f inherited to eliminate those environmental factors that have fed to a particular
factors in the aetiology of malocclusion has come from studies of families malocclusion. Research suggests that for the majority of malocclusions
and twins. The facial similarity of members of a family. for example the the aetiology is multifactorial, and orthodontic treatment can effect
prognathic mandible of the Hapsburg royal family, is easily appreciated. only limited skeletal change. Therefore. as a patient's skeletal and
However. more direct testimony is provided in studies of twins and growth patter n is largely genetically determined, if orthodontic treat­
triplets, which indicate that skeletal pattern and tooth size and number ment is to be successful clinicians must recognize and work within
are largely genetically determined. those parameters.
Examples of environmental influences include digit-sucking habits Of necessity, the above is a brief summary, but it can be appreciated
and premature loss of teeth as a result of either caries or trauma. Soft that the aetiology of malocclusion is a complex subject. much of which is
tissue pressures acting upon the teeth for more than 6 hours per day still not fully understood. The reader seeking more information is advised
can also influence tooth position. However, because the soft tissues to consult the publications listed in the section on further readi ng.

2.2 Classifying malocclusioo

...
.. } P? J . 1) .
-' >�-.}> I; ,_r-
'
.

."'
""· ,.
�
•

The categorization of a malocclusion by its salient features is helpful •

for describing and documenting a patient's occlusion. In addition,

Important attributes of an index
classifications and indices allow the prevalence of a malocclusion within • Validity - Can the index measure what it was designed to
a population to be recorded. and also aid in the assessment of need, measure?
difficulty. and success of orthodontic treatment.
• Reproducibility - Does the index give the same result
Malocclusion can be recorded qualitatively and quantitatively.
when recorded on two different occasions, and b y different
However. the large number of classifications and indices which have
' x...� � examiners?
been devised, are testimony to the problems inherent in both these
approaches. All have their limitations, and these should be borne in
mind when they are applied.

7.2. Qualitative assessment of main drawback to a qualitative approach is that malocclusion is a

continuous variable so that clear cut-off points between different
malocclusion
categories do not always exist. This can lead to problems when classi­
Essentially, a qualitative assessment is descriptive and therefore this fying borderline malocclusions. In addition, although a qualitative
category includes the diagnostic classifications of maloccusion. The classification is a helpful shorthand method of describing the salient
 Commonly used classifications and indices

features of a malocclusion. it does not provide any indication of the 2.2... Quantitative assessment of malocclusion
difficulty of treatment.
In quantitative indices two differing approaches can be used:
Qualitative evaluation of malocclusion was attempted historically
before quantitative analysis_ One of the better known classifications was • Each feature of a malocclusion is given a score and the summed total
devised by Angle in 1899, but other classifications are now more widely is then recorded (e.g. the PAR Index).
used. for example the British Standards Institute (1983) classification • The worst feature of a malocclusion 1s recorded (e.g. the Index of
of incisor relationship. Orthodontic Treatment Need).

2.3 Co mmonly used classificati ons and i nd ices

2.3 . '" Angle's classification -
which could be used to assess the anteroposterior relationship of the
• • .# � arches. In addition to the fact that Angle's classification was based upon
an incorrect assumption, the problems experienced in categorizing cases
Angle·s classification was based upon the premise that the first perman­
ent molars erupted into a constant position within the facial skeleton.
with forward drift or loss of the first permanent molars have resulted
• I l l ll II� JJdl {1\..Uidl dJJJJI Ud\..1 1 IJCII It) !iU!)JI �
!> UC � Oy UtllCI C l<l:S�InC
<lt iO n:S
•

However. Angle's classification is still used to describe molar relation­

ship, and the terms used to describe incisor relationship have been
adapted into incisor classification.
• Angle described three groups (Fi g. 2.1 ):

• Class I or neutrocclusion - the mesiobuccal cusp of the upper first

molar occludes with the mesiobuccal groove of the lower first molar.
In practice discrepancies of up to half a cusp width either way were
1\ also included in this category.
• Class If or distocclusion - the mesiobuccal cusp of the lower first
•

molar occludes distal to the Class I position. This is also known as a

Class I postnormal relationship.
• Class Ill or mesiocclusion - the mesiobuccal cusp of the lower first
molar occludes mesial to the Class I position. This is also known as a
prenormal relationship.

v V\ 2.3.2 British Standards Institute classification

)�
'\
This is based upon incisor relationship and is the most widely used
"'- ..., '- /
� descriptive classification. The terms used are similar to those of Angle's
_/ --
� classification, which can be a little confusing as no regard is taken of
molar relationship. The categories defined by British Standard 4492 are
shown in the box below (see also Figs 2.2. 2.3. 2.4. 2.5):
v v v v u
Class II British Standards incisor classification

,.... I' r\ • Class 1- the lower incisor edges occlude with or lie immediately
rvy below the cingulum plateau of the upper central incisors.
• Class II- the lower incisor edges lie posterior to the

v h cingulum plateau of the upper incisors. There are two

) ) '\ subdivisions of this category:
Division 1 - the upper central incisors are proclined o r
llo.. .J........ -......
'
�7
"'-.;
_/
of average inclination and there is an increase in overjet.
Division 2 - The upper central incisors are retroclined.
The overjet is usually minimal or may be increased.
\,) v v u v • Class Ill - The lower incisor edges lie anterior to the
cingulum plateau of the upper incisors. The overjet is
Class Ill reduced or reversed.
Fig. 2.1 Angle ' s classification.
 The aetiology and c l assification of malocclusion

As with any descriptive analysis it is difficult to classify borderline

cases. Some workers have suggested introducing a Class II intermediate
category for those cases where the upper incisors are upright and the
overjet increased between 4 and 6 mm. However, this suggestion has
not gained widespread acceptance.

2.3�3 Summers occlusal index

This index was developed by Summers, in the USA. during the 1960s.
It is popular in America, particularly for research purposes. Good
reproducibility has been reported and it has also been employed to
determine the s uccess of treatment with acceptable results. The index
scores nine defined parameters including molar relationship, overbite,
Fig. 2.2 I n ciso r classification - Class I.
overjet, posterior crossbite. posterior open bite, tooth displacement,
midline relation, maxil lary median diastema, and absent upper incisors.
Allowance is made for different stages of development by varying the
weighting applied to certain parameters i n the deciduous, mixed, and
permanent dentition .

.., ., 4 Index of Orthodontic Treatment

Need (JOTN)
The Index of Orthpdontic Treatment Need was developed as a result
'ri
of a govern�ent i itiative. The purpose of the index was to help deter­
mine the likely impact of a malocclusion on an individual's dental health
and psychosocial well-being. ll comprises two elements.

Fig. 2.3 I ncisor classification - Class II division 1. Dental health component

This was developed from an index used by the Dental Board i n Sweden
designed to reflect those occlusa ltfa its. which could affect the function
and longevity of the dentition. The single worst feature of a mal occlu­
sion is noted (the index is not cumulative) and categorized into one of
five grades reflecting need for treatment (Table 2.1 ):

• Grade 1 - no need
• Grade 2 - little need
• Grode 3 - moderate need
• Grade 4 - great need

• Grode 5 - very great need

A ruler has been developed to help with assessment of the dental

Fig. 2.4 Incisor classification - Class II d ivisi on 2. health component (reproduced with the kind permission of UMIP Ltd.
i n Fig. 2.6), a nd these are available commercially. As only the single
worst feature is recorded. an alternative approach is to look consecut­
ively for the following features (known as MOCDO):

• Missing teeth

• Overjet
• Crossbite
• Displacement (contact poi nt)
• Overbite

Aesthetic component
This aspect of the index was developed in an attempt to assess the
aesthetic handicap posed by a malocclusion and thus the likely psycho­
Fig. 2.5 Incisor classification - Class Ill. social impact upon the patient - a difficult task (see Chapter 1 ). The
 •

Commonly used classifications and indices

Table 2.1 The Index of Orthodontic Treatment Need (Reproduced with the kind permission of UMIP Ltd.)

Grade 5 (Very Great) 4m Reverse overjet 1 .1-3.5 mm with recorded masticatory and
• 4 • o • o o o o o o o o o o o o 0 0 0 I 0 0 0 o e e • o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o 0 0
speech difficulties
•
5a Increased overjet greater than 9 mm 0 0 0 0 o 0 o 0 0 0 o o 0 o 0 o o o 0 0 0 0 0 0 0 0 0 I 0 0 I 0 I I 0 0 0 0 0 0 0 o o 0 o o o o o o o o o o o o o 0 0 o o 0 o o o o o o o o o o 0

• 0 • • • • • • • • • • 0 • • • 0 • • 0 • • 0 • • • • • • • • • 0 • • • • • • 0 • • 0 0 0 0 • • • • • • 0 • • • • 0 • • • • • 0 0 • • • 0 • • •
4t Partially erupted teeth, tipped and impacted against adjacent
5h Extensive hypodontia with restorative implications (more teeth
than one tooth missing in any quadrant) requiring pre­ 0 0 0 0 0 o o o 0 o 0 0 0 o 0 o o 0 t 0 I 0 o o o o o 0 I 0 0 0 0 I 0 0 I I I t 0 0 0 0 I 0 0 I 0 0 0 0 0 o o o o 0 o o o o o o o o o 0 o o o o o

restorative orthodontics 4x Supplemental teeth

o o o o o o o o o o o o o o o o o 0 o I o o o o o o o o o o o o o o o o • o o o o o o o o o o o o o o o o o o o o o o o o o o o o � o o o o o

5i Impeded eruption of teeth (with the exception of third Grade 3 (Moderate)

molars) due to crowding. displacement. the presence of · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · 4 · · · · · · · · · · · · · · · · · · · · · · · · ·

supemumerary teeth, retained deciduous teeth, and any 3a Increased overjet 3.6 6 mm with incompetent lips
pathological cause . . . . . . . . . . . . . . . . . . � . . . . . . ..... . . .. . . ..... ... . . . . ... .. . . . . . . .. . . . . . . . . . . . .

3b Reverse overjet 1.1-3.5 mm

Reverse overjet greater than 3.5 mm with reported
• • • • • • • • • • • • • • • • • • • # • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Sm • • • • • • • • • • • • • • • • • • # • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

masticatory and speech difficulties 3c Anterior or posterior crossbites with 1.1-2 mm discrepancy
. . . .. . . . ..
. . . .
. . ..... .. .. .
. . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... • • • • • • • • • • • • • • • • • • # • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

5p Defects of cleft lip and palate 3d Displacement of teeth 2.1-4 mm

• • • • • • • • • • • • • • • • • • # • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
• • • • • • • • • • • • • • • • • • • # • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

5s Submerged deciduous teeth 3e Lateral or anterior open bite 2.1-4 mm

Grade 4 (Great)
• • • • • • • • • • • • • • • • • • # • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

3f Increased and complete overbite without gingival trauma

• • • • • • • • • • • • • • • • • • • # • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

4a Increased overjet 6.1-9 mm Grade 2 {Little)

• • • • • • • • • • • • • • • • • • • # • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

4b Reversed overjet greater than 3.5 mm with no masticatory 2a Increased overjet 3.6-6 mm with competent lips
or speech difficulties .. . . . . . .. .... ... .. . .. . . ... .. . .
. . . . .. .. . . . . . . . . . . . . . . . . . . . . . . ' . . . . . . . .. . . .

• • • • • • • • • • • • • • • • • • • # • • • • • • • • • • • • • • • • • • • • • • .. • • • • • • • • • • • • • • • • • • • • • • • • • • • • 2b Reverse overjet 0.1-1 mm

4C Anterior or posterior cross bites with greater than 2 mm • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

discrepancy between retruded contact position and 2c Anterior or posterior crossbite with up to 1 mm discrepancy
between retruded contact position and intercuspal position
...
\ntercuspal position
.... . .. .... ... ... ..
. . . .
. . ..... ..
. ..
. . ... ... . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . � . . . . . . . . . . . . .

4d Severe displacement of teeth. greater than 4 mm 2d Displacement of teeth 1. 1-2 mm

... .. ... . . .. .
. .....
. . .. .. ... . . ..
. . .... ..
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • t • t • • • • • • • • • •

4e Extreme lateral or anterior open bites. greater than 4 mm 2e Anterior or posterior open bite 1 . 1-2 mm
... . . .. . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . .. .. . . . . . . .. .... . . . . . . . . ...
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

4f Increased and complete overbite with gingival or 2f Increased overbite 3.5 mm or more. without gingival contact
palatal trauma • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 2g Prenormal or postnormal occlusions with no other anomalies;

4h Less extensive hypodontia requiring pre-restorative orthodontic includes up to half a unit discrepancy
space closure to obviate the need for a prosthesis
Grade 1 (None)
.... .. ..... .. .. . .. .. .. .. . .. . .. .
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

41 Posterior lingual crossbite with no functional occlusal contact in . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

one or both buccal segments 1 Extremely minor malocclusions including displacements less
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • than 1 mm

Copyright © The University of Manchester 2005. All rights reserved

3 0.8. with NO G + P trauma

3

5 N on eruptio n of teeth
5 Defect of CLP
3 Crossbite 1.2 mm discrepancy open bite
I Displacement
•

0 4 5

2 0.8. >
-
2
5 Extensive hypodontia
2 Dev. From full interdig
c
v
3 4 4 Less extensive hypodontia

I I
I
I
4 Scissors bite
4 Crossbite >2 mm discrepancy 2 Crossbite < 1 mm discrepancy Fig. 2.6 IOTN ruler (Copyright ©
4 ms - 5
4 0.8. with G + P trauma IOTN M•nchener (clinic•IJ 4 3 2 1 The University of Manchester 2005.
All rights reserved).

aesthetic component comprises a set of ten standard photographs anterior aspect and the appropriate score determined by choosing the
(Fig. 2.7), which are also graded from score 1 . the most aesthetically photograph that is thought to pose an equivalent aesthetic handicap.
pleasing. to score 10. the least aesthetically pleasing. Colour photo­ The scores are categorized according to need for treatment as follows:
graphs are available for assessing a patient in the clinical situation
• score 1 or 2 - none
and black-and-white photographs for scoring from study models alone.
The patient's teeth (or study models). in occlusion. are viewed from the • score 3 or 4 - slight
 The aetiology and classification of malocclusion

Fig. 2.7 Aesthetic component of IOTN

•
(the Aesthetic Component was originally
•
described as 'SCAN' and was first
published in 1987 by Evans, R. and
Shaw, W. C. (1987). A preliminary
evaluation of an illustrated scale for
rating dental attractiveness. European
Journal of Orthodontics, 9, 314-18).

• score 5 , 6, or 7 - moderate/borderline • overjet (x6)

• score 8, 9, or 10 - definite • overbite (x2)
• centrelines (x4)
An average score can be taken from the two components, but the •

dental health component alone is more widely used. The aesthetic The difference between the PAR scores at the start and on comple­
component has been criticized for being subjective - particular dif­ tion of treatment can be calculated. and from this the percentage change
ficulty is experienced in accurately assessing Class Ill malocclusions in PAR score, which is a reflection of the success of treatment, is
or anterior open bites, as the photographs are composed of Class I and derived. A high standard of treatment is indicated by a mean percent­
Class II cases, but studies have indicated good reproducibility. age reduction of greater than 70 per cent. A change of 30 per cent or
less indicates that no appreciable improvement has been achieved. The
2.3.5 Peer Assessment Rating (PAR) size of the PAR score at the beginning of treatment gives an indication
of the severity of a malocclusion. Obviously it is difficult to achieve a
The PAR index was developed primarily to measure the success (or
significant reduction in PAR in cases with a low pretreatment score.
otherwise) of treatment. Scores are recorded for a number of para­

? .3. () Index of Complexity Outcon1e and

meters (l isted below), before and at the end of treatment. using study
models. Unlike IOTN, the scores are cumulative; however, a weighting
is accorded to each component to reflect current opinion in the UK as
Need ( ICON) •

to their relative importance. The features recorded are listed below, This new index incorporates features of both the Index of Orthodontic
with the current weightings in parenthesis : ·../ ;,if-:.
1..) / Need (IOTN) and the Peer Assessment Rating (PAR). The following are
• crowding - by contact point displacement (x1) scored and then each score is multiplied by its weighting:
\
l
• buccal segment relationship - in the anteroposterior. vertical, and • Aesthetic component of IOTN (x7)
transverse planes (x1) • Upper arch crowding/spacing (xS)

I
•

-
•

And rews' six kevs •

-

• Crossbite (x5) Following treatment the index is scored again to give an improvement
• Overbite/open bite (x4) grade and thus the outcome of treatment.
• Buccal segment relationship (x3) Improvement grade = pre-treatment score - (4 x post-treatment score)

The total sum gives a pretreatment score. which is said to reflect the This ambitious index has been criticized for the large weighting
need for, and likely complexity of, the treatment required. A score of given to the aesthetic component and has not yet gained widespread
more than 43 is said to ind icate a demonstrable need for treatment. acceptability.
.

