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

very small proportion of the total malocclusion. Class-Ill
malocclusions are most prevalent in Oriental populations
(3-5% in Japan[2] and 1.75% in China[3]). Its etiology is generally believed to be genetic, and familial occurrence has been
demonstrated in several studies.[4,5] Certain X-chromosome
aneuploidal conditions can also leads to mandibular prognathism[6] and are predominantly inherited trait.[7] A wide
range of environmental factors have been suggested as contributing to the development of class-Ill malocclusion.
Among those are enlarged tonsil, [8] difficulty in nasal
breathing,[8] congenital anatomic defects,[9] disease of the
pituitary gland,[10] hormonal disturbances,[11] a habit of protruding the mandible,[10] posture,[10] trauma and disease,[9]
premature loss of the sixth-year molar[10] and irregular eruption of permanent incisors or loss of deciduous incisors.[12]
Other contributing factors such as the size and relative positions of the cranial base, maxilla and mandible, the position of the temporomandibular articulation and any displacement 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 genetically determined variables in orthodontics, twin study
method is the most effective. Baker reported a case in which
monozygotic twins were concordant for mandibular prognathism.[20] Korkhaus also reported two cases of monozygotic 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 complex of monozygotic twins with class-Ill malocclusion.

A pair of monozygotic female twins is presented. The girls

exhibited a marked similarity in facial appearance (Figure 1
and 2). Both had similar dentition; however their occlusions
were dissimilar to some extent (Figure 3 and 4). In twin-1
reverse overjet, overbite and class-Ill molar relations were
more severe than twin-2 (Figure 3 and 4). Both the twins
had bilateral posterior crossbite. Cephalometric parameters
of twins are shown in Table 1. Few cephalometric parameters also revealed marked differences in skeletal morphology. The degree of differences in cranio-dento-facial morphology of twins is shown in cephalometric superimposition (Figure 5). Cephalometric analysis showed class-Ill
maxillo-mandibular relationship in both twins but more severe in twin-1. As compared to twin-1, twin-2 had flat cranial bases. The position of the maxilla was more backward
and the position of mandible was more forward hi twin-1
as compared to twin-2. Height of the anterior face was similar in both the twins but posterior facial height was more
in twin-2. Position of the mandible in relation to anterior

Senior Resident, bAssociate Professor, cSenior Research Officer,

Professor and Head, Departtment of Dental Surgery All India Institute
of Medical Sciences, New Delhi - 110029, India
d

Figure 1: Extraoral photographs of twin-1; 1a-Front view and

1b-Lateral view
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J Indian Soc Pedo Prev Dent - March 2005

Class - III malocclusion : Genetics or environment

Table 1: Cephalometric parameters of twins
Parameters
Angle SNA
Angle SNB
Angle ANB
Ramus angle (Ar-Pog x S-N)
Anterior facial height
Posterior facial height
Jarabak ratio
Mandibular plane angle (FMA)
Y-axis
SN-GoGn
Anterior cranial base length
Ramus height (Ar-Go)
Mandibular body length (Go-Me)
Effective mandibular length
Effective maxillary length
Maxillo-mandibular difference
Facial angle
Basal plane angle
Saddle angle
Articular angle
Angle of convexity
N Perpendicular to point-A
N Perpendicular to Pog
Upper lip to esthetic line (E-line)
Lower lip to esthetic line (E-line)
Upper incisor to A-Pog line
Upper incisor to NA
Upper incisor to N-Pog line
Lower incisor to NB
Lower incisor to N-Pog line
Overjet
Overbite

Figure 2 : Extraoral photographs of twin-2; 2a-Front view and

2b-Lateral view

cranial base and Frankfort-horizontal plane was significantly different among twins. Effective length of the maxilla and mandible were less in twin-2, however the maxillomandibular differences in both the twins were almost equal.
Position of upper lip in relation to the esthetic line was
significantly different among twins. However, both twins
had no absolute difference in lower lip position. The position of the underlying skeletal bases and their dentition
contributed such difference. Class-Ill relationship of the incisors (Reverse overjet) and vertical overlap of incisors (Overbite) were more severe in twin-1. Thus marked differences
in the cranio-dento-facial structures were noted in the
monozygotic twins.

(a)

Twin study is one of the most effective methods available

(b)

(c)

(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

Twin-2
73
73
0o
88
109 mm
67 mm
61.46%
29
61
34o
64 mm
40 mm
62 mm
110 mm
78 mm
32 mm
84
26
138o
132o
0o
-4 mm
-9 mm
-1 mm
+1.5 mm
4.5 mm
5 mm
6 mm
5 mm
7 mm
-1 mm
1 mm

Discussion

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

(a)

Twin-1
70
75
-5
92o
110 mm
61 mm
55.45%
30
58o
40
65 mm
39 mm
63 mm
104 mm
73 mm
31 mm
89
35
129
143
-9
-5 mm
0 mm
-4.5 mm
+1.5 mm
4 mm
7 mm
1 mm
3.5 mm
4 mm
-3 mm
4 mm

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Class - III malocclusion : Genetics or environment

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 agreement 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 environmental factors.[27] The relative position of the maxilla (Angle
SNA), temporomandibular joint (Articular angle) and effective 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 authors.[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 genetic 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 elucidate the true etiology of the class-Ill malocclusion.

Figure 5: Cephalometric superimposition of twin- 1 and 2

for investigating genetically determined variables in orthodontics and in other medical field. Discordancy for classIll 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 craniodento-facial morphology relate to additive genetic and environmental 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 environmental factors can be improved by orthodontic treatment. Many
cephalometric studies showed distinct skeleto-facial pattern in monozygotic twins having class-III malocclusions.[14,15,21] It has been pointed out that because of a relatively weak genetic control similarity in facial structures decrease in older monozygotic twins.[25]

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In the present study, concavity of the face (Angle of convexity) in twin-1 was more as compared to twin-2. Relatively
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that antero-posterior position of the mandible is geneti-

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Class - III malocclusion : Genetics or environment

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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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