Welcome to the electronic edition of Twin Studies:

Research in Genes, Teeth and Faces.

The book opens with the bookmark panel and you will
see the contents page. Click on this anytime to return to
the contents. You can also add your own bookmarks.
Each chapter heading in the contents table is clickable
and will take you direct to the chapter. Return using the
contents link in the bookmarks.
The whole document is fully searchable.
Enjoy.

Twin Studies:
Research in Genes,
Teeth and Faces

The high-quality paperback edition of this book

is available for purchase online:

https://shop.adelaide.edu.au/

Twin Studies:
Research in Genes,
Teeth and Faces
by

Grant C Townsend, Sandra K Pinkerton,

James R Rogers, Michelle R Bockmann
and Toby E Hughes
School of Dentistry,
The University of Adelaide

Published in Adelaide by
University of Adelaide Press
The University of Adelaide
Level 14, 115 Grenfell Street
South Australia 5005
[email protected]
www.adelaide.edu.au/press
The University of Adelaide Press publishes externally refereed scholarly books by staff of
the University of Adelaide. It aims to maximise access to the Universitys best research by
publishing works through the internet as free downloads and for sale as high quality printed
volumes.
2015 The authors
This work is licenced under the Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International (CC BY-NC-ND 4.0) License. To view a copy of this
licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0 or send a letter to Creative
Commons, 444 Castro Street, Suite 900, Mountain View, California, 94041, USA. This
licence allows for the copying, distribution, display and performance of this work for
non-commercial purposes providing the work is clearly attributed to the copyright holders.
Address all inquiries to the Director at the above address.

For the full Cataloguing-in-Publication data please contact the National Library of Australia:
[email protected]

ISBN (paperback) 978-1-925261-14-1

ISBN (ebook) 978-1-925261-15-8
Editor: Rebecca Burton
Editorial Support: Julia Keller
Book design: Midland Typesetters Pty Ltd
Cover design: Emma Spoehr
Cover images: Courtesy of the authors
Paperback printed by Griffin Press, South Australia

FOREWORD

This book presents a unique account of a comprehensive research program on the

genetics of teeth and faces, carried out over three decades at the School of Dentistry
within the University of Adelaide by Professor Grant Townsend and colleagues.
It is unique in several senses, firstly in that perhaps no other centre in the world
has carried out such a long-term and wide-ranging program on so many facets of
dentistry and craniofacial biology. But it is also unique in the sense that I know of
no other academic endeavour that has so thoroughly documented its own history
and intellectual progression, including the description not just of the main projects
but also the smaller side-projects and all the people, including other researchers and
students, who carried them out. Thus the book is not just a heartfelt thank you to all
the twins and their families who took part in these studies over the decades, but also
a valuable scientific and photographic record of the research projects, their planning,
execution and findings.
I am privileged to have played some small part in this research program in
introducing Grant and his team to structural equation modelling methods for analysis
of twin data. The great attraction for me was (and still is) not only the inherent
interest in the dentition, but that the measurements are so very reliable and the traits
are so heritable. This is in contrast to my other domain of interest, human behaviour,
where, for many traits, measurement is often quite unreliable and heritabilities are
modest. Another appealing feature of the dentition is that the same basic structure of
eight teeth is replicated four times left and right sides, on both upper and lower
jaws. This provides very rich opportunities for statistical modelling, and Grant and
I spent many hours, days, weeks fitting what I think are rather elegant models to
explain the genetics of tooth size.
Another inherently appealing aspect of this research is that its research subjects
are normal identical (monozygotic) and non-identical (dizygotic) twins growing up
together in normal Australian households. In fact, the classical twin method the
comparison of the similarity of the two types of twins is the most powerful design
we have in humans to estimate the relative influence of genes and environment on any

Twin Studies
trait one cares to measure. Twins occur more or less at random throughout society, so
carrying out a project of this size and duration represents quite a large-scale societal
engagement with science and its methods, to the benefit of all parties the twins find
out a lot about their teeth and other aspects of their health and, most importantly for
same-sex pairs (two-thirds of all twins), whether, from powerful objective blood tests,
they are identical or non-identical. The researchers obtain beautiful and powerful
data from willing, interested and interesting volunteer subjects.
Despite its simplicity and widespread use (and perhaps because some people
do not like the answers it gives), the classical twin design has been subject to repeated
criticism as producing estimates of heritability (genetic influence) biased upwards
from their true values, mainly on the grounds that identical (monozygotic MZ)
twins are freakish or atypical and therefore cannot tell us anything about normal
individuals. However, Peter Visscher and colleagues have developed a clever new
method (called Genome-Wide Complex Trait Analysis, or GCTA) for estimating
heritability in a completely different way, making use of large-scale molecular
genotyping on thousands of unrelated individuals. Initial estimates using GCTA did
indeed suggest that twin heritabilities were somewhat inflated, but as the analyses
have become more sophisticated it is gradually emerging that, for most traits,
there is a high degree of consistency between the molecular heritability and the
twin heritability. This can be seen as a great endorsement of the twin method (and
a comfort to twin researchers) and comes at a particularly auspicious time for the
launch of the current book!
Like any good science, the work described in these chapters raises more
questions than it answers. In particular, knowing that the dentition is so strongly
genetically influenced whets the appetite to know what the particular genes are that
are involved, and how they act. Only ten years ago, it seemed impossible to answer
such a question but in 2005 the first successful genome-wide association study
(GWAS) was published, in which hundreds of thousands of genetic markers (SNPs)
are typed on large samples of cases and controls. That study found an entirely new
and unsuspected gene influencing risk of age-related macular degeneration, the most
common cause of blindness in old people. Since that time there have been thousands
of GWAS studies published on hundreds of different biomedical traits and diseases,
and new genes have been found for many of them, elucidating the biological processes
shaping complex traits; for example, over 700 genes have been identified influencing

vi

Foreword
human height. In this book Grant Townsend and his colleagues convince us of the
huge importance of genes in shaping teeth, when they emerge, how big they are, how
susceptible they are to decay and other dental anomalies. Surely now is the time to
exploit the powerful new molecular technologies becoming available and take our
understanding of the mouth, and all that is therein, to a new detailed level!
Nick Martin
Queensland Institute of Medical Research
Brisbane

vii

PREFACE

This volume is about an ongoing long-term research initiative led by researchers from
the School of Dentistry at the University of Adelaide. The aim of this book is to
provide an overview of our studies of the teeth and faces of Australian twins and
their families studies that have extended over more than thirty years. Rather than
providing detailed accounts of the methodologies and results of each of the individual
research projects, we have provided general descriptions of the approaches that have
been adopted, and have emphasised some of our key findings.
The book is aimed primarily at the participants of our studies over 1200 pairs
of twins and more than 2000 of their family members as well as other families of
twins who may be interested in being involved in future research projects. A common
question asked by participants over the years has been, What have you found? We
now hope that these generous people, without whom our studies would have been
impossible, will enjoy reading about our research in a single volume, rather than
having to go through a large number of more focused, technical articles published in
various journals.
The book provides some historical perspectives of studies of twins, including
those involving teeth and faces. It also gives an insight into the technological and
scientific changes that have occurred over the past thirty years, including various twin
models that enable exploration of genetic, epigenetic and environmental contributions
to variation in teeth and faces. For this reason, it should also be of interest to students
planning to undertake research involving twins, as well as to researchers and academics
in the fields of dentistry and craniofacial biology. We are now in the so-called omics
era, but the importance of twin studies has not diminished, as some had predicted
it would. Rather, studies of twins and their families have become even more relevant
to understanding how genetic, epigenetic and environmental factors contribute to
observed variation in health and disease.
One of the features of the studies described in this book is that several of them
incorporate a longitudinal design, meaning that the twins were examined on more than

viii

Preface
one occasion. This has enabled questions to be asked about how genetic factors influence
growth and development over time. The book also shows why an interdisciplinary
approach can be so valuable, and how studies that are mainly focused on dental features
can have broader implications in clarifying general biological mechanisms.
The first chapter of this book provides a tour of the mouth, introducing dental
terms and concepts for those without a detailed knowledge of dentistry. The second
chapter provides a historical account of twins and twinning, including how societies
tended to view twins in the past. The contributions of some of the key figures who
studied twins, including Francis Galton, are also summarised in this chapter. Chapter
Three focuses on key researchers worldwide who have studied human teeth and faces
using samples of twins. Three eras are identified: from the early 1920s to the 1940s;
from the 1950s to the 1980s; and from the 1990s to the present.
Chapters Four, Five and Six describe the three main cohorts of twins included
in our studies, as well as highlighting research questions posed, methods of analysis
adopted, and some key findings. These chapters include many illustrations of
participants and researchers.
The first cohort of twins included around 300 pairs of mainly teenage twins
living in Adelaide, as well as their siblings. The second cohort involved over 300 pairs
of young twins aged around 4 to 5 years of age from South Australia and Victoria,
who were examined on three occasions, corresponding to when they had primary
teeth, mixed dentitions, and then permanent teeth. Siblings of the twins and some
parents were also included. The third cohort comprised over 600 pairs of twins and
their families, including siblings and parents. These latter families have come from
all over Australia and have carried out much of the record collection themselves
initially, which involved processes including recording times of tooth emergence of
their twins and collecting samples of dental plaque and cheek cells for subsequent
microbiological assessment and DNA analysis. We are currently examining many of
the twins in this third cohort in the clinic to determine the types of bacteria in their
mouths and to record the development of any dental decay.
Chapter Seven includes a detailed summary of the published papers arising
from our studies of twins, as well as theses completed by Honours and postgraduate
students. We have also added a Glossary to help readers understand some of the
dental and scientific terms that have been used in the book, and we have included an
Appendix which provides a list of colleagues, visiting researchers, collaborators and key

ix

Twin Studies
contributors, as well as more photographs of twins and their families participating in
our studies and some of the researchers who have been involved in gathering records
from the twins. Hopefully, these photographs will convey a sense of the enjoyment
that both groups have experienced over the years.
Grant Townsend
Sandra Pinkerton
James Rogers
Michelle Bockmann
Toby Hughes

DEDICATION
This book is dedicated to all of the twins and their families who have participated
in our ongoing studies and to the research and support staff who have made it all
happen.

PHOTOGRAPHIC ACKNOWLEDGEMENTS
All photographs and illustrations in this book, unless otherwise attributed, are the
property of
The Craniofacial Biology Research Unit
School of Dentistry
The University of Adelaide
All participants in the twin studies have given permission for their photographs to be
used. Their names have been deleted, except for Jane and Carolyn Ferrett, our first
pair of twins, who gave permission for their names to be included.

ETHICAL APPROVAL
Ethical approval has been granted for all of our studies of twins by the Human Ethics
Committee of the University of Adelaide.

xi

ACKNOWLEDGEMENTS

We wish to express our sincere thanks to the twins, triplets and their families who
have agreed to participate in our studies over the past thirty years.
We also wish to acknowledge the support of the Australian NHMRC Twin
Registry and the Australian Multiple Birth Association.
Support for this research has been provided by grants from the National
Health and Medical Research Council (NHMRC) of Australia including several
project grants, a five-year Competing Epidemiological Grant and a grant to establish
a Clinical Centre for Research Excellence (CCRE). Support was also provided by the
Australian Dental Research Foundation, the Australian Dental Industry Association,
the Australian Society of Orthodontics Foundation for Research and Education, the
University of Adelaide including the Centre for Oro-facial Research and Learning
(CORAL) and the Financial Markets Foundation for Children.
We want especially to acknowledge the ongoing support provided by Colgate
Oral Care Australia, which has enabled us to give packs of oral health products
to participating families. Thanks also to the South Australian Dental Service and
staff of the Adelaide Dental Hospital for providing access to their clinical facilities
and assisting with examination visits. Thanks as well to staff of the former Dental
Therapy School Melbourne, on St Kilda Road, and to staff of the Royal Dental
Hospital of Melbourne, the Melbourne Dental School and the Colgate Australian
Clinical Dental Research Centre, Adelaide. Thanks to Christine Swann for several
of the illustrations and Corinna Bennett for photography. A special thanks to Ms
Karen Squires for her excellent work in helping to put this book together.
Thank you to all of the people who have helped at various stages of the research,
including colleagues in Adelaide, Sydney, Canberra, Brisbane, Perth and Melbourne,
postgraduate, Honours and undergraduate students, research collaborators, clinical
examiners, recorders, dental assistants and clinic staff.
Without all of this support, we would not have been able to carry out our
research.

xii

CONTENTS

Foreword
Preface
Dedication
Photographic acknowledgements
Ethical approval
Acknowledgements

v
viii
xi
xi
xi
xii

Chapter One A tour of the mouth

Introduction
How do our faces and teeth develop?
What is the normal timing and sequence of dental development?
What is the normal timing and sequence of tooth emergence?
What are the main features of the primary and permanent teeth?
How are the teeth arranged in the oral cavity? 
Tooth notation
What are the main tissues that make up a tooth?
How can we study dental morphology?
Why is the dentition such a good model system for studyingdevelopment?
What are some of the common developmental anomalies affectingteeth?
What are the most important diseases or problems that can affectour teeth?
Is there a relationship between oral health and general health?
Why might twins teeth look the same or different?
References

1
1
3
7
7
10
13
13
16
18
20
21
25
27
29
34

Chapter Two A historical perspective

Introduction
Mythological beginnings
Twins in the theatre

35
35
36
38

xiii

Twin Studies
Twins in literature
Twins in science
The concept of nature versus nurture
Inheritance and Mendelian genetics
Twin research: a question of ethics 
Twin research: specialisation
Twin research: the great steps forward
References 

39
41
46
51
53
55
56
59

Chapter Three Phases of research involving twin studies of teeth and faces 62
Studies of twin resemblance: hereditary and environmentalinfluences 
62
Understanding genetic control over dental variation
67
Development of more sophisticated methods: path analysis, model-fitting
andgenetic expression
73
Studies of twins: the Adelaide Dental School
76
References80
Chapter Four Cohort 1: Teeth and faces of South Australian
87
teenage twins
Introduction87
89
Cohort 1 (April 1983)
Methodology and data acquisition
90
Fitting genetic models to dental data from twins
99
Some key findings of our studies involving Cohort 1
104
References109
Chapter Five Cohort 2 A longitudinal study of dental and facial
developmentin Australian twins and their families
113
Introduction113
118
Collection of records and examination of twins
Cohort 2 as a longitudinal study
124
Twins in Melbourne
126
Some key findings of our studies involving Cohort 2
129
References133

xiv

Contents
Chapter Six Cohort 3 Tooth emergence and oral health in
Australian twins and their families
135
Introduction135
The vagaries of the grant funding process 
141
Getting beaten to the punch
141
An exciting new collaboration
144
Developments in epigenetics
145
Next-generation sequencing
149
A new NHMRC grant
151
The future
154
Some of the key findings relating to Cohort 3
158
References161
Chapter Seven Publications and theses relating to theAdelaide
165
Twin Studies
1980s 
165
1990s166
2000s168
2010 to 2015
172
Theses175
Glossary of terms

178

Appendix 1

185

xv

Chapter One
A TOUR OF THE MOUTH

Introduction
On 27 April 1983, identical twins Jane and Carolyn, aged 15 years, arrived at the
Adelaide Dental School as the first participants in our new study of the teeth and
faces of twins. The girls would have been wondering what they might be asked to do
and we, as researchers, hoped that all our planning would translate into an enjoyable
and scientifically valuable experience.

Figure 1.1
Twins 1A and 1B, Jane (right) and Carolyn Ferrett (left).

Twin Studies
Jane and Carolyn would represent the beginning of a series of studies involving
Australian twins and their families that has spanned over thirty years and is still
continuing in 2015.
Over 1200 pairs of twins and over 2000 family members have participated
in our studies (Hughes etal., 2013; 2014), freely giving their time to help advance
knowledge about how genetic, epigenetic and environmental factors contribute to
variation in the development and appearance of human teeth and faces, and to clarify
further the nature of the twinning process.
Although the concept of genetic and environmental contributions to observed
variation has been referred to often over the years and is familiar to most, epigenetics is
a term that has only become widely used in recent times. Figure 1.2 provides a musical
metaphor that emphasises how epigenetic factors influence the expression of genes to
produce the variation observed in different features (referred to as phenotypes).
The aim of this opening chapter is to provide sufficient background
information about the development and morphology of human teeth and faces so
that, hopefully, the reader can make sense of the material presented subsequently.
This chapter also introduces some relevant dental terminology that will be familiar
to dental researchers but may not be so familiar to readers without a background in
dentistry. Our reasons for believing that teeth and faces are so valuable for studying
the roles of genetic, epigenetic and environmental factors on development in twins
are also highlighted.
We commence by reviewing the main stages and processes involved in the
development of teeth and faces. The way in which the teeth are arranged in themouth
and the tissues that make up teeth are also discussed. Some of the reasons why the
teeth as a group (referred to as the dentition) provide such a good model system for
investigating human development are provided and some of the methods that can be
used to study dental morphology are described.
Although our studies of twins have often addressed basic aspects of human
growth and development, our research has become increasingly more focused on oral
health. We anticipate that the findings from these studies will lead, in the longer term,
to improved methods of diagnosing and managing oral diseases and abnormalities.
For this reason, a brief introduction to some of the more common dental anomalies
has been included. The two most common dental diseases are also described: dental
decay (dental caries) that may lead to toothache and loss of vitality of teeth; and gum

A tour of the mouth

Figure 1.2
A musical metaphor for how epigenetic factors influence the expression of our
genetic code to produce variation in different features. The sheet music represents the
epigenetic code, the conductor represents the epigenetic machinery, the musicians
represent the individual genes, and the resultant sound is equivalent to the phenotype.
Reproduced with permission from the Australian Dental Journal (Williams etal.,
2014).

disease (gingivitis) that may lead on to the destruction of the supporting tissues of the
tooth (periodontal disease).
Recent research has provided support for links between oral health and general
health, and vice versa, and this issue is also introduced in this first chapter.

How do our faces and teeth develop?

Development of our faces begins around twenty-five days in utero with the appearance
of localised tissue swellings and the migration of cells, referred to as neural crest cells,
into the underlying tissue. These neural crest cells are derived from the ectoderm

Twin Studies
in the embryo, one of three layers of primitive tissue along with the mesoderm and
endoderm. The primitive mouth (referred to as the stomatodeum or stomodeum), is
surrounded initially by the frontonasal process, maxillary and mandibular processes.
The oropharyngeal membrane, which separates the primitive mouth from the pharynx,
then begins to break down. This marks the establishment of a communication
between the oral cavity and the rest of the gastrointestinal tract. Soon after, the nasal
pits form and odontogenic (or tooth-forming) epithelium develops where the upper
and lower teeth will form (Figure 1.3).
The continuous band of thickened epithelium is referred to as the dental
lamina. At each of the ten places where primary teeth will usually form in both the
upper and lower jaws, thickenings of the dental lamina (tooth buds) appear which go

Figure 1.3
Early stages of development of the face and teeth.

A tour of the mouth

on to produce structures referred to as enamel organs. An enamel organ comprises an
epithelial cap that sits over a ball of condensed mesenchyme, which is referred to as
the dental papilla. The enamel organ and dental papilla, with their surrounding sac,
are referred to as a tooth germ (Figure 1.4).
The interactions that occur between the inner cells of the enamel organ, the socalled inner enamel epithelium, and the mesenchyme of the dental papilla into which
neural crest cells migrate, are referred to as epithelial-mesenchymal interactions. These
interactions, mediated by various signalling molecules and growth factors, influence
folding of the inner enamel epithelium, which in turn determines the future shape
of the dental crown that is, whether the tooth will become an incisor or a molar
(Figure 1.5).

Figure 1.4
The sagittal section indicated in (a) allows the dental lamina to be visualised in (b),
atooth bud in (c), and a developing tooth germ in (d).

Twin Studies

Figure 1.5
Stages of dental development, commencing with a down-growth of epithelium
(yellow) towards the underlying mesenchyme (grey). This is followed by the formation
of the primary enamel knot (red circle) and then the folding of the inner enamel
epithelium with formation of secondary enamel knots. Enamel and dentine are laid
down and the crown of the tooth is formed prior to emergence into the oralcavity.

In the past, studies focused on explaining the nature and extent of variation in
fully formed teeth (so-called phenotypic variation) and then making inferences about
the developmental processes that led to observed variability. However, molecular
biologists have made great advances over the past decade or so in identifying the various
signalling molecules that pass back and forward between epithelial and mesenchymal
tissues in developing dental tissues, leading to initiation, proliferation, differentiation
and morphogenesis of teeth. Furthermore, the development of modern genome-wide
scanning approaches means that it is now possible to search for the specific genes that
are involved in the process of dental development.
The tooth is an excellent model system for studying developmental processes
in general as it can be grown in vitro, and the epithelial and mesenchymal parts can
be separated and then recombined. The dentition, including all of the teeth, is also
a very useful model system to study the development and arrangement of structures

A tour of the mouth

that show patterning and modularity in their morphology for example, incisors,
canines, premolars and molars. The arrangement of the teeth in dental arches also
allows symmetrical and asymmetrical expression of features on corresponding teeth
from the right and left sides to be explored.

What is the normal timing and sequence of

dental development?
While the first signs of development of the primary (or deciduous) teeth are evident
around four to six weeks in utero, it is not until around eighteen weeks that the
crowns of these teeth begin to calcify that is, it is not until then that enamel and
dentine are laid down. By birth, all of the primary tooth crowns have usually begun
to calcify, although only the regions where the tips of the cusps will be located have
calcified in the primary second molars. The calcification process for the permanent
dentition is usually a postnatal event, with the first molars commencing to calcify
around birth and then the second and third molars starting to calcify some years
later. Each tooth passes through a definite series of stages during its development,
commencing with calcification of the crown followed by formation of the root(s) of
the tooth. Usually the roots of teeth are about two-thirds formed when they appear
in the mouth, and further root development occurs after emergence until the apex of
the root is fully formed (Figure 1.6).

What is the normal timing and sequence of tooth emergence?

The primary teeth tend to emerge into the oral cavity between the ages of around 6to
8 months and 2.5 years, although there is considerable variation in the timing and
sequence. The primary lower central incisors are usually the first teeth to emerge, with
the second molars being the last (Table 1.1).
Variations in the sequence of emergence are not uncommon, and we have
documented some of the common variations in publications based on data derived
from twins enrolled in our studies.
Each primary tooth is normally shed, or exfoliated, prior to the emergence of
its permanent successor. The first permanent teeth to emerge are usually the lower
central incisors around the age of 6 years, while the third molars may not emerge

Twin Studies

Figure 1.6
An orthopantomogram (OPG) showing the mixed dentition of deciduous (d)
andpermanent (p) teeth in a 10-year-old female twin.

Table 1.1
Timing of primary teeth emergence in Australian twins (months)1
Right
n

mean

Left

SD

CV

mean

SD

CV

Maxillary
central incisor

207

10.8

2.0

18.8

206

10.8

2.2

20.4

lateral incisor

199

12.3

2.9

23.4

201

12.1

2.9

24.1

canine

136

19.3

3.5

18.3

139

19.3

3.5

18.1

first molar

179

15.9

2.4

15.0

180

15.9

2.4

15.1

second molar

69

27.9

4.4

15.8

70

27.7

4.4

16.1

central incisor

204

8.6

2.0

23.7

206

8.7

2.1

24.8

lateral incisor

189

14.2

3.3

23.1

185

13.9

3.4

24.1

canine

135

19.9

3.7

18.6

138

19.7

3.9

20.0

first molar

175

16.7

2.5

15.0

175

16.5

2.4

14.4

second molar

73

27.1

3.8

14.1

72

26.7

3.7

13.8

Mandibular

Woodroffe etal., 2010. Data for boys and girls combined. SD = standard deviation; CV = coefficient
of variation (CV = 100(SD/mean)).

A tour of the mouth

until the late teens. The third molars are prone to impaction due to lack of space
in the jaws. There is considerable variation in the timing of emergence of teeth
between individuals. For example, maxillary (upper) central incisors may emerge
between 5.8 and 9.1 years in boys with a median value of 7.4 years (Table 1.2).
The permanent teeth tend to emerge a little earlier in girls than boys, with the
biggest difference being for the canines (Table 1.3).
Fortunately for some people, their third molars do not form at all, so they are
not faced with having to decide whether their wisdom teeth should be extracted.
The biological reason for congenitally missing teeth, also referred to as hypodontia or
dental agenesis, is one question that we have addressed in our studies but there is still
much more to learn.

Table 1.2
Median emergence times (years) for permanent teeth in Australian males,
including 5th and 95th percentiles1
Median

5th
percentile

95th
percentile

7.43

5.79

9.06

8.61

6.36

10.86

11.81

9.46

14.15

11.28

8.94

13.62

12.05

9.67

14.43

6.71

5.05

8.37

12.68

10.28

15.08

6.63

4.96

8.29

7.77

5.97

9.58

11.02

8.94

13.10

11.15

9.01

13.29

12.11

9.68

14.54

6.63

4.96

8.30

12.15

9.83

14.48

Tooth
Males
Maxillary

Mandibular

Diamanti and Townsend, 2003. Median is the 50th percentile: 5% of children fall below the 5th
percentile and 5% above the 95th percentile.

