Journal of Research in Medical and Dental Science

2022, Volume 10, Issue 11, Page No: 244-247

Copyright CC BY-NC 4.0
Available Online at: www.jrmds.in
eISSN No. 2347-2367: pISSN No. 2347-2545

Genetic Influence of Class III Bimaxillary Proclination: A Case Report of

Monozygotic Twins

Liyana Ghazali*
Orthodontic Unit, School of Dental Sciences, University Sains Malaysia, Kota Bharu, Kelantan, Malaysia

ABSTRACT
Introduction: Dental bimaxillary proclination is a common malocclusion among Asian and Afro-Caribbean population.
Facial aesthetics is normally the primary concerns of the patients which characterized by protrusive and proclined
upper and lower incisors with increased lips procumbency. Patients may be presented with anterior open bite,
incompetent lips and gummy smile.
Aim: The aim is to highlight the genetic influence in development of dental malocclusion: dental proclination.
Case history: Cases of a pair of monozygotic female twins with Class III incisor relationship with bimaxillary
proclination of upper and lower incisors on Class 1 skeletal pattern with average vertical proportion are presented.
Both patients exhibited similar craniofacial and dental features undergone orthodontic camouflage to improve dental
conditions. Pre and post cephalometric findings were found to be identical in both patients.
Discussion: Genetic plays a major role in development of dental malocclusion which was clearly exhibited in
monozygotic twins.
Key words: Dental malocclusion, Monozygotic twins, Bimaxillary proclination, Genetic influence

HOW TO CITE THIS ARTICLE: Liyana Ghazali, Genetic Influence of Class III Bimaxillary Proclination: A Case Report of Monozygotic Twins, J
Res Med Dent Sci, 2022, 10 (11): 244-247.

Corresponding author: Liyana Ghazali [4]. Monozygotic twins have similar genes are compared
e-mail: [email protected] with dizygotic twins who shared only half of their genes
Received: 14-Oct-2022, Manuscript No. JRMDS-22-79129; by assuming the environmental influence are the same
for in both groups [5]. Therefore, in this study, we
Editor assigned: 17-Oct-2022, PreQC No. JRMDS-22-79129(PQ);
would like to highlight the role of genetic influences
Reviewed: 02-Nov-2022, QC No. JRMDS-22-79129(Q); of monozygotic twins on development of bimaxillary
Revised: 07-Nov-2022, Manuscript No. JRMDS-22-79129(R); proclination of upper and lower incisors in Class 1
Published: 15-Nov-2022 skeletal pattern patients.

INTRODUCTION CASE REPORT

Dental bimaxillary protrusion or better known as bimax A 18-year-old identical Malay female twins in good health,
is another common malocclusion among Asian and Afro- presented with chief complaint of crowding of anterior
Caribbean population with prevalence as high as 68.8% teeth. Patients have no relevant past medical and allergy
[1]. This condition is characterized by protrusive and history. Frontal examination showed both patients have
proclined upper and lower incisors with an increased symmetrical face with 90% of incisors shown upon full
in procumbency of the lips [2]. Facial aesthetics is the smiling and upper dental midline coincident with facial
primary concern of the patients as this condition is midline. From lateral view, both patients exhibited
associated with incompetence lip, gummy smile and straight profile with average nasolabial angle and
in worse condition, anterior open bite. The aetiology labiomental fold. Vertical assessment of the face showed
of bimaxillary is multifactorial involving genetic and average Frankfort mandibular plane angle and lower
environmental causes. Typical orthodontic treatment face height.
includes orthodontic camouflage [3] and in more severe
The twins have complete permanent dentition with
cases might require orthognathic surgery.
generalized fluorosis with palatal caries of UL2 on Twin2
Twin studies are a special type of epidemiological (Figures1 and Figure 2). Both had moderate crowding
studies designed to measure the contribution of genetics of upper with palatally displaced lateral incisors and
as opposed to environment in phenotypic expression distolabially rotated upper central incisors. In the lower

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arch with real mirror image of both twins showed Cephalometric analysis revealed significant resemblance
moderate crowding of anterior segments with impeded between the two twins. Both twins have SNA of 83o,
mesioangulated LR7. In Twin1, lower second premolar SNB of 79o and average ANB of 3.5o showing a Class 1
was temporarily restored. In occlusion, both patients skeletal pattern with average vertical proportion. Their
had Class III incisor relationship with edge-to-edge bite, upper and lower incisors are proclined with reduced
Class I molar and Class II bilateral canine relationships. interincisal angles (Table 1). Canine relationships were
The severity of presenting malocclusion especially the Class II in both patients.
crowding was greater in Twin1 as compared to Twin2.

Table 1: Comparison of cephalometric analysis of Twin 1 and Twin 2.

Measurement Pre-treatment Twin1 Near-end treatment Twin1 Pre-treatment Twin2 Near- end treatment Twin 2
SNA (0) 83.1 83.8 83.4 84.7
SNB (0) 79.6 80.2 79.6 80.9
ANB (0) 3.5 3.6 3.8 3.7
MMPA (0) 23.8 22.6 20 19.7
LFH ratio % 54.7 54 53.9 54.8
UI-Mx (0) 117.3 112.5 117.6 108.2
LI-Mn (0) 110.2 95.3 110 95.8
IIA (0) 108.6 130.87 112.7 137.2

Figure 1: Pre and post treatment intra-oral photo of Twin 1.

Figure 2: Pre and post treatment intra-oral photos of Twin 2.

