ISSN 0970 - 4388

Class - III malocclusion: Genetics or environment? A twins study

JENA A. K.a, DUGGAL R.b, MATHUR V. P.c, PARKASH H.d

Abstract

Etiology of class-III malocclusion is generally believed to be genetic. A wide range of environmental factors have been suggested
as contributing factors for the development of class-III malocclusion. Twin study is one of the most effective methods available for
investigating genetically determined variables of malocclusion. Discordancy for class-III malocclusion is a frequent finding in
dizygotic twins. However, class-III malocclusion discordancy in monozygotic twins is a rare finding. The purpose of this study of
monozygotic twins is to assess the genetic and environmental components of variation within the cranio-dento-facial complex.

Key words: Class-Ill malocclusion, Genetics, monozygotic twins

Introduction Case Report

As defined by Angle,[1] class-Ill malocclusion represents a A pair of monozygotic female twins is presented. The girls
very small proportion of the total malocclusion. Class-Ill exhibited a marked similarity in facial appearance (Figure 1
malocclusions are most prevalent in Oriental populations and 2). Both had similar dentition; however their occlusions
(3-5% in Japan[2] and 1.75% in China[3]). Its etiology is gener- were dissimilar to some extent (Figure 3 and 4). In twin-1
ally believed to be genetic, and familial occurrence has been reverse overjet, overbite and class-Ill molar relations were
demonstrated in several studies.[4,5] Certain X-chromosome more severe than twin-2 (Figure 3 and 4). Both the twins
aneuploidal conditions can also leads to mandibular prog- had bilateral posterior crossbite. Cephalometric parameters
nathism[6] and are predominantly inherited trait.[7] A wide of twins are shown in Table 1. Few cephalometric param-
range of environmental factors have been suggested as con- eters also revealed marked differences in skeletal morphol-
tributing to the development of class-Ill malocclusion. ogy. The degree of differences in cranio-dento-facial mor-
Among those are enlarged tonsil, [8] difficulty in nasal phology of twins is shown in cephalometric superimposi-
breathing,[8] congenital anatomic defects,[9] disease of the tion (Figure 5). Cephalometric analysis showed class-Ill
pituitary gland,[10] hormonal disturbances,[11] a habit of pro- maxillo-mandibular relationship in both twins but more se-
truding the mandible,[10] posture,[10] trauma and disease,[9] vere in twin-1. As compared to twin-1, twin-2 had flat cra-
premature loss of the sixth-year molar[10] and irregular erup- nial bases. The position of the maxilla was more backward
tion of permanent incisors or loss of deciduous incisors.[12] and the position of mandible was more forward hi twin-1
Other contributing factors such as the size and relative po- as compared to twin-2. Height of the anterior face was simi-
sitions of the cranial base, maxilla and mandible, the posi- lar in both the twins but posterior facial height was more
tion of the temporomandibular articulation and any dis- in twin-2. Position of the mandible in relation to anterior
placement of the lower jaw also affect both the sagittal
and vertical relationships of the jaw and teeth.[13-16] The
position of the foramen magnum and spinal column[17] and
habitual head position[18] may also influence the eventual
facial pattern. The etiology of class-Ill malocclusion is thus
wide ranging and complex.[19] For investigation of geneti-
cally determined variables in orthodontics, twin study
method is the most effective. Baker reported a case in which
monozygotic twins were concordant for mandibular prog-
nathism.[20] Korkhaus also reported two cases of monozy-
gotic twins; one pair was concordant and another pair was
discordant for class-Ill malocclusion.[21] The purpose of this
study is to assess the variation of cranio-dento-facial com-
plex of monozygotic twins with class-Ill malocclusion.

a
Senior Resident, bAssociate Professor, cSenior Research Officer,
d
Professor and Head, Departtment of Dental Surgery All India Institute Figure 1: Extraoral photographs of twin-1; 1a-Front view and
of Medical Sciences, New Delhi - 110029, India 1b-Lateral view