Twin Studies
Table 1.3
Median emergence times (years), for permanent teeth in Australian females,
including 5th and 95th percentiles
Median

5th
percentile

95th
percentile

7.17

5.64

8.69

8.24

5.99

10.49

11.23

8.80

13.65

Tooth
Females
Maxillary

Mandibular

10.77

8.58

12.96

11.67

9.17

14.17

6.57

4.84

8.30

12.30

9.90

14.70

6.38

4.77

7.99

7.47

5.67

9.28

10.11

8.03

12.20

10.59

8.45

12.73

11.66

9.11

14.22

6.42

4.86

7.98

11.75

9.42

14.07

Diamanti and Townsend, 2003. Median is the 50th percentile: 5% of children fall below the 5th
percentile and 5% above the 95th percentile.

What are the main features of the primary and permanent teeth?
There are usually twenty primary or deciduous teeth in the human dentition, comprising
a central incisor, lateral incisor, canine and two molars in each quadrant (quarter) of
the mouth. The primary teeth tend to be smaller than their permanent successors, with
slightly different crown shapes. Their roots are more slender and flared in the molar
region, and they undergo a process of resorption that leads to the teeth being exfoliated
just prior to the emergence of their permanent successor. A full permanent dentition
comprises thirty-two teeth, with central and lateral incisors, canine, two premolars and
three molars in each quadrant. The incisor crowns display relatively flat incisal edges,
whereas the canine has a single cusp. The premolars often have two cusps on their
occlusal surfaces, while molar teeth tend to be four- or five-cusped (Figure 1.7).

10

A tour of the mouth

a)Primary

b)Permanent

Figure 1.7
Diagrams showing (a) primary and (b) permanent human dentitions.

As mentioned, sometimes teeth may fail to develop, leading to a reduced

number of teeth in the arch and often spacing between those teeth that are present in
the mouth. As shown in Figure 1.8, if one member of a pair of monozygotic twins has
a missing tooth or teeth, the other member is also likely to be affected. However, the
expression of missing teeth often differs between the two, suggesting that epigenetic
and/or environmental factors are involved.

Figure 1.8
Monozygotic female twins where Twin A (left) displays bilateral agenesis of the
maxillary lateral incisors (both upper lateral incisors have failed to form); and Twin B
(right) has a peg-shaped maxillary right lateral incisor and agenesis of the maxillary
left lateral incisor.

11

Twin Studies
Occasionally, there may be an extra tooth or teeth present in the mouth
these are referred to as supernumerary teeth. These teeth may emerge into the
mouth or remain within the jaws. If they are associated with pathology they may be
extracted. Again, if one member of a monozygotic twin pair has a supernumerary
tooth, the other is also likely to have one, but the expression often differs between
the twins. In the case shown in Figure 1.9, one twin has one supernumerary and
the other has two.

Figure 1.9
Supernumerary teeth of a pair of monozygotic twin boys and panoramic radiographs
showing the location of the teeth prior to extraction (circled).

12

A tour of the mouth

How are the teeth arranged in the oral cavity?

The teeth are arranged in dental arches that are often parabolic in shape but they
may vary from a very broad ovoid shape to a narrow U-shaped arrangement. The
upper and lower teeth normally fit together to facilitate the functions of the biting,
chewing and speaking. We are all aware that sometimes the arrangement of the teeth
varies from what is considered normal for example, a buck-toothed arrangement
where the upper anterior teeth protrude anteriorly in front of the lowers. At the other
extreme, there can be instances where the lower dental arch protrudes in front of
the upper, producing a so-called crossbite arrangement of the teeth. These extreme
variations in the relationships between upper and lower teeth can have significant
effects on appearance (aesthetics), as well as function, and they are commonly referred
to as malocclusions.
Most individuals display some variation from a so-called ideal dental
occlusion, so we prefer to use the term occlusal variation to encompass everyone,
rather than focusing on so-called malocclusions and comparing them to normal
occlusions. Interestingly, we have found that variation in some occlusal features,
such as anterior overbite and overjet, is not influenced by genetic factors as much
as variation in others for example, arch dimensions. Figure 1.10 (overleaf ) shows
good alignment of teeth in a pair of monozygotic twins and crowded teeth in another
pair of monozygotic twins.

Tooth notation
There are several notations that have been developed to assist dentists who are charting
the teeth that are present in their patients mouths. One is the Fdration Dentaire
Internationale (FDI) notation and another is Palmers notation. These notations are
often used in tables and figures in research papers when referring to teeth and so we
provide a brief summary of each here.
The FDI notation uses a two-digit system and can be adapted easily to computer
charts. The first digit refers to the quadrant in the mouth in which the tooth is located.
For the permanent dentition, the quadrants are numbered from 1to 4 commencing
with the upper right quadrant, which is denoted quadrant 1. The numbering then
continues in a clockwise direction (from the dentists viewpoint of the patients mouth)

13

Twin Studies
(a)

(b)

Figure 1.10
(a) A pair of monozygotic twins showing good occlusion and (b) a pair of monozygotic
twins showing crowding.

to the upper left (quadrant 2), then the lower left (quadrant3), then the lower right
(quadrant 4). Continuing on for the primary or deciduous dentition, the upper right
quadrant is labelled 5, the upper left is 6, the lower left is 7 and the lower right is 8.
The second digit identifies the tooth within the quadrant. The permanent teeth are
numbered from 1 to 8 in each quadrant and the primary teeth are numbered from 1
to 5. The numbering commences in the front of the mouth and proceeds posteriorly
toward the molars. The numbers are pronounced separately, so that a permanent upper
left first molar tooth would be labelled as a 26, pronounced two six (Figure 1.11).
Palmers notation also divides the mouth into quadrants or quarters, but it
employs a diagrammatic representation of the four quadrants using a cross. The
permanent teeth are numbered from 1 to 8 in each quadrant, beginning in the
midline, whereas the primary teeth are identified by the letters, A to E (Figure 1.12).
Individual teeth are denoted by either a number (for the permanent dentition) or by
a letter (for the primary dentition), which is enclosed in the two sides of the cross that
indicate the quadrant (as shown in Figure 1.12).

14

A tour of the mouth

a)Primary

b)Permanent

Figure 1.11
The Fdration Dentaire Internationale (FDI) notation for charting the (a) primary and
(b) permanent dentitions.

a)Primary

b)Permanent

Figure 1.12
Palmers notation for (a) primary and (b) permanent dentitions.

15

Twin Studies

What are the main tissues that make up a tooth?

The crowns of teeth are covered with a highly mineralised, hard and brittle substance
referred to as enamel. This tissue is composed of hydroxyapatite crystals that are
arranged in rods to form a grain structure, which means that enamel tends to
fracture along the line of the rods. Because of its high inorganic content, enamel
is particularly susceptible to dissolution by acids, whether these are produced by
bacteria in dental plaque around the teeth or by ingested foods and drinks that are
acidic. The thickness of the enamel varies in different parts of the crown, being
thickest in the regions of the cusps and the incisal edges and thinnest in the cervical
regions.
Dentine forms most of the tooth and it is a tubular, mineralised tissue that is
not as hard as enamel. In contrast to enamel, dentine contains the processes of living
cells, referred to as odontoblasts, so it is a vital tissue that can elicit a painful response
if exposed to the oral cavity, or in response to the spread of dental decay (also referred
to as dental caries). The dentine and the enamel of teeth contact at the dentinoenamel junction (DEJ), which represents the original site where the inner part of the
enamel organ (the inner enamel epithelium) and the dental papilla were next to one
another during dental development.
The inner part of teeth is filled with a soft connective tissue referred to as
the dental pulp. This tissue comprises cells, fibres, blood vessels, nerves and ground
substance. If the pulp of a vital tooth is exposed, either through trauma or during
restorative treatment, a small amount of blood will be visible. Teeth with exposed
pulps are usually highly sensitive (Figure 1.13).
A thin layer of cement covers the roots of teeth, and the roots are attached
to the surrounding bone of the jaws (alveolar bone) by a system of fibres referred to
as the periodontal membrane or ligament. This structure normally enables a small
amount of mobility of each tooth in its socket but, if the membrane is broken down
due to inflammatory processes (periodontitis) and there is also resorption of alveolar
bone, then the tooth can become more mobile.
On radiographs of teeth, the pulp tissue appears dark (radiolucent) compared
with the lighter appearance of the calcified dentine and enamel (radiopaque).
Figure 1.14 shows teeth in varying stages of development, with two restored with
radiopaque fillings.

16

A tour of the mouth

Figure 1.13
The main tissues that make up and support a tooth.

17

Twin Studies

Figure 1.14
A bite wing radiograph showing the developing dentition. The occlusal surfaces of the
molars have been restored and the fillings appear as bright white areas. Adeveloping
permanent premolar can be seen under a primary molar.

The overall size of dental crowns is determined by a combination of the

thickness of the enamel and dentine, and the size of the underlying pulp chamber.
These structures can be visualised on radiographs and, provided these images are
standardised, measurements can be made from them. A question that continues to
evoke interest is the extent to which each of these tissues contributes to the final size
and shape of dental crowns. For example, we know that the dental crowns of males
tend to be larger, on average, than those of females but why? Recent applications
of three-dimensional (3D) imaging techniques for example, 3D CT scanning
are now helping to unravel these questions. 3D imaging also enables researchers to
explore the inner aspects of teeth, to see to what extent the external appearance of a
particular tooth is a reflection of the blueprint laid down during development at the
site of the future junction between the enamel and the dentine, the dentino-enamel
junction (DEJ).

How can we study dental morphology?

Traditionally, the size and shape of teeth have been recorded using hand-held callipers
to measure certain dimensions on dental models for example, the maximum
mesiodistal and buccolingual crown diameters (Figure 1.15) or by describing
certain features according to their degree of expression, such as grooves, pits, small

18

A tour of the mouth

cusps or large cusps. While these methods have yielded considerable information about
the nature and extent of variation in the dentition within and between populations,
they are relatively crude measures that fail to capture much of the variability in tooth
surfaces. More recently, high-precision two-dimensional (2D) and 3D imaging
systems have been applied to record not only traditional measurements but also to
define new dental phenotypes, including intercuspal distances (Figure 1.15), crown
contours, areas and volumes.
We have coined the term dental phenomics to refer to this new era of studying
dental phenotypes both intensively and extensively (Townsend et al., 2012; Yong
et al., 2014). It is our belief that these sophisticated measuring systems will prove
to be valuable in building up large sets of data that will define both the external and
internal morphologies of teeth. If these new dental phenotypes can be recorded in
large samples of twins, and we can then apply modern methods of genome-wide
scanning, it should be possible to locate and identify the key genes involved in human
dental development. Such discoveries will have major implications for many fields of

Figure 1.15
Diagrammatic representation of tooth surfaces and some selected measurements.

19

Twin Studies
research and also, ultimately, for practising dentists faced with treating individuals
presenting with various oral diseases and disorders.

Why is the dentition such a good model system for

studyingdevelopment?
The dentition provides a unique model system for studying developmental events
occurring over an extended period of time, from early on prenatally through until
adolescence. As we have seen, development of the primary incisors commences
in the first few weeks of life, followed by the other primary teeth and then the
permanent teeth. Each tooth passes through a series of well-defined developmental
stages, beginning with rapid growth of soft tissue, then subsequent crown and root
calcification. Final crown morphology is determined well before each tooth emerges
into the oral cavity and does not change thereafter, apart from the effects of tooth
wear and restorative procedures. Therefore, by studying final crown size and shape,
and applying knowledge of the timing and sequence of dental development, one can
attempt to retrospectively elucidate the nature of tissue interactions and disturbances
in early growth which may have affected final crown morphology.
The stability and durability of dental crowns are particularly valuable features
in genetic studies because they allow comparisons of tooth size and shape to be made
between related and non-related individuals irrespective of their age. Investigations of
the associations between teeth in the primary and permanent dentitions of individuals
help to clarify co-ordinating mechanisms that may be operating and to disclose
possible pleiotropic effects of genes that is, genes that appear to affect more than
one feature. Comparisons can also be made between upper and lower teeth, between
teeth within a particular tooth class for example, the molar series as well as
between corresponding teeth on right and left sides, so-called antimeric teeth.
Apart from obtaining dental impressions from many of the twins enrolled in
our studies to enable stone models (or casts) to be constructed, we have also obtained
fingerprints and palm-prints. The reason for doing this has been that both teeth and
fingerprints form as a result of interactions between a surface epithelial layer and
underlying mesenchymal tissue. Furthermore, once fingerprints are formed, they
do not change in their appearance, similar to teeth. Also, it is possible to compare
the different patterns of expression of the fingerprints between different fingers of
one hand or between right and left hands. Although we have collected extensive

20

A tour of the mouth

dermatoglyphic records from twins and their families, we have only just begun to
analyse them to see whether there are common co-ordinating mechanisms and
possibly common genes involved in establishing the patterns we observe in both teeth
and fingerprints.

What are some of the common developmental anomalies

affectingteeth?
There are many anomalies that can affect the teeth, including variations in number,
size and shape. As mentioned previously, certain teeth may fail to form in some
individuals. Most commonly the third molars are affected, but other teeth that may
display agenesis or hypodontia are the permanent upper lateral incisors and the
second premolars. Figure 1.16 shows panoramic radiographs of a pair of monozygotic
twins who both show evidence of missing teeth, but the expression varies between
the two. For example, Twin A has a missing lower right second premolar (arrowed)
whereas this tooth is present in Twin B. It appears that both twins have developing
lower third molars but missing upper third molars (circles). These differences in
expression of missing teeth between the members of a monozygotic twin pair provide
further support for the role of epigenetic and/or environmental influences on dental
development.
In contrast to missing teeth, occasionally there may be extra, or so-called
supernumerary, teeth present (Figure 1.17). Commonly these occur behind the upper
central incisors, referred to as a mesiodens, but there may also be supernumerary
premolars or molars. Interestingly, missing teeth are more common in females than
males, whereas supernumeraries are more common in males. There is a link between
tooth size and shape, and the presence or absence of teeth, and this has been described
elegantly by Alan Brook and colleagues (2014). Alan is currently an Adjunct Professor
in the School of Dentistry at the University of Adelaide and a valued and active
member of our research group.
Variations in size of teeth include very small teeth, so-called microdontia,
and very large teeth, referred to as macrodontia (Figure 1.18). These anomalies may
involve a single tooth within the dentition, or many or all teeth may be affected. A
commonly described example of a small tooth is the microdont upper lateral incisor,
which is also associated with other variations of this tooth, including peg-shaped
upper lateral incisors and agenesis of upper laterals (Figure 1.18).

21

Twin Studies

Figure 1.16
Panoramic radiographs of a pair of monozygotic twins showing missing teeth.
Thecircled areas indicate the regions where third molars would normally develop.
The arrows point to regions where permanent second premolars usually form.
Reproduced with permission from the Australian Dental Journal (Hughes etal.,
2014).

Other dental features that have been described extensively by dental

anthropologists include the following: Carabelli trait, which varies in expression
from pits and grooves of various types to cusps of different sizes on the mesio-lingual
surface of primary upper second molars and permanent upper first molars mainly;
small cusps or tubercles on the lingual aspect of anterior teeth; shovelling of incisor
teeth with marked expression of the marginal ridges; and extra cusps on molar teeth,
such as accessory cusp 7 which appears between the lingual cusps of lower molars
(Figure1.19). Standard plaques have been constructed to enable researchers to reliably
score the different expressions of these features on dental models. It is then possible to

22

A tour of the mouth

Figure 1.17
Examples of supernumerary teeth in the upper incisor region.

Figure 1.18
(a) A patient with a supernumerary upper left lateral incisor, a megadont/double upper
right central incisor and generalised large tooth size, and (b) a patient with hypodontia
of the upper left lateral incisor and microdontia of the upper right lateral incisor. The
upper central incisors also show a reduction in shape from the average. Reproduced
with permission from the Australian Dental Journal (Brooketal., 2014).

23

Twin Studies

Figure 1.19
Dental features including (a) Carabelli trait, (b) lingual tubercles, (c) shovel-shaped
incisors and (d) extra cusps on molar teeth.

compare their appearance in related individuals to try to unravel the contributions of

genetic and environmental influences to observed variation.
Anomalies of tooth structure may affect any of the dental tissues. For
example, developmental disturbances may lead to poorly formed enamel (enamel
hypoplasia), which presents clinically as white patches, pits or grooves on dental
crowns (Figure 1.20). Hypoplasia may be due to a mutation of one of the genes
involved in the formation of enamel (amelogenesis) or it may result from an
environmental disturbance during dental development, such as a viral illness or
fever. The distribution of structural anomalies across the dentition, together with
a patients history, gives the clinician some insight into the possible causes. For
instance, enamel hypoplastic defects that affect all teeth in both dentitions are likely
to have a genetic cause (aetiology), whereas a single affected tooth suggests some
local environmental disturbance. Some types of enamel hypoplasia that present
as linear defects on the tooth crown or pitting can be studied on dental models,
provided the models are of good quality.

24

A tour of the mouth

Figure 1.20
Two examples of enamel hypoplasia, presenting as (a) white patches on the central
incisors and a localised defect on the upper left lateral incisor and (b) generalised
pitting and grooving.

What are the most important diseases or problems that can

affectour teeth?
The most common dental diseases, which affect most of us to some extent, are dental
decay (caries) and gum disease (gingivitis). Dental caries refers to the progressive
localised demineralisation and destruction of tooth tissues (the word caries is derived
from Latin and means rottenness). Dental caries results from a prolonged imbalance
of factors that favour demineralisation over those that favour mineralisation. The
factors that need to be considered include the host, particularly their saliva and
the structure and morphology of their teeth; the oral microflora, particularly the
composition of the dental plaque that adheres to the teeth; and the diet, which forms
the substrate for the bacteria in dental plaque.
Bacteria in dental plaque and refined carbohydrates in the diet interact with
protective factors, including saliva and good oral hygiene, to determine the balance
between demineralisation and remineralisation. Repeated pH drops (due to acid
production by plaque bacteria) can lead to demineralisation of enamel, with the
frequency of these drops in pH being very important (Figure 1.21).
Inflammation of the gums around the teeth is referred to as gingivitis. Clear
signs of gingivitis are evidence of blood on a toothbrush after cleaning, or bleeding
from around the necks of the teeth when an oral health professional gently probes
the gingival crevice around the neck of a tooth. More severe inflammation leads to

25

Twin Studies

Figure 1.21
This graph, referred to as a Stephan curve, shows the drop in pH that occurs in dental
plaque after rinsing the mouth with a sugar solution. Below the critical pH, enamel
will demineralise.

red, puffy, swollen gums. In a fairly small percentage of individuals, the process of
inflammation may extend to involve the supporting tissues of the tooth (periodontal
ligament or membrane), causing loss of attachment of the gingival tissues to the tooth,
apical migration of the epithelial attachment, pocket formation, gingival recession,
loss of alveolar bone, mobility of teeth and possible loss of teeth.
As with dental caries, periodontitis has a complex aetiology. Basically, bacteria in
plaque around the necks of teeth produce toxic products which may cause inflammation
of the periodontal tissues. However, the balance between bacteria and the bodys defence
system is very important. That is, bacteria are essential agents, but their presence is in
itself insufficient. Host factors must be involved if the disease is to develop and progress.
Figure 1.22 shows the teeth and gums of a pair of monozygotic twins who both show
evidence of gum disease (gingivitis) and dental decay (dental caries).
While genetic factors are clearly involved in both of these diseases, their
aetiologies are complex. The application of different twin models offers many
advantages in exploring the relative contributions of genetic, epigenetic and
environmental contributions to observed variation in these common dental diseases.

26

A tour of the mouth

Figure 1.22
Intra-oral photographs of a pair of monozygotic twins, aged 38 years, showing
evidence of inflammation of the gums (gingivitis) and also dental decay (dental caries),
with associated build-up of dental plaque around the teeth.

Is there a relationship between oral health and general health?

There has been an increasing realisation over the past decade or so that oral health
and general health are intimately related. We know that many systemic diseases
have oral manifestations, with oral signs and symptoms often being the first
indicators of disease. The oral cavity is also an entry point for various microbial
infections that can affect general health. Not only is the mouth a potential site
of entry for micro-organisms, it may also harbour microbial infections for
example, dental caries and periodontal diseases which have the potential to
affect general health.
Associations have now been documented between periodontal diseases and
several chronic systemic diseases or problems, including cardiovascular disease,
diabetes and respiratory disease, highlighting the fact that oral diseases are not merely
localised problems but can have significant implications for our general health and
well-being (Figure 1.23).
Clearly, future discoveries about genetic, epigenetic and environmental
contributions to oral health and disease will have much wider ramifications than many
researchers and clinicians may have thought in the past. So, while our earlier studies of
twins and their families were focused on dental development and morphology, our more
recent investigations have broadened to consider the way in which the microbiome of
the oral cavity that is, all of the bacteria living in the mouth isestablished and
how this is associated with an individuals susceptibility to future disease.

27

Twin Studies

Figure 1.23
Diagrammatic representation of reported associations between oral disease and
systemic diseases and disorders.

28

A tour of the mouth

Interestingly, a recent investigation of the placental microbiome in 320 subjects
showed that the placental profiles were most similar to the human oral microbiome
(Aagaard et al., 2014). These findings are particularly significant given the known
association between periodontal disease and increased risk of pre-term birth and low
birthweight.

Why might twins teeth look the same or different?

Parents of twins are often curious to know whether their twins teeth will look the
same or not. Given that there seems to be a relatively strong genetic contribution to
variation in the size, shape, arrangement and development of teeth (which we will
discuss further in subsequent chapters), one would expect that monozygotic twins
(also called identical twins) should display similar dental features. Indeed, this is
generally what is found. Sometimes, the teeth of a pair of monozygotic twins cannot
be distinguished from one another, even after very close inspection or measurement.
In fact, we have come across examples where the upper dental arch of one co-twin
can be matched (or occluded) precisely with the lower arch of the other co-twin. This
is quite remarkable given the number of interacting factors that are involved both
in producing the upper and lower dental arches and in designing them so that they
occlude together perfectly.
However, we have noted many examples where the teeth of monozygotic cotwins can differ in appearance, sometimes quite markedly. For example, there may be
differences in the size and shape of one or more teeth, in the shapes of the dental arches,
or differences in the number or position of extra or missing teeth. These differences
may be due to environmental factors which act differentially on the members of
the twin pair. Alternatively, they may be due to differences in the way in which the
genes of the monozygotic co-twins are expressed referred to as epigenetic factors.
A specific example of differences between monozygotic co-twins, referred to as mirror
imaging, occurs when one twin mirrors the other for one or more dental features. In
these cases, the right side of one twin will match the left side of the other and viceversa (Figures 1.24 and 1.25). We will give further examples of monozygotic co-twins
with very similar and dissimilar teeth, including some fascinating examples of mirror
imaging, in the following chapters.
If twins are dizygotic (also called fraternal twins) they will only share 50 per
cent of their genes on average. These twins are no more closely related than siblings

29

Twin Studies

Figure 1.24
A pair of monozygotic twins showing mirror imaging in the crowding of their anterior
teeth. Twin As upper right central incisor has crossed over the upper right lateral and Twin
Bs upper left central incisor has partially obscured the upper left lateral.

Figure 1.25
Dental models of a pair of monozygotic twins with mirror-imaged emergence of the
upper canine.

30

A tour of the mouth

and, therefore, they may share some common dental features, in terms of size, shape,
arrangement, and timing of development, but they will usually be fairly easy to
distinguish (Figure 1.26).
A pair of dizygotic twins may share more than 50 per cent of their genes and,
when this occurs, they may have very similar dental features. It is well established
that males have, on average, larger teeth than females, although the magnitude of the
differences is only a few tenths of a millimetre. This feature is referred to as sexual
dimorphism. This means that we would expect the teeth of males from dizygotic
opposite-sex pairs (boy-girl twin pairs) to be larger on average than those of their
female co-twins (Figure 1.27).
While this seems to be true, we have found that the extent of sexual dimorphism
in these twin pairs is less than expected, due to an increase in the size of the females
teeth. The most likely reason for this effect is that the females are affected in utero
by male hormones produced by the male co-twin. This effect is explained by the
Twin Testosterone Transfer (TTT) hypothesis, and our studies of tooth size in twins

Figure 1.26
A pair of dizygotic (fraternal) twin girls with different hair, eye colour, facial features
and stages of dental development.

31

Twin Studies

Figure 1.27
A pair of opposite-sex dizygotic twins.

provide one of the strongest pieces of evidence in support of the TTT hypothesis
based on a physical feature. We will discuss this finding further in Chapter Five.
We hope that you have found this first chapter informative, in providing some
basic dental terminology and brief descriptions about dental development, as well
as common oral diseases and abnormalities. Dental research involving twins is a
relatively recent innovation, whereas reports of twinning and the effects of twins on
those around them have existed since humans first recorded their history. To provide
some context for a more detailed description of our studies of Australian twins,
Chapter Two provides an historical perspective of twin studies in general and with
particular reference to how twins were seen by those involved in twin exploration.
Some of the key studies that have been carried out in the past on the teeth and faces
of twins are described in Chapter Three. Chapters Four to Six then provide details
about our own studies of Australian twins and their families, based in the School
of Dentistry at the University of Adelaide. We have studied three main cohorts of
twins over the past thirty years, referred to as Cohort 1, Cohort 2 and Cohort 3,
and the main investigations and findings related to each of these groups are provided
in Chapters Four, Five and Six respectively. Also in Chapter Six, we look to the

32

A tour of the mouth

future and consider where our studies of twins are going. Chapter Seven provides
a full listing of publications and theses arising from our twin studies, followed by a
section containing a glossary of terms. There is also an Appendix that includes a list of
colleagues, visiting researchers, collaborators and key contributors, as well as a gallery
of photographs of some of the researchers, twins and their families.