2.4 Andrews' six keys

Andrews analysed 120 'normal' occlusions to evaluate those features
which were key to a good occlusion (it has been pointed out that these Andrews� six keys
occlusions can more correctly be described as 'ideal'). He found six fea­ Correa. molar rel�tionship: the mesiobuccal cusp of the
tures. which are described in the box. These six keys are not a method
•

upper first molar occludes with the groove between the

of classifying occlusion as such. but serve as a goal. Occasionally at the mesiobuccal and middle buccal cusp of the lower first molar.
end of treatment it is not possible to achieve a good Class I occlusion­ The distobuccal cusp of the upper first molar contacts the
in such cases it is helpful to look at each of these features in order to mesiobuccal cusp of the lower second molar
�:>n�rt crown angulation.
evaluate why.
all tooth crowns are angulated
Andrews used this analysis to develop the first pre-adjusted bracket
mesially
system, which was designed to place the teeth (in three planes of
space) to achieve his six keys. This prescription is called the Andrews' f'ot .. rt crown indina�.-ion: incisors are inclined towards the

bracket prescription. For further details of pre-adjusted systems see buccal or labial surface. Buccal segment teeth are inclined

Chapter 18. lingually. In the lower buccal segments this is progressive

No ,otations

No spaces •

Flat occlusal plane

Andrews, l. F. (1972). The six keys to normal occlusion. American Journal Richmond, S., Shaw, W. C.. Roberts, C T., and Andrews. M. (1992).
o{ Orthodontics, 62. 296-309. The PAR index (Peer Assessment Rating): methods to determine
the outcome of orthodontic treatment in terms of improvements
Angle, E. H. (1899). Classification of malocclusion. Dental Cosmos.
and standards. European Journal of Orthodontics. 14. 180-7.
4 1 ' 248-64.
The PAR index, part 2.
British Standards Institute (1983). Glossary of Dental Terms (85 4492), BSI ,

London. Summers, C. J. (1971). A system for identifying and scoring occlusal

disorde rs. American Journal of Orthodontics. 59, 552-67.
Daniels, C. and Richmond. S. (2000). The development of the Index of
For readers requiring further Information on Summers• occlusal index.
Co mplexity Outcome and Need (ICON). Journal of Orthodontics,
.

27, 149-62. Shaw, W. C., O'Brien, K. D., and Richmond, S. (1991). Quality control

Harradine, N. W. T., Pearson, M. H., and Toth. B. (1998). The effect of in orthodo ntics: indices of treatment need and treatment standards .

BntJsh Dento/Journol. 170, 107-1 2.

extraction of third molars on late lower incisor crowding: A randomized
controlled clinical trial. British Journal ofOrthodontics, 25. 1 1 7-22. An interesting paper on the role of indices. with good explanation�
of the IOTN and the PAR index.
•

Markovic, M. (1 992). At the crossroads of oral facial genetics. European

Journal of Orthodontics, 1 4, 469-81. Tang, E. L. K. and Wei , S. H. Y. (1993). Recording and measuring
A fa!>nnating study of twins and triplets with Class 11/2 malocclusions. malocclusion: a review of the literature. Amencan Journal of
Orthodontics ond Dentofoetol Orthopedics. 103. 344-51.
Useful for those rescarchmg the !.ubject
Mossey, P. A. (1999). The heritability of malocclusion. British Journal of
·

OrthodontiCs. 26, 103-13. 195-203.

Richmond, S., Shaw, W. C., O'Brien, K. D., Buchanan. I. B.. Jones. R., References for this chapter can also be found at www.oxfordtextbooks.eo.uk/
Stephens C. D., et of. (1992). The development of the PAR index
(Peer Assessment Rating): reliability and validity. European Journal of
,
orc/ mitchell3e. Where possible. these are presented as active lmks which
direct you to an electronic version of the work, to help facilitate onward
Orthodonttcs. 14, 125-39. study. You may find this feature helpful towards assign ments and
The PAR index. part 1 . literature sea rches
.
•

•
•
 .....

I
I

••,
,·�
"•
...
..
-

.. ..
• ,_

• .
. ,
.

• •
 •

• •
•

Chapter contents
-------

3.1 Normal dental development 16

3.1 .1 Calcification and eruption times 16
3.1.2 The transition from primary to mixed dentition 16
3. 1.3 Developmem of the dental arcf1es 17

•
3.2 Abnormalities of eruption and exfohution 18
3.2.1 Screening 18
3.2.2 Natal teeth 18
3.2.3 Eruption cyst 18
3.2.4 Failure of/delayed eruption 18
3.3 Mixed dentition proi' . ... n� 19
3.3. 1 Premature loss ot deciduous teeth 19
3.3. 2 Retained deciduous teeth 20
3.3 1 Infra-occluded (submergerl) primary molars 20
:;.3 4 Impacted first permanent molars 21
3.3 5 Dilaceration 22
3.3.6 Supernumerary teeth 22

3.3. 7 Habits 25
3.3.8 First permanent r.1ol<!:-s of poor long-term prognosis 25
3.3. 9 Median diastema 26
•

3.4 Planned tr�ct• "' of deciduous teeth 27

3.4. 1 Serial extraction 27
3.4.2 lndicaticns for the extraction of deciduous canines 27

Principal 5ources and further reading 28

•
 Management of the developing dentition
I ll
.

Many dental practitioner5 find it d'1fficu\t to judge when to intervene in a decisions to intercede are often made in response to pressure exerted by
.:.___ . -
�J
developing malocclusion and when to let nature take its course. This is the parents 'to do something'. lt is hoped that this chapter will help impart
....
J
because experience is only gained over years of careful observation, and some of the former, so that the reader is better able to resist the latter.

\' c\ \.J ·
�
--

{f
•

-< "k " r" c "' .,.,._, �

3 . 1 Normal dental develop ment

' ./I l.

It is important to realize that 'normal' in this context means average,

Table 3.1 Average calcification and e ru ption times
rather than ideal. An appreciation of what constitutes the range of
normal development is essential. One area in which this is particularly
Calcification commences Eruption
(weeks in utero)
pertinent is eruption times (Table 3.1 ).
(months)

3 .1 . ·1 Calcification and eruption t\mes

0 0 0 0 0 0 0 0 0 ° 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 I 0 0 0 0 o o o o o o 0 0 0 0 0 0 0 0 0 0 0 0 I 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 0 0 0 t

Primary dentition
• • • • • • • • • • • • • • • • • • • • • • • • 0 • • • • • • 0 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

" Knowledge of the calcification times of the permanent dentition is Central incisors 12-16 6-7
'
• � invaluable if one wishes to� i � pr�ss patients and colle �g�es. It is • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

also helpful for assessing dental as opposed to chronological age; for lateral incisors 13-16 7-8

determining whether a developing tooth not present on radiographic

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Canines 1 5-18 18-20

examination can be considered absent; and for estimating the tim­ . . ...
. . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ing of any possible causes of localized hypocalcification or hypoplasia First molars 14-17 12-15
(termed in this situation chronological hypoplasia). • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Second molars 16-23 24-36

3.1 '1 The transition from primary Root development complete 1-1 'h years after eruption

,_
to mixed dentition
•

•
� ,w
. ·I • ' ��
,
• .....:1
•
•J
,,.. •
�
, -
).IJ"' \. I(.,�'\""
.

Calcification commences Eruption

.,.

[J>'
•
' • The eruption of a baby's first tooth is heralded by the pro�d parents as
� • a major landmark in their child's development. This milestoneis described
(months) (years)
r ).(> . .... .
.�
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

• .lL
in many baby-care books as occurring at 6 months of age, which can Permanent dentition
' lead to unnecessary concern as it is normal for the mandibular incisors
:•
to erupt at any tirne iQ �e first year. Dental textbooks often dismiss
• • • • • • • • • • • • • • • • • • • • • • • • • • • 4 • • • • • • • • • • • • • • • • • • • • • • � • • • • • • • • • • • • • • • • • • • •

Mand. central incisors 3-4 6-7

'teething', as"cribing1he symptoms that occur at this time to the diminu-

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.. Mand. lateral incisors 3-4 7-8

tion of maternal antibodies. Any parent will be able to correct this fallacy! 0 o o t o o o o o o o o o t 0 0 0 t t o o o o I o o o o 0 0 t t t 0 t 0 t t t t 0 0 0 0 t I 0 0 0 0 I 0 I t t 0 0 o o o o o o o o o o o o o o

Eruption of the primary dentition (Fig. 3.1) is usually completed Mand. canines 4-5 9-10
around 3 years of age. The deciduous incisors erupt upright and spaced • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Mand. first premolars 21-24 10-12

-a lack of spacing strongly suggests that the permanent successors will . . . .
. . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

be crowded. Overbite reduces throughout the primary dentition until Mand. second premolars 27-30 11-12
the incisors are edge to edge, which can contribute to marked attrition. . .. ....
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . � . . . . . . . . . . . . . . . . . . . .

•
Mand. first molars Around birth 5-6
The mixed dentition phase is usually heralded by the eruption of
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

either the first permanent molars or the lower central incisors. The Mand. second molars 30-36 12-13
•

lower labial segment teeth erupt before their counterparts in the upper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . � . . . . . . . . . . . . ..
. . . . . .

arch and develop lingual to their predecessors. It is usual for there to Mand. third molars 96-120 17-25
_..:o -
. . .. ..
be some crowding of the permanent lower incisors as they emerge
. . . . . . . . . . . . . . . . . . . . . . . . . ' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.

Max. central incisors 3-4 7-8

into the mouth, which reduces with intercanine growth. As a result • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • # • • • • • • • • • • • • • • • • • • • •

the lower incisors often erupt slightly lingually placed and/or rotated Max. lateral incisors 10-12 8-9
(Fig. 3.2), but will usually align spontaneously if space becomes avail­ . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
,
.

Max. canines 4-5 11-12

able. If the arch is inherently crowded, this space shortage will not
. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . .

resolve with intercanine growth. Max. first premolars 18-21 -1 1

10
The upper permanent incisors also develop lingual to their predeces­ • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • # • • • • • • • • • • • • • • • • • • • •

sors. Additional space is gained to accommodate their greater width Max. second premolars 24-27 10-12

Max. first molars 5-6

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

because they erupt onto a wider arc and are more proclined than the
• •

Around birth
primary incisors. If the arch is intrinsically crowded, the lateral incisors • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

will not be able to move labially following eruption of the central Max. second molars 30-36 12-13
. . . . .
incisors and therefore may erupt palatal to the arch. Pressure from the
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . .

Max. third molars 84-108 17-25

developing lateral incisor often gives rise to spacing between the cent­
ral incisors which resolves as the laterals erupt. They in turn are tilted Root development complete 2-3 years after eruption

distally by the canines lying on the distal aspect of their root. This latter
(
I

Normal dental development

l

il Fig. 3.1 Primary dentition. Fig. 3.3 'Ugly duckling' stage.

stage of development used to be described as the 'ugly duckling' stage ous buccal segment teeth are retained until their normal exfoliation time,
of development (Fi g. 3.3). although it is probably diplomatic to describe there will be sufficient space for the permanent canine and premolars.
it as normal dental development to concerned parents. As the can i nes ·· The deciduous second molars usually erupt with their distal surfaces
' '-"""'
...

erupt, the lateral incisors usually upright themselves and the spaces flush anteroposteriorly. The transition to the stepped Class I molar rela-
close. The upper canines develop palatally, but migrate labially to come tionship occurs during the mixed dentition as a result of differential
to lie slightly labial and distal to the root apex of the lateral incisors. In mandibular growth and/or the leeway space. ;

normal development they can be palpated buccally from as young as 8

years of age. 3 . 1 . 3 Development of the dental arches
The combined width of the deciduous canine, first molar. and second
molar is greater than that of their permanent successors, particularly lntercanine width is measured across the cusps of the deciduous/
in the lower arch. This difference in widths is called the leeway space permanent canines. and during the primary dentition an increase of
(Fig. 3.4) and in general is of the order of 1-1.5 mm in the maxilla and around 1-2 mm is seen. In the mixed dentition an increase of about 3 mm
2-2.5 mm in the mandible (in Caucasians). This means that ifthe deci du- occurs, but this growth is largely completed around a developmental

(a) (b) (c)

•

(d) (e) (f)

Fig. 3.2 Crowding of the labial segment reducing with growth in

intercanine width: (a-c) age 8 years; (d-f) age 9 years.
 ��-

Management of the developing dentition

Average width = 23 mm stage of 9 years with some minimal increase up to age 13 years. After
this time a gradual decrease is the norm.
Arch width is measured across the arch between the lingual cusps of
the second deciduous molars or second premolars. Between the ages
of 3 and 18 years an increase of 2-3 mm occurs; however. for clinical
purposes arch width is largely established in the mixed dentition.
Arch circumference is determined by measuring around the buccal
cusps and incisal edges of the teeth to the distal aspect of the second
deciduous molars or second premolars. On average, there is little
5 change with age in the maxilla: however, in the mandible arch circum·
ference decreases by about 4 mm because of the leeway space. In indi­
viduals with crowded mouths a greater reduction may be seen.
I n summary, on the whole there is little change in the size of the arch
anteriorly after the establishment of the primary dentition, except for
an increase in intercanine width which results in a modification of arch
Average width = 21 mm
'
•
shape. Growth posteriorly provides space for the permanent molars,
Fig. 3.4 Leeway space. and considerable appositional vertical growth occurs to maintain the
relationship of the arches during vertical facial growth.

3.2 Abnormal ities of eruption and exfol iation

3.2. Screening teeth can be quite mobile, but they usually become firmer relatively
quickly. If the tooth (or teeth) interferes with breast feeding or is so
Early detection of any abnormalities in tooth development and eruption mobile that there is a danger of in halation. removal is indicated and
is essential to give the opportunity for interceptive action to be taken. this can usually be accompl i shed with topical anaesthesia. If the tooth
This requires careful observation of the developing dentition for evidence is symptomless, it can be left in situ.
of any problems, for example deviations from the normal sequence of
eruption. If an abnormality is suspected then further investigation includ­ 3.2.3 Eruption cyst
ing radiographs is indicated. Around 9 to 10 years of age it is important
An eruption cyst is caused by an accumulation of fluid or blood i n the
to palpate the buccal sulcus for the permanent maxillary canines in
follicular space overlying the crown of an erupting tooth (Fig. 3.6). They
order to detect any abnormalities in the eruption path of this tooth.
usually rupture spontaneously, but very occasionally marsupialization

3.2.2 Natal teeth

may be necessary.

3.2.4 Failure of/delayed eruption

'

A tooth, which is present at birth, or erupts soon after, is described as a

natal tooth. These most commonly arise anteriorly in the mandible and
There is a wide individual variation i n eruption times, which is illus­
are typically a lower primary incisor, which has erupted prematurely
trated by the patients in Fig. 3.7. Where there is a generalized tardiness
(Fig. 3.5). Because root formation is not complete at this stage. natal
in tooth eruption in an otherwise fit child, a period of observation is

Fig. 3.5 Natal tooth present at birth. Fig. 3.6 Eruption cyst.

•
 Mixed dentition problems

(a) (b) (c)

Fig. 3.7 Normal variation in eruption times: (a) patient aged (b, c) patient aged 9 years with all permanent teeth to the second
12.5 years with deciduous canines and molars still present; molars erupted.

Table 3.2 Causes of delayed eruption

I
Generalized causes

Hereditary gi ngival fibromatosis

• • • • • • • • • • • • 0 • .. • • • • • • • • • • • • • • 0 • • • 0 • 0 • • • • • 0 • • • • • 0 • • 0 • • 0 • • • • • • • • • 0 • • • 0 • • 0

.
Down s syndrom e
• • • • • • • 0 ·• 0 • 0 • • • .. • • • • • 0 • 0 • 0 • • • 0 .. .. 0 • • 0 • • • • • • • • • • • • • • • • • • • • • • • 0 • • .. • • 0 0 • 0 ..

'

• • • f • • • • 0 • • • 0 • • • • • • • • • • • 0 0 0 0 • • • • 0 • 0 0 • • 0 • • • • 0 • 0 • • • • • • 0 • 0 • • • • • • • • • • • • • • 0 •

Cleidocranial dysostosi s
• • • • • • • • • • 0 • • • 0 • • • 0 • • • • • • • • • • • • • 0 • 0 • • 0 • • • • 0 • • • • • • • 0 • • • ,. .. • • 0 • • • 0 • • • � 0 . .. 0

Cleft I ip and palate

• • • • 0 • • • • • • • • • 0 • • • • • • • • • • • • • • • 0 • • • • • • • 0 0 • • • • • • 0 • • • 0 • • • • • • • • • 0 • • • 0 • • • • • •
•

Rickets

localized causes
0 • • • • • • 0 • 0 • • • 0 • 0 • • • • • 0 • • • • • • • 0 0 • • 0 0 0 • • 0 • • 0 • • • • • • • • • • • . .. 0 • • • • 0 • • • 0 0 • • 0 . ..

Congenital absence
Fig. 3.8 Di srupti on of normal eruption sequence as 21/2 erupted, but • • 0 • • •• • • 0 • • 0 • 0 • • 0 • • • 0 • • • • • • • • • • • • • • • • • • • • • 0 • • • 0 • • • • • • • • • • • 0 • • � • • 0 • • • • • •

L1 unerupted. Crowding
-

t Delayed exfoliation of pr i mary predecessor

• • • • • • • • • • 0 • • • • • • • • • • • • • • • • • • • • - • • • • • • • • • • - • • • • - • - • � • • 0 • • • • • • • • • • • • • •
•

indicated. However. the following may be indicators of some abnorm­

ality and therefore warrant further investigation (Fig. 3.8): • • • 0 • 0 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • ' • • ' • • • • • • • 0 • 0 • 0 •

Supernumera ry tooth
• A disruption in the normal sequence of eruption.
Di laceration
• • • • • • • • • • • 0 • • • • • • • • 0 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • " • • • • 0 • • .. • • • 0 0 • • • •

• An asymmetry in eruption pattern between contralateral teeth. If a • • • 0 • • • • • • • • • • • • • 0 • • • • • • • • • • • • • • • • • • • • • • • • 0 • • • • • • 0 • • • • • • • • • • � • • 0 • • • • • • •

tooth on one side of the arch has erupted and 6 months later there Abnormal position of crypt
is still no sign of its equivalent on the other side, radiographic 0 • • 0 • • 0 • • • • • 0 0 • 0 0 • • • • � 0 • • • • 0 • • • • 0 • • • • • • • 0 • • • • • • • • • • • • • • 0 • • 0 • • • • • .. • • • • • •

Primary failure of eruption

examination is indicated.
'

Localized failure of eruption is usually due to mechanical obstruction ­

this is advantageous as if the obstruction is removed then the affected (the tooth erupts. but then fails to keep up with eruption/devel­
tooth/teeth has the potential to erupt. More rarely, there is an abnorm­ opment). This problem usually affects molar teeth and unfortunately
ality of the eruption mechanism, which results in primary failure of for the individuals concerned, commonly affects more than one molar
eruption (the tooth does not erupt into the mouth) or arrest of eruption tooth in a quadrant. Extraction of the affected teeth is often necessary.

