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Genetic, epigenetic and environmental

influences on dental development
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there is a group of “dental genes” on assumptions that may not always present in Twin B (arrowed). There
that not only influences the size and be valid. is also no evidence of the lower
shape of teeth but also the expres- There is a simpler research right third molar in Twin A but the
sion of missing or extra teeth. In model involving twins that can also corresponding tooth is present in
other words, there are both be employed by practising dentists. Twin B (arrowed). The upper third
pleiotropic genetic effects operating This model is referred to as the MZ molars are evident in Twin A
on the human dentition and spatial co-twin design and it essentially (arrowed) but not in Twin B
and/or temporal variations in local involves studying pairs of MZ twins (arrowed).
epigenetic events during odontogen- who may have different habits,
esis that lead to distinct phenotypic receive different treatments, or dif- Dif f erences in ex pression of
differences in the dentition, even in fer in expression for one or more ex tra t eet h in MZ tw in pairs
genetically identical twin pairs. features of interest. Because each Not only have we observed differ-
MZ pair is matched for sex, age and ences of expression of missing teeth
genetic make-up, the co-twins pro- in MZ twin pairs, there are also
vide an extremely valuable research examples of different expression of
model. For example, just one pair of extra teeth in our samples. For
MZ twins displaying differences in Fig. 5. MZ co-twins showing different example, panoramic radiographs of
their dentitions offers a great oppor- expressions of missing lower second pre- a pair of MZ twins aged 9.5 years
tunity to explore the underlying bio- molars and third molar development. show different expressions of super-
logical processes of tooth formation. numerary teeth (Fig. 6). Twin A has
Given that MZ twin pairs almost Dif f erences in toot h size in one mesiodens (arrowed), whereas
always share the same genes, any MZ t w in pairs Twin B has two (arrowed). Futher-
differences observed between the We have found many examples of more, the development of the
members of an MZ pair are assumed MZ twin pairs who show quite unerupted teeth is more advanced in
to be due to differences in environ- marked differences in tooth size and Twin B than Twin A.
mental effects between the co-twins an example of one pair who show The examples shown of missing
or to the way in which their genes marked differences in the size of their and extra teeth in our twin samples
are expressed, that is, epigenetic upper right central incisors is provid- are not rare. Of 24 MZ pairs who
effects. The MZ pairs described in ed (Fig. 1). The crowns of these teeth were selected from our records
Fig. 2. MZ co-twins showing different this article have a very high proba- differ in mesiodistal size between the because they showed at least one
expressions of missing, tapering and small
bility of being genetically identical co-twins by 0.5 mm, the measure- missing lateral incisor or second
maxillary lateral incisors.
based on DNA analysis. Further- ment in Twin A being 7.9 mm and premolar, 21 pairs showed differ-
that in Twin B being 8.4 mm. Given ences in the number or position of
that the error of measurement for the affected teeth between co-twins.
dental crown diameters is around 0.1 A similar pattern emerged for super-
to 0.2 mm, the discrepancy observed numerary teeth. Of nine MZ twin
represents a “real” difference in the pairs who showed evidence of
size of these teeth. Around 5% of mesiodentes, eight pairs were dis-
nearly 200 MZ pairs examined as cordant for the number of supernu-
part of our studies have shown size meraries (Townsend et al., 2005a,b).
differences in upper central incisors
that are at least as large, or larger, as
that shown in the example.
Fig. 3. MZ co-twins showing different expression of missing and small maxillary lateral inci-
sors. Twin A displays agenesis of the maxillary right lateral incisor and a small maxillary left Dif f erences in ex pression of
lateral incisor, whereas Twin B has two small maxillary lateral incisors. The mandibular pre- m issing t eet h in MZ tw in pairs
molars had been extracted for orthodontic reasons. We have also found many exam-
ples of MZ twin pairs who show dif-
ferences in the expression of miss-
ing teeth, both in terms of number
and location. Panoramic radio-
graphs of a pair of MZ twins aged 14
years are provided (Fig. 2). Twin A
has a missing maxillary right lateral
incisor and a tapering maxillary left
lateral incisor (arrowed), whereas
Twin B has two small maxillary lat-
eral incisors (arrowed). Several Fig. 6. MZ co-twins showing different
expressions of supernumerary teeth.
Fig. 4. MZ co-twins showing different expression of missing and tapering maxillary lateral other examples of different expres-
incisors. Twin A displays bilateral agenesis of the maxillary lateral incisors, whereas Twin B has sion of missing, tapering and small
a tapering maxillary right lateral incisor and a missing maxillary left lateral incisor. lateral incisors in MZ twin pairs Asymm et rical ex pression of
have been observed in our studies d en t a l f ea t u r es
more, there is no evidence in their (Figs. 3, 4), supporting the idea that It is generally assumed that the
Tw in m odels records of major differences in envi- there is a strong relationship genetic information controlling the
We agree completely with Profes- ronmental influences, either pre- between these features (Townsend development of bilateral structures,
sor Carels that studies of twins have natally or post-natally. Therefore, et al., 1995). such as teeth, is the same on both
contributed greatly to our under- the differences between these The panoramic radiographs of sides. However, teeth rarely display
standing of the role of genetic and co-twins could have been caused by another pair of MZ twins aged 12.5 complete symmetry in their mor-
environmental influences on dental epigenetic differences in the control years highlight the fact that dental phology or their development.
development. However, the tradi- of their DNA and/or by relatively development can differ quite marked- Asymmetrical expression of fea-
tional twin approach involving com- minor variations in local environ- ly between MZ co-twins (Fig. 5). tures can be either random in its
parisons between monozygotic (MZ) mental conditions during the Twin A has a missing lower right expression, so-called fluctuating
and dizygotic (DZ) twin pairs process of odontogenesis. second premolar (arrowed), asymmetry, or favour one side over
requires large samples and is based whereas the corresponding tooth is the other, so-called directional