33

Twin Studies

References
Aagaard K, Ma J, Antony KM, Ganu R, Petrosino J, Versalovic J (2014). The
placenta harbors a unique microbiome. Sci Transl Med 6:237ra65.
Brook AH, Jernvall J, Smith RN, Hughes TE, Townsend GC (2014). The dentition:
the outcomes of morphogenesis leading to variations of tooth number, size
and shape. Aust Dent J 59 (1 Suppl):131-142.
Diamanti J, Townsend GC (2003). New standards for permanent tooth emergence
in Australian children. Aust Dent J 48:39-42.
Hughes T, Bockmann M, Mihailidis S, Bennett C, Harris A, Seow WK, etal.
(2013). Genetic, epigenetic, and environmental influences on dentofacial
structures and oral health: ongoing studies of Australian twins and their
families. Twin Res Hum Genet 16:43-51.
Hughes TE, Townsend GC, Pinkerton SK, Bockmann MR, Seow WK, Brook AH,
etal. (2014). The teeth and faces of twins: providing insights into dentofacial
development and oral health for practising oral health professionals. Aust
Dent J 59 (1 Suppl):101-116.
Townsend G, Bockmann M, Hughes T, Mihailidis S, Seow WK, Brook A (2012).
New approaches to dental anthropology based on the study of twins. In:
NewDirections in Dental Anthropology: paradigms, methodologies and outcomes.
Townsend G, Kanazawa E, Takayama H, editors. Adelaide: University of
Adelaide Press, pp. 10-21.
Williams SD, Hughes TE, Adler CJ, Brook AH, Townsend GC (2014). Epigenetics:
a new frontier in dentistry. Aust Dent J 59 (1 Suppl):23-33.
Woodroffe S, Mihailidis S, Hughes T, Bockmann M, Seow WK, Gotjamanos
T, etal. (2010). Primary tooth emergence in Australian children: timing,
sequence and patterns of asymmetry. Aust Dent J 55:245-251.
Yong R, Ranjitkar S, Townsend GC, Smith RN, Evans AR, Hughes TE, etal.
(2014). Dental phenomics: advancing genotype to phenotype correlations in
craniofacial research. Aust Dent J 59 (1 Suppl):34-47.

34

Chapter Two
A HISTORICAL PERSPECTIVE

Introduction
The birth of twins has been of interest throughout human history. From the earliest
recorded times a multiple birth generated considerable attention both within and
outside the family. The fact that these offspring often shared the same physical
characteristics led to many explanations about the possible underlying causes. These
explanations often related more to the depth of the imagination than to any factual
evidence. Without knowing the complexities of the twinning process, early societies
had to construct explanations that ordinary people could understand and accept,
and it is not surprising that many of these explanations were centred on the mythical
aspects of their cultures and religions.
Attitudes toward twins and twinning varied considerably in different parts of the
world and could change quite dramatically over time. In pre-industrial societies there
appeared to be two distinct attitudes towards them. One linked more to the unexplained
(mythological) supernatural aspect and the other to the practicality of living with twins.
The lives of twins depended on their cultural acceptance by society. If they were seen
as freaks of nature, then some societies would have no compunction in killing them,
and this occurred widely throughout history. Reasons for killing twins varied, but most
concerned the idea that twin creation went against the laws of nature. One example of
this may be seen in the belief that it was animal-like for a mother to produce two children
at the same time, or that to have given birth to two babies must mean two fathers. Other
beliefs likened twinning to the practice of adultery or even the involvement of an evil
spirit, which could well have decided the fate of twins (Bryan, 1983).

35

Twin Studies
The practicality of living with twins was also an important factor in determining
how they were treated, particularly in nomadic societies where it became almost
impossible to breastfeed two babies when food was scarce and the population was
continually on the move to find food and water. In contrast, other societies accepted
and even welcomed twins if, for example, the chief of a tribe had twins and the tribe
then prospered. If the birth of twins coincided with good omens, then the likelihood
of good fortune would normally be associated with them.
One of the difficulties confronting those who developed and dictated the laws
of a particular society arose when providing some form of explanation as to why twins
should be accepted or not. Many early interpretations represented a fusion or balance
between mythology or fantasy and reality or the truths of everyday life. When it came
to rearing twins, ordinary people probably had more down-to-earth views, not the least
being that they had two more mouths to feed rather than one. It seems that when it
became necessary for any early society to explain the twinning process to its people, the
explanation tended to incorporate mystery with the practicality of the known world.

Mythological beginnings
In one of the earliest recordings of twins found in the Pantheon of Ancient Mesopotamia,
it is noted that the twin divinities Lugalgirra and Meslamtaea were interpreted as godlike
beings, as indeed were the twins recorded in both the Babylon and Assyrian civilizations
(Gedda, 1961). In these early references, twins were endowed with supernatural powers
but had little influence over the everyday lives of the people. With the discovery of
the Vedic Sanskrit Hindu texts of Ancient India, it was noted that the god-like twins
referred to as Asvins adopted the occupation of medical practitioners with the power to
heal and reverse the ageing process through the medium of prayer.
By reading these selected early twin references it is possible to see the
development of explanations about twinning and twins from the purely supernatural
to something that could be recognised and understood more by ordinary people. This
incorporation of human values into twin mythology provided much greater meaning
and understanding of their existence within their respective societies. Unlike so many
other mythical stories and beliefs, the tangible presence of twins required more than
parental acceptance; it required societies to accept them as being different. If society
did not approve, then the parents of twins faced ostracism and they had to decide
whether they were prepared to live with their twins or not.

36

A historical perspective
Because many twins were noted to be similar in appearance, the idea of twin
inseparability emerged. Some beliefs included the notion that twins were two people
with a single mind, and that they would be incapable of surviving unless they stayed
together. This was a belief fostered in the Greek myth of the twins Castor and Pollux.
When Castor was killed in battle, Pollux pleaded with his father, Zeus, to be reunited
with his dead brother. His wish was granted and both brothers were installed as twin stars
in the constellation of Gemini. Elizabeth Bryan, in her book The Nature and Nurture of
Twins, uses the myth of Narcissus to further illustrate twin inseparability. She explains
that when Narcissuss twin sister died, he spent many hours looking at his reflection in
a pool, not to admire his own image, but to be reminded always of hers (Bryan, 1983).
Not all interactions between twins were harmonious. The myth of Romulus and
Remus, whilst accentuating twin sharing (both twins having been suckled by a shewolf ), developed the theme of competition, culminating in the death of Remus over
a dispute with Romulus about where the city of Rome should be built (Figure2.1).

Figure 2.1
The statue of Romulus and Remus in the Palazzo dei Conservatori, Capitolini Musie,
Rome. Photograph courtesy of Geraldine Yam.

37

Twin Studies
Romulus was attributed with the virtues of courage, strength and purpose, and it was
imperative to the Roman mentality that these attributes should predominate and be
inculcated in the founder. Competition also governed the actions of the biblical twins
Esau and Jacob in their struggle for recognition of first birthright.

Twins in the theatre

With the advent of theatre and literature, new dimensions were created whereby the
perception of twins became less concerned with myth and superstition and more with
the idea that twins were normal human beings. Whether by travelling players or by
the conventional theatre, it became possible to produce works that emphasised the
involvement of twins in everyday life.
One of the earliest of these plays was the Menaechmi. Thought to have been
composed in Sicily by Epicharmus in the fifth century BC, this play developed plots
concerning twin resemblance, separation, confusion and comedy. The central theme in
these works and also the works of the sixteenth-century playwrights Gian Giorgio
Trissino, Agnolo Firenzuola and Juan de Timoneda was the farce of mistaken
identity. These plays were written before William Shakespeare wrote his twin-inspired
comedy plays, The Comedy of Errors (probably written between 1589 and 1595) and
Twelfth Night or What You Will (probably written between 1600 and1602).
These plays, perhaps more than any other means of communication, informed
the populace about what it was like to be a twin and about the problems twins faced
in the world. In these plays the previous supernatural concepts associated with twins
were replaced by an observed twin lifestyle, with comedy often being the predominant
theme (Figure 2.2).
Shakespeare, himself the father of twins (Hamnet and Judith), emphasised,
whether knowingly or not, the concept that twinship need not necessarily be an
entirely male preserve. Twelfth Night has a male/female format with the different-sex
twins being developed in the male leading roles. Shakespeares development of the
character Viola places an emphasis on female involvement in affairs central to the
theme of the play (diplomatic negotiation). The development of the male/female twin
combination in this play may well have been the result of Shakespeares experience
as a father of a different-sex twin pair. What is particularly interesting is how both
the male and female characters are mistaken for each other: one face, one voice, one

38

A historical perspective

Figure 2.2
These facial contour maps of a pair of twins from one of our studies were used in
the program for The Comedy of Errors, a State Theatre Company presentation at the
Festival Theatre, Adelaide, during the 1990s.

habit and two persons. It raises an interesting question: how masculine did Viola
appear to the other characters in the play, and also to the audience? Or how feminine
in appearance was Sebastian?
Twins became effective characters in theatrical productions because playwrights
could bring together the very attributes that made them interesting to ordinary
people. Their similarities and their differences could be developed and used to create
situations which highlighted the thoughts and feelings we all experience in facing the
problems of everyday life. While theatre opened peoples minds to what it was like to
be a twin, it could not expand that understanding to the same extent that literature,
in the form of a novel, could.

Twins in literature
One example of the inclusion of twins in novels is the development of fear and
prejudice experienced by twins in George Sands nineteenth-century novel La petite

39

Twin Studies
Fadette. Sand uses a family situation to develop the concept of twin separation being
allied to obsession. The difference in parental attitudes over the rearing of the twin
boys, with the fathers interests becoming paramount, leads to conflict which results
in tragedy (Sand, 1849). Another interesting study of the relationship between twins
is provided in Thornton Wilders classic novel The Bridge of San Luis Rey. In this book,
Wilder (himself a twin survivor whose twin brother died at birth) explores the theme
of twin compatibility and loss. Brought up as orphans, Esteban and Manuel live their
lives isolated from the world around them.
Wilder (1927) described his twins in these words:
Because they had no family, because they were twins, and because they were
brought up by women, they were silent. There was in them a curious shame
in regard to their resemblance. They had to live in a world where it was the
subject of continual comment and joking. It was never funny to them and they
suffered the eternal pleasantries with stolid patience.

Their isolation was so complete that little was allowed to penetrate their self-imposed
insulation from society. The only thing that did was Manuels love for Camila, and
the way his unrequited love threatened the world they had made for themselves.
With the death of Manuel and the consequent remorse of Esteban, the collapse of the
bridge at San Luis Rey united the twins in death.
Sands and Wilders novels, written 100 years apart, share the similar theme of
twin unrest caused by external pressures imposed by the societies in which they lived,
and over which they had little control. What was important to both sets of twins
and to the plots of both novels was the unreasonable attitudes of the communities
in which the twins lived. In both instances society had great difficulty in accepting
that each member of a twin pair needed to be seen and treated as an individual
with control over his or her own life. The other characteristic of twins emphasised in
these novels was the bonding between co-twins and how that bonding affected their
behaviour. The more the twins behaved and acted as one person, the more society
reacted against them. Such cause and effect supports the notion of ESP (extra sensory
perception), in that it became a way in which society attempted to explain why twins
could converse with each other in ways that nobody else could understand.
The notion that twins should be seen as being naturally different from other
people was challenged in Aldous Huxleys Brave New World (1932). In this book
Huxley created a totalitarian world populated with genetically engineered clones. Each

40

A historical perspective
member was produced from the same gene pool and subjected to different oxygen
levels during development. The higher the levels of oxygen given to individuals, the
more intelligent they became and, conversely, the lower the levels, the less intelligent
the individual. Each person was subjected to conditioning programmes designed to
create a society in which every member was designed to perform specific tasks and
to want nothing more than to perform those tasks for the sake of the society. Society
in Huxleys world was based upon unnatural stability supported by conditioned
contentment. Brave New World removed entirely the distinction between twins and
singletons and with it every accepted notion that might set them apart.

Twins in science
From a historical viewpoint, the scientific interpretations of twins and twinning
differed considerably from interpretations made by non-scientific commentators.
Perhaps the biggest difference was that the scientific approach considered that the
twinning process could be explained within the context of medical knowledge, not in
terms of myths or unsubstantiated beliefs. Many of the early scientific theories relating
to the twinning process arose in Ancient Greece between 500 and 350 BC. This was
a period when philosophers tried to separate fact from superstition, with the study of
natural sciences holding a pre-eminent position in their thoughts. Hippocrates of Kos
was one thinker who believed that twin births were caused by the sperm dividing into
two sections, with each section impregnating one of the two uterine horns (Gedda,
1961). He also reasoned that conjoined twins were created when there was excessive
sperm produced more than enough for one child, but not enough for two.
If there was one guiding principle in these philosophers thinking, it appears
to be that everything that occurred in nature must have a reason. Empedocles was
another who believed that an excess of sperm was the cause of twins. He also thought
that excessive heat in the uterus could possibly divide the sperm, leading to more than
one individual being formed. Democritus of Abdera, originator of the atomic theory,
considered that acts of sexual intercourse performed within relatively short periods of
time enabled the sperm to produce more than one embryo (Gedda, 1961).
Aristotle also considered the issue of twin births, but, instead of limiting
his considerations to the action of sperm alone, he developed ideas relating to the
phenomenon of co-development. His theories were based upon the multiparous

41

Twin Studies
nature of animal births and, in particular, the often observed conjoined monstrosities
which accompanied such births. Evidence from animal studies convinced him that
two or more separate embryos were normally created, which would produce separate
individuals if allowed to remain apart. However, if through some unknown cause
they were allowed to come into contact with each other they would fuse and form a
monstrosity. The degree of fusion was relative to the degree of contact. Should two
or more embryos be created without contacting each other, then Aristotle favoured
Democrituss concept of the twinning process (Gedda, 1961).
It could be argued that through his association of ideas Aristotle had opened
up the possibilities for future researchers to develop new notions about how twins
were formed. This linking of research between human and animal twin studies
could well have been the foundation for the discipline of teratology. This subject was
popularised in the seventeenth century, and referred at that time to any observations
of the physically abnormal; in the eighteenth century it was considered as the study
of biological deformation; and in the twentieth century the term teratology was used
to refer to the study of congenital malformations.
During Roman times there appears to have been little work done to either
support or to refute the Greek theories of multiple births. Galen of Pergamon, like
other eminent medical practitioners of the day, whilst specialising in medical theory
and practice and having an interest in human reproduction and foetal development,
was not known for any notable interest in the twinning process. Gaius Plinius
Secundas better known as Pliny the Elder, author of The Natural History
devoted much of his time to the reporting of multiple births, but he offered little or
no explanation as to the reasons behind their formation (Gedda, 1961). These Roman
men of science and medicine set the stage for future research, with less emphasis being
placed on the theoretical view of the twinning process and more on the obstetrical
problems associated with it.
Between the eighth and thirteenth centuries, the Arabic and the Salernitan
schools of medicine were held in high regard and did much to promote medical
knowledge; but they seem to have done little more than repeat the observations of
twins made in the past. It was in the Renaissance Period that significant developments
occurred, enabling twin research to advance in ways it had never done before. These
developments centred upon the revival of the ideas of Greek, Roman and Arabic
medical scientists, the advent of the written word, and the ability to read translations

42

A historical perspective
of the works of past and present men of science. Of the past medical commentators,
Hippocrates, Aristotle and Galen became important to the Renaissance scientists
the former two because of their comments relating to the phenomenon of conjoined
twins, and the latter because of his book Spiritus Animalis, of which 500 English
translation editions were printed between 1490 and 1538 (Snow-Smith, 2004).
Jacob Locher (1499) produced one of the first printed illustrations of
conjoined twins, and Ambroise Par (1575) attempted to explain the different
types of conjoined twins in terms that everyone could understand. He thought
that constriction of the womb whether through external or internal pressure,
as in muscle constriction or tight clothing was a prime cause of conjoined
twins or monstrosities. This view of conjoined twins as being monstrosities was
common throughout much of this period and beyond, and those conjoined twins
who survived became objects of study or curiosity. Drawings of conjoined twins
appeared in scientific publications for example, Fortunio Licetis De monstrorum
caussis, natura, et differentiis libri duo (1634) and twins also often appeared in
sideshows, being depicted as freaks of nature (Bondeson, 1993).
There have been other issues that have made people think differently about
twins. In the seventeenth and eighteenth centuries, the phenomenon of conjoined
twinning caught the publics attention through the medium of published pamphlets.
These popular publications were known in England as Monster Broadsides, and they
were used to exploit the sensational. Conjoined-twin births fell into that category
because they enabled the authors to emphasise, in every lurid detail, the birth of
conjoined twins. In one of these pamphlets, conjoined twins appeared as a monstrous
work of Nature and, besides describing their physical appearance, the author (an
unknown gentleman of Taunton Deane in Somerset) went to great lengths to outline
the religious implications of their birth (Anon, 1680).
Publicity of this nature was both good and bad for the parents of conjoined
children. It was good in the sense that, through the interest generated by the pamphlet,
many people thronged to view the twins and purchased mementos of their visit, thus
generating income to provide for the twins future welfare. It was bad in the sense that
society often viewed these children as portents of impending evil, a belief common in
the period 1600-1800 when ordinary people attempted to understand the inexplicable.
Galens work was one of several medical textbooks that were referred to
extensively during the Renaissance period (Snow-Smith, 2004). The value of his work

43

Twin Studies
was its ability to inform and inspire the work of others. Perhaps the greatest of Galens
readers was Leonardo da Vinci. With past knowledge affecting Renaissance thinking,
it was not surprising that there was a blending of art and science during this time in
attempts to further knowledge relating to the human body. Sculptors, such as Carlo
Mondini of Bolongna, prepared wax depictions of dichorionic and monochorionic
twins in the uterus. These depictions were not only works of art but also accurate
representations of the anatomy of twins within the womb. As more books were
published and people became literate, further artistic representations were made that
were based on direct obstetrical observations. These representations could be formed
from metal (copper) engravings or woodcuts, and were predominantly designed for
use in conjunction with medically inspired literature.
Leonardo da Vinci, above all others of his time, was instrumental in integrating
the transcription of anatomical observations with direct anatomical dissections. The
collection of notes and sketches in his Treatise on Anatomy, whilst highlighting his
anatomical knowledge and artistic ability, did not impact upon those who shared
hismedical interests, to the degree that the Treatise only came to light 300 years after
his death. When it did, it set new standards in anatomical depiction, and da Vinci
could well be thought of as the originator of scientific illustration (Snow-Smith, 2004).
The seventeenth century saw important advances in several key areas of
medicine. One area was the description of a form of twinning which was characterised
by twins occupying a common amniotic sac (monoamniotic twin pregnancy).
According to Ferdinand Pauls (1969):
[t]he first comprehensive review of the literature on monoamniotic twinning
was made in 1935 by Quigley, who found 109 cases. The next review by
Raphael in 1961 added a further 74 cases, bringing the total reported in the
world literature to 183.

This observation illustrates the fact that many years were to pass between the discovery
of a twinning phenomenon and reports being made about its frequency.
One interesting fact about conjoined twins was that, despite the problems
associated with their physical deformities and the limited surgical knowledge at
the time, the first recorded successful separation of conjoined twins was made by
Johannes Fatio in 1689 (Kompanje, 2004). Meanwhile, another problem associated
with conjoined twins was: how could the mother survive the trauma of such a birth?
For example, how many required caesarean deliveries? It must be assumed that the

44

A historical perspective
circumstances surrounding such a delivery were different in every case, making
reporting of conjoined-twin births very difficult.
In the eighteenth century, studies of the twinning process did not seem to
dominate the minds of the great medical and scientific people of the day. Obstetrics,
surgery and anatomical dissection were the prime topics for research, with Johann
Friedrich Meckel the Younger, John Hunter and William Smellie making their names
in these fields. Although they did not concentrate directly on building knowledge
about twins and twinning, these men did contribute to related areas, including
teratology and obstetrics.
Meckel, famous for his discovery of the diverticulum (an abnormal pouch or sac
opening from a hollow organ such as the colon or bladder), also made an impressive
contribution to understanding abnormalities during embryological development.
He made the first comprehensive and analytical description of birth defects. When
consideration is given to the association of birth defects, multiple births and the
conjoined monstrosity syndrome, his work stands out as not being influenced by
fantasy or morality. One of the greatest pathologists and anatomists of his day, John
Hunter, added to the knowledge of twinning by his dissections of freemartins. These
are normally associated with twin births in cattle, in which the female of the twin pair
does not breed or give milk. Through his dissections he detected that a freemartin
always had a male twin (Hunter, 1779).
Meckel and Hunter were primarily anatomists, while William Smellie was a
leader in obstetrics. His contribution to medical science concerned the theoretical
basis and practice of childbirth. He based both his teaching and practice upon
scientific principles, and he created a set of anatomical tables which were designed to
provide detailed explanations of most aspects of midwifery. These men applied science
to their respective research interests, and were instrumental in establishing methods
which those who followed could emulate. In particular, they laid the foundations of a
scientific approach to solving problems, medical or otherwise, which so characterised
the nineteenth century.
Perhaps the most well-known and publicised conjoined twins in history were
Chang and Eng. Born in Siam in 1811, they became famous as public exhibits
travelling from Siam to America and England (Figure 2.3). As showground curiosities
they were billed as The Siamese Double Boys. Joined at the lower chest, they also
became subjects for medical examinations aiming to discover the key structures which

45

Twin Studies

Figure 2.3
Chang and Eng Bunker in later life.
http://dc.lib.unc.edu/cdm/singleitem/collection/bunkers/id/376/rec/1

joined them together. They were very popular with the public, and they were feted
wherever they went. Returning to America in 1832, they became naturalised citizens
and eventually married, having twenty-one children between them. Chang died on
17 January 1874 and a few hours later Eng also died. Their importance to the way
society viewed conjoined twins was dramatic.
Chang and Eng, through their popularity, made people aware of the problems
suffered by conjoined twins. Their condition proved that their physical handicap did
not mean they could not live normal lives. It was also through their Asian origin that
the term Siamese twins became associated with conjoined twins in general.

The concept of nature versus nurture

It was not until the nineteenth century that the relationship between human individ
uality and the environment in which that individuality developed was seriously

46

A historical perspective
researched. The Age of Enlightenment provided the necessary conditions for those
promoting human knowledge to have both a belief in the essence of nature, and a
devotion to understanding human development. From the point of view of twins,
these beliefs led to scientific debate about nature versus nurture. A leading figure in
this debate was Sir Francis Galton (Figure 2.4). He expressed his understanding of
the phrase in these words:
The phrase nature versus nurture is a convenient jingle of words, for it separates
under two distinct heads the innumerable elements of which personality is
composed. Nature is all that a man brings with himself into the world; nurture
is every influence from without that affects him after his birth. The distinction
is clear: the one produces the infant such as it actually is, including its latent
faculties of growth of body and mind; the other affords the environment amid
which growth takes place, by which natural tendencies may be strengthened or
thwarted, or wholly new ones implanted. (Galton, 1874)

Figure 2.4
Sir Francis Galton, photographed circa 1870.
Courtesy of Gavan Tredoux, site editor http://galton.org/

47

Twin Studies
Galton was influenced in his thinking by the publication of Charles Darwins
On the Origin of Species (1859), particularly Darwins comments on the observed
variation associated with the breeding of animals. The study of human variation
became a central theme in Galtons work. According to David Burbridge (2001),
Galtons primary studies regarding twins began in November 1874. He was interested
in establishing whether the differences observed in human intelligence could be
attributed to hereditary (nature) or to environmental (nurture) factors.
One method Galton used to determine the contributions of nature and
nurture to observed similarities and differences between twins was to provide a
questionnaire to 190 fellows of the Royal Society. His intention in using this survey
was to see whether the intelligence exhibited by the fellows was acquired through
inheritance or predominantly through environmental influences. In other words, was
their interest in science innate or had it developed through their upbringing? He
was also interested in finding out whether there was evidence of twin births in the
family histories of the fellows in his sample, and whether they would agree to pass
his questionnaire to other contacts who were twins or who were related to twins.
The results of this research were published in 1874 in a book entitled English Men of
Science: Their Nature and Nurture. Galton felt that his results did show that a level
of intelligence was inherited, but his findings were inconclusive in determining how
much variation could be attributed to nature over nurture.
Realising that his study was limited, Galton designed a more specific
programme which concentrated on twin comparisons. Questions were devised that
concerned twins who appeared alike at birth but were placed into totally different
environments, and twins who were unlike each other at birth but placed into
similar environments. Following the format of his earlier questionnaire, Galton
sought details on the strength of resemblance between twins, including features
such as height, weight, fit of clothes, hair and eye colour, athletic abilities, manual
skills, handwriting, tone of voice, tastes, disposition and health. He also asked the
twins about their education and subsequent pursuits, the extent to which their
similarity had decreased with age, and their own assessment of why this may have
occurred (Burbridge, 2001).
What is important to note is that Galton, at this time, had decided on a
method of study in which a hypothesis was formed and then the data obtained were
used to test that hypothesis. In other words, he structured what later became known

48

A historical perspective
as a method or model of twin research a specific method of research involving
comparisons within and between pairs of twins.
His conclusion, published under the title The History of Twins (Galton, 1875),
echoed the findings of his 1874 paper, which concluded that when consideration
was given to the degrees of similarity, twins generally exhibited moderate forms of
similarity to each other, but that more extremes of similarity or dissimilarity were
noted in those twins who were of the same sex. This observation reinforced the idea
that nature had more input upon twin formation than nurture. It also emphasised
the point that when it came to distinguishing physical characteristics within a
collection of twin data, it was easier to define and categorise similarity in a more
organised way. Burbridge (2001) makes the observation:
The modern reader may assume that Galton is here recognizing the distinction
between monozygotic (identical) and dizygotic (fraternal) twins Galton was
indeed aware that some twins were produced from a single egg, while others
came from separate eggs.