3.3 Mi xed dentition p roblems

3.3.1 Premature loss of deciduous teeth extent to which this occurs depends upon the degree of crowding,
the patient's age, and the site. Obviously, as the degree of crowding
The major effect of early loss of a primary tooth, whether due to caries, increases so does the pressure for the remaining teeth to move into the
premature exfoliation, or planned extraction. is localization of pre­ extraction space. The younger the child is when the primary tooth is
existing crowding. In an uncrowded mouth this will not occur. How­ extracted, the greater is the potential for drifting to ensue. The effect of
ever, where some crowding exists and a primary tooth is extracted, the the site of tooth loss is best considered by tooth type, but it is important
adjacent teeth will drift or tilt around into the space provided. The to bear in mind the increased potential for mesial drift in the maxilla.
 •

Management of the developing dentition

Fig. 3.9 Centre-line shift to patient's left owing to early unbalanced Fig. 3.10 Loss of a lower second deciduous molar leading to forward
loss of lower left deciduous canine. drift of first permanent molar.

It should be emphasized that the above are suggestions. not rules.

Balancing and compensating extractions and at all times a degree of common sense and forward planning should
Balancing extraction is the removal of the contralateral tooth - be applied - in essence a risk-benefit analysis needs to be worked
rationale is to avoid centreline shift problems through for each child/tooth. For examf;'le. if extraction of a carious first
primary molar is required and the contralateral tooth is also doubtful,
Compensating extraction is the removal of the equivalent
then it might be preferable in the long term to extract both. Also, in
opposing tooth - rationale is to maintain occlusal relationships
children with an absent permanent tooth (or teeth) early extraction of
between the arches
the primary buccal segment teeth may be advantageous to encourage
forward movement of the first permanent molars if space closure
(rather then space opening) is planned.
The effect of early extraction of a primary tooth on the eruption of its
• Deciduous incisor: premature loss of a deciduous incisor has little
successor is variable and will not necessarily result in a hastening of
impact. mainly because they are shed relatively early in the mixed
eruption.
dentition.
• Deciduous canine: unilateral loss of a primary canine in a Space maintainance
crowded mouth will lead to a centreline shift (Fig. 3.9). As this is It goes without saying that the best space maintainer is a tooth -
a difficult problem to treat, often requiring fixed appliances, pre­
particularly as this will preserve alveolar bone. Much has been written in
vention is preferable and therefore premature loss of a deciduous paedodontic texts about using space maintainers to replace extracted
canine should be balanced in any patient with even the mildest
deciduous teeth, but in practice most orthodontists avoid this approach
crowding.
in the mixed dentition because of the implications for dental health and
• Deciduous first molar: unilateral loss of this tooth may result to minimize straining patient co-operation (which may be needed for
in a centreline shift. I n most cases an automatic balancing extrac­ definitive orthodontic treatment later). The exception to this is where
tion is not necessary, but the centreline should be kept under preservation of space for a permanent successor will avoid subsequent
observation and, if indicated, a tooth on the opposite side of the orthodontic treatment.
arch removed.
• Deciduous second molar: if a second primary molar is extracted 3.3.2 Retained deciduous teeth
the first permanent molar will drift forwards (Fig. 3.10). This is par­
A difference of more than 6 months between the shedding of con­
ticularly marked if loss occurs before the eruption of the permanent
tralateral teeth should be regarded with suspicion. Provided that the
tooth and for this reason it is better, if at all possible, to try to pre­
permanent successor is present, retained primary teeth should be
serve the second deciduous molar at least until the first permanent
extracted, particularly if they are causing deflection of the permanent
molar has appeared. In most cases balancing or compensating extrac­ tooth (F i g . 3.11).
tions of other sound second primary molars is not necessary unless
they are also of poor long-term prognosis. However. where extrac­
3.3.3 Infra-occluded (submerged)
tion of a carious upper deciduous molar alone would change the
primary molars
molar relationship from a half-unit Class II to a full Class II, considera­
tion should be given to compensating with the extraction of the Infra-occlusion is now the preferred term for describing the process
lower second deciduous molar. where a tooth fails to achieve or maintain its occlusal relationship with
 Mixed dentition problems

Resorption of the primary teeth is not a continuous process. In fact.

resorption is interchanged with periods of repair, although in most cases
the former prevails. If a temporary predominance of repair occurs this
can result in ankylosis and infra-occlusion of the affected primary molar.
•
The results of recent epidemiological studies have suggested a genetic

I tendency to this phenomenon and also an association with other

dental anomalies including ectopic eruption of first permanent molars.
palatal displacement of maxillary canines, and congenital absence
of premolar teeth. Therefore, it is advisable to be vigilant in patients
r
..
exhibiting any of these features. """'
�,\.!
- � /

Where a permanent successor exists the phenomenon is usually

temporary, and studies have shown no difference in the age at exfolia­
tion of a submerged primary molar compared with an unaffected con­
tralateral tooth. Therefore extraction of a submerged primary tooth is
only necessary under the following conditions:
Fig. 3.11 Retained primary tooth contributing to deflection of the
permanent successor. • There is a danger of the tooth disappearing below gingival level
(Fig. 3.13).
• Root formation of the permanent tooth is nearing completion (as
eruptive force reduces markedly after this event).
• The permanent successor is missing, as in this situation the
submergence may be progressive.

3.3.4 Impacted first permanent molars

Impaction of a first permanent molar tooth against the second decidu­
ous molar occurs in approximately 2-6 per cent of children and is
indicative of crowding. It most commonly occurs in the upper arch
.
(Fig. 3.14). Spontaneous disimpaction may occur, but this is rare after
8 years of age. Mild cases can sometimes be managed by tightening a
brass separating wire around the contact point between the two teeth
over a period of about 2 months. This can have the effect of pushing the
Fig. 3.12 Ankylosed primary molars. permanent molar distally, thus letting it jump free. In more severe cases
the impaction can be kept under observation, although extraction of
the deciduous tooth may be indicated if it becomes abscessed or the
adjacent or opposing teeth. Most infra-occluded deciduous teeth erup�
into occlusion. but subsequently become ' su bmerged ' because bony
permanent tooth becomes carious and restoration precluded by poor
growth and development of the adjacent teeth continues (Fig. 3.12).
access. The resultant space toss can be dealt with in the permanent
Estimates vary, but this anomaly would appear to occur in around
1-9 per cent of children.
dentition.

Fig. 3.13 Marked submergence

of deciduous molar (with second
premolar affected).
 �v1anagement of the developing dentition

Fig. 3.14 Impacted bilateral upper first

permanent molars.

deflected palatally, and the enamel and dentine forming at the time
of the injury are disturbed. giving rise to hypoplasia. The sexes are
equally affected and more than one tooth may be involved depend­
ing upon the extent of the trauma.

Management
Dilaceration usually causes failure of eruption. Where the dilaceration
is severe there is often no alternative but to remove the affected tooth.
In milder cases it may be possible to expose the crown surgically and
apply traction to align the tooth. provided that the root apex will be
sited within cancellous bone at the completion of crown alignment.

3.3.6 Supernumerary teeth

A supernumerary tooth is one that is additional to the normal series.
This anomaly occurs in the permanent dentition i n approximately
2 per cent of the population and in the primary dentition in less than
1 per cent, though a supernumerary in the deciduous dentition is often
followed by a supernumerary in the permanent dentition. The aetiology
is not completely understood, but suggestions include an offshoot of
the dental lamina of the permanent dentition or a tertiary dentiti on .
This anomaly occurs more commonly in males than females. Super­
Fig. 3.15 A dilacerated central incisor. numerary teeth are also commonly found in the region of the cleft in
individuals with a cleft of the alveolus.
Supernumerary teeth can be described according to their morpho­

3.3.5 Dilaceration logy or position in the arch.

Dilaceration is a distortion or bend in the root of a tooth. It usually Morphology

affects the upper central and/or lateral incisor. • Supplemental: this type resembles a tooth and occurs at the end

of a tooth series. for example an additional lateral incisor. second

Aetiology
premolar. or fourth molar (Fig. 3.1 6).
• Conical: the conical or peg-shaped supernumerary most often
There appears to be two distinct aetiologies:

• Developmental - this anomaly usually affects an isolated central occurs between the upper central incisors (Fig. 3.17). 1t is said to be
incisor and occurs in females more often than males. The crown of more com manly associated with displacement of the adjacent teeth.
the affected tooth is turned upward and labially and no disturbance but can also cause failure of eruption or have no effect at all.
of enamel and dentine is seen (Fig. 3.15). • Tuberculate: this type is described as being barrel-shaped, but usu­
• Trauma - intrusion of a deciduous incisor leads to displacement ally any supernumerary which does not fall into the conical or supple­
of the underlying developing permanent tooth germ. Character­ mental categories is included. Classically. this type is associated
istically, this causes the developing permanent tooth crown to be with failure of eruption (Fig. 3.18).
 Mixed dentition problems

Fig. 3. 16 A supplemental lower lateral incisor.

fig. 3.18 A tuberculate supernumerary lying occlusal to U.

Effects of supernumerary teeth and their management

Failure of eruption

The presence of a supernumerary tooth is the most common reason for

the non-appearance of a maxillary central inc isor. However. failure of
eruption of any tooth in either arch can be caused by a supernumerary.
Management of this problem involves removing the supernumerary
tooth and ensuring that there is sufficient space to accommodate the
unerupte d tooth in the arch. lfthe tooth does .not erupt spontaneously
within 1 year, then a second operation to expose it and apply orthodontic
traction may be required. Management of a patient with this_ problem
is illustrated in Fig. 3.19.

Displacement

The presence of a supernumerary tooth can be associated with

displacement or rotation of an erupted permanent tooth (Fig. 3.20).
Management involves firstly removal of the supernumerary, usually
Fig. 3.17 Two conical supernumeraries lying between 1L1 with followed by fixed appliances to align the affected tooth or teeth. It is said
LA retained. that this type of displacement has a high tendency to relapse following
treatment, but this may be a reflection of the fact that the malposition
is usually in the form of a rotation or an apical displacement which, in
themselves, are particularly liable to relapse.
• Odontome: this variant is rare. Both compound and complex forms
have been described. Crowding
.

This is caused by the supplemental type and is treated by removing the

Position
most poorly formed or more displaced tooth (Fig. 3.21 ).
Supernumerary teeth can occur within the arch, but when they develop
between the central incisors they are often described as a mesiodens. No effect

A supernumerary tooth distal to the arch is called a distomolar, and Occasionally a supernumerary tooth (usually of the conical type) is
one adjacent to the molars is known as a paramolar. Eighty per cent of detected as a chance finding on a radiograph of the upper incisor region
supernumeraries occur in the anterior maxilla. (Fig. 3.22). Provided that the extra tooth will not interfere with any

l
 tv\anagement of the developing dentition

(a) (c)

Fig. 3.19 Management of a patient with

(d) failure of eruption of the upper central
incisors owing to the presence of two
supernumerary teeth: (a) patient on
presentation aged 1 0 years; (b) radiograph
showing unerupted central incisors and
associated conical supernumerary
teeth; (c) following removal of the
supernumerary teeth a URA was fitted to
open space for the central incisors, until
1L erupted 1 0 months later; (d) 7 months
later L1 erupted and a second URA with
a buccal spring was used to align L1;
(e) occlusion 3 years after initial
(b) (e) presentation.

1
I

I,

Fig. 3.20 Displacement of 1L1 caused by two erupted conical Fig. 3.21 Crowding due to the presence of two supplemental upper
supernumerary teeth. lateral incisors.
•

•
 Mixed dentition probten1s

'

(a) (b)

Fig. 3.22 Chance finding of a supernumerary on routine radiographic

examination.

•
planned movement of the upper incisors. it can be left in situ under before a decision can be react1ed for a particular individual. First per­
radiographic observation. In practice these teeth usually remain manent molars are never the first tooth of choice for extraction as their
symptomless and do not give rise to any problems. position within the arch means that little space is provided anteriorly
for relief of crowding or correction of the incisor relationship unless
3�3. 7 Habits appliances are used. Removal of maxillary first m � lars often comprom­
ises anchorage in the upper arch, and a good spontaneous result in
The effect of a habit will depend upon the frequency and intensity
of indulgence. This prob !em is discussed in greater detail in Chapter 9.
the lower arch following extraction of the first molars is rare. However,
patients for whom enforced extraction of the first molars is required
Section 9. 1.4 .
are often the least able to support complicated treatment Finally, it has

3.3.8 First permanent molars of poor to be remembered that, unless the caries rate is reduced, the pre­
molars may be sim ilarly affected a few years later. Nevertheless, lf a two­
long-term prognosis
surface restoration is present or required in the first permanent molar
The integrity of the first permanent molars is often compromised due of a child. the prognosis for that tooth and the remaining first molars
to caries and/or hypop\as1a secondary to a childhood illness. Treatment should be considered as the planned extraction of nrst permanent
planning for a child wrth poor-<lUality first permanent molars is always molars of poor quality may be preferable to their enforced extraction
difficult because several competing factors have to be considered later on (Fig. 3.23).

Fig. 3.23 All four first permanent molars

were extracted in this patient because of
the poor long-term prognosis for 61 and I.Q..

•
 Management of the developing dentition

Factors to cons1der when assessmg first permanent molars where possible as a good spontaneous result in the mandibular arch
of poor long-term prognosis is less likely.

It is impossible to produce hard and fast rules regard ing the extraction • Impaction of the third permanent molars is less likely, but not
of first permanent molars. and therefore the following should only be impossible. following extraction of the first molar.
considered a starting point
3.3.9 Median d iastema
• Check for the presence of all permanent teeth. lf any are absent. extrac­
tion of the first permanent molar in that quadrant should be avoided. Prevalence
• If the dentition is uncrowded. extraction of first permanent molars
Median diastema occurs in 98 per cent of 6-ycar-olds. 49 per cent of
should be avoided as space closure will be difficult.
1 1-year-olds. and 7 per cent of 1 2-1 8-year-olds.
• Remember that in the maxilla there is a greater tendency for mesial
drift and so the timing of the extraction of upper first permanent Aetiology
molars is less critical if aiming for space closure. Factors, which have been considered to lead to a median diastema
• In the lower arch a good spontaneous result is more likely if: include the following:

(a) the lower second permanent molar has developed as far as its • physiological (normal dental development)
bifurcation;
• small teeth in large jaws (a spaced dentition)
(b) the angle between the long axis of the crypt of the lower second
• missing teeth
permanent molar and the first permanent molar is between 15°
• midline supernumerary tooth/teeth
and 30°;
• proclination of the upper labial segment
(c) the crypt of the second molar overlaps the root of the first molar
(a space between the two reduces the likelihood of good space • prominent fraenum

closure).
A median diastema is normally present between the maxillary
• Extraction of the first molars will relieve buccal segment crowding, permanent central incisors when they first erupt. As the lateral incisors
but will have little effect on a crowded labial segment. and then the canines emerge the diastema usually closes. Therefore a
• If space is needed anteriorly for the relief of labial segment crowding midline diastema is a normal feature of the developing dentition; how­
or for retraction of incisors (i.e. the upper arch in Class II cases or the ever, if it persists after eruption of the canines, it is unlikely that it will
lower arch in Class Ill cases). then it may be prudent to delay extrac­ close spontaneously.
tion of the first molar. if possible. until the second permanent molar In the deciduous dentition the upper midline fraenum runs between
has erupted i n that arch. The space can then be utilized for correc­ the central incisors and attaches into the incisive papilla area. How­
tion of the labial segment ever, as the central incisors move together with eruption of the lateral

• Serious consideration should be given to extracting the opposing incisors. it tends to migrate round onto the labial aspect. In a spaced

upper first permanent molar. should extraction of a lower molar be upper arch, or where the upper lateral incisors are missing (Fig. 3.25),

necessary. If the upper molar is not extracted it will over-erupt and this recession of the fraenal attachment is less likely to occur and in
•

prevent forward drift of the lower second molar (Fig. 3. 24). svch cases it is obviously not appropriate to attribute the persistence
•
of a diastema to the fraenum itself. However, in a small proportion of
• A compensating extraction in the lower arch (when extraction of
cases the upper midline fraenum can contribute to the persistence of a
an upper first permanent molar is necessary) should be avoided

Fig. 3.24 Over-eruption of fli. preventing forward movement of the Fig. 3.25 Patient with missing 2/2 and a median diastema with a low
lower right second permanent molar. fraenal attachment.

.l
 Planned extraction of deciduous teeth
•

diastema. Factors, which may indicate that this is the case include the
following.

• When the fraenum is placed under tension there is blanching of the

incisive papilla.

• Radiographically, a notch can be seen at the crest of the interd ental

bone between the upper central incisors (Fig. 3.26).

• The anterior teeth may be crowded.