asymmetry. By examining the pat- teeth will occur, and the prevalence although showing variations in the researchers from Finland (Kangas et
terns and degrees of expression of of missing teeth is greater in females number and position of teeth miss- al., 2004) showing that dental char-
asymmetry between contra-lateral who have smaller teeth, on average, ing. However, there are some 300 acters seem to be non-independent
teeth, it is possible to obtain further than males. At the other extreme of genes that appear to be involved in and that increasing the levels of
insights into the roles of genetic, epi- the distribution, with increasing dental development and a number of expression of just one gene can lead
genetic and environmental influ- tooth size, another threshold is them could be candidates for miss- to increases in cusp number, altered
ences on dental development (Kha- reached above which extra teeth will ing teeth. Furthermore, the most cusp shape and position, develop-
laf et al., 2005a). occur. The prevalence of extra teeth common clinical presentation relat- ment of longitudinal crests on teeth,
One particularly interesting is greater in males who have larger ing to missing teeth is hypodontia and increases in tooth number in
expression of asymmetry that can be teeth, on average, than females (Fig 8.). where only a small number of teeth experimental mice.
observed in MZ twin pairs is the are missing. Rather than a monogenic mode of
phenomenon of mirror imaging, Int erpret ing phenot ypic st udies in the Given that there appears to be a inheritance, we believe that a multi-
where one twin “mirrors” the other light of findings at a mol ecular lev el link between the size and shape of factorial model (with genetic, epige-
for one or more features. Figure 7 To date, molecular studies in teeth, and hypodontia or supernu- netic and environmental influences)
shows panoramic radiographs of a humans have concentrated mainly merary teeth, we propose that there provides the best explanation for our
pair of MZ male twins, aged 15 on locating the genes associated is likely to be a group of “dental observations involving hypodontia
years, who show mirror-imaging for with missing teeth. As Carels has genes” that exert pleiotropic effects and supernumerary teeth in MZ twin
hypodontia of the lower second pre- pointed out, mutations in two genes, on all of these dental phenotypes, pairs. Such a model, with superim-
molars. The left premolar is missing MSX1 and PAX9, have been shown to accounting for their observed co- posed thresholds linking tooth size,
in Twin A (arrowed), whereas the be associated with familial cases of variation. Just how many genes are morphology and number, enables us
right premolar is missing in Twin B severe hypodontia (where many involved remains to be seen, but it is to explain why MZ co-twins, who
(arrowed). In addition, a developing teeth are missing) and the pedigrees possible that it may be a relatively
lower right third molar is evident in have been consistent with an autoso- small number. Support for this view
Twin A (arrowed) but not in Twin B mal dominant mode of inheritance is provided by a paper in Nature by  OT page 6
(arrowed). The biological basis of
mirror imaging is still not well
understood, although it apparently
reflects an underlying alteration in
the determination of body symmetry
at an early stage of development.