In the mid-1870s there was considerable debate amongst researchers in

Europe and America over the questions of human embryo separation and methods
of fertilisation. It was not possible for Galton or anyone else at this time to definitely
state that twins received identical genetic material from a single fertilised egg. They
simply did not know the complexities involved in the formation of monozygotic
(socalled identical) and dizygotic (so-called non-identical) twins.
What is also important in Galtons approach to research was that he was quite
willing to change his conceptions as more facts came to light. For example, he recognised
the extensive influence of nurture during the stages of human development, from
conception to the onset of birth, not just the environment after birth (Galton, 1883).
He also recognised that in asking questions about dissimilarity he might have created
a bias through encouraging exaggerated responses from his subjects. Galton, therefore,
established two fundamental principles of modern research the willingness to change
research goals once evidence demands a change, and also the need to consider factors
that may create bias or lead to unexpected outcomes.
The question of who actually proposed the twin method is controversial.
Richard Rende and colleagues (1990) make the point that
Galtons delight in discovering twins was to assess the ability of the
environment to make initially similar twins different and to make initially

49

Twin Studies
different twins similar. Galton thought that all of his twins both the similar
and the dissimilar pairs were one-egg twins, what we now call identical
twins. He did not suggest comparing one-egg and two-egg twins. Thus, it is not
correct to claim that Galton proposed the twin method.

Rende and colleagues further state that no other studies concerning twin
resemblance were published until Edward Thorndike (1905) wrote a paper
concerning twin mental and physical resemblance, relating that resemblance to a
series of carefully designed cognitive tests. It was not until twenty years later (fifty
years after Galton) that Curtis Merriman (1924) wrote a paper entitled The Intellectual
Resemblance of Twins in which he noted that there was a difference between identical
and non-identical twins. Whilst he did not follow up this observation, he had made
an important distinction between the differing twin groups.
According to Rende and colleagues, the first authors who actually compared
the correlations of monozygotic and dizygotic twins for IQ (intelligence quotient)
were Gladys Tallman (1928) and Alex Wingfield and Peter Sandiford (1928). Rende
and colleagues also emphasised that the twin model could be attributed to the joint
discoveries of Curtis Merriman and Hermann Siemens in the 1920s. However, Oliver
Mayo (2009) noted that the twin model could not be developed into a single identifiable
entity until three distinct evolutionary stages of research had been accomplished:
a proper understanding of the difference between MZ and DZ twins, which
was barely achieved by the end of 19th century; a clearly understood and correct
model for inheritance, which was rediscovered around 1900; and a clear method
for causal assignment of variability, which Fisher achieved in 1918.

Mayo further makes the point that between the years 1900 to the mid-1920s
there were discoveries made by researchers which, whilst not covering all of the above
three requirements, addressed one or two of them. Examples given are Kristine
Bonnevie (1924) and Hermann Siemens (1924), who reached similar conclusions that
monozygotic and dizygotic twins needed to be properly diagnosed. Once this difference
was established it was possible to construct correlations within the twin pairs. With
regard to the first and second requirements, Mayo felt that Wilhelm Weinberg (1901)
and Heinrich Poll (1914) had adequately satisfied these components of the twin model.
What makes Poll an important figure in the decades before the First World
War was his ability to think of identical twin pairs as subjects who could be used in
research involving genetics. According to Mayo (2009), Poll noted that

50

A historical perspective
MZ twins and triplets are in fact the sole humans with identical genomes, the
sole isozygotic individuals: for the same sperm and the same egg should yield
them the same genetical endowment, according to theory. (Poll, 1914)

Such a concept made him a pioneer of twin studies and genetic research. He
was able to show that fingerprints of twins could be used as genetic markers and, as
such, could be used in studies concerning similarity and dissimilarity, and even in
determining cases of paternity. Above all, Poll proposed the idea that monozygotic
twin pairs could be used as a type of control group whose variability would indicate
environmental differences unaffected by genetic differences.
From a historical perspective, Polls life had several fascinating aspects (Braund
and Sutton, 2008). One was that so much of his work in the early 1900s was in
German and, either through difficulty in translation or availability, was not widely
known. Other issues relate to the First World War and its anti-German aftermath.
Above all, however, it was his interest in eugenics and his belief in the state having
control over human reproductive behaviour which may have condemned his later
work to relative obscurity.
In the period under discussion, meanwhile, Hermann Siemens wrote a book
primarily concerned with psychological and skin disorders. Siemens emphasised skin
disorders in this work, and, importantly, considered comparisons in both identical
and non-identical twins. His purpose was to judge the hereditary influence on both
body features and the intellectual performance of his subjects (Siemens, 1924). Also
in this decade, the Swedish eugenist and statistician Gunnar Dahlberg designed a
statistical method that allowed measurement error to be quantified. He was one of the
first to demonstrate the value of studying twins as well (Dahlberg, 1926).

Inheritance and Mendelian genetics

Allied to Darwins theory of natural selection and to Jean-Baptiste Lamarcks thoughts
on evolution, complex questions concerning the mechanisms of inheritance were also
being considered at this time. Although never directly linked to twin research, the
discovery of how one organism can pass certain characteristics to its offspring was to
play an important part in the future understanding of the development of twins. JeanBaptiste Lamarck had devised a theory of evolution which encompassed two distinct
ideas concerning how organisms, during their lifetime, pass certain information to their

51

Twin Studies
offspring. He considered that if an animal constantly used part of its body to achieve
an outcome, then that part of its body would develop accordingly. Conversely, any
part of an animals body which was not used would weaken and deteriorate. These
modifications would then be passed on to the offspring of the animal and therefore,
over time as needs changed and behaviours changed there would be a gradual
transmutation of the animal species (Lamarck, 1809). It is fascinating to note how recent
discoveries in the field of epigenetics have reignited interest in Lamarckian evolution.
Charles Darwin (1859) also favoured the idea of inheritance of acquired factors
in his concept of continuous evolution. He developed the theory of pangenesis, which
assumed that cells could create tiny particles, or so-called pangenes or gemmules as
he termed them, and these would contain information concerning the parent. This
information would diffuse and collect in the reproductive organs, and therefore be
passed from parent to offspring. With the acquisition of knowledge about the way
genetic expression passes information from one generation to the next, Darwins ideas
were seen to be flawed. It was not until the work of Gregor Johann Mendel that the
biological laws governing the passage of information from one generation to the next
were discovered (Figure 2.5).

Figure 2.5
Gregor Johann Mendel (1822-1884).
http://commons.wikimedia.org/wiki/File:Gregor_Mendel.jpg

52

A historical perspective
Gregor Johann Mendel developed a research programme to discover how
information was passed from parents to offspring. In 1843, after a concentrated period
of time studying philosophy and physics at the Olmutz Philosophical Institute, he
entered an Augustinian monastery (the Abbey of St Thomas in Brno, Czechoslovakia).
It was at this monastery that he conducted his experiments on plants that earned him
the title of the father of genetics.
Many of his experiments were conducted using the pea species Pisum sativum,
and were designed to discover hereditary traits of plants. By studying generations of
pea specimens, Mendel was able to confirm that pea offspring retained the essential
traits of the parental plants and were not influenced by their environment. He studied
several pea plant traits: flower colour, position, length, seed colour, pod shape and pod
colour. His observations were explained in two principles: the principle of segregation
and the principle of independent assortment. These principles later became known
as Mendels Laws of Inheritance. It was not until 1900 that Mendels work was
rediscovered by the scientific community and its implications were considered in
relation to Darwins concepts of evolution and natural selection.

Twin research: a question of ethics

The nature (hereditary) versus nurture (environmental) question was to continue
for much of the first half of the twentieth century. With growing understanding of
genetic theory, studies of twins became more sophisticated. One infamous phase
of twin research concerned the study of psychology and eugenics. Based upon the
work of Kurt Gottschaldt, who used twins to explain observed psychological traits
and patterns of behaviour, research emerged that was governed more by political
ideology and less by scientific enquiry. Fostered by the political ideology of Nazi
Germany and its belief in the creation of a pure-bred Aryan race, Heinrich Himmler
gave permission for Otmar Freiherr von Verschuer, who was then working at the
Kaiser Wilhelm Institute, to conduct research designed to uncover the secrets of
heredity.
Working under von Verschuers direction, Joseph Mengele conducted
experiments on twins in the concentration camp at Auschwitz in Poland during
World War II. These experiments involved blood transfusions from one twin to
another, eye operations to induce blindness, pain induction and injections of

53

Twin Studies
disease-causing organisms. In cases of experimentation leading to death, detailed
autopsies were also performed. All these experiments on twin subjects were designed
to examine what made them different from singletons and how understanding these
differences could benefit the German race. It was thought that an understanding of
genetics could enable desirable human features to be developed (positive eugenics)
and that this would lead to the creation of a pure race. It was appreciated that not
every gene expression was desirable, and this gave rise to the concept of negative
eugenics that is, the improvement of human populations by removal of
deleterious genes.
The research practised by Mengele raised the issue of ethical experimentation,
and the question of what is acceptable, and what is not, in scientific discovery. To
Mengele and his associates, the end justified the means. Today, the involvement of
human subjects in scientific experimentation is governed by ethical values and strict
rules designed to safeguard the rights of participants. Our modern codes of scientific
ethical behaviour can trace their origins to the Judgement of Nuremberg (1947) in
which ten ethical standards were designed to form a foundation upon which future
principles could be applied, followed by The Declaration of Helsinki (1964), which
both strengthened the existing regulations and broadened their scope.
In Australia, the National Statement on Ethical Conduct in Research
Involving Humans (2007) contains guidelines for ethical conduct in scientific
research which are in accordance with the National Health and Medical Research
Council Act 1992. However, consideration of ethical values should not be restricted
to human experiments which involve direct contact with participants. They are also
important in the actual conduct of the research itself. One example of what could
be called unethical practice has been associated with the research of Sir Cyril Burt.
Burt, an educational psychologist, published a series of papers which concerned the
genetics of intelligence. Burt argued that heredity (nature) had a greater impact upon
intellectual ability than that generated by the environment (nurture). The accusations
made against Burt were based on certain anomalies researchers noted in the values
of correlation coefficients he reported between his monozygotic twin subjects for
IQ scores. Debate ensued as to whether Burts findings were generated through
inexcusable carelessness or by conscious fakery. According to Stephen J Gould in his
chapter The Real Error of Cyril Burt it was a deliberate attempt on Burts part to
falsify his data (Gould, 1981).

54

A historical perspective

Twin research: specialisation

It was in the 1920s and 1930s that twin research reached a level in which specialised
areas could be identified. Studies concerning twin resemblance, age, identity,
intelligence and handedness became areas of interest.
Some of the questions posed included: Does age have any bearing on
resemblance in twins? Do like-sex twin pairs show a greater degree of resemblance
than unlike-sex twin pairs? Do twins in general show a greater degree of resemblance
than other family siblings? (Lauterbach, 1925). These questions illustrate that research
was attempting to explain observable differences in twins and to link these differences
to a (genetic) hereditary cause rather than to environmental ones. Another leading
question asked at this time was: 'How great is the probability that, in a given trait,
one-egg twins are not alike? and: how great is the probability that (in the same trait)
two-egg twins are alike? (Siemens, 1927). Such ideas reinforced the concept that
studies involving the determination of trait expression and frequency in twin pairs
should concentrate more upon hereditary factors than environmental ones.
Intelligence testing between monozygotic and dizygotic twin pairs was also
attempted and, although the results were inconclusive, there was some evidence
to support the view that the IQ was higher in the monozygotic groups and lower
in dizygotic twins, with the lowest values being in the unlike-sex dizygotic pairs
(Wingfield and Sandiford, 1928).
In the 1930s two further twin studies were developed. These were studies of
handedness and an investigation of monozygotic twins reared apart. It had been
noticed by Wilhelm Weitz (1924), Gunnar Dahlberg (1926) and Horatio Newman
(1928a,b) that identical twins displayed a greater percentage of left-handedness than
fraternal twins. Ideas were developed in an attempt to explain why such handedness
occurred. Often these explanations related to the observed effect of higher levels of
reversed asymmetry (mirror imaging) during development in monozygotic twins
than in dizygotic twins (Wilson and Jones, 1932). The second twin study which
emerged about this time was to consider the observed similarities and differences
in monozygotic twins reared apart (Newman, 1934). Although much of this
work was descriptive, its importance to future studies was that researchers placed
greater emphasis upon environmental influences affecting individuals, rather than
concentrating solely on genetic factors.

55

Twin Studies

Twin research: the great steps forward

Perhaps the greatest discovery in the twentieth century, which revolutionised studies
involving genetically inspired research, was the discovery of the molecular structure
of deoxyribonucleic acid (DNA). Further details of the birth and development of the
DNA theory of inheritance, which culminated in this discovery, have been provided
recently by Petter Portin (2014).
Francis Crick and James Watson, working in Cambridge in 1953, announced
to the world that they had discovered the structure of the deoxyribonucleic acid
molecule and how genetic information was transferred between individuals via DNA.
What this discovery meant to twin research was that more detailed tests for zygosity
could be conducted based on comparisons of DNA. Accurate information about twin
zygosities has enabled more sophisticated genetic models to be constructed, and has
removed the problem which plagued previous research, where so much was based
on assumption. Once it could be positively established that monozygotic co-twins
shared the same genes and dizygotic co-twins only shared (on average) half their
genes, it became possible to further extend the classical twin model in ways that preDNA-discovery researchers could only dream about.
One of the most difficult problems facing researchers in the early twentieth
century was to determine how inheritance influenced quantitative factors compared
with qualitative ones. The term quantitative usually describes continuously variable
data, whereas data that are separated into distinct types or categories are thought of
as qualitative. Explanatory problems arose when attempts were made to interpret
quantitative data describing individual differences based on the Galtonian model of
inheritance. There were those who felt that Galtons data could best be expressed
using Mendelian principles. A protg of Galton was Karl Pearson, who formulated a
statistical model to Galtons theory of inheritance (Pearson, 1904).
If this model lacked one essential ingredient, it was to establish a coherent
account of how correlations between relatives could be explained. In 1910 Wilhelm
Weinberg published a paper in which he had worked out ratios regarding these
correlations between relatives in a randomly mating population. Using his statistical
method, he proved that his results were consistent with Mendelian inheritance
theory (Weinberg, 1910). He also worked out a method to determine the proportion
of monozygotic and dizygotic twins from a sample of similar-sex twins at a time

56

A historical perspective
when the biological origin of the twin types was not fully understood. In addition,
Weinberg considered phenotypic variation and segregated this variation into what
he considered to be genetically inspired and environmental causes. From his work
with twin data he came to the conclusion that the birth of dizygotic twins was
influenced more by genetic factors than the birth of monozygotic twins (Weinberg,
1901).
It fell to RA Fisher (Figure 2.6) to provide a statistical model which illustrated
that every observable human trait was caused by numbers of individual genes
which were inherited in the same way as outlined in Mendels laws (Fisher, 1936).
This model later became known as a polygenic model. Fishers statistical model,
sometimes referred to as an infinitesimal model, was based on the idea that instead of
concentrating entirely upon the effects of a few genes on a chosen human character, it
would be beneficial to consider an infinitesimal number of genes and determine the
aggregate effects of those genes on the character under investigation.

Figure 2.6
Sir Ronald Aylmer Fisher. Image courtesy of Special Collections,
Barr Smith Library, The University of Adelaide.

57

Twin Studies
Using this method, Fisher believed a better explanation could be provided
of the action of genes, their individuality from each other and the smallest effect
they could have in influencing a character. Fishers model has been further developed
to deal with the many complexities associated with understanding the quantitative
genetics of human development.
It became a keystone upon which many future twin studies were based. Toward
the end of his life in the late 1950s, Fisher lived in Adelaide, South Australia, visiting
the Division of Mathematical Statistics in the Commonwealth Scientific Industrial
Research Organisation (CSIRO). Working with Edmund A Cornish (Chief of
Division, CSIRO) and J Henry Bennett, Professor of Genetics at the University of
Adelaide, Fisher was able to influence many researchers. His Collected Papers are
still a source of inspiration to those involved with quantitative genetics. These papers
were bound into five volumes and are stored in the archives in the University of
Adelaide, Barr Smith Library (1995).
During his stay in Adelaide, many anecdotes were generated about Fisher,
which added not only to his charisma but also to his impact as a teacher. Two wellremembered anecdotes, related to the authors of this book by Emeritus Professor
Tasman Brown, illustrate the different memories people have of working with
someone of the calibre of RA Fisher.
I am sure Henry Bennett will have many memories to tell you. I remember he
told me on one occasion that when Fisher was working on a problem on his
desk electric-calculating machine, he would often pause at mid-stroke and stare
out of the window for a long time and then when he had mentally solved the
current problem, he would continue on the machine.
Sir Ronald was accustomed to dining in the University of Adelaide Staff Club
and he would usually sit in a comfortable armchair and enjoy an after-lunch
glass of milk. On one occasion Sir Ronald had dozed off but his peaceful
slumber was rudely interrupted when one of the female dental patrons sitting
at a nearby table accidently swung her handbag, which sent Sir Ronalds
glass flying. The esteemed statistician awoke with an audible start but was
soon settled again by the profuse apologies from the shocked lady. Those in
the dental school who were aware of this accident told the lady that by her
carelessness she could have deprived the world of a revolutionary new statistical
algorithm by waking Sir Ronald up too soon. The sad aftermath of the episode
was the death of Sir Ronald soon after this event.

58

A historical perspective

References
Anon. (1680). A true relation of a monstrous female-child, with two heads, four eyes,
four ears, two noses, two mouths, and four arms, four legs, and all things else
proportionably, fixed to one body. London: Mallet.
Bondeson J (1993). The Isle-Brewers conjoined twins of 1680. J R Soc Med
86:106109.
Bonnevie K (1924). Studies on papillary patterns of human fingers. J Genet
15:1113.
Braund J, Sutton DG (2008). The case of Heinrich Wilhelm Poll (1877-1939):
a German-Jewish geneticist, eugenicist, twin researcher, and victim of the
Nazis. J Hist Biol 41:1-35.
Bryan EM (1983). The nature and nurture of twins. London: Baillre Tindall.
Burbridge D (2001). Francis Galton on twins, heredity and social class. BJHS
34:323-340.
Dahlberg G (1926). Twin births and twins from a hereditary point of view.
Stockholm: Tidens.
Darwin C (1859). On the origin of species. London: John Murray.
Fisher RA (1936). Has Mendels work been rediscovered? Ann Sci 1:115-137.
Fisher R, Bennett JH, Bennetto E, The Adelaide University Library (1995).
Collected papers of RA Fisher, 1890-1962. Adelaide: Adelaide University
Library.
Galton F (1874). English men of science: their nature and nurture. London:
Macmillan and Co.
Galton F (1875). The history of twins, as a criterion of the relative powers of nature
and nurture. Frasers Mag 12:566-576.
Galton F (1883). Inquiries into human faculty and its development. London:
Macmillan and Co.
Gedda L (1961). Twins in history and science. Illinois: Charles C Thomas.
Gould SJ (1981). The mismeasure of man. New York: Norton.
Hunter J (1779). Account of the freemartin. Phil Trans R Soc Lond 69:279-293.
Huxley A (1932). Brave new world. London: Chatto & Windus.

59

Twin Studies
Kompanje EJO (2004). The first successful separation of conjoined twins in 1689:
some additions and corrections. Twin Res 7:537-541.
Lamarck JB (1809). Philosophie Zoologique. Paris: Chez Dentu.
Lauterbach CE (1925). Studies in twin resemblance. Genetics 10:525-568.
Locher J (1499). Carmen Heroicum de Partu Monstrifero. Ingolsladt: Johann
Kachelofen.
Mayo O (2009). Early research on human genetics using the twin method: who
really invented the method. Twin Res Hum Genet 12:237-245.
Merriman C (1924). The intellectual resemblance of twins. Psychol Monogr
33:1-57.
National Health and Medical Research Council, Australian Government (2007).
National Statement on Ethical Conduct in Human Research, updated May
2015. http://www.nhmrc.gov.au/guidelines-publications/e72. Accessed
30May 2015.
Newman HH (1928a). Studies of human twins: I. Methods of diagnosing
monozygotic and dizygotic twins. Biol Bull 55:283-297.
Newman HH (1928b). Studies of human twins: II. Asymmetry reversal, of mirror
imaging in identical twins. Biol Bull 55:298-315.
Newman HH (1934). Mental and physical traits of identical twins reared apart.
JHered 25:55-60.
Par A (1575). Des monstres et prodiges. Translated into English with an introduction
and notes by Pallister JL (1982). On monsters and marvels. Chicago:
University of Chicago Press.
Pauls F (1969). Monoamniotic twin pregnancy: a review of the world literature and
a report of two new cases. Can Med Assoc J 100:254-256.
Pearson K (1904). Mathematical contributions to the theory of evolution. XII.
On a generalised theory of alternative inheritance, with special references to
Mendels laws. Phil Trans R Soc Lond A 203:53-86.
Poll H (1914). ber Zwillingsforschung als Hilfsmittel menschilcher Erbkunde.
ZEthnol 46:87-105.
Portin P (2014). The birth and development of the DNA theory of inheritance:
sixty years since the discovery of the structure of DNA. J Genet 93:293-302.

60

A historical perspective
Rende RD, Plomin R, Vandenberg SG (1990). Who discovered the twin method?
Behav Genet 20:277-285.
Sand G. (1849). La petite Fadette. Paris: Calmann-Levy.
Siemens HW (1924). Die Zwillingspathologie: ihre Bedeutung, ihre Methodik, ihre
bisherigen Ergebnisse (The pathology of twins: signicance, methodology, and
results). Berlin: Springer.
Siemens HW (1927). The diagnosis of identity in twins. J Hered 18:201-209.
Snow-Smith J (2004). Leonardo da Vinci and printed ancient medical texts: history
and influence. Seattle: University of Washington.
Tallman GG (1928). A comparative study of identical and nonidentical twins with
respect to intelligence resemblances. 27th Yrbk Nat Soc Studies Educ:83-86.
Thorndike EL (1905). Measurements of twins. Arch Phil Psych Sci Methods 1:1-64.
Weinberg W (1901). Beitrgae zur Physiologie und Pathologie der
Mehrlingsgeburten beim Menschen. Arch Ges Physiol 88:346-430.
Weinberg W (1910). Weitere Beitrge zur Theorie der Vererbung. Arch Rass Ges Biol
7:35-49.
Weitz W (1924). Studien an eineiigen Zwillingen. Z Klin Med 101:154.
Wilder T (1927). The Bridge of San Luis Rey. New York: Albert and Charles Boni.
Wilson PT, Jones HE (1932). Left-handedness in twins. Genetics 17:560-571.
Wingfield AH, Sandiford P (1928). Twins and orphans. J Edu Psych 19:410-423.

61

Chapter Three
PHASES OF RESEARCH INVOLVING TWIN
STUDIES OF TEETH AND FACES

Three broad phases of research can be identified where twins have been studied to
understand more about the contribution of genetic and environmental factors to
human dental and facial variation. The number and types of studies have increased
dramatically since the early 1900s.