Management
It is advisable to take a periapical radiograph to exclude the presence
of a midline supernumerary tooth prior to planning treatment for a
midline diastema.
In the developing dentition a diastema of less than 3 mm rarely
warrants intervention: in particular, extraction of the deciduous
canines should be avoided as this will tend to make the diastema worse.
However. if the diastema ·,s greater th an 3 mm and the lateral incisors
are present, it may be necessary to consider appliance treatment to
approximate the central incisors to provide space for the laterals and
canin es to erupt. However, care should be taken to ensure that the
roots of the teeth being moved are not pressed against any unerupted
crowns as this can lead to root resorption. If the crowns of the teeth are
Fig. 3.26 Notch in interdental bone between U1 associated with a
tilted distally, an upper removable appliance (URA) can be used to
traenal insertion running between 1L1 into the incisive papilla.
approximate the teeth, but fixed appliances are required for bodily
movement. Closure of a diastema has a notable tendency to relapse.
therefore long-term retention is required. This is most readily accom­
plished by placement of a bonded retainer.

3.4 Plan ned extraction of deci duous teeth

3.4.1 Serial extraction 3 A .2 tndications for the extraction
.
Serial extraction was first advocated in 1948 by Kjellgren, a Swedish
of deciduous canines
orthodontist, as a solution to a shortage of orthodontists. Kjellgren Nevertheless there are a number ofoccasions where the timely extraction
hoped that his scheme would facilitate the treatment of patients of the deciduous canines may avoid more complicated treatment later.
with straightforward crowding by their own dentists, thus minimizing
• In a crowded upper arch the erupting lateral i nc·1sors may be forced
demands upon the orthodontic service. He suggested the employment
palatally. In a Class I malocclusion this will result i n a crossbite and in
of a planned sequence of extractions (initially the d eci duous canines.
addition the apex of an affected tooth will be palatally positioned,
then the deciduous first molars) designed to allow crowded incisor
making later correction more difficult. Extraction of the deciduous
segments to align spontaneously during the mixed dentition by shift­
canines whilst the lateral in cisors are erupting often results in their
ing lab i al segment crowding to the buccal segments where it could be
being able to escape spontaneously into a better position.
dealt with by premolar extractions. The disadvantages to this approach
• In a crowded lower labial segment one incisor may be pushed through
are that it involves putting the child through several sequences of
the labial plate of bone, resulting in a compromised labial periodon­
extractions and, as intercanine growth is occurring during this time,
tal attachment. Relief of crowding by extraction of tl:le lower
it is difficult to assess accurately how crowded the dentition will be,
deciduous canines usually results in the lower incisor moving back
at the stage when serial extraction is usually embarked upon. A nice
into the arch and improving periodontal support (Fig. 3.27).
result can be achieved with serial extractio n i n selected cases, namely
• Extraction ofthe lower deciduous canines in a Class Ill malocclusion
Class I with moderate crowding and all permanent teeth present in a
good position , but often this type of case also resp onds well to extrac­ can be advantageous (Fig. 3.28).

tion of only the first premolars upon eruption - th is latter approach • To provide space for appliance therapy in the upper arch, for example

eliminates some of the potential pitfalls and diminishes the guesswork correction of an instanding lateral incisor, or to facilitate eruption of
involved. a incisor prevented from erupting by a supernumerary tooth.
• To improve the position of a displaced permanent canine (see
Chapter 14).

•
 Management of the developing dentition

Fig. 3.27 (a) In this patient all four

deciduous canines were extracted to
relieve the labial segment crowding;
(b) note how the periodontal condition
of the lower right central incisor has
(a) (b) improved 6 months later.

Fig. 3.28 (a) Class Ill prior to extraction

of the lower deciduous canines; (b) same
(a) (b ) patient 13 months later.

Btshara, S. E. (1997). Arch width changes from 6 weeks to 45 years of age. Kurol, J. and Koch, G. (1985). The effect of extraction of infraoccluded
American Journal of Orthodontics and Dentofacial Orthopedics, 1 1 1 . deciduous molars: a longitudinal study. American Journal of
401 -9. Orthodontics, 87, 46-55.

British Orthodontic Society (http://new.bos.org.uk/) Advice Sheet 7. Larsson, E. (1988). Treatment of children with a prolonged dummy or
Dummies and Digit Sucking. finger sucking habit. European Journal of OrthodonUcs, 10. 244-8.

foster, T. D. and Grundy, M. C. ( 1986). Occlusal changes from primary to Mackie; I. C.. Blinkhom. A. S . and Davies, P. H. J. ( 1989). The extraction
.

permanent dentitions. British Journal of Orthodontics, 13, 187-93. of permanent molars during the mixed-dentition period - a guide to
treatment planning. Journal ofPaediatric Dentistry, 5, 85-92.
Faculty of Dental Surgery of the Royal College of Surgeons of England.
Extraction of primary teeth - Balance and Compensation Peck, S. M., Peck, L.. and Kataja, M. (1994). The palatally displaced
(http://www.rcseng.ac.uk/fds/cl inical_guidelines). canine as a dental anomaly of genetic origin. Angle OrthodonUst,
64. 249-56.
Gorlin, R. J.. Cohen, M. M. , and Levin, L. S. ( 1 990). Syndromes of the Head
ond Neck (3rd edn). Oxford University Press, Oxford. Stewart, D. J. (1978). Dilacerate unerupted maxillary incisors. British
Source of calcificationand eruption dates (and a vast amount of Dental Journal, 1 45. 229-33.
additional information not directly related to this chapter). Wei bury, R. R.. Duggal, M. S. and Hosey, M-T. (2005). Paediatric Dentistry
Kurol. J. and Bjerklin, K. (1986). Ectopfc eruption of maxillary first (3rd edn). Oxford University Press. Oxtord.
permanent molars: a review. Journal of Dentistry {or Children. Williams, A and McMullan, R. (2004 ). Faculty of Dental Surgery of the
53. 209-15. Royal College of Surgeons of England. A Guideline for first permanent
All you need to know about impacted first permanent molars. molar extraction in children

BjerKiin, K., Kurol, J., and Valentin, J. (1992). Ectopic eruption of

(http://www.rcseng.ac.uk/fds/clinical_guidelines).
An excellent resume of the available evidence on this important
maxillary first permanent molars and association with other tooth
•
topic.
and development disturbances. European Journal ofOrthodontics.
14, 369-75
The results of thjs study suggest a link between ectopic eruption References for this chapter can also be found at www.oxfordtextbooks.co.uk/
of first permanent molars, infra-occlusion of deciduous molars, orc/mitchell3e. Where possible, these are pfesented as active Jinks which
ectopic maxillary canines and absent premolars. Given this direct you to an electronic version of the work, to help facilitate onward
association, the wise practitioner will be alerted to other study. You may find this feature helpful towards assignments and
anomalies in patients presenting with any of these features. literature searches.

•
 ...., r an i ofac ial rowth,
the ce l l u lar as is o toot
move ment and anchora e
(Z. L. Nelson-Moon )
•

Chapter contents
4.1 Introduction 30
4.2 Craniofacial embryology 30
4.2.1 Neural crest 30
4.2.2 Pharyngeal arches 30
4.2.3 Facial development 31
4. 2.4 Formation of the palate 31
4.3 Mechanisms of bone growth 33
I
4.4 Postnatal craniofacial growth 34
4.4.1 Growth patterns 34
4.4.2 Calvarium 35
4.4.3 Cranial base 35
4.4.4 Maxillary complex 36
4.4.5 Mandible 37
4.5 Growth rotations 37
4.6 Craniofacial growth in the adult 39
4. 7 Growth of the soft tissues 39
4.8 Control of craniofacial growth 40
4.9 Growth prediction 41
4 .10 Biology of tooth movement 41
4.10.1 The periodontal ligament 41
4.10.2 Cells involved in bone homeostasis 42
4.10.3 Cellular events in response to mechanical loading 43
4.11 Anchorage 45
•
4.1 1. 1 Cellular events associated with loss of anchorage 45
4.1 1 .2 Assessment of optimal force levels 45
4.12 Cellular events during root resorption 47
4.13 Summary 47
4.1 3. 1 Facial growth 47
4.13.2 Cellular basis of tooth movement 48
4.1 3 3 Anchorage 48
---------------·
-·-·
·
-
· ·
-·.,_
_______

f.rl Principal sources and further reading 48

 Ctaniofacial growth , the cel lular basis of tooth movement and anch orage

4.1 I ntroduction
Growth may b e defined as an increase in size by natural development bone and how this relates to changes in bone shape and position have
and is the consequence of cellular proliferation and differentiation. been described for over 200 years.
Orthodontic treatment would not be possible w ithout the a bi lity
•

An understanding of c raniofacial development and growth is essen tial

for the accurate diagnosis and treatment planning of even the most of the alveolar bone to remodel to allow the teeth and the associated
st rai gh tfo rward malocclusion as the majority of orthodontic treatment periodontium to move within the alveolus. In the last 20 years,
is still performed on growing indiv idual s- chil dren Growth can affect
. rapid advances in scientific techniques, especially those related to
the severity of the malocclusion (improving it or worsenin g it as growth ce ll ular and mo lec ul a r biology, have ensured a bette r albeit not
complete. understan d ing of the cellular responses i nvolved in tooth
,

continues) the progress and outcome of orthodontic treatment, and

,

the stability of the orthodontic result. Orthodontic treatment may also movement.
have an affect on facial growth. This chapter will begin by o utl ining some essential embryology fol­
Craniofacial growth is a complex process involving many interactions lowed by a descr iption of the manner in which the craniofacial bones
between the different bones that make up the sku l l and between the grow, the control of craniofacial growth and the ability to predict cranio­
hard and soft tissues. The processes that control craniofacial growth facial growth. The cellular basis of orthodontic tooth movement and
are not fully understood and are an area of extremely active research the relevance of this to pl ann ing orthodontic a nc horage requirements
globally. However, the descriptions of where gro wt h occurs within a will also be covered.

4.2 Craniofacial embryology

A basic knowledge of cran i ofacial embryology is important for all dental
practitioners. but especially for o rthodo nti sts as ·,t gives i nsi ght ·, nto
Table 4.1 Derivatives of cranial neural crest celts

future craniofacial growth and the possible causes of developmental •

Cartilage and bone ofthe prechordal sku l l

anomalies of the c raniofacial region. However, before discussing the
• • • • • • • • • .. • • • • • •. .. • • • • • • • t • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • .. • • 0 ·• • • .. •

development of the face, an understanding of the role of neural crest Meckel's (1st), Reichart's (2nd) and other pharyn geal arch cartilages
and pharyngeal arch development is essential. • • • • • • • • • • • • • • • • • • • • • • • • • • • • 0 • • • • • • • • • • • • • • • • • • • 0 • • • • • • • � • • • • • • • • • • 0 .. 0 •

Intramembranous bones of the craniofacial skeleton

4.2.... Neural crest
• • • • • • • • • • • 0 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 0 • • • • • • • • • • • • � • • • • • • • .. .. . ..

Odonto blasts
Neural crest is ectomesenchymal tissue arising from the crest of the
• • • • • • • • • 0 • • � • • • • • • 0 • • • • • 0 • • 0 • • • • • • • 0 0 • • • • • 0 • • • • • 0 • • • • • • • • • • • • • • • • • • • 0 •

Connective tissue
neural fold (Fig. 4.1) and is con si dered to be a se parate (4th) germ layer
Dermis of the face and neck
0 • 0 • 0 • • • • • • • • • • • • • • • 0 • • • • • 0 • 0 0 • • • • • • 0 • • 0 • • • • • • • • • • • • • • • • • • • • • • • ' • .• • 0 • • •

that is capable of forming many different cell types and is highl y migratory
(Table 4.1 ) �eu ral crest from the c ran ia l region of the neural tube which
Tendons and fascia of craniofacial vol untary muscles
• • • • • • • • • • • • • • • • • • • 0 • • • • • • • • • 0 • • • • • 0 • • • 0 • • 0 0 0 0 • • • 0 • • • • • • .. • • 0 • 0 • • • • • 0 • • •
.
..
-

is desti ned to become the hind brain migrates between the ectoderm
and mesoderm and expands du ri n g migration. However, cranial neural
•

• • 0 • • • • • • 0 • • • • • 0 • • • • • • • • 0 • • • • • • • • 0 • 0 • • 0 • • • • 0 • 0 • • • • • 0 • 0 • • • • t � • • • • • • • ' • • •

Meninges of the brain

crest cells from different regions (rhombomeres) of the developing hind • • • • • • • • • 0 • • • • • • • • • • • 0 • • • • • 0 • • • • • • • • • 0 • • • • • • • • • • • • • 0 • • • • • • • • • • • 0 • • • • • 0 •

brain migrate into specific areas and neural crest derivatives are p re­ Neurones of most cranial nerve ganglia

specified. The patterning of neural crest derivatives is control led by genes

0 • 0 • • • • • • • • • • • • • 0 • • • • • • 0 • • • • • • • • 0 • • 0 • 0 • • • • • • • • • • • • • • • 0 • 0 • • 0 • • 0 • • • 0 • • • • •

Parafollicular (calcitonin) cells of thyroid gland

(Hox genes) containing a conserved DNA sequence (the hom eobox) .
• • • • 0 • • • • 0 • • • • • • • • • • • 0 • • 0 • • 0 • • • • 0 • • 0 • 0 • • • • • • • 0 • • 0 • • • • 0 • • • • • • • • 0 . .. 0 0 0 • • •

The homeobox is 180 base pai rs long and encodes for a DNA Melanocytes
bind ing domain (the homeodomain) within the protein product. The
ho m eodoma in consists of 60-61 amino acids. Homeodomain-containing
protei ns always act as transcription factors, regul ati ng the activ rty of
oth er genes. Their presence in all an imal species ind icates the huge
acting with lateral extersi on s of the endoderm germ layer lining the
importance of the Hox gen es to the existence of the animal.
,

I. - ' ' ....

>.
�
future pharynx arid augmenting the mesodermal core of these exten-
Once the neural crest reaches its destination. interaction between
sions. The arches are separated by pharyngea I grooves/clefts externally
the epithelium and the mesenchyme is required for differentiation into
particular cell types to take place.
and pouches internally. Each arch consists of a central cartilage rod that
forms th e skeleton of the arch (derived from neural crest); a muscular
component. with the muscle cells formed from mesode rm and t h e
4.2.2 Pharyngeal arches
fascia and tendons from neural crest; a vascular component, and a nerv­
Six pai rs of pharyngeal arches develop, decreasing in size fro m cranial ous element which includes sensory and special visceral motor fibres
to caudal. Development is ini ti ated by migrating neural crest cells i nte r- from a cranial nerve which supply the mucosa and muscle of that a rc h .
 Craniofacial embryology
•

A Neural plate
Table 4.2 Derivatives of first and second pharyngeaJ
arches
Ectoderm

Mesode rm 0 Arch Muscles Nerves Skeleton

T ri gem i nal (V): All the facial bones

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 0 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

First arch Muscles of

Endoderm mastication maxi\lary dnd lncus, mall eus
Notochordal process Mylohyoid mandibular
Sphenomandibular
divisions
Anterior digastric ligament

B Neural fold Tensor veli palati ni Mandible

T ensor tympani
Neural groove
•
Neural crest
• • • • • • • • • • • • • • • • � 0 • 0 0 • • • • • 0 • • • • • • • 0 • • • 0 0 • • • • 0 • • • • • • • • • • • • • • • • • • • • • • • • •

Second Muscles of facial Facial (VII) Stapes

arch expression
Styloid process
Posterior digastric Stylohyoid
Styloh yoi d ligament
Stapedius lesser hom and
Levator veli palatini upper part of body
Notochord of hyoid

c Neural crest
cells Neural tube

enlarged, ectodermal nasal sac. From 40-48 days tt1ere is lateral and
inferior expansion of the now fused medial nasal processes to form the
intermaxillary process. The tips of the maxillary swellings grow to meet
this process. The mtermaxillary process gives rise to the bridge and
septum of the nose . From 7-10 weeks the ectoderm and mesoderm of
the frontonasal process and the intermaxillary process proliferate form­ ,

ing a midline nasal septum. This divides the nasal cavity into two nas3l
passages which open into the pharynx. behind the secondary palate,
Fig. 4.1 Dia grammat ic representation of neural tube and neural crest through the definitive choana. The philtrum is now formed by merging
development. (A) Cross-section through trilaminar disc at day 1 8 i.u. of the paired maxillary processes in front of the intermaxillary process.
The appearance of the neural plate marks the beginning of neural tube and the lateral portions of the maxillary and mandibular swellings
development. (B. C) Dev elopment of the neural tube and migrati on
merge to create the cheeks and reduce the mouth to its final width
of the neural crest cells from the neural folds (redrawn from Meikle.
(Fig. 4.2).
M. C. (2002). Craniofacial Development. Growth and Evolution.
Bateson Publishing, Norfolk. England).
4.2.4 Formation of the palate (7-9 weeks i.u.)