How can t he dif ferences bet w een

MZ co-tw ins be ex plained?
The examples provided in this
article and in other studies we have
performed support the view that,
even though there is a relatively
strong genetic basis to missing or
extra teeth, the number or position
of affected teeth can be influenced
by epigenetic factors. The exact
nature of these influences is still
unclear but they do not need to be
due to differences in methylation of
DNA or acetylation of histones.
Rather, we suggest that they may
reflect different responses of odonto-
genic cells to minor variations in the
spatial and temporal expression of
local signalling molecules passing
between cells during development.
In other words, we are proposing
that “disturbances” in epigenetic
events at the local level during tooth
formation can lead to quite major
differences in the final appearance
of the dentitions of MZ co-twins.
A multi-factorial model linking
tooth size and number has been pro-
posed to account for the different
patterns of expression of missing
and extra, and also large and small
teeth observed in males and females
(Brook, 1984; Brook et al., 2002;
McKeown et al., 2002; Khalaf et al.,
2005b). The relatives of individuals
with missing or extra teeth have
been found to be more likely to also
display missing or extra teeth,
supporting the concept of an under-
lying genetic predisposition to
hypodontia or supernumerary teeth.
We believe that such a multifactorial
model, with multiple genetic and
environmental influences, provides
the best explanation for our observa-
tions involving missing and extra
teeth in MZ twin pairs. With the
superimposition of thresholds on
this underlying distribution, it is pos-
sible to explain the relationship
between tooth size and the presence
or absence of teeth. Below a certain
threshold for tooth size, missing
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have the same genotypes, may dis- organizing properties is consistent