Studies of twin resemblance: hereditary and

environmentalinfluences
1920s-1940s
An initial phase of studies can be identified in the period from the 1920s to the early
1940s (see Table 3.1 at the end of this section for a summary of these studies). Several
researchers around the world began studies of twins which highlighted resemblances
of dental structures. Through being able to identify similarities in dental tissues they
began to separate what could be thought of as genetically influenced (or hereditary)
factors from environmentally influenced ones (Bachrach and Young, 1927; Goldberg,
1930; Korkhaus,1930; Newman 1923, 1928a,b, 1930; Newman etal.,1937). Indeed,
publications involving Horatio H Newman commenced as early as 1913.
Henriette Bachrach and Matthew Young (1927) studied the resemblances of
dental features in twin pairs who had been grouped into so-called identical pairs
(development of more than one embryo from a fertilised egg) and non-identical
pairs (development of embryos from separate fertilised eggs). The reason for forming

62

Phases of research involving twin studies of teeth and faces

these groupings conformed to the general belief that identical twin pairs shared the
same inherited characteristics and that non-identical twin pairs shared only part of
theirinherited characteristics.
Using these two twin categories they set out to compare the degrees of
influence that heredity and environment had upon chosen dental characteristics.
These included tooth eruption times, dental caries in deciduous and permanent teeth,
enamel hypoplasia, the state of dental occlusion and gingivitis. With the exception
of total caries prevalence, data collected for all of the other features (particularly in
subjects displaying different degrees of malocclusion) showed that correlations were
higher in identical twin pairs than in non-identical twin pairs. This study and its
choice of multiple dental features provided an important foundation for future
studies involving dental morphology and disease in twins.
A paper written by Samuel Goldberg (1930) reported on dental arch size and
shape in identical twins. His research considered resemblances of arch symmetry
and asymmetry, as well as mirror imaging, in monozygotic twin pairs. Goldberg
attempted to determine both the degree of arch variation and the severity of dental
malocclusion. Using fifty sets of dental casts obtained from monozygotic twin
pairs enrolled in Newmans University of Chicago studies, he concluded that arch
symmetry and malocclusion were inherited. His assessment regarding malocclusion is
interesting in that he makes the observation that teeth would be subject to intrinsic
pressures with hereditary influence on tooth position, as well as extrinsic factors
exerting an environmental effect. Such reasoning has orthodontic implications, in
that attempts to prevent relapse of teeth to their original positions after treatment
need to take account of the neutral zone where the pressures exerted by the lips and
cheeks are balanced by those of the tongue.
In all three phases involving research into dental variation, particularly research
into malocclusion, researchers have often been orthodontists, or their research has
been of value to orthodontic diagnosis and/or treatment. The fact that Goldberg
used twin material from Newmans study emphasises the importance of the work
conducted by Newman.
As early as 1913, Horatio H Newman was involved in understanding
polyembryony (identical twin development) in armadillo species found in Texas
and, in 1923, he conducted experiments on asymmetry in echinoderms (starfish).
His work concerned identification of epigenetic factors related to polyembryony

63

Twin Studies
(that is, development of more than one embryo from a fertilised egg). The induced
temperature variations upon the embryonic development of starfish eggs led him to
consider the biological aspects of human twinning and higher order births.
Newman formulated a research programme on biological, statistical and
psychological observations of identical and fraternal (non-identical) twins who were
reared together (Newman, 1934). Later, it became possible to add data from identical
twins reared apart. The dental component of this work was limited to observing
dental irregularities and using this information to assist in determining twin zygosity.
It was important because it brought together three distinct areas of study into a single
research project concerning the rearing of twins (Newman etal., 1937). The fact that
Newmans work began ten years before publication in 1937, and the fact that it was
used by different researchers years later, shows the importance of data collections
being shared in collaboration with other disciplines. Summarising this work, the
three authors (Newman etal., 1937) noted that, despite generally higher correlations
for identical twins, it was not possible to positively determine what influence genetic
or environmental factors had upon the observed traits. They left the reader with the
thought that what heredity can do environment can also do.
Another paper by Gustav Korkhaus (1930) also considered questions relating
to inherited dental characteristics. The difference between this paper and the
others mentioned in this period is that Korkhaus used a different approach for his
research. Instead of looking at subject data in a cross-sectional manner, he adopted
a longitudinal approach to study facial and skull characteristics, tooth structure and
size, colour of teeth and hypoplasia in twins. With regard to tooth size, Korkhaus
felt that the observed variability in crown size of incisor teeth (particularly in lateral
incisors) pointed to definite genetic causation. He also noted that only a large number
of cases will justify distinct conclusions ... whereon to enlarge continuously will be
our next task.
Because Korkhaus was open-minded about his observations, he accepted
criticism over some of his conclusions. For example, he admitted that his opinion
that the diastema (a space between front teeth) was an inherited characteristic was
open to question (Figure 3.1).
Earlier work had raised the issue of what constituted a diastema (Siemens and
Hunold, 1924), and Korkhaus realised that without clear guidelines to define the
extent of spacing between teeth, it was impossible to accurately record the feature.

64

Phases of research involving twin studies of teeth and faces

Figure 3.1
Diastema in a pair of monozygotic twin boys.

Today, researchers measure dental variables with high degrees of accuracy using either
direct methods for example, high-precision callipers or indirectly, using 2D or
3D digital imaging systems.
In the late 1940s, Anders Lundstrm, Professor of Orthodontics at the
Karolinska Institutet in Stockholm, Sweden, published two landmark papers on
dental occlusion and malocclusion in twins (Figure 3.2).

Figure 3.2
Professor Anders Lundstrm, Karolinska Institutet, Stockholm.
Photograph courtesy of Professor Jan Huggare, Department of Dental Medicine, Karolinska
Institute, Huddinge, Sweden. We acknowledge with thanks Fredric Lundstrm for allowing
this photograph of his father to be published in this book.

65

Twin Studies
In the late 1940s, Anders Lundstrm (1948, 1949) considered tooth size
in twins and the causal background of various types of malocclusion. In his study
of malocclusion, he reasoned that environmental factors included two categories:
internal and external.
The concept of an internal component is compatible with the physiological
notion of the milieu intrieur, whereby homeostatic mechanisms attempt to main
tain a constant environment within the individual. This idea of two environmental
components acting within and outside the body was considered earlier by Gunnar
Dahlberg (1948). Lundstrm was influenced by Dahlbergs work, and felt that
variation in tooth position was associated with the internal factor. He also considered
that this variation occurred at random. To this end he structured his study to
determine what percentage of the observed variation could be attributed to random
factors, and what could not. Through identification of the random element he was
able to construct clearly distinguished categories between what he felt were external,
internal and hereditary causation factors. This approach enabled Lundstrm to more
accurately define the environmental component affecting variation associated with
malocclusion.

Table 3.1
Key studies of the teeth and faces of twins 1920s-1940s
Researchers

Country

Date

Key publications

Siemens HW

Germany

1927

The diagnosis of identity in twins

Bachrach FH,
Young M

England

1927

A comparison of the degree of resemblance in

dental characters shown in pairs of twins of
identical and fraternal types

Goldberg S

USA

1929

Biometrics of identical twins from the dental

viewpoint

Goldberg S

USA

1930

The dental arches of identical twins

Korkhaus G

Germany

1930

Anthropologic and odontologic studies of twins

Newman HH etal.

USA

1937

Twins: a study of heredity and environment

Lundstrm A

Sweden

1948

Tooth size and occlusion in twins

Lundstrm A

Sweden

1949

An investigation of 202 pairs of twins regarding

fundamental factors in the aetiology of
malocclusion

66

Phases of research involving twin studies of teeth and faces

Understanding genetic control over dental variation

1950s-1980s
The second phase of dental research involving twins can be considered to have spanned
the years from the 1950s to the 1980s (see Table 3.2 at the end of this section for a
summary of this research). The key researchers in this phase continued with attempts
to define the extent of genetic control over dental variation using more sophisticated
methods. One focus was to clarify the aetiology of dental occlusion and malocclusion.
Leading researchers during this period were Richard Osborne and Sidney Horowitz
in the USA (Horowitz etal., 1958a,b; Osborne etal., 1958), Anders Lundstrm in
Sweden (Lundstrm, 1954), and Stanley Garn at the Fels Research Institute in Ohio,
USA (Garn etal., 1965).
This period also saw the extended use of odontometrics. Osborne and his
colleagues concentrated their research on the hereditary factors influencing variation
in anterior tooth size and occlusion in monozygotic (MZ) and dizygotic (DZ) twins
(Figure 3.3).

Figure 3.3
Professor Lassi Alvesalo (centre) pictured with Professor Richard H Osborne (farright)
in Oulu (May 1996). Photograph courtesy Professor Tuomo Heikkinen (far left),
Institute of Dentistry, University of Oulu, Finland.

67

Twin Studies
Using twin pairs enrolled in the Collaborative Perinatal Study of the National
Institute of Neurological Disorders and Stroke, they recorded information on ethnicity,
geographic background and religion. Zygosity was determined through blood group
factors and through observed similarities in physical structures. Osborne and his
colleagues also obtained dental radiographs and impressions of the mouths of their
subjects and poured casts in dental stone. These casts enabled measurements of the
teeth to be made, which provided odontometric data for analysis. They concluded that
there was a strong genetic influence on variability of mesiodistal crown dimensions of
permanent anterior teeth. Osborne, like many other dental anthropologists, believed in
sharing information with colleagues around the world. He attended numerous dental
morphological symposia and organised access for others to the databases used in his
research. The ability to access twin databases throughout the world is becoming more
and more important in building adequate sample sizes to address research questions.
Without doubt, Stanley Garn was one of the key figures in physical anthropology
in the twentieth century (Figure 3.4). He was a prolific author of many papers, some
of which relied on data obtained from twins in relation to body composition, skeletal
development and dental development. An important event in Garns life occurred
when he joined the Department of Physical Growth and Genetics at the Fels Research

Figure 3.4
Stanley M Garn (1922-2007).
Photograph courtesy of B Holly Smith, University of Michigan.

68

Phases of research involving twin studies of teeth and faces

Institute in Yellow Springs, Ohio, USA. Becoming its chairman in 1952, Garn became
responsible for enlarging the physical anthropology component within the Fels database,
and he was also instrumental in its development into the most extensive, and longest
running, continuous longitudinal growth study in the world. Many of his publications
were derived from this extensive database. The sixteen years he spent at Fels enabled
him to broaden his interests in research into human growth, population epidemiology
and family-related genetic studies. His work on the genetics of dental development
including siblings and twins became a blueprint for future studies (Garn, 1977).
Another early and extensive longitudinal twin study into growth and dental
development of monozygotic and dizygotic twins was undertaken in 1959 by
Coenraad Moorrees at the Forsyth Dental Centre in Boston, USA (Figure 3.5).
Moorrees, working with Anna-Maria Grn and Laure Lebret, developed a database
to which they added orthodontic and anthropometric measurements for the next
twenty years. Over 400 twin pairs were involved, aged between 6 to 16 years. Records
of parents and non-twin siblings were also included in the database. Unfortunately,
relatively few publications resulted from this ambitious study, apparently due to
funding inadequacies (Peck and Will, 2004).

Figure 3.5
Coenraad F. A. Moorrees (1916-2003).
Reprinted from the American Journal of Orthodontics and Dentofacial
Orthopedics. Copyright 2004 with permission from Elsevier.

69

Twin Studies
Although the statistical analyses that were available during this period were
limitedto simple variance ratios and correlations, the researchers of this time provided
many of the ground rules for future research. In the latter half of this era, more
sophisticated analyses of twin data became possible, with greater access to increasing
computer power. There was also a growing awareness that the various assumptions of
the twin model needed to be tested rigorously before calculating estimates of genetic
variance. In the 1970s, Joe Christian and colleagues undertook research to estimate
genetic variance for various features in twins and also to construct a basic methodology
for twin analysis (Christian et al., 1974; Christian, 1979). Consideration was also
given to the assertion that monozygotic co-twins were likely to share more similar
environments postnatally than dizygotic co-twins. This led to the testing of the equal
environments assumption (that both monozygotic and dizygotic co-twins shared similar
environments), which had been a centrepiece of the classical twin study paradigm. This
was particularly relevant when considering the development of psychological traits in
twins and how those traits could be affected in different environments.
The development of a twin model which considered genetic and
environmental factors acting upon monozygotic and dizygotic twin pairs who had
been reared apart from birth provided a way of overcoming the problem of similar
environments affecting features in co-twins. However, the twins reared apart
model has assumptions of its own, most of which are related to the different twin
environments and how these environments may affect measured characteristics in
individual co-twins (Bouchard, 2006).
Some of the key researchers during this time were Robert Biggerstaff in
Kentucky (Biggerstaff, 1970, 1975), Rose Potter in Indianapolis (Potter etal., 1976),
Robert Corruccini in Illinois (Corruccini and Potter, 1980), Minuro Nakata in
Japan (Nakata etal., 1973, 1974; Nakata, 1985), Yuji Mizoguchi in Japan (1977),
and Winfried Harzer in Germany (Harzer, 1987). In addition to studies estimating
genetic contributions to observed variation of teeth, there was increasing interest
in exploring the nature and causes of asymmetry within the dentition using data
obtained from twins (Potter and Nance, 1976).
Not only were the traditional measures of dental crown size used in these
analyses, but variations in cusp expression and crown components were also explored
(Staley and Greene, 1974; Corruccini and Potter, 1981). Another researcher, Charles
Boklage, placed the investigation of dental asymmetry in twins into a broader

70

Phases of research involving twin studies of teeth and faces

biological context and proposed that craniofacial development in twins differed from
that in singletons, and that this difference was related in some way to the biological
basis of the twinning process (Boklage, 1987). This work provides an important
reminder of the need to test whether data derived from twins can be extrapolated to
the general population.
It was not until the 1990s that statistical approaches based upon path analysis
and model-fitting could be applied. These approaches enabled estimations of the
different contributions of genetic and environmental factors to phenotypic variation
to be made and the fit of different models to be tested statistically.
Table 3.2
Key studies of the teeth and faces of twins 1950s-1980s
Researchers

Country

Date

Key publications

Lundstrm A

Sweden

1954

The importance of genetic and non-genetic factors in the

facial skeleton studied in 100 pairs of twins

Horowitz SL
etal.

USA

1958a Caries experience in twins

Horowitz SL
etal.

USA

1958b Hereditary factors in tooth dimensions, a study of the

anterior teeth of twins

Osborne RH
DeGeorge FV

USA

1959

Genetic basis of morphological variation: an evaluation

and application of the twin study method

Kraus BS etal.

USA

1959

Heredity and the craniofacial complex

Hunter WS

USA

1959

The inheritance of mesiodistal tooth diameter in twins

Horowitz SL
etal.

USA

1960

A cephalometric study of craniofacial variation in adult

twins

Osborne RH

USA

1961

Applications of twin studies to dental research

Horowitz SL

USA

1963

Clinical aspects of genetic research in dentistry

Lundstrm A

Sweden

1963

Tooth morphology as a basis for distinguishing

monozygotic and dizygotic twins

Garn S etal.

USA

1965

Genetic, nutritional, and maturational correlates of

dental development

Hunter WS

USA

1965

A study of the inheritance of craniofacial characteristics

as seen in lateral cephalograms of 72 like-sexed twins

Mulick JF

USA

1965

An investigation of craniofacial asymmetry using the

serial twin-study method

Keene HJ

USA

1968

Discordant dental development in twins

71

Twin Studies

Researchers

Country

Date

Key publications

Shapiro BL

USA

1969

A twin study of palatal dimensions partitioning genetic

and environmental contributions to variability

Biggerstaff RH

USA

1970

Morphological variations for the permanent mandibular

first molars in human monozygotic and dizygotic twins

Keene HJ

USA

1971

Birth weight and congenital absence of teeth in twins

Staley RN,
Green LJ

USA

1971

Bilateral asymmetry in tooth cusp occurrence in human

monozygotic twins, dizygotic twins, and nontwins

Nakata M etal. Japan,

USA

1974

Genetic determinants of cranio-facial morphology: a

twin study

Biggerstaff RH

USA

1975

Cusp size, sexual dimorphism, and heritability of cusp

size in twins

Potter R,
NanceW

USA

1976

A twin study of dental dimension. I. Discordance,

asymmetry, and mirror imagery

Potter RH etal. USA

1976

A twin study of dental dimension. II. Independent

genetic determinants

Rebich T,
Markovic M

USA,
1976
Yugoslavia

Inheritance of tooth dimension: a quantitative genetic

twin study

Garn SM

USA

1977

Genetics of dental development

Mizoguchi Y

Japan

1977

Genetic variability of permanent tooth crowns as

ascertained from twin data

Kent RL etal.

USA

1978

Associations in emergence age among permanent teeth

Corruccini RS,
Potter RHY

USA

1980

Genetic analysis of occlusal variation in twins

Markovic M

Yugoslavia 1982

Hypodontia in twins

Sognnaes RF
etal.

USA

1982

Computer comparison of bitemark patterns in identical

twins

Boklage CE

USA

1984

Differences in protocols of craniofacial development

related to twinship and zygosity

Hauspie RC
etal.

Belgium

1985

Testing for the presence of genetic variance in factors of

face measurements of Belgian twins

Boraas JC etal. USA

1988

A genetic contribution to dental caries, occlusion, and

morphology as demonstrated by twins reared apart

Nystrm M,
Ranta R

Finland

1988

Dental age and asymmetry in the formation of mandibular

teeth in twins concordant or discordant for oral clefts

Townsend GC
etal.

Australia

1988

Genetic and environmental determinants of dental

occlusal variation in South Australian twins

72

Phases of research involving twin studies of teeth and faces

Development of more sophisticated methods: path analysis,

model-fitting and genetic expression
1990s to the present
A third phase of research relating to dental and facial development in twins extends
from the 1990s to the present (see Table 3.3 at the end of this section for a summary
of this research). This period has seen increasing application of statistical approaches
based on path analysis and model-fitting, whereby models incorporating different
contributions of genetic and environmental factors to phenotypic variation can be
applied to data and tested statistically for their goodness of fit. Initially, the computer
program LISREL was applied to dental data, but then an improved version of
LISREL, referred to as Mx, was applied (Neale, 1995).
A study of dental and facial morphology in Australian twins commenced in
Adelaide in 1983 and, following discussions at the 7th International Symposium
on Dental Morphology in Paris in 1986, a collaborative approach to data analysis
was adopted between Rob Corruccini and Grant Townsend (Townsend etal., 1988;
Corruccini et al., 1990). As the number of twins enrolled in the Australian study
increased, a further collaboration was developed with Professor Louise Brearley
Messer in Melbourne, Australia, with Professor Brearley Messer focusing particularly
on the analysis of facial morphology (Tangchaitrong etal., 2000).
With the encouragement and support of Nick Martin, an Australian and a key
international figure in twin research, model-fitting methods began to be applied to
dental data in the 1990s (Townsend and Martin, 1992; Dempsey etal., 1995). With
ever-increasing computer power and technology it has become possible to carry out
more sophisticated analyses. One researcher in Adelaide involved in this process is
Toby Hughes, who has applied structural equation modelling to data from twins. An
important benefit provided by Hughess work has been clarification of the sources
of covariation between correlated variables derived from longitudinal data (Hughes
etal., 2000; Townsend etal., 2003; Hughes etal., 2007).
A recent innovative method of understanding the effect of genes upon
developing dental features is the use of GWAS (Genome-Wide Association
Studies). This method involves the use of large twin and family cohort collections
to identify genetic variants or loci responsible for the dental feature under review.
Current dental research using GWAS has involved the identification of genes at

73

Twin Studies
designated loci which are associated with primary and permanent tooth emergence
(Pillas etal., 2010; Geller etal., 2011). The ability to identify gene expression on
developing phenotypes is not limited to tooth emergence, but is proving to be
valuable in research into other dental and body organ development. It has also been
of value in determining loci implicated in the development of ovarian, breast and
colorectal cancer.
Genetic research has moved beyond analysing phenotypic variability into
the realm of exploring the aetiology of disease. The search for genetic markers using
classical twin study methods has made inroads into understanding the biological
mechanisms of disease. One example of this type of research is a study which
compared the DNA methylation patterns of discordant monozygotic twins. DNA
methylation is a controlling factor in gene expression (Bell and Spector, 2011).
Methylation changes, or differences in epigenetic profiles, were noted in twins who
were discordant for systemic lupus erythematosus (van Dongen etal., 2012).
Genetically inspired research into the aetiology of dental development is
becoming more involved with understanding the communication pathways between
cells and tissues during cellular differentiation. Multifactorial interactions of genetic,
epigenetic and environmental influences are thought to contribute to various dental
anomalies, including variations in tooth size, shape, number and structure (Brook,
2009; Brook etal., 2014). Already, over 300 genes have been associated with dental
development (Thesleff 2006; Crton etal., 2013).
A large-scale study of oral health in twins is currently being undertaken by
Walter Bretz at New York University, together with other colleagues in the USA.
Bretz has collected data from over 1000 pairs of twins living in disadvantaged areas
of Montes Claros in Brazil. Because there is inadequate fluoridation of the water
supply and also poor access to dental care, the children in the study are at risk of
developing dental caries. The study aims to determine the importance of genetic
and environmental influences on the development of dental caries, and involves
comparisons between monozygotic and dizygotic twin pairs, as well as comparisons
between monozygotic co-twins where one has evidence of dental caries and the other
does not (Bretz etal., 2006; Corby etal., 2007).

74

Phases of research involving twin studies of teeth and faces

Table 3.3
Key studies of the teeth and faces of twins 1990s to the present
Researchers

Country

Date

Key publications

Corruccini RS
etal.

USA, Australia 1990

Genetic and environmental determinants of dental

occlusal variation in twins of different nationalities

Markovic MD

Yugoslavia

1992

At the crossroads of oral facial genetics

Townsend GC
Martin NG

Australia

1992

Fitting genetic models to Carabelli trait data in

South Australian twins

Dempsey PJ etal. Australia

1995

Genetic covariance structure of incisor crown size

in twins

Carels C,
Vlietinck R

Belgium

1999

Role of inheritability of tooth form, tooth

malformation and tooth position

Tangchaitrong K
etal.

Australia

2000

Fourier analysis of facial profiles of young twins

Kabban M etal.

UK

2001

Tooth size and morphology in twins

Townsend G etal. Australia

2003

Molar intercuspal dimensions: genetic input to

phenotypic variation

Bretz WA etal.

USA

2005a Dental caries and microbial acid production in twins

Bretz WA etal.

USA

2005b Longitudinal analysis of heritability for dental

caries traits

Corby PM etal.

USA

2005

Mutans streptococci in preschool twins

Bretz WA etal.

USA

2006

Heritability estimates for dental caries and sucrose

sweetness preference

Hughes TE etal.

Australia

2007

Strong genetic control of emergence of human

primary incisors

Corby PM etal.

USA

2007

Heritability of oral microbial species in cariesactive and caries-free twins

Su C-Y etal.

USA

2008

Inheritance of occlusal topography: a twin study

Boklage CE

USA

2010

How new humans are made

Bockmann MR
etal.

Australia

2011

Timing of colonization of caries-producing

bacteria: an approach based on studying
monozygotic twins

Hughes T etal.

Australia, UK 2012

Genetic, epigenetic, and environmental influences

on dentofacial structures and oral health: ongoing
studies of Australian twins and their families

Ribeiro DC etal.

Australia, UK 2013

Intrauterine hormone effects on tooth dimensions

Hughes T etal.

Australia, UK 2014

The teeth and faces of twins: providing insights

into dentofacial development and oral health for
practising oral health professionals

75

Twin Studies

Studies of twins: the Adelaide Dental School

The genesis of the studies of twins in the Adelaide Dental School can be traced back
to Grant Townsends experiences as a PhD student under the supervision of Professor
Tasman Brown. Having completed his PhD on variation in tooth size within the
Aboriginal people from Yuendumu in Central Australia, and after publishing some
papers presenting these findings, Townsend began thinking about commencing
another study to provide further insights into the roles of genetic and environmental
influences on variation in human tooth size.
His PhD had used a special familial relationship that existed amongst the
Yuendumu Aboriginal people to explore the roles of genetic and environmental
factors on tooth size variation. These people practised a custom of polygyny, where
a male could have more than one wife. There were also very detailed genealogical
records available of the family groupings that had been collected by Murray Barrett
(Fleming etal., 1971). Therefore, it was possible to look at the similarities in tooth
size and morphology in full-siblings and also half-siblings who had the same father
but different mothers. Data of this type are very rare and the relationships enabled the
researchers to calculate not only the heritability estimates that is, how much of the
variation in features could be explained by genetic influences but also how much
of the variation could be attributed to so-called common environmental influences
or maternal effects. These analyses highlighted a strong genetic influence on tooth
size variation, but also showed for the first time that there was a significant maternal
effect, presumably due to prenatal, and possibly perinatal, influences during dental
development.
Given that the sample sizes were relatively small in the Yuendumu sample,
Townsend was keen to explore another sample and to build up larger numbers
of subjects. This is particularly important when attempting to calculate accurate
estimates of heritability. Drawing on his experiences studying genetics and human
variation with Professor Henry Bennett during his Honours year, and drawing also on
discussions with Nick Martin who tutored in the course, Townsend began thinking
about a study of tooth size and shape in twins. He was aware of the value of twin
studies that compared monozygotic pairs with dizygotic pairs, and he was also aware
of new, more sophisticated statistical techniques that were beginning to be used to
analyse data derived from twins.