4.2.3 Facial development

At the beginning of the 7th week i.u., the floor of the nasal cavity is a
posterior extension of the intermaxillary process known as the primary
The development of the face begins at the end of the 4th week in utero pal ate. During the 7th week. the medial walls of the maxillary swellings
$
(i.u.) with the appearance of five prominef\ es aJound the stomodeum begin to produce a pair of thin medial extensions, ·palatine shelves',
which is the primitive mouth and form ;the'tO'pog�hical centre of the which grow i nferior l y on either side of the tongue. The tongue moves
developing face. The maxillary swellings can be distinguished lateral, downward and the palatine shelves rapidly rotate upwards towards the
and the mandibular swell ing
J)""'" ' �"
s caudal . to the stomodeum. The midline midline, growing horizontally during the 8th week i.u. The palatine
frontonasal process l1 es rostral to the stomodeum. Between 24 and shelves begin to fuse ventrodorsally with each other. the primary palate
28 days i.u. the paired maxitlary swellings enlarge and grow ventrally and the inferior border of the nasal septum in the 9th week (Fig. 4.3).
and medi al ly. A pair of ectodermal thickenings called the nasal piacodes Any disturbance in the timing and/or process of palatal shelf eleva­
appear on the frontonasal process and begin to enlarge. From 28 to tion from a vertical to a horizontal orientation and their subsequent
32 days the ectoderm at the centre of each nasal placode invaginates fusion is likely to cause cl eftin g. The processes that bring about shelf
to form a nasal pit, dividing the raised rim of the placode into a late ral elevation involve both an i ntern al shelf-elevating force a nd develop­
nasal process and a medial nasal process. Between 32 and 35 days mental changes in the surrounding face . The internal shelf-elevat\ng
each medial nasal process begins to migrate towards the other and force results from progressive accumulation and hydra tio n of glycos­
they merge. The mandibular swellings have now merged to create the aminoglycans which creates a strongly hydrated space-filling gel result­
primordial lower lip. The nasal pits deepen and fuse to form a single, ing in swelling of the extracellular matrix. The developmental changes

•
 Craniofacial growth , the cellular basis of tooth movement and anchorage

A B

•
Maxillary processes --=J::....;:�===--flll Stomodeum
Mandibular processes

c D

Lateral nasal - Medial nasal

process process

E
Fig. 4.2 Diagrammatic representation
of early facial development from 4 to 10
weeks i.u. (A) 4th week i.u. (B) 28 days i.u.
(C) 32 days i.u. (D) 35 days i.u. (E) 48 days
i.u. (F) 10 weeks i.u. Further detail is given
in text, Section 4.2.3 (redrawn from a
previously available electronic source ­
http://www. biomed2.man.ac.uk/ugrad/
biomedical/calpage/sproject/rob/
glossary.html).
-

A B c
NS
Fig. 4.3 Diagrammatic representation of
palatal shelf elevation and subsequent
fusion. (A) During the 7th week i.u. the
•
T palatal shelves begin to develop and lie
* * on either side of the tongue. (B) During the
8th week i.u. the palatine shelves elevate
rapidly due to the internal shelf-elevating
force and developmental changes in the
face. (C) During the 9th week i.u. the
shelves fuse with each other, the primary
palate and the nasal septum. NS = nasal
septum. T = tongue. MC = Meckel's
cartilage, SC = septal cartilage, *palatal
shelves.

include unfolding of the embryo lowering the developing heart and required to establish ectomesenchymal continuity. A number of methods
allowing differential growth of the face - an increase in vertical dimen­ are recognized: apoptosis (programmed cell death) of the epithelial
sion with constant transverse dimension. Also, sagittal growth ofMeckel's cells; epithelial-mesenchymal transformation leading to the cells
cartilage displaces the tongue via the attachment of the genioglossus adopting a fibroblastic morphology and remaining within the palatal
muscle. Once the shelves have elevated and the medial edges a re in mesenchyme. and migration of the epithelial cells to the oral and nasal
contact, disruption of the surface cells forming the epithelial seam is surface epithelia where they differentiate into keratinocytes. Clefts of
'
\
 Mechanisms of bone growth

the lip and palate (CLP) are the most common craniofacial malforma­ Research suggests that clefts of both lip and palate can be caused
tion in humans with an incidence of around 1 per 750 Caucasian births. by deficiency of neural crest cells. Isolated CP aetiology is usually con­
The aetiology of CLP may be explained by a failure to merge of the sidered to be of a physical nature.
maxillary and intermaxillary processes and the palatal shelves and may The role of the orthodontist in the treatment of individuals with clefts
occur from inadequate migration of neural crest or excessive cell death. of the lip and palate is covered in Chapt�r 22 .
..

4.3 Mecha ni sms of bone growth

The process by which new mi neralized bone is formed is termed growth can occur. At birth, there are three synchondroses in the cranial
ossification. Ossification occurs in one of two ways: by membrane base. the most important of which is the spheno-occipital synchondrosis.
activity (intramembranous ossification), and by bony replacement of a Condylar cartilage also lays down bone, and for a long time this
cartilaginous model (endochondral ossification). The adult structure of was thought to be a similar mechanism to epiphyseal growth, but
osseous tissue formed by the two methods is indistinguishable, both developmentally it is a secondary cartilage and its structure is different.
methods can be utilized in the same bone and both processes need Proliferating condylar cartilage cells do not show the ordered columnar
induction by interaction of the mesenchyme with overlying epithelium. arrangement seen i n epiphyseal cartilage, and the articular surface is
Intramembranous ossification is seen during embryonic develop­ covered by a layer of dense fibrous connective tissue (Fig. 4.5). The role
ment by direct transformation of mesenchymal cells into osteoblasts of the condylar cartilage during growth is not yet fully understood, but
and occurs in sheet-like osteogenic membranes. Intramembranous it is clear that it is different from that of the primary cartilages and its
ossification is seen in the bones of the calvaria, the facial bones1 the growth seems to be a reactive process in response to the growth of
1
'

mandible and the clavicle. other structures in the face.

Endochondral ossification is seen in the long bones of the limbs, the Bone does not grow interstitially, i.e. it does not expand by cell divi­
axial skeleton and the bones of the cranial base. Ossification takes sion within its mass: rather, it grows by activity at the margins of the
place in a hyaline cartilage framework and begins in a region known as bone tissue. Overall bone growth is a function of two phenomena,
- the primary ossification centre. Ossification spreads from the primary remodelling and displacement/transposition. Growth does not con­
ossification centre. At growth centres, the chrondroblasts are aligned in sist simply of enlargement of a bone by deposition on its surface:
columns along the direction of growth, in which there are recognizable periosteal (surface) remodelling is also needed to maintain the overall
zones of cell division. cell hypertrophy, and calcification. This process is shape of the bone as it grows. Thus. as well as having areas where
•
seen in both the epiphyseal plates of long bones and the synchondroses new bone is being laid down, a growing bone always undergoes
of the cranial base. Growth at these primary centres causes expansion. resorption of some parts of its surface. At the same time, endosteal
despite any opposing compressive forces such as the weight of the body remodelling maintains the internal architecture of cortical plates and
on the long bones.
Structurally, synchondroses resemble two epiphyseal cartilages
placed back to back and have a common central zone of resting cells.
Therefore, they have two directions of linear growth in response to
functional and non-functional stimuli and the bones on either side of
the synchondrosis are moved apart as it grows (Fig. 4.4). Differential

r '
•

Fig. 4.4 Synchondrosis: ossification is taking place on both sides of

the primary growth cartilage (Photograph: D. J. Reid). Fig. 4.5 Condylar cartilage of young adult (Photograph: D. J. Reid).
 C raniofacial growth , the cellular basis of tooth movement and anchorage
•

trabeculae. These processes of deposition and resorption together

constitute remodelling. Remodelling is a very important mechanism
of facial growth. and the complex patterns of surface remodelling
brought about by the periosteum which invests the facial skeleton
have been studied extensively. The change in position of a bony struc­
ture owing to remodelling of that structure is called drift, an example
being where the palate moves downwards during growth as a result
of bone being laid down on its inferior surface and resorbed on its
superior surface.
The bones of the face and skull articulate together mostly at sutures,
and growth at sutures can be regarded as a special kind of periosteal
remodelling- an infilling of bone in response to tensional growth forces
separating the bones on either side.
Growth which causes the mass of a bone to be moved relative to its
neighbours is known as d isplacement of the bone and this is brought
about by fo rces exerted by the soft tissues and by intrinsic growth of the
bones themselves. e.g. epiphyseal plates and sync hondroses: an example
is forward and downward translation oft he maxillary complex (Fig. 4.6).
Fig. 4.6 Forward and downward displacement ofthe maxillary
Both remodelling and displacement can occur in the _same bone in complex associated with deposition of bone at sutures. (After
the same or different directions. but the relative contribution of each is Enlow, D. H. (1990). Facial Growth. W. B. Saunders Co.,
difficult to determine. Philadelphia.)

4.4 Postnatal cran iofacial growth

Early cephalometric growth studies gave the impression that. overall, and differing mechanisms of growth at different stages o f development,
as the face enlarges it grows downwards and forwards away from the all of which are under the influence of a variety of factors. The overall
cranial base (Fig. 4.7). However. it is now known that growth of the pattern of facial growth results from the interplay between them and
cra niofacial region is much more complex than this, with the calvaria, they must a!! harmonize with each other if a normal facial form is to
cranial base, maxilla and mandible experiencing differing rates of growth result. Small deviations from a harmonious facial growth pattern will
cause discrepancies of facial form and jaw relationships which are of
I major significance to the orthodontist.
f
I
I

4.4. Growth patterns

Different tissues have di fferent growth patterns (curves) in terms of

rate and timing, and four main types are recognized: neural, somatic.
genital. and lymphoid (Fig. 4.8). The first two are the most relevant i n
terms of craniofacial growth.
I Neural growth is essentially that which is determined by growth of
I \ ,.,
r /..�
...
\_, I the-brain. with the calvarium following this pattern. There is rapid growth
I
I in the early years of life, but this slows until by about the age of 7 years
I
\ growth is almost complete. The orbits also follow a neural growth pattern.
I
l
I Somatic growth is that which is followed by most structures. It is seen
\
I

\
in the long bones, amongst others, and is the pattern followed by
\
' increase in body height. Growth is fairly rapid in the early years, but
'
'-..
.......... slows in the prepubertal period. The pubertal growth spurt is a time
- ....
....
....
, of very rapid growth, which is followed by further slower growth .
....
....
,
-...
, I Traditionally, the pubertal growth spurt has been reported to occur on
' I
....
....
-... \ I average at 12 years in girls, but there is evidence that the age of puberty
........ ,
..... /
.....__,
is decreasing in girls. In boys the age of puberty is later at about 1 4 years.
The maxilla and mandible follow a pattern of growth that is inter­
mediate between neural and somatic growth, with the mandible
Fig. 4. 7 Superimpositions on the cranial base showing overall
downwards and forwards direction of facial growth. Solid line. following the somatic growth curve more closely than the maxilla,
8 years of age; broken line, 1 8 years of age. ·

which has a more neural growth pattern (Fig. 4.8).

 Postnatal craniofacial growth
•

200 4.4.7 Calvarium

... ....
•
•
, .. . ..
•
•
The calvarium is that part of the skull which develops intramembran­
• •
• •
• •
ously to surround the brain and, therefore, it follows the neural growth
pattern. Development of the calvaria is dependent upon the presence
• •

lymphoid ! '
\ .
• •
• •
.
of the brain. It comprises the frontal bones, the parietal bones. and
•
'
• •
' .
• •
• •

•
• •
•
the squamous parts of the temporal and occipital bones. Qo;sification
•
•
•
•

•
•
•
•
•
centres for each bone appear in the outer membrane surrounding the
•
•
•

•
•
•
•
•
brain (ectomeninx) during the 8th week i.u. Bone formation spreads
• •
(1) • •

N •
• •
•
until the osteogenic fronts of adjacent bones meet and sutures are
..,
·-
• •
• •

....... .
• •

� formed. Where more than two bones meet the intersections between
•
:::J
-

•
• •

'0
•
•
•
• the sutures are occupied by large membrane-covered fontanelles. Six
n:l
•
• •

.... : .. .. ..

0 .. .. ... .. fontanelles are present at birth. which close by 1 8 months. By the age
100
'
•

/
•
(1)
"0.0 of 6 years the calvarium has developed inner and outer cortical tables
n:l
..... •

c: / : which enclose the diploe. Its growth consists of a combination of dis­

I
•
Q)

I
•

u
....
••
placement due to the expanding brain and osteogenesis at sutural
I
•

(1)
•
•
Q... Maxillary
I
• •

•
•
•
•
margins. and remodelling to increase thickness and change shape. The

I I
•

intracranial aspects of the bones are resorbed while bone is laid down
Mandibular
•
•
on the external surfaces. Growth of the calvaria corresponds closely to

Somati c •
I that of the brain and it ceases to grow in size by age 7 years. Eventually
all sutures unaergo varying degrees of fusion .
'
•
'

I 4.4.? Cranial base

/
•

Genital •

•
-- . ...
-- - - -- - · The cranial base develops by endochondral ossification. Cells within
the ectomeninx differentiate into chondrocytes and form discrete con­
Birth 10 years 20 years densations of cartilage from the 40th day i.u. These condensations of

Fig. 4.8 Postnatal growth patterns for neural, lymphoid, somatic and cartilage form three regional groups. A number of separate ossification
genital tissues shown as percentages of the total increase. The patterns centres appear in the cartilaginous model between 3 and 5 months i. u.
for the maxilla and mandible are shown in blue (redrawn from Proffit, Growth of the cranial base is influenced by both neural and somatic
W. R. (2000). Contemporary Orthodontics, 3rd edn. Mosby). growth patterns. with 50 per cent of postnatal growth being complete
by the age of 3 years. As in the calvarium, there is botR remodelling
and sutural infilling as the brain enlarges, but there are also primary
Thus different parts of the skull follow different growth patterns, with
cartilaginous growth sites in this region - the synchondroses. Of these,
much of the growth of the face occurring later than the growth of the
the spheno-occipital synchondrosis is of special interest as it makes
cranial vault. As a result the proportions of the face to the cranium
an important contribution to growth of the cranial base during ch ild­
change during growth, and the face of the child represents a much
hood, continuing to grow unti1 13-1 5 years in females and 1 5-1 7 years
smaller proportion of the skull than the face of the adult (Fig. 4.9) .
of age in males. fusing'at approximately 20 years. Thus the middle
cranial fossa follows a somatic growth pattern and enlarges both by
anteroposterior growth at the spheno-occipital synchondrosis and by
remodelling. The anterior cranial fossa follows a neural growth pattern
and enlarges and increases in anteroposterior length by remodelling, with
resorption intracranially and corresponding extracranial deposition.
There is no further growth of the anterior cranial fossa between the
sella turcica and foramen caecum after the age of 7 years. Therefore,
after this age the anterior cran·lal base may be used as a stable reference
structure upon which sequential lateral skull radiographs may be super­
imposed to analyse changes in facial form due to growth and orthodon­
tic treatment. The Sella-Nasion line is not as accurate because Nasion
can change position due to surface deposition and the development of
the frontal sinuses (see Chapter 6).
The sphe no -occipital synchondrosis is anterior to the temporo­
mandibular joints. but posterior to the anterior cranial fossa. and, there­
fore, its growth is significant clinically as it influences the overall facial
Fig. 4.9 The face in the neonate represents a much smaller proportion skeletal pattern (Fig. 4.10). Growth at the spheno-occipital synchon­
of the skull than the face of the adolescent. drosis increases the length of the cranial base, and since the maxillary

•
 Craniofacial growth, the cellular basis of tooth movement and anchorage

i.u. The maxilla is the third bone to ossify after the clavicle and the
mandible. The main ossification centres appear bilaterally above the
future deciduous canine close to where the infraorbital nerve gives off
the anterior superior alveolar nerve. Ossification proceeds in several
directions to produce the various maxillary processes. Postnatal growth
of the maxilla follows a growth pattern that is thought to be inter­
mediate between a neural and a somatic growth pattern (see Fig. 4.8).
Clinical orthodontic practice is primarily concerned with the denti­
tion and its supporting alveolar bone which is part of the maxilla and
premaxilla. However, the middle third of the facial skeleton is a com­
plex structure and also includes, among others, the palatal, zygomatic.
ethmoid, vomer. and nasal bones. These articulate with each other and
with the anterior cranial base at sutures. Growth of the maxillary com­
plex occurs in part by displacement with fill-in growth at sutures and in
part by drift and periosteal remodelling. Passive forward displacement
Fig. 4.10 Anteroposterior growth at the spheno-occipital -
is important up to the age of 7 years due to the effects of growth of
,

synchondrosis affects the anteroposterior relationship of the jaws. the cranial base. When neural growth is completed, maxillary growth
slows and subsequently. approximately one-third of growth is due to
displacement (0.2-1 mm per year) with the remainder due to sutural
complex lies beneath the anterior cranial fossa while the mandible growth (1-2 mm per year). In total, up to 1 0 mm of bone is added by
articulates with the skull at the temporomandibular joints which lie growth at the sutures.
beneath the middle cranial fossa. the cranial base plays an important Much of the anteroposterior growth of the maxilla is in a backward
part in determining how the mandible and maxilla relate to each other. direction at the tuberosities which also lengthens the dental arch,
For example, a Class II skeletal facial pattern is often associated with the allowing the permanent molar teeth to erupt. A forwards displacement
presence of a long cranial base which causes the mandible to be set of the maxilla gives room for the deposition of bone at the tuberosit­
back relative to the maxilla. ies (see Fig. 4.5). The zygomatic bones are also carried forwards,
In the same way, the overall shape of the cranial base affects the jaw necessitating infilling at sutures, and at the same time they enlarge
relationship, with a smaller cranial. base angle tending to cause a Class and remodel. In the upper part of the face, the ethmoids and nasal
bones grow forwards by deposition on their ante rio� surfaces , with cor­
•

Ill skeletal pattern, and a larger cranial base angle being more likely to
be associated with a Class II skeletal pattern (Fig. 4.1 1 ) . The cranial base responding remodelling further back, including wit h in the air sinuses,
angle usually remains constant during the postnatal period, but can to maintain their anatomical form.
increase or decrease due to surface remodelling and differential growth Downward growth occurs by vertical development of the alveolar
of the spheno-occipital synchondrosis. process and eruption of the teeth, and also by inferior drift of the hard
palate, i.e. the palate remodels downwards by deposition of bone on its

4.4.4 Maxillary complex inferior surface (the palatal vault) and resorption on its superior surface
•
(the floor of the nose and maxillary sinuses) - see Fig. 4.6. These
The maxilla derives from the first pharyngeal arch and ossification of changes are also associated with some downward displacement of the
the maxil lary complex is intramembranous. beginning in the 6th week bones as they enlarge, again necessitating infilling at sutures. Lateral

Fig. 4.11 (i) Low cranial base angle

associated with Class Ill skeletal pattern.
(ii) Large cranial base angle associated
(i) (ii) with a Class II skeletal pattern.