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Figure 3: Pre and post treatment extra-oral photos of Twin 1 and Twin 2.

Treatment plan DISCUSSION

For Twin1, extraction pattern of class III incisor
relationship was chosen by Clinician1 by extracting Bimaxillary proclination is characterized by proclination
upper second premolars and lower first premolars. incisors which is common in certain ethnic groups
Anchorage was reinforced in the upper using trans palatal particularly Asian and African- American descendants
arch. For Twin2, Clinician2 decided to extract upper first which resulted in increased lip procumbency [1,2]. The
and lower second premolars. Due to extraction pattern, aetiology is thought to be multifactorial and consists
anchorage was deemed to be low, and no reinforcement of genetic and environmental factors. Genetic factors,
was placed. ethnicity and skeletal pattern and environmental factors
include mouth breathing, tongue and lip habit and
Treatment progress tongue volume [6]. The study of monozygotic twins has
MBT appliance 0.022x0.028” bracket slots were used for been one of the most effective methods to identify role of
bonding in the upper and lower arch with banded first genes in expression of skeletal and dental malocclusion
molars. In Twin1, a transpalatal arch was fitted on maxilla [7]. Sahu, et al. stated twin studies possess its own
to enhance anchorage. Extractions of the bicuspids was strength especially with the advancement of statistical
done prior to bond-up and alignment and levelling were analysis and will continue to become an important tool
successfully achieved following sequence of arch wires; to investigate various aspects on how environmental
0.014”, 0.018”, 0.018x0.025” nickel- titanium (Niti) and factors and genetics combine to create human traits and
finished with working archwire of 0.019x0.025” stainless behavioural [4].
steel. Retraction was accomplished using elastomeric The current report shows monozygotic twins living
chain. Mesioangulated lower right second molar was in the same environmental condition, presented with
uprighted using pushcoil spring and secondary 0.016” skeletal and occlusal resemblance of class I skeletal,
Niti arch wire. Finishing and detailing was carried out reduced vertical proportion with Class III, bimaxillary
using 0.019x0.025” titanium molybdenum alloy (TMA). proclination. The clinical and radiographic presentations
Cases were debonded after 22 months of active support that genetic factor in presence of same
treatment. Figure3 showed that soft tissue profiles were environmental condition plays an important role in
maintained in both twins. Upper and lower vacuum development of dental malocclusion. Mandibular growth
formed retainers were prescribed. Post- treatment especially the shape and antero-posterior relationship
occlusion for both patients was shown in Figure 1 and are under strong genetic influences as compared which
Figure 2. greatly influence the polygon of facial similarity in twins

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[8]. The concordance for vertical and antero-posterior protrusion: A systematic review. Open J Epidemiol
facial dimensions is greater in monozygotic twins as 2020; 11:37.
than in dizygotic twins [9]. 2. Jawale B. Treatment of severe crowding and bimaxillary
The incisors retraction is minimal, and spaces had been dental protrusion in a patient with angle’s Class I
used for relief of crowding. The maintenance of lower malocclusion and a vertical growth pattern. A case
incisors inclination in both twins was ideal to prevent report on orthodontic camouflage. Saudi J Oral Dent Res
2021; 6:203-208.
relapse and to maintain profiles of both patients. A
study conducted in Peking University, China sixty digital 3. Huqh MZ, Hassan R, Abidin SB, et al. Rickett’s and
photographs of pre and post orthodontic treatment Holdaway analysis following extraction of four
of bimaxillary protrusion cases were examined. They premolars and orthodontic treatment in bimaxillary
found that the final position of lip, underlying incisors protrusion female Malays. J Int Oral Health 2020; 12:58.
and chin morphology are the most important factors in 4. Sahu M, Prasuna JG. Twin studies: A unique
expressing facial aesthetics [10]. epidemiological tool. Indian J Community Med 2016;
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CONCLUSION
5. Townsend GC, Richards L, Hughes T, et al. Epigenetic
In conclusion, twins with same genetic predisposition influences may explain dental differences in
monozygotic twin pairs. Aust Dent J 2005; 50:95-100.
living in the same environment exhibited similar
occlusal features shows the polygenic roles of genetic 6. Patel P, Shanthraj R, Garg N, et al. Class I bimaxillary
and environment in dental development. Monozygotic proclination treated by sliding mechanics-A case report.
twins showing high similarity in craniofacial and occlusal Med Sci 2015; 4.
morphology. Their identical skeletal dysmorphosis 7. Park HM, Kim PJ, Sung J, et al. Differences in the
and dental features in antero-posterior, vertical and heritability of craniofacial skeletal and dental
transverse planes exhibit the important role of genetics characteristics between twin pairs with skeletal Class I and
in the development of Class III malocclusion associated II malocclusions. Korean J Orthod 2021; 51:407-418.
with crowding and bimaxillary protrusion.
8. Šidlauskas M, Šalomskienė L, Andriuškevičiūtė I, et al.
Heritability of mandibular cephalometric variables in
ACKNOWLEDGEMENTS twins with completed craniofacial growth. Eur J Orthod
2016; 38:493-502.
The author wishes to thank the patients for giving the
permission to present these findings for the educational 9. Naini FB, Moss JP. Three-dimensional assessment of the
purposes and the author endeavoured to ensure relative contribution of genetics and environment to
anonymity. various facial parameters with the twin method. Am J
Orthod Dentofacial Orthop 2004; 126:655-665.
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