76

Phases of research involving twin studies of teeth and faces

Townsends experiences of the Yuendumu Growth Study with Tasman Brown
and Murray Barrett (Brown etal., 2011) reinforced his appreciation of the value
of longitudinal human growth studies. He also realised that if any growth studies
were to be performed in Australia that focused on dental features, the people most
likely to be able to perform the research would be dental academics working in a
university environment. This is because of the huge commitment of time and effort
needed to plan and run long-term growth studies, with the need for some stability
in terms of ongoing staffing and resources, including storage of the records that are
collected.
Townsend had seen how the records and information collected during
the years of the Yuendumu Growth Study had served as a focus for postgraduate
students and for national and international visitors who wanted to study the
material. Although the dental casts of Indigenous Australians had been collected in
the 1950s, 1960s and early 1970s, they were still being regularly accessed as new
research questions arose and they still are! Townsend could see that much of
the Adelaide School of Dentistrys international reputation for research had been
built around publications and presentations based on the unique collection of
growth records of the Yuendumu Aboriginal people. He was keen to further build
this reputation by gathering additional records, such as dental casts of twins, to
complement the Yuendumu study.
Grant Townsend, Tasman Brown and Lindsay Richards, together with
Sandy Pinkerton, began developing plans in the early 1980s for a study of twins
living in South Australia. They were helped greatly by advice from Nick Martin.
It was essential to gain some funding to support the study and it was felt that a
longitudinal study might be too ambitious as an initial project. Tasman Brown had
a particular interest in facial development and morphology, so the group decided
to focus on the teeth and faces of twins. They also felt that teenage twins would be
more comfortable with having impressions made of their teeth and giving blood
samples for the determination of zygosities than younger twins would be. The plan
was to enrol around 300 pairs of teenage twins in the study, mainly in the age
range of 12 to 15 years, as these twins would have all of their permanent teeth
present except for the third molars. With the assistance of the NHMRC (National
Health and Medical Research Council) Twin Registry located in Melbourne, and
with financial support from the NHMRC, the examination of twins commenced

77

Twin Studies
in April 1983 and was completed in 1993. While this study, now referred to as
Cohort 1, was to be a cross-sectional study, it was always hoped that the research
would proceed well, and that a subsequent longitudinal study might be possible at
some stage in the future. A fuller description of the Cohort 1 study is provided in
Chapter Four.
In 1995, a longitudinal growth study of twins around 4 to 6 years of age was
commenced, with a view to examining the twins on at least two more occasions.
It was planned to examine approximately 300 pairs of twins when all the primary
teeth were present, then again when there were both primary and permanent teeth
(the mixed dentition stage around 9 to 11 years of age) and then again when all the
permanent teeth were present apart from third molars (around 12 to 14 years of
age). This group of twins, together with their brothers and sisters, is now referred
to as Cohort 2. With continuing support from the NHMRC, as well as Colgate
and the ADRF (Australian Dental Research Foundation), the examinations of twins
in Cohort 2 continued throughout the 1990s, to be completed in 2006. Many of
the twins being examined were seen in the Dental Therapy School Melbourne, with
colleague Professor Louise Brearley Messer. More details about the Cohort 2 study
are provided in Chapter Five.
In 2003, following discussions with Professor Kim Seow in Brisbane,
Queensland, and Professor Theo Gotjamanos in Perth, Western Australia, it was
decided to broaden the focus of the twin studies by including consideration of oral
health. Toby Hughes and Michelle Bockmann, who were now part of the Craniofacial
Biology Research Group, took leading roles in this new phase, referred to as Cohort3.
A novel aspect of this study was to ask the parents of the twins to record when primary
teeth appeared in the mouth, rather than requiring all of the twins to come to the
Dental School for clinical examinations. Advances in technology also enabled the
parents to obtain samples of dental plaque from the teeth, and to use buccal swabs
to obtain samples of DNA for zygosity determination. This study is ongoing and is
described in Chapter Six.
Whilst twin research in the Adelaide School of Dentistry is ongoing, the
thought patterns and events described above are likely to be re-enacted worldwide
amongst researchers attempting to explain the causes of variation in human dental
and facial development. Two aspects that are likely to be central to the future of these
types of twin studies are increasing collaboration between researchers internationally

78

Phases of research involving twin studies of teeth and faces

and the ability of those researchers to gain access to large databases of twins and their
families while ensuring that all ethical issues are addressed.
Given our similar research interests, we have entered into an exciting new
phase of collaboration with Walter Bretz and his colleagues in the USA. The twins
involved in our respective studies represent the two largest samples currently available
worldwide for exploring the roles of genetic and environmental influences on oral
health and disease. While combining resources promises to enable some key questions
to be addressed, we are very conscious of the need to ensure that genomic data are
managed with the highest levels of ethical behaviour. It is very important that we
adopt the most appropriate approaches to the ethical management of genomic data
obtained from our twins and their families. A paper by Jean McEwen and colleagues
has recently reviewed the challenges and possible future directions in dealing with this
issue in such changing times (McEwen etal., 2013).

79

Twin Studies

References
Bachrach FH, Young M (1927). A comparison of the degree of resemblance in
dental characters shown in pairs of twins of identical and fraternal types.
BritDent J XLVIII:12931304.
Bell JT, Spector TD (2011). A twin approach to unraveling epigenetics. Trends
Genet 27:116125.
Biggerstaff RH (1970). Morphological variations for the permanent mandibular
first molars in human monozygotic and dizygotic twins. Arch Oral Biol
15:721730.
Biggerstaff RH (1975). Cusp size, sexual dimorphism, and heritability of cusp size
in twins. Am J Phys Anthropol 42:127140.
Bockmann MR, Harris AV, Bennett CN, Odeh R, Hughes TE, Townsend GC
(2011). Timing of colonization of cariesproducing bacteria: an approach
based on studying monozygotic twin pairs. Int J Dent Article ID 571573.
doi:10.1155/2011/571573. Accessed 19 May 2015.
Boklage CE (1984). Differences in protocols of craniofacial development related to
twinship and zygosity. J Craniofac Genet Dev Biol 4:151169.
Boklage CE (1987). Developmental differences between singletons and twins
in distributions of dental diameter asymmetries. Am J Phys Anthropol
74:319331.
Boklage CE (2010). How new humans are made. Singapore: WorldScientific
Publishing Co. Pte Ltd.
Boraas JC, Messer LB, Till MJ (1988). A genetic contribution to dental caries,
occlusion, and morphology as demonstrated by twins reared apart. J Dent Res
67:11501155.
Bouchard TJ Jr (2006). Identical twins reared apart. In: eLS. Chichester: John Wiley
& Sons Ltd. http://www.els.net. doi:10.1038/npg.els.0005156. Accessed
19May 2015.
Bretz WA, Corby PM, Hart TC, Costa S, Coelho MQ, Weyant RJ, etal.
(2005a). Dental caries and microbial acid production in twins. Caries Res
39:168172.

80

Phases of research involving twin studies of teeth and faces

Bretz WA, Corby PM, Schork NJ, Robinson MT, Coelho M, Costa S, etal.
(2005b). Longitudinal analysis of heritability for dental caries traits. J Dent
Res 84:10471051.
Bretz WA, Corby PMA, Melo MR, Coelho MQ, Costa SM, Robinson M, etal.
(2006). Heritability estimates for dental caries and sucrose sweetness
preference. Arch Oral Biol 51:11561160.
Brook AH (2009). Multilevel complex interactions between genetic, epigenetic and
environmental factors in the aetiology of anomalies of dental development.
Arch Oral Biol 54(1 Suppl):S3S17.
Brook AH, Jernvall J, Smith RN, Hughes TE, Townsend GC (2014). The dentition:
the outcomes of morphogenesis leading to variations of tooth number, size
and shape. Aust Dent J 59 (1 Suppl):131142.
Brown T, Townsend GC, Pinkerton SK, Rogers JR (2011). Yuendumu: legacy of
a longitudinal growth study in Central Australia. Adelaide: University of
Adelaide Press.
Carels C, Vlietinck R (1999). Role of inheritability of tooth form, tooth
malformation and tooth position. Ned Tijdschr Tandheelkd 106:
298301.
Christian JC (1979). Testing twin means and estimating genetic variance: basic
methodology for the analysis of quantitative twin data. Acta Genet Med
Gemellol 28:3540.
Christian JC, Kang KW, Norton JA Jr (1974). Choice of an estimate of genetic
variance from twin data. Am J Hum Genet 26:154161.
Corby PM, Bretz WA, Hart TC, Filho MM, Oliveira B, Vanyukov M (2005).
Mutans streptococci in preschool twins. Arch Oral Biol 50:347351.
Corby PM, Bretz WA, Hart TC, Schork NJ, Wessel J, LyonsWeiler J, etal. (2007).
Heritability of oral microbial species in cariesactive and cariesfree twins.
Twin Res Hum Genet 10:821828.
Corruccini RS, Potter RHY (1980). Genetic analysis of occlusal variation in twins.
Am J Orthod 78:140154.
Corruccini RS, Potter RHY (1981). Developmental correlates of crown component
asymmetry and occlusal discrepancy. Am J Phys Anthropol 55:2131.

81

Twin Studies
Corruccini RS, Townsend GC, Richards LC, Brown T (1990). Genetic and
environmental determinants of dental occlusal variation in twins of different
nationalities. Hum Biol 62:353367.
Crton M, van den Boogaard MJ, Maal T, Verhamme L, Fennis W, Carels C,
etal. (2013). Threedimensional analysis of tooth dimensions in the
MSX1missense mutation. Clin Oral Invest 17:14371445.
Dahlberg G (1948). Environment, inheritance and random variation with special
reference to investigations on twins. Acta Genet Stat Med 1:104114.
Dempsey PJ, Townsend GC, Martin NG, Neale MC (1995). Genetic covariance
structure of incisor crown size in twins. J Dent Res 74:13891398.
Fleming DA, Barrett MJ, Fleming TJ (1971). Family records of an Australian
community. Abor Stud News 3:15.
Garn SM (1977). Genetics of dental development. In: The Biology of Occlusal
Development. McNamara JA, editor. Ann Arbor: Center for Human Growth
and Development. pp. 6188.
Garn SM, Lewis AB, Kerewsky RS (1965). Genetic, nutritional, and maturational
correlates of dental development. J Dent Res 44:228242.
Geller F, Feenstra B, Zhang H, Shaffer JR, Hansen T, Esserlind AL, etal. (2011).
Genomewide association study identifies four loci associated with eruption
of permanent teeth. PLoS Genet 2011;7: e1002275. doi:10.1371/journal.
pgen.1002275. Accessed 19 May 2015.
Goldberg S (1929). Biometrics of identical twins from the dental viewpoint. J Dent
Res 9:363409.
Goldberg S (1930). The dental arches of identical twins. Dent Cosmos 72:869881.
Gould SJ (1981). The mismeasure of man. New York: WW Norton & Co.
Harzer W (1987). A hypothetical model of genetic control of toothcrown growth
in man. Arch Oral Biol 32:159162.
Hauspie RC, Susanne C, DefriseGussenhoaven E (1985). Testing for the presence
of genetic variance in factors of face measurements of Belgian twins. Ann
Hum Biol 12:429440.
Horowitz SL (1963). Clinical aspects of genetic research in dentistry. J Dent Res
42:13301343.

82

Phases of research involving twin studies of teeth and faces

Horowitz SL, Osborne RH, DeGeorge FV (1958a). Caries experience in twins.
Science 128:300301.
Horowitz SL, Osborne RH, DeGeorge FV (1958b). Hereditary factors in tooth
dimensions, a study of the anterior teeth of twins. Angle Orthod
28:8793.
Horowitz SL, Osborne RH, DeGeorge FV (1960). A cephalometric study of
craniofacial variation in adult twins. Angle Orthod 30:15.
Hughes T, Dempsey P, Richards L, Townsend G (2000). Genetic analysis of
deciduous tooth size in Australian twins. Arch Oral Biol 11:9971004.
Hughes T, Bockmann M, Mihailidis S, Bennett C, Harris A, Seow WK, etal.
(2012). Genetic, epigenetic, and environmental influences on dentofacial
structures and oral health: ongoing studies of Australian twins and their
families. Twin Res Hum Genet 16:4351.
Hughes TE, Bockmann MR, Seow K, Gotjamanos T, Gully N, Richards LC, etal.
(2007). Strong genetic control of emergence of human primary incisors.
JDent Res 86:11601165.
Hughes TE, Townsend GC, Pinkerton SK, Bockmann MR, Seow WK, Brook AH,
etal. (2014). The teeth and faces of twins: providing insights into dentofacial
development and oral health for practising oral health professionals.
AustDent J 59 (1 Suppl):101116.
Hunter WS (1959). The inheritance of mesiodistal tooth diameter in twins. Thesis,
University of Michigan, Ann Arbor.
Hunter WS (1965). A study of the inheritance of craniofacial characteristics as seen
in lateral cephalograms of 72 likesexed twins. Rep Congr Eur Orthod Soc
41:5970.
Kabban M, Fearne J, Jovanovski V, Zou L (2001). Tooth size and morphology in
twins. Int J Paediatr Dent 11:333339.
Keene HJ (1968). Discordant dental development in twins. J Dent Res 47:175.
Keene HJ (1971). Birth weight and congenital absence of teeth in twins. Acta Genet
Med Gemellol 20:2342.
Kent RL Jr, Reed RB, Moorrees CFA (1978). Associations in emergence age among
permanent teeth. Am J Phys Anthropol 48:131142.

83

Twin Studies
Korkhaus G (1930). Anthropologic and odontologic studies of twins. Int J Orthod
Oral Surg Rad 16:640647.
Kraus BS, Wise WJ, Frei RH (1959). Heredity and the craniofacial complex. Am J
Orthodont 45:172217.
Lundstrm A (1948). Tooth size and occlusion in twins. Basel: Karger.
Lundstrm A (1949). An investigation of 202 pairs of twins regarding fundamental
factors in the aetiology of malocclusion. Dent Rec LXIX:251264.
Lundstrm A (1954). The importance of genetic and nongenetic factors in the facial
skeleton studied in 100 pairs of twins. Eur Orthod Soc Rep Cong 30:92107.
Lundstrm A (1963). Tooth morphology as a basis for distinguishing monozygotic
and dizygotic twins. Am J Hum Genet 15:3443.
Markovic M (1982). Hypodontia in twins. Swed Dent J (Suppl)15:153162.
Markovic MD (1992). At the crossroads of oral facial genetics. Eur J Orthod
14:469481.
McEwen JE, Boyer JT, Sun KY (2013). Evolving approaches to the ethical
management of genomic data. Trends Genet 29:37582.
Mizoguchi Y (1977). Genetic variability of permanent tooth crowns as ascertained
from twin data. J Anthrop Soc Nippon 85:301309.
Mulick JF (1965). An investigation of craniofacial asymmetry using the serial
twinstudy method. Am J Orthod 51:112129.
Nakata M (1985). Twin studies in craniofacial genetics: a review. Acta Genet Med
Gemellol 34:114.
Nakata M, Yu PL, Davis B, Nance WE (1973). The use of genetic data in the
prediction of craniofacial dimensions. Am J Orthod 63:471480.
Nakata M, Yu PL, Davis B, Nance WE (1974). Genetic determinants of
craniofacial morphology: a twin study. Ann J Hum Genet 37:431443.
Neale MC (1995). Mx: statistical modeling, 3rd edn. Virginia: Virginia
Commonwealth University.
Newman HH (1923). The physiology of twinning. Chicago: University of Chicago
Press.
Newman HH (1928a). Studies of human twins. I. Methods of diagnosing
monozygotic and dizygotic twins. Biol Bull 55:283297.

84

Phases of research involving twin studies of teeth and faces

Newman HH (1928b). Studies of human twins. II. Asymmetry reversal, of mirror
imaging in identical twins. Biol Bull 55:298315.
Newman HH (1930). Identical twins reared apart. Eugen Rev 22:2934.
Newman HH (1934). Mental and physical traits of identical twins reared apart.
Case I. Twins A and O. J Hered 25:4964.
Newman HH, Freeman FN, Holzinger KJ (1937). Twins: a study of heredity and
environment. Chicago: University of Chicago Press.
Nystrm M, Ranta R (1988). Dental age and asymmetry in the formation of
mandibular teeth in twins concordant or discordant for oral clefts. Scand J
Dent Res 96:393398.
Osborne RH (1961). Applications of twin studies to dental research. In: Genetics
and Dental Health. Witkop C Jr, editor. New York: McGrawHill, pp. 7991.
Osborne RH, De George FV (1959). Genetic basis of morphological variation: an
evaluation and application of the twin study method. Cambridge: Harvard
University Press.
Osborne RH, Horowitz SL, De George FV (1958). Genetic variation in tooth
dimensions: a twin study of the permanent anterior teeth. Am J Hum Genet
10:350356.
Peck S, Will LA (2004). In Memoriam: Coenraad F. A. Moorrees, 19162003. Am J
Orthod Dentofacial Orthop 125:396398.
Pillas D, Hoggart CJ, Evans DM, OReilly PF, Sipil K, Lhdesmki R, etal.
(2010). Genomewide association study reveals multiple loci associated
with primary tooth development during infancy. PloS Genet 6:e1000856
doi:10.1371/journal.pgen.1000856. Accessed 19 May 2015.
Potter RH, Nance WE (1976). A twin study of dental dimension. I. Discordance,
asymmetry, and mirror imagery. Am J Phys Anthropol 44:391395.
Potter RH, Nance WE, Yu PL, Davis WB (1976). A twin study of dental
dimension. II. Independent genetic determinants. Am J Phys Anthrop
44:397412.
Rebich T, Markovic M (1976). Inheritance of tooth dimension: a quantitative
genetic study. 52nd Congress June 28Jul 2, Trans Europ Orthod Soc:
5970.

85

Twin Studies
Ribeiro DC, Brook AH, Hughes TE, Sampson WJ, Townsend GC (2013).
Intrauterine hormone effects on tooth dimensions. J Dent Res 92:425431.
Shapiro BL (1969). A twin study of palatal dimensions partitioning genetic and
environmental contributions to variability. Angle Orthod 39:139151.
Siemens HW (1927). The diagnosis of identity in twins. J Hered 18:201209.
Siemens HW, Hunold X (1924). Zwillingspathologische Untersuchungen der
Mundhhle. Arch Dermatol Syph 147:409423.
Sognnaes RF, Rawson RD, Gratt BM, Nguyen NBT (1982). Computer comparison
of bitemark patterns in identical twins. J Am Dent Assoc 105:449451.
Staley RN, Green LJ (1971). Bilateral asymmetry in tooth cusp occurrence in
human monozygotic twins, dizygotic twins, and nontwins. J Dent Res
50:8389.
Staley RN, Greene LJ (1974). Types of tooth cusp occurrence asymmetry in human
monozygotic and dizygotic twins. Am J Phys Anthropol 40:187195.
Su CY, Corby PM, Elliot MA, StudenPavlovich DA, Ranalli DN, Rosa B, etal.
(2008). Inheritance of occlusal topography: a twin study. Eur Arch Paediatr
Dent 9:1924.
Tangchaitrong K, Messer LB, Thomas CDL, Townsend GC (2000). Fourier analysis
of facial profiles of young twins. Am J Phys Anthropol 113:369379.
Thesleff I (2006). The genetic basis of tooth development and dental defects. Am J
Med Genet A 140:25302535.
Townsend GC, Martin NG (1992). Fitting genetic models to Carabelli trait data in
South Australian twins. J Dent Res 71:403409.
Townsend G, Richards L, Hughes T (2003). Molar intercuspal dimensions: genetic
input to phenotypic variation. J Dent Res 82:350355.
Townsend GC, Corruccini RS, Richards LC, Brown T (1988). Genetic and
environmental determinants of dental occlusal variation in South Australian
twins. Aust Orthod J 10:231235.
van Dongen J, Slagboom PE, Draisma HHM, Martin NG, Boomsma DI (2012).
The continuing value of twin studies in the omics era. Nat Rev Genet
13:640653.

86

Chapter Four
COHORT 1: TEETH AND FACES OF SOUTH
AUSTRALIAN TEENAGE TWINS

Introduction
There is an interesting lineage of researchers who influenced Grant Townsend and
contributed directly or indirectly to the establishment of the three major studies
of Australian twins and their families at the Adelaide Dental School. These studies
commenced in 1983 and still continue today.
Townsend studied the subject Genetics and Human Variation IH presented
by Professor John Henry Bennett from the Department of Genetics at the University
of Adelaide in 1973. This was part of his Honours year, referred to as a BScDent
(Hons) degree. This subject included a practical component which involved Nick
Martin as a tutor in the laboratory. Another member of the staff in the Department
of Genetics at that time was Dr George Mayo, who was more than happy to answer
questions about genetic aspects of dentistry and to help subsequently with any issues
that arose in writing up papers from Townsends PhD (Figure 4.1). Nick Martin has
continued to be a magnificent supporter of the Adelaide Dental School twin studies
over the past thirty-five years, always prepared to provide advice and to encourage and
challenge us to push back the frontiers of knowledge.
JH Bennett subsequently put together the combined works of Sir Ronald
Fisher, who spent time in Adelaide during the 1960s. Fisher was a mentor to Kenneth
Mather and John Jinks, who supervised Lindon Eavess PhD; and Eaves, in turn, was
a supervisor of Nick Martins PhD.

87

Twin Studies

Figure 4.1
John Henry Bennett, George Elton Mayo and Nick Gordon Martin.

After being appointed to the academic staff of the Adelaide Dental School in
1977, Townsend and his PhD supervisor, Professor Tasman Brown, published some
papers presenting the main findings of the thesis entitled Tooth size variability in
Australian Aboriginals: a descriptive and genetic study (Townsend and Brown, 1978a,b;
Townsend, 1978; Brown and Townsend, 1979; Townsend and Brown, 1979a,b).
Townsend was well aware of the ongoing importance of the records collected in the
1950s and 1960s during the longitudinal growth study of Aboriginal Australians
living at Yuendumu in the Northern Territory (Brown etal., 2011). He was keen to
establish another ongoing study that would enable questions about the genetic basis
of dental development and morphology to be further addressed, and he realised the
potential of studying twins.

Figure 4.2
Tasman Brown.

88

Cohort 1: Teeth and faces of South Australian teenage twins

In November 1982, in collaboration with Nick Martin, who was with the
Australian Twin Registry at the time, detailed planning for examination of the first
cohort of South Australian twins began. This study drew heavily on the classical twin
model, where comparisons are made between pairs of monozygotic and dizygotic
twins to unravel the influences of genetic and environmental factors on observed
variability of features. However, with the development around that time of more
sophisticated statistical methods of genetic modelling, together with a growing
appreciation of the unique nature of the twinning process, a clearer insight into the
causes of non-genetic variability in twins was also beginning to emerge.

Cohort 1 (April 1983)

The general aim of this first study (now referred to as Cohort 1) was to estimate
the relative contributions of genetic and non-genetic factors to observed variation
in the teeth and faces of South Australian twins. It was hypothesised that there
would be a strong genetic influence on variation observed in the dentition and facial
structures, but that non-genetic (environmental) influences acting during pre- and
postnatal development would also be important contributors to observed variability.
Specifically, it was aimed to compare variability, including asymmetry, in different
features of the teeth and dental arches in monozygotic and dizygotic twins, and also
in singleton groups. It was also aimed to quantify and compare facial morphology,
particularly asymmetry, in twins using stereophotogrammetric and computer-based
techniques for the analysis of data in three dimensions.
This was the first study of the teeth and faces of twins using techniques such
as stereophotogrammetry and computer modelling to be undertaken in Australia
and one of the first in the world. It was hoped that when the collection of twin
material was complete, there would be a unique resource available in Adelaide which
would attract local and overseas researchers for years to come, in a similar manner
to the Yuendumu material. Indeed, this has occurred, with a stream of researchers
continuing to visit the Adelaide Dental School to examine the material.
The dentition provides an excellent model system, not only to study the genetic
basis of craniofacial development, but also to investigate some of the questions of
altered laterality (sidedness) associated with the twinning process. As we explained
in Chapter One, teeth are particularly suitable for genetic studies because their

89

Twin Studies
final crown morphology is determined well before they emerge into the mouth,
and they then remain stable, apart from the effects of wear or dental restorative
procedures. Furthermore, embryological development of the dentition extends from
about four weeks in utero through a series of recognisable stages of morphogenesis,
differentiation, calcification and emergence until around twenty-one years postnatally.
The teeth can therefore serve as a model system for studying the nature and timing of
developmental disturbances that occur from early in life until after adolescence. The
bilateral arrangement of the teeth also enables comparisons to be made of the size
and shape of corresponding teeth on the right and left sides of the dental arches. This
provides insights into questions of symmetry and asymmetry.
It was felt that combining the unique features of the dentition with the twinning
process should prove to be a very fruitful avenue for research. Furthermore, it was
considered that this type of research would have important implications, not only in
clarifying the relative contributions of genetic and environmental influences to normal
variation in dental and facial structures, but also in providing a rational approach to
the prevention of disharmonies in the system. The studies that were planned aimed
to provide insights into early developmental events in twinning, including the
determination of body symmetry and the fascinating phenomenon of mirror imaging,
where one member of a twin pair can mirror the other for one or more features.

Methodology and data acquisition

The first study of twins was limited mainly to teenage twins living in Adelaide. By
the ages of 12 to 13 years, most children have all of their permanent teeth, except the
third molars (or wisdom teeth). It was felt that this age group would be prepared to
participate in a study that would involve dental examinations and obtaining dental
impressions, as well as the donation of a blood sample to confirm zygosity.
In setting up the study, close liaison was maintained with the Australian
Twin Registry in Melbourne, where a large database had been compiled of the
names of twins and their families interested in participating in research projects.
Letters inviting participation in the study were sent out to families of twins, and
approximately 50 per cent of those contacted agreed to participate. The study was
approved by the Research Advisory Committee of the Australian NHMRC Twin
Registry, the Research Review Committee of the Royal Adelaide Hospital, and the

90

Cohort 1: Teeth and faces of South Australian teenage twins

Ethics Committee of the University of Adelaide. The NHMRC guidelines on human
experimentation were followed.
The study involved examinations of the twins in the Adelaide Dental School.
All of the participants were volunteers and were able to withdraw from the study at
any time. There was no experimentation carried out in the strict sense, as the study
only involved making observations and obtaining records from the participants. Apart
from direct examination of the teeth and oral structures, records collected included
dental impressions from which dental casts were constructed, stereophotographs of
the face, extra-oral and intra-oral colour photographs of the face and teeth, and blood
samples for zygosity determination.
The examinations took about forty-five minutes for each pair of twins, and
often over twelve pairs of twins and their siblings would be seen each day. Other family
members were also examined if they were agreeable. Colgate, a well-known company
which produces various dental products including toothpaste and toothbrushes, was
happy to offer its products to be included in special show bags for the participants.
Indeed, Colgate continues to support our research and we are extremely grateful for
their ongoing generosity. We had arranged for a staff member from the Institute of
Medical and Veterinary Science (IMVS) to come over to the Dental School (which is
located next door) to obtain blood samples of the twins for zygosity testing. Ted Wild
fulfilled this role very ably for many years and then, later, the twins would walk across
to the IMVS building to be seen there.
It was decided to also record fingerprints and palm-prints from the twins.
Dermatoglyphics, or the study of fingerprints, is a recognised area in physical
anthropology and there have been many studies of fingerprint patterns in twins.
These studies have confirmed that there is a strong genetic contribution to
variation in the pattern of fingerprints on each finger. However, there were no
published studies aimed at finding out whether there were common genetic factors
influencing the shape of the teeth and the shape or pattern of fingerprints within
individuals. Given that teeth and fingerprints are both derived from an interaction
between epithelial tissue and mesenchymal tissue during development, it seemed
that there could be common controlling mechanisms operating on both features.
Furthermore, the arrangement of the fingers, with five on each hand, provides an
opportunity to compare the expression of the patterns between fingers on one hand
and between corresponding fingers on opposite hands. The dentition provides

91

Twin Studies

Figure 4.3
The team at work obtaining photographs of teeth, dental impressions, blood samples
for zygosity determination and facial stereophotographs.

similar opportunities to compare the size and shape of different teeth within the
same dental arch for example, it is possible to compare the first molar with the
second molar, as well as to make comparisons between corresponding teeth on
opposite sides of the dental arch or in opposing arches. This is an area of research
that we are currently exploring. Interestingly, there have been some recent reports
of associations between different patterns of fingerprints and susceptibility to dental
decay (Abhilash etal., 2012).
In collaboration with Dr David Hay, at that time in the Department of
Genetics and Human Variation at La Trobe University, fingerprints and palmprints were also collected (Figure 4.4), as well as information relating to laterality

92

Cohort 1: Teeth and faces of South Australian teenage twins

Figure 4.4
Examples of fingerprint patterns: a loop, a whorl and a tented arch (left to right).