•
Exploring the Variety of Random
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 “Forgive me for wearying you, Fräulein. I am afraid I am rather
an enthusiast on the subject of education. But I won’t bore you any
more with my theories.”
“You are trying to revenge yourself upon the Queen by torturing
her through her son!” burst from Fräulein von Staubach.
“Surely, Fräulein, you must be aware that her Majesty makes my
post such a delightful one, and responds with so much alacrity to the
slightest suggestion I may venture to make for her guidance, that
the feeling at which you hint would be entirely out of place and
uncalled for?”
“She—she has not perhaps treated you as graciously as you
may have expected; but then, is it noble—is it even manly—to act in
this way? To work upon an unhappy mother’s feelings——”
“Fräulein, permit me to remind you that you are speaking of her
Majesty in terms for which there is no justification. If I had any wish
for revenge—to which you seem to consider I am entitled—I could
find no better way of wreaking it than by simply resigning my office
and returning to England. I am actuated by no feelings but those of
the greatest respect and kindness towards the Queen, who was left
in my charge under the most solemn circumstances by my dead
friend. It is not my fault, but I fear it will be her own great
misfortune, that she herself is the worst enemy of her son’s
kingdom.”
“I wish I could trust you!” she cried with a gasp. “But no, you
must have some other motive. You could not endure her coldness,
her childish peevishness, her foolish little affronts, as you do, unless
you had some end in view.”
“My end is solely to see King Michael seated safely on his
father’s throne, Fräulein. I have given up my life first to Otto Georg
and now to his son, and it strikes one as a little hard that the
sacrifice should be supposed to be made for the sake of some
personal advantage. If you can suggest one, I should be glad to
hear it, for I confess it has occurred to me more than once that I am
wasting my pains on an ungrateful family.”
“I long to believe you,” said Fräulein von Staubach. “I might be
able to make your path easier, but how can I, knowing what I know?
I remember you of old—your intrigues, your deceptions, all the
course of trickery you carried on when your brother was King. I do
not—I cannot—believe that you have really changed.”
“Perhaps, Fräulein, you will believe in my disinterestedness
when the kingdom is ruined in spite of my best efforts. Pray don’t
misunderstand me. I am not uttering any threat, for I shall continue
to do my best for the King, for his father’s sake. But I cannot hope
to succeed, and you know to whom my failure will be owing.”
“I wish I could trust you!” she said again, as she passed out of
the door he held open for her, and Cyril went back to his desk well
pleased.
“Now she is divided in mind,” he said to himself. “The new light
is beating fiercely on all her preconceived notions of a martyr Queen
persecuted by a revengeful Minister. She will do all she can to
reconcile the two views, and meanwhile she will improve matters a
little.”
And Cyril turned his attention to other subjects, feeling perfect
confidence in his new agent. It was no surprise to him a few days
later to receive a visit from Mrs Jones, who entered the office with a
face wreathed in smiles.
“You’ll be pleased to hear as I’ve changed my mind about goin’
home, my lord,” she said. “I hope as your lordship haven’t give
yourself no trouble about findin’ out trains for me?”
“I am extremely glad to hear this,” returned Cyril. “You decided
that you had been a little too hasty, I suppose?”
“No, my lord, that I never will give in to. Them as was hasty has
made amends, as was proper. Her Majesty come into my nursery
this mornin’, and I stood up very stiff-like, as my feelin’s bein’ hurt.
But she speaks to me very pleasant, and says, says she, ‘Mrs Jones,
I spoke hasty to you a short time ago, and it may be that through
ignorance of your language I said more nor I meant. I hope very
much that you have made no other arrangements, and will stay with
us. I ask it as a favour to myself, and also to the King, as will break
his heart if you leave him.’ There, my lord! I was all in a flutter to
think of a crowned Queen talkin’ to me of favours, and the little King
come runnin’ and says, ‘Nursie not goin’ away. Nursie stay and tell
stories,’ and I burst out cryin’ like any old crocodile, as they say, and
told the Queen that my heart was just about broke to think of
leavin’, and that I asked no better than to stay. And this afternoon
her Majesty have sent me a beautiful gown-piece of black silk, that
thick you might use it for a parachute if you wanted to, and so I’ve
took back my notice, my lord.”
This was extremely satisfactory so far as it went, but Cyril was
not long in discovering that the part he had played with respect to
Mrs Jones’s remaining a member of the royal household was not
appreciated by the Queen. It was tolerably clear that Fräulein von
Staubach had repeated verbatim, or, at any rate, rather in an
exaggerated than a diminished form, the conversation she had held
with him, and that the Queen had taken it to heart. She was very
careful in these days to entrench herself behind an impassable
barrier of etiquette, and she indulged in no freaks and no outbursts
of temper, while yet she kept Cyril at a distance, and made it evident
that he was in disgrace. This little exhibition of spite could do Cyril
no harm, for he still held the reins of authority and controlled the
purse-strings; but it was a very uncomfortable state of affairs for the
other members of the Court, who were obliged to do their utmost to
keep in favour with both parties. In these circumstances, Cyril
thought it a suitable opportunity to ask for a few days’ leave of
absence in order to pay his projected visit to Bellaviste, and the
permission was granted with a most unflattering readiness, which,
however, only caused him amusement.
“I don’t think she’ll be up to much in the way of tricks while I’m
gone,” he said to himself; “this last pulling-up has taken her rather
aback. She must know that I shall hear of all that goes on, and hurry
back if there is anything wrong. I don’t really like going, and yet I
must have a word or two with Drakovics. He shall learn to
understand that our partnership is not to be all on one side. If he is
not going to back me up, he may look out for some one else to pull
the chestnuts out of the fire for him. And I’m not sorry to have a
little change from this wretched place. I wonder whether there
would be time to run up to Vienna for a day or two? Oh no; my
precious charge would be getting into mischief, and, after all,
Bellaviste is better than this dull hole. Nothing much can happen in
five days. The servants know that I am master, and Stefanovics and
the Baroness will keep me posted up. If any one launches out on the
strength of my being gone, I shall be able to deal with them when I
come back.”
But on the day before that fixed for his departure, he discovered
that his authority in the household was not quite so firmly rooted as
he had imagined. It happened that in the course of the morning a
telegram arrived for him, and was brought into his office by one of
the royal footmen. The telegram was of little importance, but
something unfamiliar in the aspect of the bearer struck Cyril.
“Wait a minute,” he said, as the man was leaving the room.
“How is this? You are not Alexander Sergeivics, but Peter, and you
were one of the servants left at Bellaviste to look after the Palace.”
“Yes, Excellency; but my brother’s wife is dangerously ill at
Bellaviste, and I am taking his place that he may be with her.”
“Indeed! an excellent arrangement; but you will have to learn,
and so will your brother, that servants in the royal household are not
at liberty to exchange their posts to suit their own convenience.”
“Not if they have her Majesty’s sanction, Excellency?” There was
triumph clearly visible under the man’s deferential manner.
“Her Majesty’s pleasure overrides all regulations, of course. I am
to understand that your brother obtained her consent?”
“It is so, Excellency. Having obtained leave of absence, I came
to Tatarjé to tell my brother about his wife, and her Majesty, on
hearing the news, granted him permission to return to Bellaviste
immediately. When my brother ventured to suggest that it was
requisite for him to obtain leave from your Excellency, her Majesty
was pleased to say, ‘What has Count Mortimer to do with it? I have
told you to go, I the Queen. That is enough.’”
“Quite enough,” returned Cyril genially. “Ask M. Paschics to step
this way, and to bring with him the household book. The change and
the reason for it must be entered.”
The man departed, and Cyril walked to the window.
“There’s something fishy about the business,” he said; “but the
Queen has made it next to impossible to clear it up. I am pretty sure
I remember that there was something suspicious about this man
Peter. Come in, Paschics.”
M. Paschics, who entered in response to the invitation, was
ostensibly Cyril’s most confidential clerk, and there were only a few
who knew that he was in reality a member of the Secret Police,
specially detailed to watch over the royal household. The book which
he brought with him was to all appearance merely a record of the
comings, goings, and conduct of the domestics attached to the
Court; but by means of a series of private marks, the meaning of
which was known only to himself and Cyril, it contained also an
account of their political opinions and personal histories.
“You have heard that Peter Sergeivics is at present taking his
brother’s place,” said Cyril. “Turn up his name, and let me see what
there is against him.”
“He is a member of the Golden Eagle Society for the study of
Scythian literature, your Excellency, and has been heard on several
occasions to express approval of the sentiments uttered on St
Gabriel’s day by his Beatitude the Metropolitan.”
“I knew there was something wrong. Those literary societies are
invariably political clubs in disguise. Well, Paschics, this man is to be
watched. Notice his resorts and his associates, and let me know the
result of your shadowing.”
“Yes, your Excellency. He is not on duty this afternoon and
evening, and I hear that he is going into the town. As a stranger, he
wishes to see what the place is like.”
“And very natural too. If he finds any friends here, it is as well
that we should know it. That is all for the present.”
Paschics retired, and Cyril returned to his accounts. Later in the
day he was witness of a curious little incident which he did not at
the time connect with Peter Sergeivics and his suspicious record, but
which proved afterwards to have a bearing upon it. Standing at a
window which overlooked the approach, Cyril saw, to his
astonishment, the O’Malachy advancing to the door of the Villa. His
clothes were faultless, his moustache waxed; there was something
jaunty about his very limp. A stranger would have taken him for a
prince travelling incognito, or at the least for an exquisite of the
Pannonian Court; and Cyril, who knew him only too well, wondered
what on earth he was up to now. The door of the room was slightly
ajar, and he heard the familiar voice, with its rich rolling intonation,
asking leave to see over the Villa. The obvious answer was returned
that sightseers were not admitted at present, to which the
O’Malachy appeared to reply by producing the local guidebook,
which mentioned that visitors were allowed to go through the State
apartments on two days in the week. On being assured, however,
that this did not apply to the times at which the Court was in
residence, he perceived his error, and retired, with profuse
apologies, to view the Villa from the gardens, admission to which
was practically unrestricted.
“Pretty cool cheek of him to come here!” said Cyril to himself. “I
wonder he didn’t make use of my name as a reference. Now, what
was the object of this, I should like to know?”
But his curiosity remained unsatisfied, and he thought no more
of either the O’Malachy or Sergeivics until Paschics presented himself
as soon as he entered his office the next morning. A glance at the
detective’s face showed Cyril that he was bubbling over with news,
and he looked about for eavesdroppers, and made sure that the
door and windows were shut, before he would allow him to tell his
tale.
“According to your Excellency’s orders, I shadowed Peter
Sergeivics yesterday,” began Paschics. “In the afternoon I saw him
leave the Villa by the servants’ entrance, and take the road to the
town. While still in the grounds, however, he was met by an elderly
gentleman of military appearance, walking with a slight limp.” Cyril
uttered an exclamation. “As your Excellency has surmised, I
recognised this person as the Scythian officer who was arrested by
mistake some time ago, and set at liberty immediately afterwards.
Perceiving by his livery that Sergeivics belonged to the household,
he stopped him, and apparently requested him to point out to him
the principal architectural features of the Villa; for Sergeivics gave up
his intention of proceeding to the town, and escorted him round the
gardens, exhibiting the chief points of interest. I must confess with
regret that I could not succeed in following them sufficiently closely
to hear their conversation. At last Colonel O’Malachy presented
Sergeivics with a handsome pourboire, and departed. I discovered
afterwards that he had tried to gain admission to the interior of the
Villa, but had been refused an entrance.”
Cyril nodded. “I saw that myself,” he said.
“After this, your Excellency, Sergeivics returned to the servants’
quarters, and did not go out again until the evening. Following upon
his steps, I tracked him to a tavern in a low part of the town. Having
seen him seated at one of the tables, I hurried to the lodging of an
acquaintance of mine near at hand, and borrowed from him the long
coat, high boots, and fur cap of a droschky-driver. With the aid of
the wig and false beard which I always carry about with me, my
disguise was complete, and I entered the tavern and sat down at the
same table as my quarry. I then noticed that the table was close to
the end of a passage, in which was a door. From time to time one of
the men in the room would enter the passage and disappear
through the doorway. Again, several persons came in one by one
from the street, and, believing themselves unnoticed, also slipped
through. Among these, I am certain, was Colonel O’Malachy. He was
disguised in a country cloak and cap; but I could not mistake his
limp, nor his white moustache. I observed that all who passed in at
this mysterious door were subjected to some test. They knocked, I
think, in a peculiar scraping manner; but I cannot be sure of this,
owing to the distance and to the noise around me, and also to the
necessity of not appearing to watch too closely. Moreover, certain
questions, which also I could not hear, were asked and answered
before the door was opened. Then, as it seemed to me, a badge of
some kind was exhibited, which was worn on the under-side of the
left-hand lapel of the coat, and admission was immediately granted.
All this time, your Excellency, I was behaving as though I had
already drunk too much brandy, and offering to treat Sergeivics and
the other guests. The Thracians, as your Excellency knows, do not
become hilarious when excited by liquor; but I was talkative and
inclined to be quarrelsome. Sergeivics tried to shake me off, and
when he thought he had directed my attention to a group of fresh
arrivals, rose and endeavoured to slip down the passage. But I
caught him by the coat, and said in a drunken voice, ‘Not so fast, my
friend. There seems to be something interesting going on in there,
and I should like to come too.’ He looked at me as though he could
have killed me, but bent over the table and fixed me with his eye.
‘Look here,’ he said, ‘I have no business to tell you what it is; but
you have been so liberal with the brandy that I don’t mind letting
you know in confidence. You have heard of the Freemasons?’ ‘Oh
yes,’ I said; ‘they worship the devil, and their rites are proscribed.’
‘Stuff!’ he said; ‘that is what the priests tell you. Count Mortimer
himself is a Freemason, and therefore the police have orders to wink
at their doings, in spite of the law. This is one of their lodges, and I
am a member, so you see I can’t take you in, much as I should like.’
I gave a tipsy grunt, and let him go, when he vanished down the
passage at once. I sat there some time longer, talking and treating,
and saw other people go in, some of them officers, as I knew by
their walk, and others, I am sure, priests. Then, fearing to arouse
suspicion, I staggered out, and, taking up a position from which I
could watch the place, tracked Sergeivics back to the Villa about an
hour and a half later. That is my report, your Excellency.”
“And a very good one it is. I shall require you again presently,
Paschics. You can go now, and tell Sergeivics that I want him.”
“But your Excellency does not intend to tax the man with his
treachery? He will be desperate—and he is probably armed.”
“So am I,” was the brief response; and Paschics retired. When
Sergeivics entered the room, Cyril was seated at his writing-table,
looking for something in one of the drawers.
“Ah, Peter Sergeivics—wait a minute,” he said, glancing up. “By
the way, what’s that on the left-hand lapel of your coat?”
The man’s face turned pale, and his hand went up in a terrified
snatch. Finding nothing, he recollected himself immediately.
“Perhaps you will kindly tell me what is wrong there,
Excellency?”
“Nothing—now,” responded Cyril; “but something very wrong
was there last night.” There was a sudden movement of the
footman’s arm, but Cyril was too quick for him. The right hand which
had been hidden in the drawer came up suddenly, holding a revolver.
“Throw up your hands this moment, and stand where you are, or
you are a dead man!” were the words which smote upon the ear of
the astonished Sergeivics, as he found himself covered by the
weapon.
“You will not murder me, Excellency?” he faltered.
“Not on any account; but I shall have no compunction in killing
you in self-defence. Peter Sergeivics, you came to Tatarjé under the
orders of a revolutionary committee, charged to help them in
carrying out their schemes. By an ingenious device, you obtained an
opportunity for receiving orders from the Scythian agent here and
furnishing him with information. Last night you attended a meeting
at which the final plans for the outbreak were agreed upon, and the
parts to be played by the various conspirators assigned to them.”
“What does your Excellency want with me?” whined the luckless
man.
“I want nothing, as you see. If you care to offer any
information, the fact will be taken into account in deciding your
sentence. If you do not, you will merely be dismissed from the royal
household, and it will become known that you have retired with a
pension, awarded in consideration of the loyal assistance furnished
by you to the Government, which has led to the detection of the
plot.”
Sergeivics writhed. “You know that I should be dead within an
hour, Excellency,” he whimpered. “If I tell you all I know, will you
guarantee that I shall be saved from the vengeance of the rest?”
“Stay where you are, if you please,” as the wretched man made
a movement as though to throw himself at Cyril’s feet. “It will be just
as uncomfortable for you to be shot by me as by your fellow-
conspirators. I have said that I do not ask you for information; but if
yours should prove to be of any value, I will guarantee that you shall
be sent to Bellaviste under a sufficient escort to protect you from the
vengeance of your friends. This is showing quite undeserved mercy
to one who has deliberately plotted to murder the Queen and the
young King——”
“Never, Excellency! There was no thought of murder. We merely
——”
 “Ah, your information differs from mine, then?”
“Your Excellency must have been misinformed. Our object was
simply to secure the persons of the King and Queen, and to induce
the Queen to consent to the King’s conversion to the Orthodox faith.”
“To induce her? yes. And when persuasion failed——?”
The man’s face grew pale again. “There was something said
about a few days without food for the Queen, and the knowledge
that her child and attendants were suffering in the same way,” he
muttered.
“Exactly; and what would that have meant but murder, in the
case of delicate women and a child? And this precious scheme was
to be carried out to-night, was it, that you might have at least three
clear days before I should begin to feel surprised at receiving no
news from Tatarjé? or perhaps you would like to set me right on this
point also?”
“No, Excellency; your information is correct.”
“And the plot is supported by the garrison, the Church, and the
townspeople, headed no doubt by the mayor?”
“Yes, Excellency; and as you know, of course——”
“Yes, I was waiting for this. By whom besides?”
“I—I fear your Excellency knows more than I do. The message
which the head of our circle at Bellaviste gave me to bring here was
merely that a certain person was propitious, but must not be too
confidently relied upon.”
“Take care. To whom did you understand that message to
allude?”
“To—to the Metropolitan, Excellency.”
“You are telling me lies.”
“No, no, indeed, Excellency. I will swear it by the Holy Fire, by
all the saints! We of the lower levels are not admitted into the
possession of important secrets, but we conjectured among
ourselves that the Metropolitan was meant.”
“Well, be careful. To continue: the King and Queen were to be
imprisoned in the Bishop’s Palace, which is capable of standing a
siege; and when the conversion was effected, the Queen was to be
further compelled to place the kingdom under the protection of
Scythia, and request the favour and support of the Emperor?”
“Yes, Excellency.”
“And if by any chance I did not start to-night for Bellaviste, I
was to be killed?”
“That is only natural, Excellency.”
“Quite so. Well, I will take you with me to Bellaviste when I start
to-night.”
“You start to-night, Excellency? But—the station is watched.
Their Majesties will not be allowed to travel.”
“That need not interfere with my journey. I have unmasked
plots before this one, my friend. You see this cigarette-case with the
monogram in brilliants? I will place it on the edge of the table close
to you. Lower your left hand—be careful, I am ready to shoot—take
the case, and put it in your right-hand outside pocket. You
understand? Good.”
He rang sharply the bell which stood on the table, and Paschics
burst open the door and rushed in, followed by two or three
servants, and pausing in astonishment when he saw the tranquil
condition of affairs.
“I must have this man searched,” said Cyril. “I suspect him of
being in possession of the cigarette-case presented to me by the
Emperor of Pannonia, and bearing his Majesty’s cipher in brilliants. It
is possible that you may find other stolen property upon him as well.
I missed one of my revolvers the day before yesterday.”
In an instant Sergeivics was seized and held by two footmen
while Paschics searched his pockets. The cigarette-case and a
revolver were produced almost immediately, and laid in triumph on
the table; but nothing else was revealed by the search. Cyril nodded
pleasantly.
“I thought so,” he said. “Well, it is quite out of the question that
I should postpone my journey on account of this, and therefore the
man had better be taken to Bellaviste to-night by the train in which I
shall travel. Instruct the police to provide a proper guard, M.
Paschics, and report to me when you have made arrangements.”
 CHAPTER X.
A NEW RELATIONSHIP.