play different expressions of miss- with our current understanding of the
ing, tapering and microdont inci- molecular basis of tooth development.
sors. Presumably these MZ twin The various stages of odontogenesis,
pairs have a genetic predisposition including initiation, morphogenesis
for hypodontia that places them near and differentiation, result from a
the threshold for agenesis, but minor series of epithelial-mesenchymal
variations in local epigenetic events interactions between oral epithelial
during odontogenesis may lead to and ecto-mesenchymal tissues that
different phenotypic expression are facilitated by the exchange of var-
between co-twins. A similar expla- ious signalling molecules. The work
nation may also account for the dis- of Jernvall and colleagues in Helsinki
has shown how the same genes are
expressed and the same signalling
molecules released in a reiterative
fashion to produce each of the cusps
of a molar tooth (Jernvall and Jung,
2000). In fact, these genes seem to be Fig. 8. Multifactorial model with superimposed thresholds that explains the relationship
highly conserved in an evolutionary between tooth size and missing or extra teeth in males and females. (Brook, 1984)
sense and once the process of odonto-
genesis has been initiated, it tends to be considered to be examples of individuals. This is where further
proceed as a continuous self-organiz- epigenetic control. In the case of exploration of epigenetic factors will
ing process as described by Molenaar variation between species the con- be essential. Already researchers are
and colleagues (Molenaar et al., 1993). trol is likely to reside at the level of beginning to study epigenetic bio-
Our studies of intra-coronal DNA, whereas in variation within a markers in an attempt to explain the
dimensions of molar teeth in twins species the epigenetic influences are reasons for observed differences
are also consistent with the concept likely to occur at the local tissue level. between MZ twin pairs (Wong et al.,
of a dynamically developing crown 2007). At this stage, the focus is on try-
Fig. 7. MZ co-twins showing mirror-imaging pattern during odontogenesis, Finding the genes f or dental ing to determine the extent of differ-
for missing lower second premolars and differ- linked to the formation of signalling developm ent ences in global genomic DNA methy-
ent expressions of third molar development. centres referred to as enamel knots Genome-wide association studies lation levels but it is likely that more
(Townsend et al., 2003). We suggest (GWAS) are currently being used to specific analyses will be developed
cordant patterns of missing premo- that variations in dental crown form identify genes linked to various com- soon. Once these approaches aimed
lars or supernumerary teeth within between species probably result mon diseases, including coronary at the level of DNA are refined further,
MZ co-twins. Presumably, these MZ from regulation of a relatively small heart disease, hypertension, diabetes and our understanding of the nature
twin pairs have a genetic make-up number of highly conserved genes and arthritis. We plan to use a similar of the epigenetic influences at a local
that places them near to a threshold that control tooth formation in verte- approach to identify the key genes tissue level improves, we should be
for either missing or extra teeth, but brates, whereas variations observed involved in dental development. able to provide a clearer picture of
variations in local epigenetic events within a species, for example in While the identification of key how genetic, epigenetic and environ-
during odontogenesis, probably humans, probably result from alter- genes for dental development in mental factors influence human den-
relating to the spatial arrangement ations in the timing of interactions humans will undoubtedly be a major tal development. With this knowl-
of cells or temporal events, deter- between cells during odontogenesis, step forward, there will still be much edge, we will be in a better position to
mine on which side of the threshold as well as the positions of cells rela- work to do. Merely identifying the consider preventive and therapeutic
they fall. tive to each other. genes will not necessarily mean that approaches to many of the common
Molenaar’s concept of develop- Using our broad definition of epi- we will be able to explain fully how developmental problems affecting
mental systems with emergent self- genetics, both of these processes can various dental anomalies arise in the human dentition.

OT About the authors OT References

1. Brook AH. A unifying aetiological explana- Orthodont 2002;24:131–141.

Professor Townsend Professor Brook’s
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supported by the currently the Royal
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National Health and Society of Medi-
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Medical Research Council of Australia. He cine Frohlich Visiting Professor to estab-
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spent eight months during 2007-2008 on lish collaborative international research
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Finland to establish an International Award on Biomineralisation.
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Collaborating Research Centre in
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OT Contact
Fluctuating dental asymmetry of multiple ereed proceedings, 13th International Sym-
crown variables measured by an image posium on Dental Morphology, University
analysis system. Arch Oral Biol of Lodz, Poland, 2005a;337–352.
2005a;50:249–253. 13. Townsend G, Richards L, Hughes T,
Grant Townsend, BDS, BScDent, Alan Brook, BDS, LDS, MDS, FDS, ILTM
7. Khalaf K, Robinson DL, Elcock C, Smith RN, Pinkerton S, Schwerdt W. Epigenetic influ-
PhD, DDSc, FICD, FADI Professor of Paediatric Dentistry
Brook AH. Tooth size in patients with super- ences may explain dental differences in
Professor of Dental Science Director, International Collaborating
numerary teeth and a control group meas- monozygotic twin pairs. Aust Dent J
School of Dentistry Research Centre in Orofacial Genetics
ured by image analysis system. Arch Oral 2005b;50: 95–100.
University of Adelaide and Development
Biol 2005b;50:243–248. 14. Wong NC, Joo EJ, Weinrich B, Mossman D,
South Australia, 5005 School of Dental Sciences
8. McKeown HF, Robinson DL, Elcock C, Scott RJ, Morely R, Craig JM and Saffery R.
Professor of Basic Dental Sciences University of Liverpool
Al-Sharood M, Brook AH. Tooth dimensions Investigating epigenetic biomarkers
School of Dental Sciences UK, L69 3GN
in hypodontia patients, their unaffected underlying phenotypic discordance in
University of Liverpool Email:
relatives and a control group measured with monozygotic twins. Twin Res Hum Genet
UK, L69 3GN
a new image analysis system. Europ J 2007;10 (Supplement): 58.