(for example, handedness, foot dominance and eye dominance). Information about
birthweights and lengths of the twins was also gathered, as well as medical histories.
With the assistance of Professor Bhim S Savara, a visiting Fulbright scholar in
1983, a procedure for obtaining facial stereophotographs of the twins was developed
using two Hasselblad cameras mounted on a special frame for photogrammetric
accuracy (Figure 4.5).

Figure 4.5
The stereophotographic set-up with Bhim Savara and an example of stereophotographs
of a pair of monozygotic twins.

93

Twin Studies
George Travan was appointed as a Research Officer in the Adelaide School of
Dentistry in 1984 (Figure 4.6). His background in computer science was invaluable
for the development of the software, and he also established an excellent liaison with
the Faculty of Engineering. This enabled access to computer packages that were
very advanced for the time and that ran on the Universitys VAX system, enabling
manipulation of three-dimensional (3D) data, including the display and modelling of
complex surfaces such as those characterising the human face. With the assistance of
scientists from different South Australian Government departments, Travan produced
machine-milled facial models. These were visually striking, and the approaches
developed were subsequently applied by surgeons in the Australian Craniofacial Unit
at the Adelaide Womens and Childrens Hospital.
This facial mapping procedure was similar to that used to survey contour maps,
and it quantified the face in three dimensions, with contour lines at regular intervals
representing the third dimension. Output in the form of 3D co-ordinates, stored on
magnetic tape in those days, could then be transferred to the mainframe computer at
the University of Adelaide for further processing. Tasman Brown and George Travan
then developed custom-made software to enable the facial images to be generated by
the computer and displayed in any orientation.
When a Sun 3/60 workstation was installed in our own laboratory, we were
able to better process the large data sets that we were generating, particularly in

Figure 4.6
George Travan with his SUN workstation.

94

Cohort 1: Teeth and faces of South Australian teenage twins

Figure 4.7
Examples of early attempts to produce contour maps and wireframe and solid models
of twins faces.

relation to graphic representations. Codenamed Ferrari by the manufacturers, the

Sun workstation was considered to be a very powerful computer at this time. By
todays standards, however, its specifications would be surpassed by a smartphone!
For the genetic analysis of the faces of twins, we took the stereopairs obtained
from the two Hasselblad cameras and positioned them in a Wild-Leitz stereoviewer.
Reference points and principal points were marked on the left and right images. The
films were then positioned on a Summagraphics digitiser in appropriate orientation,
and co-ordinates of each reference point were obtained on each left and right image
(Figure 4.8). Software, developed from standard photogrammetric algorithms,
allowed us to calculate the 3D co-ordinates of each point, taking into account scaling
factors and the geometry of the photographic system. We selected reference points
from those in common use in medicine and anthropology, representing anatomical

95

Twin Studies

Figure 4.8
Stereoviewer for examining facial photographs and Wendy Schwerdt digitising.

features of the eyes, nose and mouth. There are obvious limitations with these types
of soft tissue points, many of which are located in movable tissues, but the results of
our replicability studies were encouraging.
Another piece of equipment that we thought was state-of-the-art in the 1980s
was a set of digital callipers with specially sharpened tips that enabled us to measure
the size of thousands of tooth crowns from the dental models that we had constructed
(Figure 4.9). These callipers enabled measurements to be made to an accuracy of
0.1mm and they were connected to an Apple IIc computer that was set up to enable
measurements to be recorded rapidly and accurately in digital format. Although

Figure 4.9
Jim Rogers measuring teeth with digital callipers connected to
an Apple IIc computer.

96

Cohort 1: Teeth and faces of South Australian teenage twins

callipers are still used by some researchers to record tooth size measurements, there
is always a risk that the sharpened beaks of the callipers will scratch the dental
models. For this reason, and coupled with the rapid developments in digital imaging,
many studies of tooth size, including our own, are now based on obtaining indirect
measurements from 2D or 3D digital images.
In collaboration with researchers from Nihon University at Matsudo in Japan,
including Dr Mitsuo Sekikawa, we also applied techniques of Moir photography to
enable complex surfaces, such as dental crowns, to be imaged and then measured in
3D with an accuracy of 0.2 mm (Figure 4.10).
A number of developments for the analysis of twin data were being applied in
the 1980s. The approach of Martin and Eaves from Birmingham (Martin etal., 1978)
and also those of Christian and colleagues from Indiana (Christian, 1979) were used
in Adelaide. The twin model computer programs developed by Christian, referred to
as TANOVA and TWNAN, were adapted for use on the Universitys VAX computer
and then tested and verified. These were the days when big jobs like this had to be
run on the Universitys central mainframe computer how things have changed!
Development of this software in Adelaide led to a very productive collaboration with
Rob Corruccini (Figure 4.11) from Southern Illinois University,USA.

Figure 4.10
Mitsuo Sekikawa adjusting the Moir equipment and the resultant images of
permanent upper first molars from a pair of monozygotic (MZ) twins and a pair of
dizygotic (DZ) twins. Images of teeth reproduced with permission of Nihon University
Journal of Oral Science (copyright) (Sekikawa etal., 1989).

97

Twin Studies

Figure 4.11
Rob Corruccini, and Rob with Samvit Kaul, Grant Townsend, Tasman Brown and
Lindsay Richards.

Townsend met Corruccini at the VIIth International Symposium on Dental

Morphology in Paris in 1986 (Russell et al., 1988). Corruccini had previously
presented evidence that non-genetic factors, probably related to food consistency and
chewing force, were likely to be important determinants in the development of dental
occlusion that is, the way the teeth fit together. He proposed that the increased
frequency of malocclusion in modern human populations following industrialisation
had occurred too rapidly to be explained in genetic terms and that it was more likely
that this trend was related to the adoption of softer Western-style diets. During a
period of sabbatical leave in Adelaide in 1987, Corruccini scored occlusal traits in the
South Australian twin sample, using similar methods to those that he had applied to
US and Indian samples. He made various observations and measurements from our
dental models, and then the genetic analyses of Christian and colleagues were applied
to the data. This research led to a paper published in the Australian Orthodontic Journal
and another in Human Biology (Townsend etal., 1988a; Corruccini etal.,1990).
In 1986, Townsend also participated in the 5th International Congress on Twin
Studies, in Amsterdam, the Netherlands. It was here that he met Charles (Chuck)
Boklage and was fortunate enough to spend some time talking with him about twins
and twinning, and listening to some of his ideas. Boklage has been a provocative
figure in twin research for decades and the results of his research on tooth size in twins
have served as an impetus for many of our projects in Adelaide. He recently published
a book summarising his main findings entitled How New Humans are Made. It is a

98

Cohort 1: Teeth and faces of South Australian teenage twins

very stimulating read and poses many thought-provoking questions about the nature
of the twinning process and the development of body symmetry (Boklage, 2010).
In the foreword to the papers inspired by an international workshop on twin
methodology held in Belgium in 1987 and published in a special issue of the journal
Behavior Genetics, Martin and colleagues pointed out that
twin studies are growing larger and more complex every year as workers from a
wide variety of biomedical and behavioural disciplines realize the power of twin
designs. Yet many of these studies are analyzed in no more depth than could
have been achieved in 1929 when Holzinger formulized the intuitive argument
put forth by Galton in 1875. (Martin etal., 1989)

This statement was particularly relevant to twin studies of dental morphology

which had been carried out in the past or were being carried out at the time, where
the ultimate aim was merely to calculate values of heritability, usually without any
attempt to provide error estimates. Martins statement had a strong effect on our
research group, and it was decided that the most up-to-date methods needed to be
used when analysing our twin data.

Fitting genetic models to dental data from twins

In the early 1990s, with the help of Nick Martin, model-fitting approaches began
to be applied to analyse our twin data. The software program for structural equation
modelling, called LISREL, was used, along with its pre-processor, PRELIS. These
programs were applied to both discrete and continuous data. At this point, structural
equation models had been used for some time in the social and behavioural sciences,
but they were only beginning to be used more widely in human genetics. Indeed,
to our knowledge, we were the first group of dental researchers to apply these much
more sophisticated types of genetic modelling to large sets of dento-facial data.
Until this time, many dental researchers had tended to concentrate on rarer
Mendelian disorders rather than trying to analyse the more common, but complex,
traits, such as tooth size and facial dimensions. Many of the variables that we planned
to examine in our study did not display simple modes of inheritance for example,
autosomal dominant or recessive but appeared to be modified to varying degrees
by environmental factors. Indeed, many of the phenotypes of interest to oral health
professionals, such as dental caries and periodontal disease, show multifactorial

99

Twin Studies
modes of inheritance, with genotypes responding to an array of environments. These
phenotypes tend to show continuous distributions ranging from normal to abnormal
in the extremes.
The shape-fitting algorithms that our group was using for comparisons of
facial images between the twins also needed to be developed and implemented on
our personal computers, the Sun system and the universitys VAX computer. These
programs enabled representations of the faces of monozygotic and dizygotic twins
to be rotated and superimposed to highlight similarities and differences between
cotwins, including evidence of mirror imaging (Figures 4.12 and 4.13).
An advanced database system was also developed using SIR software to
electronically store and access the twin records. This is essential in studies that
generate large amounts of data. More recently, we have implemented a new relational
database using a Microsoft Access front-end user interface and an MS SQL 2015
Server backend to store the data. Similar to the advances in computing technology
mentioned above, this new system is several orders of magnitude more sophisticated
than the original SIR system. It provides ease of data entry and access and has
significant redundancy to ensure data are maintained with high fidelity in the event
of a system failure. This is important, as funding bodies such as the NHMRC now
have specific requirements for how funded medical research data are collected,
stored, archived and, where necessary, disposed of, in line with ethical and privacy
requirements. The University of Adelaide has also implemented a broad-based data
repository to assist with reporting requirements, and our system will eventually send
summary research data to this server.

Figure 4.12
Contour maps of the face of a twin rotated from frontal to lateral views.

100

Cohort 1: Teeth and faces of South Australian teenage twins

Figure 4.13
Theoretical combinations of facial asymmetry. Twins 1 symmetry of both faces;
Twins 2 asymmetry in one face (in right facial image); Twins 3 concordant
asymmetry in both faces; and Twins 4 discordant asymmetry of faces, with mirror
imaging. Reproduced with permission of the Australian Dental Journal (Hughes etal.,
2014).

Some of the variables studied in this first study included various features of the
teeth such as the size of the dental crowns for example, maximum mesiodistal and
buccolingual crown diameters, as well as intercuspal distances. However, traditional
measures of maximum tooth crown size provide little insight into the nature of dental
crown shape. Some previous studies from our group had indicated that measurements
based on the cusp tips would be more likely to provide biologically meaningful data,
as these sites represent the sites of initial crown calcification (refer to Figure 1.5 in
Chapter One).
One of the first morphological crown features studied was Carabelli trait.
An example of its expression in the form of a large additional cusp on permanent
maxillary first molars in a pair of monozygotic twins is provided in Figure 4.14. The
heritability estimate for this feature was found to be very high, around 90 per cent,
indicating that most of its variation could be accounted for by genetic factors.

101

Twin Studies

Figure 4.14
Estimates of heritability (h2) for different dental features: dental
crown size, Carabelli trait and anterior overbite and overjet.
Values for heritability can range from 0 to 100 per cent
(Townsend etal., 2012).

102

Cohort 1: Teeth and faces of South Australian teenage twins

By examining the mixed dentition of individuals and scoring the expression of
features such as Carabelli trait on both primary and permanent teeth, it is possible to
gaininsight into both genetic and environmental influences on observed variation of teeth
that have formed at different times. That is, such an examination provides something like
a mini-longitudinal study of an individual based on a single dental model.
Apart from showing an example of Carabelli trait in a pair of monozygotic
twins, Figure 4.14 also shows that the heritability estimates obtained for dental
crown size have also been high, ranging from 60 per cent to 90 per cent. In contrast,
estimates of heritability for some occlusal features, such as anterior overbite and
overjet, have been low, indicating that non-genetic factors contribute significantly to
observed variation.
On a side-note, it is rather exciting to realise that a pair of monozygotic twin
boys, sons of one of a pair of monozygotic twin girls who participated in Cohort 1 at
age 17 years, participated in Cohort 2. The boys are now adults in their mid-twenties
and their parents are in their forties (Figure4.15).

Figure 4.15
Two generations of twins who participated in Cohorts 1 and 2.

103

Twin Studies

Some key findings of our studies involving Cohort 1

Some of the studies summarised below were untaken while we were involved in
collecting data for Cohort 2 (described in the next chapter). However, they were based
on data obtained from Cohort 1 and were related to the main aims of that study.
1. Using newer methods of analysis, our studies showed that previous
estimates of heritability for tooth size were probably exaggerated because
various assumptions of twin research had not been tested. Using a
method for shape matching based on least squares fit of homologous
co-ordinates (a statistical method of comparing two shapes represented
by corresponding points), differences in facial asymmetry were detected
between male and female dizygotic twins, and evidence of mirror imaging
was noted in some monozygotic twin pairs (Townsend et al., 1986;
Brown et al., 1992). This was one of the earliest applications of shape
matching in this context and a precursor to the present-day geometric
morphometric analyses that are being increasingly used in studies of
evolution and development (Al-Shahrani etal., 2014).
2. It was shown that it is possible to determine the zygosity of twins very
accurately by making comparisons of the appearance of their teeth.
Only three pairs of twins from 120 pairs were misclassified on the basis
of dental morphology, all being classified as dizygotic whereas blood
tests indicated that they were monozygotic (Townsend et al., 1988b).
This finding has implications in the field of forensic odontology for
identification of individuals from their teeth.
3. It was noted that there was a relatively small contribution of genetic
factors to variation in some of the features that indicate how the upper
and lower teeth fit together for example, anterior overbite and
overjet. This emphasises the importance of environmental influences on
occlusal variation, a finding that has implications for the way in which
orthodontists view the causes of malocclusions and, consequently, the
way in which they may be prevented or treated (Townsend etal., 1988a;
Corruccini etal., 1990).
4. It was noted that genetic factors play an important role in contributing
to variation in dental arch shape but not to asymmetry in arch form

104

Cohort 1: Teeth and faces of South Australian teenage twins

(Richards et al., 1990). This finding confirms the clinical impression
that the symmetrical shapes of the dental arches are under strong
genetic influence but that asymmetries are likely to be due to localised
environmental effects, such as pressures from the tongue, lips and
cheeks.
5. By fitting newly developed genetic models to data for Carabelli trait,
a morphological feature that appears mainly on permanent upper first
molars and primary upper second molars, values for heritability of around
90 per cent were found, suggesting that there is a very strong genetic
influence of variation of this feature. This has important implications for
anthropological studies that use dental features, such as Carabelli trait,
to make inferences about affinities and migratory patterns of past and
present human populations (Townsend and Martin, 1992).
6. Many examples of mirror imaging in the teeth and faces of twins in
Cohort 1 have been noted, and approximately 30 per cent of monozygotic
twins in the sample showed discordance for handedness, presumably
reflecting differences in cerebral lateralisation. At the time that the study
was performed, it was not possible to demonstrate any clear association
between mirror imaging and chorion (foetal membrane) type of the
twins, as ultrasound technology had not advanced to its present stage
(Townsend etal., 1994).
7. A mathematical approach based on Fourier functions showed that there
is a significant genetic contribution to variation in the convexity of the
facial profile, facial height and facial depth. Variability in nose and lip
morphology, however, appeared to be under stronger environmental
influence (Vanco et al., 1995). These findings have significance for
researchers in the field of craniofacial biology and for practising
orthodontists.
8. A study of congenitally missing upper lateral incisors (agenesis) in our
twin sample showed that the frequency was similar to singletons (around
2 per cent) and identified five pairs of monozygotic twins who displayed
varying expressions of normal, small, peg-shaped and missing upper
laterals. These findings were consistent with a multifactorial threshold
model linking tooth size and number, as described initially by Brook

105

Twin Studies
(1984). It was proposed that developmental influences were likely to
modify the appearance of the lateral incisors in those monozygotic twin
pairs whose genetic make-up placed them near the threshold for either
having a lateral incisor or not (Townsend etal., 1995). This concept was
expanded further in a later paper that is reported in Chapter Five.
9. Paula Dempsey completed her PhD entitled The nature of genetic and
environmental contributions to dental variation in twins and their families
in 1998. Her co-supervisors were Townsend and Martin. Several excellent
papers arose from her research, which was one of the first comprehensive
analyses of the human dentition based on sophisticated genetic modelling
of data derived from a large sample of twins. By applying multivariate
genetic modelling methods to tooth size data, it was possible to partition
out the various sources of genetic and environmental variation in much
greater detail than had been possible previously. This study revealed a strong
contribution of additive genetic effects, as well as shared environmental
influences and unique environmental effects. There also appeared to be
symmetry of the genetic and environmental influences between right and
left sides. Other papers based on Dempseys research reported evidence of
non-additive genetic effects on the canines, suggesting an important role
for these teeth during human evolution. Common environmental effects
were most strongly associated with the permanent first molars, indicating
a possible role of the uterine environment in the determination of the size
of these teeth (Dempsey etal., 1995; Dempsey etal., 1999a; Dempsey
and Townsend, 2001). These findings have important implications for
studies of human evolution and dental development.
10. Collaborative studies of facial asymmetry and attractiveness in our
sample of twins with an American psychologist, the late Linda Mealey,
showed that the more symmetric twin of a pair was consistently rated as
more attractive, and that the magnitude of the difference between twins
in perceived attractiveness was directly related to the magnitude of the
perceived difference in symmetry. These results support the evolutionary
model of mate choice and also the medical model of fluctuating
asymmetry as an indicator of developmental health. This work has been
cited widely and shows how studies of teeth and faces can have very wide-

106

Cohort 1: Teeth and faces of South Australian teenage twins

ranging applications and significance (Mealey etal., 1999, Mealey and
Townsend, 1999).
11. There are several different twin models that can be used for research
purposes. One involves studying opposite-sex dizygotic twin pairs. We
showed, for the first time, that the females from opposite-sex dizygotic
twin pairs had larger teeth than the females from either dizygotic samesex twin pairs or monozygotic twin pairs. This study provided support for
the Twin Testosterone Transfer (TTT) hypothesis, which proposes that
androgens can diffuse from a male to a female foetus in utero, influencing
behavioural and morphological traits (Dempsey etal., 1999b). A more
recent study by Daniela Ribeiro, which formed part of her PhD thesis,
provided further support for the TTT hypothesis (Ribeiro etal., 2013).
12. In another study, we hypothesised that intercuspal distances of human
molar teeth would show greater phenotypic variation but lower
heritabilities (that is, the contribution of genetic factors to observed
variation) than traditional overall crown measures (that is, maximum
mesiodistal and buccolingual crown diameters). Our findings supported
this hypothesis and were, therefore, consistent with substantial epigenetic
influence on the progressive folding of the internal enamel epithelium
of developing molar teeth, following the formation of the primary and
secondary enamel knots. The significance of these findings was that they
helped to draw together the results of molecular biologists and dental
anthropologists in providing a more comprehensive explanation of the
developmental events that lead to the phenotypic appearance of fully
formed teeth (Townsend etal., 2003).
13. Although our studies of twins have focused on teeth and faces, we have
also collected data on handedness, and our findings have been included
in two publications (Dempsey etal., 1999c; Medland etal., 2009). In the
earlier one of these papers, which was based entirely on our Australian
sample, it was shown that the frequency of non-right-handedness was
elevated in twins of all zygosities (12 to 23 per cent) compared with
frequencies reported for the general population (around 10 per cent). In
this study, no significant associations were found between handedness and
sex, or zygosity, or birth order or birthweight. There was no evidence for

107

Twin Studies
a significant genetic effect on handedness or for birth factors. However,
there is always an issue of statistical power in these types of studies
that is, whether the sample sizes are large enough to show a significant
effect. The later study included many twin studies from all around the
world, with a total sample of 54 270 individuals and 25 732 families.
Interestingly, there was no evidence of hormonal effects, mirror imaging
or twin specific effects in this very large sample. Furthermore, there
were no differences in the prevalence of non-right-handedness between
zygosity groups or between twins and their singleton siblings. There was
evidence that additive genetic effects contributed to about 25 per cent
of the observed variation in handedness, with the rest due to non-shared
environmental influences.

108

Cohort 1: Teeth and faces of South Australian teenage twins

References
Abhilash PR, Divyashree R, Patil SG, Gupta M, Chandrasekar T, Karthikeyan R
(2012). Dermatoglyphics in patients with dental caries: a study on 1250
individuals. J Contemp Dent Pract 13:266274.
AlShahrani I, Dirks W, Jepson N, Khalaf K (2014). 3DGeomorphometrics
tooth shape analysis in hypondontia. Front Physiol. 5:154. doi:10.3389/
fphys.2014.00154 Accessed 21 May 2015.
Boklage CE (2010). How new humans are made. Singapore: World Scientific
Publishing Co. Pte. Ltd.
Brook AH (1984). A unifying aetiological explanation for anomalies of human
tooth number and size. Arch Oral Biol 29:373378.
Brown T, Townsend G (1979). Sex determination by single and multiple tooth
measurements. In: Occasional Papers in Human Biology 1. Canberra:
Australian Institute of Aboriginal Studies, pp. 116,
Brown T, Townsend GC, Pinkerton SK, Rogers JR (2011). Yuendumu: legacy of
a longitudinal growth study in Central Australia. Adelaide: University of
Adelaide Press.
Brown T, Townsend GC, Richards LC, Travan GR, Pinkerton SK (1992). Facial
symmetry and mirror imaging in South Australian twins. In: Craniofacial
Variation in Pacific Populations. Brown T, Molnar S, editors. Adelaide:
Anthropology and Genetics Laboratory, The University of Adelaide,
pp.7998.
Christian JC (1979). Testing twin means and estimating genetic variance: basic
methodology for the analysis of quantitative twin data. Acta Genet Med
Gemellol 28:3540.
Corruccini RS, Townsend GC, Richards LC, Brown T (1990). Genetic and
environmental determinants of dental occlusal variation in twins of different
nationalities. Hum Biol 62:353367.
Dempsey PJ, Townsend GC (2001). Genetic and environmental contributions to
variation in human tooth size. Heredity 86:685693.