Left to himself, Cyril rose from his chair, and began to walk rapidly
up and down the room, maturing some plan in his mind as he
walked. Once or twice his meditations were interrupted by the
entrance of a servant with a letter or a message; but he disposed
quickly of these stray pieces of business, and returned to the
consideration of his more important scheme. When Paschics came
back, he sent him to summon M. Stefanovics, and then unfolded to
the two men the tale of the conspiracy which he had forced from the
wretched Sergeivics.
“But this is fearful!” cried M. Stefanovics. “Surely you have taken
some steps, Count? Their Majesties ought to have left the town
already.”
“The railway-station is watched, and even if it was too early to
oppose the departure of the Court by force, nothing could be easier
than to wreck the train,” said Cyril curtly.
“But why not telegraph for help to Bellaviste—or to Feodoratz, if
M. Drakovics is too far off to be of any assistance?”
“Because I have for some time past suspected that some one
was tampering with our telegrams, and now I am sure of it. I have
just received a telegram which ought to have reached me three days
ago, but which the operator says must have been delayed in
transmission. It is from M. Drakovics, begging me not to leave
Tatarjé until I have heard again from him, and if it had arrived in
proper time it would have delayed my journey. Now, of course, it is
too late.”
The eyes of the other two men met with a puzzled expression.
“But if you suspect the officials here,” suggested M. Stefanovics,
“why not despatch a telegram from some point outside the city?”
“Because the danger does not arise merely from treachery here.
That would scarcely explain the delay in this telegram, and certainly
not the confusion and omissions which have puzzled me in others.
No; I believe that the conspirators are in the habit of tapping the
wires between this and Bellaviste, and so reading, and occasionally
altering, the telegrams which pass between the Premier and myself.”
“Then, you consider, Count, that to telegraph for assistance
would simply defeat all our hopes of catching the miscreants
unawares?”
“Exactly. Whatever is to be done must be done from this end.”
“You would perhaps suggest that their Majesties should cross
the frontier, and take refuge in Dardanian territory?”
“No. I had thought of that at first; but besides producing an
extremely unfortunate impression abroad, the attempt would be
useless, for the Prince and Princess have left their country residence,
and returned to Bashi Konak for the opening of the Legislature.”
“But still, would it not be advisable for their Majesties, under the
pretext of a simple drive, to cross into Dardania, and then to make
all speed for Bashi Konak?”
“It might be, except that everybody in the Villa and the town
knows that no one belonging to the Court will drive to-day. You
cannot surely have forgotten that the Queen is commemorating the
late King’s birthday in retirement in her own apartments? If orders
were given to prepare a carriage, it would instantly be surmised that
something alarming had occurred, and a small band of resolute men
could easily stop us at a dozen points between this and the
Dardanian frontier. Moreover, we must not forget that the relations
between the Scythian and Dardanian Courts are very close, and to
my mind the message brought by this man Sergeivics to his fellow-
conspirators here points to some knowledge of the plot on the part
of Baron Natarin, if not of a more exalted individual behind him. It
might even be a portion of the design to drive her Majesty into
seeking refuge in Dardania.”
“One must hope,” said M. Stefanovics, with some pique, “that
you have some plan of your own to propose for securing the safety
of their Majesties, Count, since you see so many flaws in all that I
can suggest.”
 “Exactly; I have a plan—but I know that you will see
innumerable flaws in it, although it is the only one that seems to me
to offer a hope of success.”
“If it commends itself to your Excellency,” said Paschics stoutly,
“that is enough for me.”
M. Stefanovics gave a nod of acquiescence, and Cyril brought
out a map of the district and unrolled it. “You perceive,” he said,
“that in this case the railway and the telegraph, instead of being, as
usual, our friends, are our enemies, since they are in the power of
the conspirators. My idea is, then, to avoid them altogether, and
provide a means of escape for their Majesties by way of the old
post-road, which takes quite a different route from the railway, and
reaches at last the estates of Prince Mirkovics, whose loyalty no one
can doubt, and who will provide us with a safe asylum until help can
be obtained from Bellaviste.”
“But you forget, my dear Count, that spring can scarcely be said
to have begun, and that the post-road passes through the forest and
across the mountains before it reaches the Mirkovics domain.”
“I do not forget it; but this is a matter of life and death,
Stefanovics.”
“But surely the presence of so large a body of travellers on the
old road would create such a stir that it would be impossible for the
Court to travel unnoticed, not to mention the difficulty of providing
transport for so many?”
“You are right, and delay or recognition would simply mean that
we should be pursued and brought back. No; I do not intend to
conduct a Court progress, after the manner of a second flight to
Varennes. My idea is simply that M. Paschics and I should smuggle
the Queen, the little King, and one lady-in-waiting, through the
country in disguise.”
The audacity of the proposal took away M. Stefanovics’s breath.
“And the rest of the Court?” he inquired blankly.
“I am afraid they must stay here, in blissful ignorance, until the
escape of their Majesties is discovered. The conspirators are not
likely to be bloodthirsty, except in the case of unfortunate suspects
like myself.”
 “We are to remain at the Villa, while you and the Queen—Holy
Peter! do you imagine the Queen would ever consent to such a plan
of escape, Count?”
“I trust she may, if it is put before her suddenly. If she had time
to think over it, I agree with you that there would be no hope. You
see how the thing works out. I must pretend to start for Bellaviste as
I had arranged to do, in order to avert suspicion; but you must let
me into the Villa again by the private stairway. Then we must lay the
matter before the Queen, and prevail upon her to start at once. We
can only count on being left in peace until the time when the Villa is
usually quiet for the night.”
“The risk is terrible. And yet, what else——? But you will never
obtain her Majesty’s consent.”
“Then her Majesty will have the pleasure of seeing me shot
down before her eyes, I presume. But do you agree to the plan in so
far as you are concerned?”
“How can I venture to object to it? It seems the only hope, and
you are risking more than the rest of us. A few days’ imprisonment
would be the worst punishment we should receive. But the hardships
of your journey will be dreadful for women and a child.”
“Better than the dungeons of the Bishop’s palace—that is all one
can say. The season is altogether on the side of the conspirators.
Then you will come into the scheme, Stefanovics? Now, Paschics, for
your part. You have some relations living not far off, I believe?”
“Yes, Excellency; a married brother, who farms his own land.”
“And you did not go to see them at Christmas, I think? Well, it
will be convenient if you pay them a visit to-day. Start after lunch,
and take a bag—full of presents for the children, or delicacies from
the town, or anything of the sort. You may let it be known that you
will not be back to-night. At your brother’s, hire his lightest cart, with
the two best horses he has, and tell him he will find it the day after
to-morrow left for him at No. 4 posting-house on the old road to
Bellaviste. Put in some straw—as much as you can—and any rugs
you can get to make it comfortable, and as soon as it is dark this
evening, drive the cart to the spot where the corner of the Alexova
estate touches the old road. Wait there under the trees and give
your horses a good feed. If we succeed we will join you; if not, you
had better get back to your brother’s as fast as you can, for your
own sake. By the bye, could you disguise yourself as a courier?”
“With the greatest ease, your Excellency.”
“Then take with you anything you will require. You will be
wanted to-morrow as courier to an English family whose carriage
has met with an accident. I will see about the passport.”
“One moment, Count,” said M. Stefanovics, with some
embarrassment. “I do not wish to interfere with your excellent plans;
but you are, after all, a young man and unmarried. Would it not be
more suitable—less open to unfavourable remark—if Madame
Stefanovics and I undertook the responsible task of conducting her
Majesty’s flight, in conjunction, of course, with M. Paschics?”
“It would simply be putting my neck in a noose,” muttered
Paschics, gazing apprehensively at the placid face and comfortable
girth of the worthy chamberlain.
“I have no objection whatever,” returned Cyril. “You must see
for yourself that I risk my life in coming back at all, and the slightest
misfortune or accident might lead to our being hunted down like
wolves. By all means carry the thing through, Stefanovics. No doubt
you have more influence than I have over the Queen, who is not
exactly the easiest of ladies to manage.”
“True,” remarked M. Stefanovics sadly. “Count, I have done you
an injustice. You alone can carry out this scheme, if any one can do
it. I will not venture, for I should only fail, and do harm to others.”
Cyril laughed silently to himself as the two men left the room,
and then turned his attention to arranging several matters of
importance connected with the great scheme. It was necessary first
to write to M. Drakovics; but when the letter was finished he put it
into his pocket, and did not post it. Next he busied himself in
drawing up a passport for the party of English travellers of whom he
had spoken to Paschics, and who comprised a Mrs Weston, her
brother, her little son, her nurse, and an Italian courier. The
document did not leave Cyril’s hands; but when he had finished with
it, it bore other signatures than his, carefully copied from a genuine
passport which lay before him on the table. There was one thing
which he did not attempt to imitate—the stamp of the frontier
official whose duty it was to see that all passports were in order.
Cyril had not a stamp at hand, and it would risk suspicion, and
certainly cause delay, to send for one, while a bad imitation might
arouse doubts as to the genuineness of the whole thing. It went to
his heart to set out with the document incomplete; but he knew that
it is sometimes necessary to sacrifice technical perfection to practical
utility, and after drying his handiwork carefully in the sun, he put it
by safely. He had intended after this to take advantage of Dietrich’s
absence at dinner to go to his own quarters and pack a small bag
with necessaries, hiding it in his office, where the valet would not be
likely to find it; but he decided that it was improbable he would be
able to carry it, and contented himself with putting two or three
indispensable articles in his pockets. There were still various things
to be arranged in view of his impending departure, and he spent the
afternoon in attending to these. He had his farewell audience of the
Queen, dined with the household, and drove to the station with
Stefanovics, who was deputed to see him off. There were several
dignitaries on the platform, who had come for the same purpose—
the mayor of the town, the commandant of the garrison, an
archdeacon to represent the Bishop, and one or two others. It was
only right that they should be there; but Cyril felt sure that some of
them would have found excuses and stayed away if it had not been
that they were eager to assure themselves of his departure by the
evidence of their own eyes. He stayed on the platform talking to
them for some minutes, and then entered his carriage, which was
one of those belonging to the royal train, but had been detailed for
the service of the Minister of the Household.
“It’s a blessing all that fuss is over!” he said aloud, as the door
was shut after he had shaken hands with the officials outside. “Now
that we are left to ourselves, Dietrich, I think I will change my
things. What is the good of a holiday if one doesn’t wear holiday
clothes?”
To Dietrich, who knew that his master shared the
incomprehensible dislike of most Englishmen for livery of any kind, it
was quite natural that he should be anxious to change his official
uniform at once for a suit of ordinary clothes, and the transformation
was quickly effected and concealed by the regulation overcoat which
had been worn in driving to the station. It was well that this
precaution had been taken, for before long a sudden hubbub arose
on the platform, followed by a visit of the mayor to the carriage.
Sergeivics, with his escort of police, had just been conducted to a
third-class compartment, and the gentlemen on the platform were
anxious to know of what crime he was accused. Happily Cyril was
able to gratify their curiosity by a vivid description of the theft of the
cigarette-case, aggravated, as it was, by the possession of the
revolver, which had, no doubt, also been purloined, and his account
interested them so much that they all crowded into the carriage to
hear it. Cyril began to fear that they would insist on travelling with
him as far as the next station, which would have complicated
matters seriously; but it was as important for them to be in Tatarjé
that night as to see him out of it, and they returned to the platform
precipitately when the bell rang. The moment for Cyril’s great coup
was close at hand; but there was not the slightest trace of
excitement visible in his manner as he stretched himself in an arm-
chair, and raised his arms behind his head in a long yawn.
“I shan’t want you any more to-night, Dietrich; and don’t come
bothering me at every station. Get a good night’s rest; I shall ring
fast enough if I want you. And, by the bye, if I don’t call out to you
when we get to Bellaviste in the morning, don’t come in and wake
me. See that the car is shunted into the siding, and take this letter
straight to his Excellency the Premier. You understand? You are not
to lose a minute. Then go home: if I have got there before you, it
will be all right; if not, wait for orders. You can go now.”
But Dietrich had failed fully to comprehend the order, and it was
necessary to repeat and emphasise it, so that the train was already
in motion when he betook himself to his own compartment. Cyril,
who had drawn up one of the blinds, and was bowing his farewells
to the group on the platform, turned with a sudden quickening of
the heart as he heard the door shut behind the valet. The speed was
increasing; in another moment his time for action would come. He
threw off his overcoat, and felt mechanically in his pockets to see
whether he had transferred to them everything he wanted. The train
moved slowly out of the lighted station into the dark night, and Cyril
opened the door of communication, and stepped out on the
gangway between the two carriages. Climbing over the railing, he
remained for a moment holding to its outer edge, then let himself
drop. He fell clear of the line, and rolled out of the way of the train,
remaining prostrate at the side of the road until the last carriage had
passed, then climbed the bank (the station stood outside the town),
and plunged into the wood which fringed it. He had studied his route
carefully on the map, and carried a compass on his watch-chain,
which he consulted every now and then with the help of a match, so
that he succeeded in making his way safely round the outskirts of
the town without approaching any house. He was tired, wet, and
muddy when he reached at length the wall which surrounded the
grounds of the Villa, and he felt it to be an additional grievance that
he failed to strike the gate exactly, and had to make a considerable
circuit before he came to it. The gate was reached at last, however,
and it responded easily and noiselessly to the well-oiled key which
he took from his pocket. Crossing the grounds, he came to the
shrubbery opposite the terrace, and for some few minutes watched
the sentry pacing up and down. Then there came the sound of the
opening of a door, and the little red ball of light from a cigar became
visible. This was the signal which Cyril had agreed upon with
Stefanovics, and the next time that the sentry’s back was turned he
crept across the terrace, and arrived in the doorway so suddenly as
to startle the chamberlain almost into a cry. Leaving the door ajar,
they crept up the narrow winding staircase on which it opened, and
which was a relic of the days of the last king of the house of Franza.
It communicated with a room which had been used by King Peter for
receiving his Ministers—and other persons—and which now served
the Queen for holding private audiences. She disliked the secret stair
on account of its associations, and had wished to have it bricked up;
but Cyril had succeeded in persuading her that it was an interesting
historic survival, and might possibly prove useful again, little thinking
how soon he was to discover the truth of his own words. One of the
only two keys which fitted this door was in his possession by virtue
of his office, and the lock moved easily.
“Ask to speak to Baroness von Hilfenstein,” he whispered to
Stefanovics, as the latter preceded him into the room; “but on no
account let out that I am here until you are sure that no one else
can hear what you have to say.”
He waited in darkness behind the partially closed door until the
sound of voices showed him that Stefanovics had succeeded in
finding some one; but still he was not summoned, and time was
flying. Pushing open the door, he appeared in the room, to the
accompaniment of a little scream from the Baroness, and an
outpouring of self-justification from Stefanovics.
“The Baroness refuses to admit us to her Majesty’s presence,
Count, although she tells me that the Queen has sent away her
maids, and is talking over the fire with Fräulein von Staubach. It is in
vain that I——”
“Consider the hour, my dear Count,” said the Baroness
reprovingly. “I must beg of you to retire immediately. It is in the
highest degree irregular for you to seek an audience of the Queen at
such a time.”
“My dear Baroness,” returned Cyril, “you know me pretty well by
this time, and will believe me when I tell you that my business is of
such importance that if you won’t consent to inform her Majesty of
my desire to see her I must announce myself.”
After a glance at his face to assure herself that he was in
earnest, the Baroness withdrew without a word, and the next sound
that reached his ears was the Queen’s voice in the adjoining room.
“Count Mortimer here again? I thought we were free from him
for a week at least! He asks to see me at this hour? The man must
be mad. Most certainly I refuse to see him, Baroness. Be so good as
to tell him that I shall know how to resent this intrusion.”
A low-toned remonstrance from the Baroness and a frightened
murmur from Fräulein von Staubach followed, interrupted ruthlessly
by Cyril.
“Madame,” he cried, approaching the door of communication, “I
have returned at the risk of my life to bring you news of a plot which
aims at the forcible conversion of your son to the Orthodox Church,
and the subjugation of his kingdom to Scythia.”
“A plot to convert my son!” The door was thrown open, and
Cyril had a momentary glimpse of a figure with terrified dark eyes,
and rippling chestnut hair flowing over a white dressing-gown. Then
the Baroness dashed forward, shutting the door in his face, and he
heard her agonised voice—
“Madame, remember your position! I entreat your Majesty——”
The rest was inaudible, and Cyril stood fuming over the precious
time which was being lost because the old woman would not allow
him to see the Queen in a dressing-gown. But the door opened
again almost immediately, and the Queen stood on the threshold,
pale and calm. The other ladies had clad her in a loose black gown,
and hidden away her hair under the flowing crape veil she wore in
the daytime, and she looked a different being.
“Tell me, Count,” she said, “when is this plot to be carried out?”
“To-night, madame; and I believe very shortly. You and the King
were to be seized in your beds and carried off to the Bishop’s palace,
there to be starved into compliance with the demands of the
conspirators.”
“And you would advise us, no doubt, to take refuge in the castle
immediately?”
“I fear, madame, that you would only be running into danger.
The garrison is honeycombed with disaffection.”
“Then there is only one chance left, for I know well that it is
impossible to defend this house. We must go to the municipal
offices, and throw ourselves on the protection of the burghers.”
“Unfortunately, madame, there is no safety there. The whole of
Tatarjé is utterly disloyal.”
“Then what are we to do?” Her voice rang piteously in his ears;
but she dashed the tears resolutely from her eyes. “Count, I rely
upon you to help me. This plot threatens my son’s honour—not only
his kingdom. You have not come here simply to warn us of the
approach of inevitable danger. You have a plan to save the King. Tell
me what it is. I will follow your advice.”
 She had risen so completely above her usual level that for the
moment Cyril was tempted to forget her inveterate distrust of him.
He answered promptly—
“There is one way to save the King and yourself, madame. If
you will consent to adopt a disguise, and to start immediately upon a
somewhat troublesome journey, with your son and one lady in
attendance, I will do my best to conduct you safely to Bellaviste.”
“Ah! you have made plans for this journey?”
“One does not generally undertake such a venture at
haphazard, madame. I have done what I could to ensure success,
and I may say that I have good hopes of attaining it.”
“And what,” she demanded, in a voice that made him jump, “is
there to assure me that this is not a plot of your own, invented for
the purpose of making me ridiculous or even humiliating me in the
eyes of the world? Where are the proofs of the conspiracy you have
discovered?”
“I have none,” said Cyril laconically. Her change of tone had
restored his mind immediately to its usual balance. “If you will wait
half an hour or so, madame, the proofs will probably arrive in the
persons of the conspirators; but it will then be too late to save your
son.”
She bit her lips with vexation. “It is useless to ignore the fact,
Count, that the relations between us have not been wholly amicable
of late, and you are popularly supposed never to let slip an
opportunity of revenging yourself.”
“A guilty conscience is usually an unpleasant companion,
madame; but on this occasion it is also an untrustworthy adviser.”
“How? Do you venture to imply—— You must be aware that you
are asking me to repose an extraordinary degree of confidence in
you, Count.”
“Not more than your husband reposed in me, madame. Have I
ever betrayed that confidence? Even when you most disliked my
measures, have they not proved to be advantageous—even
necessary?”
“Unhappily they have. But this case is wholly without
precedent.”
 “It is for you, madame, to decide whether you prefer to be
saved in an unprecedented way, or ruined in a manner which is
unfortunately not entirely new. If your son is to be rescued, I must
ask you to make up your mind quickly now, and to be obedient
afterwards.”
“Obedient! That is a strange word to use to me!”
“I have no doubt that the action is equally new to you,
madame.”
She turned from him with a gesture of disgust. “How am I to
decide?” she asked angrily. “On the one side I risk my son’s
kingdom, on the other my good name. If I could only trust him!
Baroness, I will not appeal to you. If Count Mortimer suggested a
journey to the moon, you would only inquire mildly, ‘By what route
does the Herr Graf propose to conduct us?’ Sophie, you are not a
blind idolater. Tell me quickly—shall I trust him?”
Poor Fräulein von Staubach, finding herself thus appealed to,
turned first red and then white, twisted her fingers painfully
together, and sought inspiration in the corners of the ceiling. Her
advice came suddenly, accompanied by a rush of tears and a great
gulp: “Trust him, madame. I believe you may.”
“Then you also have gone over to the enemy!” said the Queen
sarcastically, as she turned again to Cyril. “I congratulate you upon
your convert, Count. I wish you would exercise the same influence
over me; but as you have not thought fit to do so, I am afraid I must
ask you to swear that you have told me nothing but the truth, and
that your motives are what you represent them to be. Will you do
this?”
“No, madame, I will not swear. If you cannot accept the word of
a man who has endangered his life in order to serve you, you must
drag him down to destruction with yourself.”
She looked up in alarm, and caught sight of the repressed fury
in his face. She gave a little gasp, and her eyes fell before his.
“Forgive me, Count. I do trust you. I will obey.”
Cyril’s heart leapt within him, but he betrayed no sign of
exultation over his victory. His tones were sternly business-like as he
said—
 “Then, madame, I must beg of you to disguise yourself as an
Englishwoman. Put on a tailor-made gown and a small felt hat, if
you please, and a short straight veil à l’anglaise, covering only the
upper part of the face. It would make it less easy for you to be
recognised if the dress was not black, but of some coloured cloth.
Bring also a fur cloak, for you will find it very cold. Which of the
ladies is to be summoned to attend you?”
“Pardon me, madame; that is my place,” said Baroness von
Hilfenstein, as the Queen looked round helplessly.
“I cannot consent to that, Baroness,” said Cyril. “You could not
support the fatigues of the journey, and moreover, your presence will
be needed here. Have you any preference as to your attendant,
madame?”
“I should like to have Fräulein von Staubach if—if you—if it
would not do any harm,” faltered the Queen.
“That is the very selection I would have ventured to suggest,
madame. Fräulein von Staubach speaks Thracian well, and although
the passport is made out for a German, we may find it desirable to
change our disguise after a time. May I beg of you, Fräulein, to
dress yourself to play the part of a nurse, and to see that the King is
warmly wrapped up? Will you also pack a small bag with necessaries
for her Majesty, and another for yourself. They must not be too large
to be carried conveniently in the hand, for we have to cross the park
on foot before we can reach the vehicle which is awaiting us. And
pray waste no time. Every minute is precious.”
The three ladies disappeared promptly, and Cyril stood waiting
for what seemed to him to be hours. He curbed his impatience, and
whiled away the time by making one or two final arrangements with
M. Stefanovics; but they had both relapsed into an uneasy silence
before Baroness von Hilfenstein entered the room, and beckoned
Cyril out of earshot of the chamberlain.
“You think success is possible in this enterprise of yours,
Count?”
“Certainly possible, Baroness; and possibly certain.”
“I did not come to ask you to play upon words,” very severely.
 “I ask your pardon, Baroness. The danger has excited me. I
think I must be fey.”
“I do not know that word, my dear Count.”
“It only means that some one is walking over my grave,
Baroness.”
“Do not speak in that way,” said the old lady, looking at him with
alarm not unmixed with tenderness. “Count, I cannot forget to-night
that you are a young man, although it has never struck me before.
Can I depend upon you to take such care of the Queen as I myself
should take were I with you?”
“I promise you, Baroness, that I will take as much care of the
Queen as she will allow me.”
“She will prove somewhat trying, I do not doubt. But you have
mastered her to-night, and that may change her manner towards
you. I cannot tell—I am afraid——”
“Are you afraid of her Majesty or of me, Baroness?”
The sudden question recalled the Baroness to her duty. “I am
not afraid of either of you; but I am very much afraid of
circumstances,” she replied, looking straight at Cyril.
“I have always aimed at moulding circumstances, Baroness, and
not at allowing them to mould me.”
“That is very well, but circumstances are sometimes too strong
—— But guard well the proprieties, my dear Count. Maintain the
niceties of etiquette with even unusual care, for they will form a
barrier to protect the Queen from her unfortunate surroundings. You
will promise me this?”
“Anything in reason, Baroness. I will do my best, certainly. But,”
changing the subject with some impatience, “may I remind you that
our escape will largely depend upon you? Of course it is impossible
to defend this house; but the longer you can keep the conspirators
in talk before they discover the Queen’s absence, the better for us.”
“You are right. I will meet them and argue with them, refuse to
allow them to proceed, and retreat only inch by inch before threats
of violence. And then, Count, I will try another expedient. When they
insist on seeing the Queen, my daughter shall personate her
Majesty. They are about the same height, and through the crape veil
it will be impossible to detect the difference.”
“It is an excellent idea, Baroness, if Baroness Paula has the
nerve to carry it out. But what about the King?”
“We will dress up a pillow in his clothes, and Mrs Jones shall
carry it. If we are hurried away to the Bishop’s palace at once, they
will not detect the trick until the morning, which will—— Oh, is that
you, Mrs Jones?”
“Yes, ma’am, it is; and hearin’ no good of myself, as they say no
eavesdroppers don’t. I think I see myself carryin’ about a pillow
dressed up in his Majesty’s clothes, and the precious lamb himself
left to that there Frawline!”
“Mrs Jones, we cannot take you with us.” Cyril spoke sharply,
noting that Mrs Jones was ready equipped for the journey. “You
would be recognised anywhere,” for tales of the magnificence of
demeanour of the King’s nurse, and her unbending deportment
towards the natives of her land of exile, circulated wherever the
Court moved, “and that would ruin the whole scheme. You must stay
here, and obey the orders of the Baroness, and so help us to save
the King.”
“Thank you, my lord; and what if I declines to stay here?”
“Then you will have the responsibility of destroying the King’s
only chance of escape. We are in your hands, Mrs Jones. If you will
stay behind, it will help to gain time for us to get beyond the reach
of pursuit; but you may as well go and inform the conspirators at
once that we are trying to escape as insist on coming with us. Which
is it to be?”
“My lord, if me stayin’ here can help the King and your lordship
to escape, I’ll stay here till Doomsday, and no one shan’t drag me
from the house, not if wild horses was to try it. I thank you, my lord,
for talkin’ to me like a reasonable Christian woman, and here I stays,
and no thanks to no one else, neither!”
And Mrs Jones retired with added dignity, just as the Queen
entered the room, looking absurdly young and girlish in her grey
tweed dress and simple hat, and followed by Fräulein von Staubach,
with the little King, well wrapped up, fast asleep in her arms.
 “One moment before we start, madame,” said Cyril. “From this
time forward you are an English lady, Mrs Weston, and I am your
brother, Arthur Cleeves. Your Christian name is Lilian. The King is
your son Tommy, Fräulein von Staubach is his German nurse Julie,
and my clerk Paschics, who is waiting for us on the other side of the
park, is Carlo, an Italian courier. We are travelling by road, and our
carriage has broken down, which makes it necessary for us to hire a
country cart to convey us to the next posting-station. Let me
impress upon you the necessity of speaking nothing but English, and
of keeping to our assumed names, even when no strangers are
present, for the sake of practice. I think you had better give me the
child, Fr—Julie, and I will take my sister’s bag, if you can manage
your own. Now we had better start—Lilian.”
The Queen gave Baroness von Hilfenstein a half-tearful, half-
smiling glance, for the old lady’s face was a study when she heard
Cyril’s words, and it was with difficulty that she restrained herself
from insisting, even at this late hour, on the abandonment of the
scheme. “Take care of her Majesty,” she whispered anxiously to
Fräulein von Staubach, holding her back from descending the stairs
after the other two; “remind her constantly of her position. Maintain
all the restraints possible, and remember that if anything happens, I
shall never forgive you or myself.”
Very much flurried, and totally unable to comprehend the full
force of the warning, Fräulein von Staubach nevertheless promised
faithfully to observe it, and hurried down the steps after her
mistress, who had reached the door at the foot of the staircase.
Here the fugitives stood for a moment in the shadow, listening to the
beating of their own hearts, while M. Stefanovics, emerging from the
doorway, joined the sentry in his walk, and accompanied him to the
end of the terrace, where he directed his attention to an imaginary
glare in the sky over the city, which he suggested was due to a
street-fire. While the sentry, deeply interested (for he knew
something of the plot, and was watching for any sign of its being
carried out), was doing his best to see the remarkably faint and fitful
glow pointed out to him, Cyril directed the Queen and Fräulein von
Staubach to cross the terrace as quietly as possible, and conceal
themselves among the shrubs on the farther side. The next moment
he followed them; but the interval had been long enough to allow a
fear to seize him which covered his brow with cold sweat. What if
the conspirators were already in hiding among those very bushes?
But no one appeared, and no movement was made, and he led the
way through the gardens, walking on the grass wherever he could
so as to avoid making any sound, and then through a wicket-gate
into the park. Here their progress was much more satisfactory, for
they were quite out of sight from the house, and could walk rapidly
over the turf, although it required some care to avoid coming into
unpleasantly close and sudden contact with the trees. But when the
more open ground was left behind, and it was necessary to plunge
into a thick wood, the ladies found their difficulties greatly increased,
and the more so that Cyril, encumbered as he was with the sleeping
child and the Queen’s bag, could do little to aid them. They made no
complaint, and toiled on bravely through briers and wet bushes,
which had a perverse way of springing back and striking the unwary
traveller on the face; but it was no small relief to Cyril when they
reached the boundary of the estate, and a whistle from him brought
up Paschics to relieve him temporarily of the burden of the little
King, and to help the ladies over the fence. They descended the
steep bank to the road, where the Queen stopped suddenly, aghast
at the sight of the vehicle awaiting them, and then laughed until the
tears came into her eyes. It was the usual light wooden cart of the
more advanced among the farmers, without springs or tilt, and
provided with a board by way of driving-seat. The floor was covered
thickly with straw, and there were several rugs stowed away in the
front, while the two rough, stout little horses had had their bells
carefully removed.
“Come, Lilian, let me help you up,” said Cyril briskly, handing the
little King to Fräulein von Staubach, and mounting into the cart. “I
can make you and Tommy a most comfortable nest in the straw, and
there is a rug for Julie as well. Give me your hand, and Carlo will
show you where to put your foot.”
The Queen, with the tears still in her eyes, allowed herself to be
helped in, and sat silent as Cyril lifted the child and laid him in her
arms; but when Fräulein von Staubach had been established beside
her, and Paschics had produced a piece of tarpaulin, which he
fastened to the sides of the cart so as to shelter the inmates, she
put out her hand suddenly and laid it on Cyril’s.
“Don’t think I am ungrateful,” she said; “it is all so strange. I
feel as if I were in a dream. But I will do all I can to avoid being a
trouble to you.”
 CHAPTER XI.
WAYFARING.