27 J Indian Soc Pedo Prev Dent - March 2005

 Class - III malocclusion : Genetics or environment

Table 1: Cephalometric parameters of twins

Parameters Twin-1 Twin-2
Angle SNA 70° 73°
Angle SNB 75° 73°
Angle ANB -5° 0o
Ramus angle (Ar-Pog x S-N) 92o 88°
Anterior facial height 110 mm 109 mm
Posterior facial height 61 mm 67 mm
Jarabak ratio 55.45% 61.46%
Mandibular plane angle (FMA) 30° 29°
Y-axis 58o 61°
SN-GoGn 40° 34o
Anterior cranial base length 65 mm 64 mm
Ramus height (Ar-Go) 39 mm 40 mm
Mandibular body length (Go-Me) 63 mm 62 mm
Effective mandibular length 104 mm 110 mm
Effective maxillary length 73 mm 78 mm
Maxillo-mandibular difference 31 mm 32 mm
Facial angle 89° 84°
Figure 2 : Extraoral photographs of twin-2; 2a-Front view and Basal plane angle 35° 26°
2b-Lateral view Saddle angle 129° 138o
Articular angle 143° 132o
Angle of convexity -9° 0o
cranial base and Frankfort-horizontal plane was signifi- N Perpendicular to point-A -5 mm -4 mm
N Perpendicular to Pog 0 mm -9 mm
cantly different among twins. Effective length of the max-
Upper lip to esthetic line (E-line) -4.5 mm -1 mm
illa and mandible were less in twin-2, however the maxillo- Lower lip to esthetic line (E-line) +1.5 mm +1.5 mm
mandibular differences in both the twins were almost equal. Upper incisor to A-Pog line 4 mm 4.5 mm
Position of upper lip in relation to the esthetic line was Upper incisor to NA 7 mm 5 mm
Upper incisor to N-Pog line 1 mm 6 mm
significantly different among twins. However, both twins
Lower incisor to NB 3.5 mm 5 mm
had no absolute difference in lower lip position. The posi- Lower incisor to N-Pog line 4 mm 7 mm
tion of the underlying skeletal bases and their dentition Overjet -3 mm -1 mm
contributed such difference. Class-Ill relationship of the in- Overbite 4 mm 1 mm
cisors (Reverse overjet) and vertical overlap of incisors (Over-
bite) were more severe in twin-1. Thus marked differences Discussion
in the cranio-dento-facial structures were noted in the
monozygotic twins. Twin study is one of the most effective methods available

(a) (b) (c)

Figure 3: Intraoral photographs of twin-1; 3a- Right lateral view, 3b- Front view and 3c-Left lateral view

(a) (b) (c)

Figure 4: Intraoral photographs of twin-2; 4a- Right lateral view, 4b- Front view and 4c-Left lateral view

J Indian Soc Pedo Prev Dent - March 2005 28

 Class - III malocclusion : Genetics or environment
Figure 5: Cephalometric superimposition of twin- 1 and 2
for investigating genetically determined variables in orth-
odontics and in other medical field. Discordancy for class-
Ill malocclusion is a frequent finding in dizygotic twins;[22]
however, class-Ill malocclusion discordancy in monozygotic
twins is a rare finding. The variation in shape and size of
the cranio-dento-facial structures depends on both genetic
and environmental influences.[23] Many traits in cranio-
dento-facial morphology relate to additive genetic and en-
vironmental factors.[24] The separation of these two factors
in the contribution of severity of class-III malocclusion is
significant for clinical orthodontics. It may be possible to
assess the prognosis of each type of patient with class-III
malocclusion on the basis of hereditary background and
environmental factors. The region affected by environmen-
tal factors can be improved by orthodontic treatment. Many
cephalometric studies showed distinct skeleto-facial pat-
tern in monozygotic twins having class-III malocclu-
sions.[14,15,21] It has been pointed out that because of a rela-
tively weak genetic control similarity in facial structures de-
crease in older monozygotic twins.[25]
In the present study, concavity of the face (Angle of con-
vexity) in twin-1 was more as compared to twin-2. Relatively
more backward position of the maxilla (Angle SNA, N per-
pendicular to point-A) and forward position of the chin
(Angle SNB, N perpendicular to Pog) contributed to such
difference in the severity of facial concavity. The antero-
posterior position of the mandible (Angle SNB, N perpen-
dicular to Pog) in the present twin study was influenced
significantly by environmental factors. However in a previ-
ous study undertaken by Townsend and Richards[26] reported
that antero-posterior position of the mandible is geneti-
29
cally determined. Anterior facial height of both twins was
apparently equal. It showed that the height of the anterior
face is genetically determined and did not play any role in
the discordance of class-III malocclusion. This is in agree-
ment with the result of study done by Townsend and
Richards.[26] The shape of the cranial base (Saddle angle)
was different among twins. This characteristic played a
major role in the discordance of class-Ill malocclusion. It
was suggested that the form of the cranial base is least
genetically controlled and strongly influenced by environ-
mental factors.[27] The relative position of the maxilla (Angle
SNA), temporomandibular joint (Articular angle) and effec-
tive length of mandible and maxilla were different in both
twins. These characteristics played a significant role in the
severity of class-Ill malocclusion as described by many au-
thors.[14,15,16] Vertical position of the mandible in relation to
the Frankfort-horizontal plane (FMA) was identical in both
twins, but the interesting difference was the position of
mandible in relation to anterior cranial base (SN-GoGn). Such
severe spatial discrepancy of mandible in twin-1 was due
to more upward tipping of anterior cranial base. Positions
of the upper incisors were more variable than the lower
incisors. Proclination of the lower incisors was relatively
more in twin-2. Such dento-alveolar compensation was
considered as an important environmental factor in the
variation of severity of class-Ill incisor relationship among
the twins. From this twin study it was concluded that ge-
netic is not the sole controlling factor for the etiology of
the class-III malocclusion. The multifactorial etiology of
class-Ill malocclusion was confirmed. Environmental factors
plays significant role in its severity. There are many open
questions and further study need to be carried out to elu-
cidate the true etiology of the class-Ill malocclusion.
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Reprint requests to:
Dr. Ritu Duggal
Department of Dental Surgery
All India Institution of Manipal Sciences,
New Delhi, India.
E-mail: rituduggal@rediffmail.com
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