When in after-days Cyril looked back to the events of that night, they
seemed to him like the course of a bad dream. The first part of the
journey was easy enough, for the road was good, and he occupied
the driving-seat with Paschics, exchanging a word with him
occasionally, and keeping him supplied with cigars, for the Queen
had entreated them to smoke. But when some ten English miles had
been covered without interruption, it became necessary to leave the
road for an old and almost disused cart-track, leading through rough
and hilly country. By this means the first three posting-stations on
the road would be missed altogether, a step which was imperative
unless the fugitives were simply to be traced from point to point
along their way; but time was so precious that Cyril would have
been inclined to try whether it was impossible to slip past them
unnoticed, if it had not been that the hill-track, though rough, was
far shorter than the post-road. There was no more easy driving now.
Cyril and Paschics spent the greater part of the night in walking up
and down interminable hills, sometimes dragging the horses on,
sometimes holding them back, and varying these occupations by
pushing at the cart behind, or lifting the wheels out of pits of mud.
The two women and the child were so completely tired out that they
were scarcely awakened even by the most tremendous jolts, and
descents which would have appeared impossible in daylight were
attempted confidently by the light of the lantern which Paschics
carried, and which was constantly in request for the purpose of
consulting the map or the compass. At length the worst and longest
hill, having been successfully passed, proved to be the last one, and
the two men and the worn-out horses stumbled painfully into the
highroad. Looking at one another, in the grey light of the March
morning, Cyril and Paschics became aware that they both presented
a very disreputable appearance, and the short interval which was