109

Twin Studies
Dempsey PJ, Townsend GC, Martin NG (1999a). Insights into the genetic basis of
human dental variation from statistical modelling analyses. Perspec Hum Biol
4(3):917.
Dempsey PJ, Townsend GC, Richards LC (1999b). Increased tooth crown size in
females with twin brothers: evidence for hormonal diffusion between human
twins in utero. Am J Hum Biol 11:577586.
Dempsey P, Schwerdt W, Townsend G, Richards L (1999c). Handedness in twins: the
search for genetic and environmental causes. Perspec Hum Biol 4(3):3744.
Dempsey PJ, Townsend GC, Martin NG, Neale MC (1995). Genetic covariance
structure of incisor crown size in twins. J Dent Res 74:13891398.
Hughes TE, Townsend GC, Pinkerton SK, Bockmann MR, Seow WK, Brook AH,
etal. (2014). The teeth and faces of twins: providing insights into dentofacial
development and oral health for practising oral health professionals. Aust
Dent J 59 (1 Suppl):101116.
Martin NG, Boomsma DI, Neale MC (1989). Foreword. Behav Genet 19:57.
Martin NG, Eaves LJ, Kearsey MJ, Davies P (1978). The power of the classical twin
study. Heredity 40:97116.
Mealey L, Townsend GC (1999). The role of fluctuating asymmetry on judgements
of physical attractiveness: a monozygotic cotwin comparison. Perspec Hum
Biol 4(1):219224.
Mealey L, Bridgstock R, Townsend GC (1999). Symmetry and perceived facial
attractiveness: a monozygotic cotwin comparison. J Pers Soc Psychol
76:151158.
Medland SE, Duffy DL, Wright MJ, Geffen GM, Hay DA, Levy F, etal. (2009).
Genetic influences on handedness: data from 25,732 Australian and Dutch
twin families. Neuropsychologia 47:330337.
Ribeiro DC, Brook AH, Hughes TE, Sampson WJ, Townsend GC (2013).
Intrauterine hormone effects on tooth dimensions. J Dent Res 92:425431.
Richards LC, Townsend GC, Brown T, Burgess VB (1990). Dental arch
morphology in South Australian twins. Arch Oral Biol 35:983989.
Russell DE, Santoro JP, SigogneauRussell D (1988). Teeth revisited: Proceedings
of the VIIth International Symposium on Dental Morphology. Mmoires du

110

Cohort 1: Teeth and faces of South Australian teenage twins

Musum National DHistoire Naturelle, Sciences de la Terre, Tome 53. Paris:
ditions du Musum Paris.
Sekikawa M, Namuri T, Kanazawa E, Ozaki T, Richards LC, Townsend GC etal.
(1989). Threedimensional measurement of the maxillary first molar in
Australian Whites. Nihon Univ J Oral Sci 15:457464.
Townsend G (1978). Genetics of tooth size. Aust Orthodont J 5:142147.
Townsend G, Bockmann M, Hughes T, Mihailidis S, Seow WK, Brook A (2012).
New approaches to dental anthropology based on the study of twins. In:
NewDirections in Dental Anthropology: paradigms, methodologies and outcomes.
Townsend G, Kanazawa E, Takayama H, editors. Adelaide: University of
Adelaide Press, pp. 1021.
Townsend GC, Brown T (1978a). Inheritance of tooth size in Australian
Aboriginals. Am J Phys Anthropol 48:305314.
Townsend GC, Brown T (1978b). Heritability of permanent tooth size. Am J Phys
Anthropol 49:497504.
Townsend GC, Brown T (1979a). Family studies of tooth size factors in the
permanent dentition. Am J Phys Anthropol 50:183190.
Townsend G, Brown T (1979b). Tooth size characteristics of Australian Aborigines.
Occasional papers in Human Biology 1. Canberra: Australian Institute of
Aboriginal Studies, pp. 1738.
Townsend GC, Brown T, Richards LC, Rogers JR, Pinkerton SK, Travan GR etal.
(1986). Metric analyses of the teeth and faces of South Australian twins.
ActaGenet Med Gemellol 35:179192.
Townsend GC, Corruccini RS, Richards LC, Brown T (1988a). Genetic and
environmental determinants of dental occlusion variation in South Australian
twins. Aust Orthod J 10:231235.
Townsend GC, Richards LC, Brown T, Burgess VB (1988b). Twin zygosity
determination on the basis of dental morphology. J Forensic Odontostomatol
6:115.
Townsend GC, Martin NG (1992). Fitting genetic models to Carabelli trait data in
South Australian twins. J Dent Res 71:403409.

111

Twin Studies
Townsend G, Richards L, Brown T, Pinkerton S (1994). Mirror imaging in twins:
some dental examples. Dent Anthropol News 9:25.
Townsend G, Richards L, Hughes T (2003). Molar intercuspal dimensions: genetic
input to phenotypic variation. J Dent Res 82:350355.
Townsend G, Rogers J, Richards L, Brown T (1995). Agenesis of permanent
maxillary lateral incisors in South Australian twins. Aust Dent J 40:186192.
Vanco C, Kasai K, Sergi R, Richards LC, Townsend GC (1995). Genetic and
environmental influences on facial profile. Aust Dent J 40:104109.

112

Chapter Five
COHORT 2 A LONGITUDINAL STUDY OF
DENTAL AND FACIAL DEVELOPMENT IN
AUSTRALIAN TWINS AND THEIR FAMILIES

Introduction
In 1994 the Craniofacial Biology Group decided that it would be valuable to carry out
a comprehensive study of dental and facial development and morphology in young
twins in the 4-6-year-old age interval to supplement previous studies of teenage twins.
At that time, there had been no detailed studies of the teeth or faces of young twins
with primary (deciduous) teeth. It was also not known whether special features of the
twinning process affected dental and facial features of young twins. It was planned,
if funding allowed, to re-examine these twins again around the ages of 9 to 11 years
and then at around 12 to 14 years of age. This would then become one of the few
longitudinal studies of twins focusing on teeth and faces to be carried out worldwide.
The aim in setting up this study of young twins, who are now referred to as
Cohort 2, was to extend the use of newly developed methods of genetic model-fitting
to data obtained from teeth and faces of both monozygotic and dizygotic twins, so that
we could clarify in more detail than previously the roles of genetic and environmental
determinants on observed variation. We also aimed to compare the expression of bilateral
dental and facial features on the right and left sides, in both twins and singletons, to see
the extent to which the twinning process affects the determination of body symmetry.
This included our desire to explore more fully the fascinating phenomenon of mirror
imaging, where one twin of a pair mirrors the other for one or more features.

113

Twin Studies
As has been emphasised earlier, the primary teeth provide an excellent model
system to study genetic aspects of dental and facial development. They also have
advantages for investigating some of the questions relating to observed developmental
differences between dental and facial features on the right and left sides (disturbed
laterality) thought to be associated with the twinning process.
Most of the development of the primary tooth crowns occurs between
approximately four weeks in utero and birth, with all the crowns being completely
formed by around twelve months postnatally. This developmental span enables
an assessment of how various pre- and perinatal factors, such as maternal health,
smoking and alcohol consumption, placenta type and birth weight, might influence
dental structures.
Once the primary teeth have emerged into the oral cavity, their crowns do not
change in size or shape, apart from due to the effects of wear, disease or restorative
procedures. The bilateral arrangement of teeth within the dental arches also enables
comparisons to be made of the size and morphology of corresponding teeth on the
right and left sides, providing insight into questions of symmetry and asymmetry.
The high standard of oral health in South Australian children during the
1990s meant that most of the children in the 4-6-year-old age range had full primary
dentitions with very few restorations. Interestingly, this has changed over the past
twenty years, with nearly half of Australian children in the 5-6-year-old age bracket
now having a history of dental decay affecting their primary teeth. Similarly, nearly
half of Australian 12-year-olds now have a history of decay in their permanent teeth.
Of considerable concern is that those children from the lowest socioeconomic areas
have about 70 per cent more dental decay than those from the highest socioeconomic
regions of Australia (Ha etal., 2011). The reasons for this recent increase in decay
in Australian children are likely to include a decrease in the proportion of children
who brush their teeth twice a day with fluoridated toothpaste (many children only
brush once a day) and the consumption of soft drinks, cordial and juices rather than
fluoridated tap water. This reinforces the point that any gains achieved in oral health
within a community can be rapidly lost if there are changes in dietary practices and
oral health care.
Given that there are twenty primary teeth and that the sizes of these teeth are
correlated that is, if a central incisor is larger than average in a child, then the
other teeth will also tend to be larger it was clear that statistical approaches would

114

Cohort 2 A longitudinal study of dental and facial development

be needed to analyse our data that could take account of intercorrelations between
variables. These types of analyses which include many intercorrelated variables are
referred to as multivariate analyses. It was particularly important for the proposed
multivariate studies that full sets of data were obtained for as many children as
possible, because missing values always pose a problem for such analyses. As very few
children in the 4-6-year-old age group were likely to have received any orthodontic
treatment, the problems of selection bias that can be a major confounding problem
for studies of the permanent dentition were also overcome to a large extent.
Following discussions with the NHMRC Twin Registry, from whom it was
intended to recruit twins for the study, it was clear that a large proportion of the twins
enrolled with the Registry were in the 2-6-year-old age bracket. This provided an
excellent pool of potential participants. We had also estimated that there were around
200 pairs of twins, enrolled with the Registry, who fell within the desired age group
and were living in the Adelaide metropolitan area.
Reflecting on the Foreword written by Nick Martin and colleagues to the
papers arising from the 12th International Congress on Twin Studies in Belgium,
published in the journal Behavior Genetics (Martin et al., 1989; see also page 13
of Chapter Four), we were aware that many of the previous twin studies of dental
morphology had employed rather simplistic analyses and focused almost entirely on
trying to estimate heritabilities.
Around this time, the methods of genetical analysis of covariance structure
that had been introduced by Karl Jreskog in the early 1970s (Jreskog, 1973), which
had then been adapted by Nick Martin and Lyndon Eaves (Martin and Eaves, 1977),
were being further developed. For example, Andrew Heath and colleagues, and Mike
Neale and Lon Cardon were developing powerful new methods that would enable
hypotheses about the structure of variation within, as well as covariation between,
variables to be tested.
In the 1990s, Professor Mike Neale from the Medical College of Virginia,
USA, the author of LISREL and Mx manuals for genetic modelling, visited Adelaide
and provided us with very helpful advice about how to apply his software to our
dental data. Although opportunities for face-to-face contact have been limited
since then, Professor Neale has provided our group, especially Paula Dempsey
throughout her PhD (Dempsey etal., 1995) and more recently Associate Professor
Toby Hughes, with invaluable advice, and we are very grateful that he continues

115

Twin Studies
to do so. Some of the advantages of using LISREL and its successor, Mx, are that
they allow various genetic models to be fitted to the data that have been collected,
and then these models can be tested statistically to assess their goodness-of-fit to
the data.
It was decided to use the software program Mx, developed by Mike Neale,
to analyse our dental data from Australian twins. A collaboration had already been
commenced with Nick Martin applying Mx to dental crown measurements of the
permanent dentitions of teenage twins (Cohort 1), but it was now planned to extend
these studies to include the primary dentition (Cohort 2), and eventually to analyse
data from both dentitions of individuals to see whether the same genetic factors
operated over time, influencing the development of both sets of teeth.
Mx is essentially an improved version of LISREL, the linear structural
modelling program that was developed by Karl Jreskog and Dag Srbom (1989).
The advantage of Mx over previous approaches for analysing twin data was that
it enabled various genetic models to be fitted to correlation matrices by a method
referred to as maximum likelihood. Initially, the pre-processing package PRELIS
was used to generate the correlation matrices from raw data for monozygotic and
dizygotic twin pairs. Different models could then be tested using Chi-square tests
to determine the goodness-of-fit of the data to the models; and then estimates of
the model parameters for example, additive genetic variance and environmental
variance, as well as their standard errors could be obtained.
This innovation represented a major advance over traditional methods, which
were based on various assumptions and did not provide for different models to be
tested, one after the other, to see how well they fitted the data. Previous methods
tended to lead to the calculation of estimates of heritability based on simple formulae,
and did not enable standard errors of estimates to be calculated readily. The use of
LISREL and Mx was facilitated by the application of path analysis, which enabled
path diagrams to be generated. (For an example of a path diagram, see Figure5.1
below.) These diagrams showed the relationships of the so-called latent (or hidden)
variables which represented genetic and environmental causes of individual
differences to the dental and facial features being measured that is, the various
dento-facial phenotypes. Mx also provided a number of particularly useful additional
features, including the ability to model group means and to test for sex-limitation and
interactions between the genotype and environment.

116

Cohort 2 A longitudinal study of dental and facial development

Figure 5.1 presents a simple path diagram of a structural equation model
(SEM) representing the twin relationship for a single trait. Variation in the observed
twin phenotypes (square boxes) is influenced by a number of latent (unmeasured)
variables (circles). Broadly speaking, these are the additive effects of an individuals
genes (A), the non-additive effects (dominance, epistasis) of an individuals genes
(D), the influence of the environment shared by co-twins (C), and the unique
environment experienced by an individual twin (E). This last variable also encapsulates
experimental error. The model completely decomposes observed variation into a
number of discrete linear relationships between latent and measured variables, related
by a series of parameters (a, d, c and e) which can be estimated using likelihoodbased approaches. The structural elements of the model (intra-pair correlations,r)
capitalise on the observers knowledge of biology underpinning the relationships
between latent variables. To this end, additive genetic effects have a correlation (r) of
1.0 in monozygotic twins, and 0.5 in dizygotic twins. Unsurprisingly, the correlation
between shared environments is 1.0 regardless of zygosity for twins raised together.
It was also decided to use the co-twin control design where appropriate. As
we explained in Chapter Three, this model involves studying pairs of monozygotic
twins where one member of the pair may have been exposed to a different treatment

Figure 5.1
Path diagram showing the relationships between a pair of twins for a single trait.

117

Twin Studies
or experience than the other. Assuming that all other influential environmental
factors are the same in each twin, the differences observed between monozygotic cotwins can be related to the treatment or the different experience. It was felt that this
design would be relevant to comparisons of various dental and facial features. For
example, it would be possible to look at differences in expression of various dental
anomalies between monozygotic co-twins, such as congenitally missing teeth or extra
(supernumerary) teeth. There was also the possibility of exploring the outcomes when
one twin displayed a habit, such as thumb-sucking, and the other did not; or where
one co-twin had orthodontic treatment and the other did not. At that time, there was
very little literature published on what role epigenetic factors might play as a source
of differences between monozygotic co-twins.

Collection of records and examination of twins

Twins were recruited from the NHMRC Twin Registry in Melbourne and invitations
to participate were mailed to twin families in Adelaide and Melbourne. Professor
Louise Brearley Messer, a specialist paediatric dentist at the Dental School in
Melbourne, was contacted, and she agreed to join the study (Figure 5.2).

Figure 5.2
Sandy Pinkerton (front left) with Professor Louise Brearley Messer (front right)
with other members of the Melbourne team.

118

Cohort 2 A longitudinal study of dental and facial development

The initial plan was to examine and obtain records of around 250 pairs of twins
in Adelaide and Melbourne in the 4-6-year-old age bracket. It was envisaged that
about fifty pairs of twins would be recruited into each of the following five groups:
monozygotic twin boys, monozygotic twin girls, dizygotic twin boys, dizygotic twin
girls, dizygotic boy/girl pairs.
It was planned to obtain a comprehensive range of observations and records
from the twins, including direct examinations of their teeth and oral structures, to
record teeth present, dental caries, restorations, dental anomalies (such as missing
teeth, fused teeth, extra teeth), and type of occlusion. It was also important to arrange
for the necessary photographic equipment and other items to be ready at each
appointment in the Adelaide and Melbourne Dental Hospitals. Logistical demands
were made even more difficult, as it was intended to obtain fingerprints and dental
impressions using alginate impression material from which study models would be
poured up in dental stone. Stone dental models have the advantage of providing
permanent records of the dentitions of twins which can be studied for years and years
the only disadvantage being the space they take for storage. Recently, orthodontists
have begun producing virtual models, which are produced by obtaining 3D scans of
impressions or previously obtained dental models. This is clearly a development with
important research implications, provided the accuracy of the virtual models can be
shown to be good enough. We are in the process of scanning all of our dental models,
not only as a means of saving space but also as a back-up for the original models in
case they are damaged.
Initially, it was unclear how difficult it would be to obtain high-quality dental
impressions from children who would be only 4 to 6 years of age. Although several
members of the research team who had been assembled were dentists, managing
young children in the dental surgery can be tricky, and there was some concern
that specialist input from a paediatric dentist might be needed to ensure that the
impressions were of high enough quality to enable the acquisition of highly precise
measurements. Our plan was to examine primary teeth of the twins soon after
they were all present in the mouth (usually by around 4 years of age) and then
again when the twins were around 9 to 11 years old (when there is usually a mix
of primary and permanent teeth), and then a third time when they were 12 to
14years old (when all of the permanent teeth have usually emerged except for the
third molars).

119

Twin Studies
The length of time this longitudinal project would involve was also a matter for
some concern initially. Would the study be able to hold the interest of the children over
those years? Would the families be available for the arranged appointments? To cover
the second problem, concerning appointment availability, twin appointments were
made when school holidays and the university vacations overlapped, so that parents,
twins, their siblings, postgraduate dentists and academic staff could be available at
the same time. Importantly, too, would it be possible to obtain the continual funding
required to run a longitudinal study?
As it turned out, the clinical procedures went well, with good dental impressions
being obtained from most of the children, even the 4- and 5-year-olds, and the interest
of both parents and children remained excellent (Figure 5.3). To many of the researchers
it was a revelation that the parents responded so well to the requirements of the study,
with many parents freely giving their time and covering their own expenses to travel
large distances to attend the clinical sessions. After the first field trip to Melbourne in
July 1995, another trip was arranged in September of the same year. Then a return
trip was made in January 1996. The combined collection of records obtained in both

Figure 5.3
Dental assistant modelling a ghost on a twins finger whilst her impression was being
obtained by a dentist. Melbourne session, September 1998.

120

Cohort 2 A longitudinal study of dental and facial development

Adelaide and Melbourne for those six months totalled 200 twin pairs (Figure 5.4).
One of the most important issues to consider when making alginate impressions is the
ability to pour dental stone into the impressions as soon as possible. Therefore, in both
Melbourne and Adelaide, it was essential to be able to have a fast and reliable service
to pour the impressions in stone before the impression material became distorted. This
was achieved by having dedicated laboratory technicians or senior dental students on
hand throughout the period of the visits.
Another important requirement in the acquisition of records was the need to
obtain fingerprints from the young participants. Grant Townsend had commenced
collecting fingerprints and palm-prints (dermatoglyphics) of twins and family
membersduring the data collection in Cohort 1 (see Chapter Four). The children
particularly enjoyed getting their fingers dirty with printers ink when making

Figure 5.4
Serial upper dental models of a pair of twins in Cohort 2.

121

Twin Studies
fingerprints. These records added to those already acquired, which we hope will
establish whether there are common genetic factors that influence the size, shape and
patterning of teeth and fingerprints within individuals (Figure 5.5).
Hand, eye and foot preference records were also collected. Based upon the
Edinburgh Inventory (Oldfield, 1971), testing was conducted for hand, eye and foot
dominance. Previously, with the teenage twins in Cohort 1, a small number of items
had been used to remind the twins whether they predominantly used their left or
right hand when carrying out a task. With much younger participants in Cohort 2,
an obstacle course was devised, designed to downplay the fact that this was a test and
to replace it with entertaining tasks. Balls were kicked and thrown around, and toy
telescopes and microscopes were used. The children had fun (and so did we) as their
hand, eye and foot actions were noted. It was easier, and more objective, to observe
them at play with their unconscious actions than it was to ask them direct questions.
Parental comments after watching their children play were important in order to

Figure 5.5
Comparison of fingerprint patterns in a pair of monozygotic twins (above and below).
The patterns are very similar but not identical.

122

Cohort 2 A longitudinal study of dental and facial development

compare what was observed at home and what the researchers observed during the
testing period.
It was decided that it would be valuable to ask the parents of the twins to gather
their twins primary (baby) teeth as they were lost (or shed). Sophisticated imaging
techniques were becoming available and, although they were still very expensive at that
time, it was thought that the teeth could be kept in storage until it became feasible to
scan them later on. This would enable the different dental tissues composing teeth to be
examined in detail for example, the enamel, dentine and pulp cavities.
Previous research with Professor Lassi Alvesalo and his colleagues in Finland
had been aimed at clarifying the roles of the sex chromosomes in human dental
development. By measuring tooth crowns on intra-oral radiographs obtained from
individuals with extra or missing sex chromosomes, it was evident that the thickness
of the enamel and dentine varied significantly as the number of X and Y chromosomes
varied. In fact, the X chromosome appeared to mainly regulate enamel thickness,
with increasing thickness being associated with more X chromosomes. In contrast,
the Y chromosome seemed to affect both enamel and dentine thickness (Alvesalo
etal., 2009; 2013). Using exfoliated teeth from the twins, it is now planned to further
explore the roles of genetic and environmental influences on the dental tissues, to
build on the pioneering work of Lassi Alvesalo and his team.
Meanwhile, it was decided that during the visits to Melbourne we would
continue to obtain facial photographs in a standardised manner, as had been done for
Cohort 1. This was one aspect of the study where Louise Messers expertise and access

Figure 5.6
Testing eye dominance and hand dominance.

123

Twin Studies

Figure 5.7
Exfoliated primary teeth with chart recording the dates when teeth were shed.

to a standardised 2D photographic system in Melbourne proved to be invaluable, and

the equipment that was used is described in more detail later in this chapter. Medical
histories of the mothers during pregnancy were also recorded, including placenta type
(for example, whether one or two placentas were present), and also information about
smoking and alcohol consumption.

Cohort 2 as a longitudinal study

There are definite advantages in carrying out longitudinal growth studies of humans
rather than using the more common cross-sectional approach. Given that we all grow
and develop at different times and rates, the best way to accurately characterise the
growth process is to follow individuals throughout their period of growth, rather than
to group children of different ages together and examine them only once. However,
by their very nature, longitudinal studies take a long time to complete, so there is
inevitably attrition of participants over time, as they move to other places or lose
interest in the study. There is also the issue of ongoing commitment by the researchers
and, of course, the high cost involved. We knew that we were committed enough to
ensure that we would maintain our enthusiasm for the proposed research, but the

124

Cohort 2 A longitudinal study of dental and facial development

funding of these types of studies is always problematic. For longitudinal studies, it is
essential to have ongoing funding, and we were acutely aware when we commenced
this study that we would be reliant on continual funding from the NHMRC and
other funding bodies.
In terms of the potential significance of the proposed research, it was
very apparent to us that a better understanding was needed of how genetic and
environmental factors influenced dental and facial growth over time in young,
growing children. This would provide a stronger scientific basis for early preventive
and treatment-planning approaches in those individuals who develop disharmonies
of the teeth and/or jaws, such as crooked teeth or altered contact between the
dental arches. These disharmonies are commonly described as malocclusions, but
they actually represent the extremes of normal variation in the development of the
dentition. Furthermore, there is no definite cut-off point beyond which it can be
stated definitively that a malocclusion is present or not. Thus it is imperative to
understand how genetic and environmental factors, and also epigenetic factors,
influence normal growth and development before we can hope to understand the
factors that contribute to the variation observed in the number, size, shape and
arrangement of teeth in the population at large.
Dental malocclusion represents a significant problem in Australia, with the
prevalence estimated to be around 60 per cent, and treatment costs running into
millions of dollars per year. More recently, there has been increased interest in
early intervention to prevent malocclusions, but relatively little is known about the
appropriate age at which to intervene, or about the effectiveness of early treatment in
the longer term.
Around the time that we were beginning our longitudinal study, Juha Varrela
and Pentti Alanen (1995) made the following statement in an editorial in the topranking dental research journal, the Journal of Dental Research: There is a clear need
for research programs on early occlusal and craniofacial development from the point
of view of prevention and early treatment. Juha Varrela is Professor of Orthodontics
at the University of Turku in Finland, and for many years he has been a pioneer in
treating occlusal problems in the primary dentition phase, so it was very encouraging
to read this statement. We felt we were on the right track!
Given the early timing of development of the primary teeth, it was also
thought that this study should help to better understand the early developmental

125

Twin Studies
events in the twinning process, including the determination of body symmetry and
the phenomenon of mirror imaging.
As the plans for running an ongoing longitudinal study of dental and facial
growth and morphology developed further, we realised that we would need to
package the study into components when seeking support for funding from the
NHMRC. After successfully collecting records of over 300 pairs of twins at the
primary dentition phase, we felt confident that we could extend the study to include
re-examining the same twins at two other important milestones in terms of their
dental development at the mixed dentition stage around 8 to 10 years of age, and
then again at the permanent dentition phase, around 12 to 14 years of age. It was
decided to concentrate initially on the collection of records and acquisition of data at
the mixed dentition stage, while simultaneously testing several hypotheses relating to
the primary and mixed dentitions. Fortunately, this proved to be a successful strategy
and we received funding from the NHMRC which enabled us to move forward with
the study. We realised that we would need to travel to Melbourne to examine many
of the twins, so we were very pleased to extend our ongoing collaboration with Louise
Messer, who was a Chief Investigator on our NHMRC grant application.

Twins in Melbourne
As the study proceeded, the exploration of facial morphology became centred on
the Dental School in Melbourne, where an orthogonal photographic system had
been set up in the Department of Orthodontics. Professor Louise Brearley Messer
took charge of photographing the twins when they came to the School for their
dental appointments. The system allowed a right facial profile and a frontal view
to be obtained simultaneously under standardised conditions of lighting and facial
position. The frontal images could be used for linear and plane measurements, and the
profiles could be used for Fourier analysis. We had also developed software to allow us
to calculate the 3D co-ordinates of facial reference points, taking into account scaling
factors and the geometry.
It was decided to record some additional features of the dentition, as well
as those already mentioned. These included wear facets on teeth, which indicated
the nature and extent of tooth wear that had occurred. Wear facets on opposing
teeth that can only be matched in extreme, eccentric jaw positions provide evidence
that individuals have been grinding their teeth. The term often used to describe this

126

Cohort 2 A longitudinal study of dental and facial development

activity is bruxism and this is an activity that commonly occurs at night while we
are asleep. The aetiology of bruxism remains a contentious area in dentistry, with
some researchers emphasising the importance of local factors within the dentition
(for example, occlusal interferences between opposing teeth), and others favouring
an origin within the central nervous system, linked to stress. Our twin data
provided an ideal opportunity to try to unravel the relative importance of genetic
and environmental influences on wear facet frequency and patterning, and hence to
clarify what the underlying causes of tooth grinding might be.
We also decided to examine the teeth of the twins for evidence of enamel
hypoplasia. This condition includes a variety of quantitative developmental defects
that may be evident on dental crowns as single or multiple pits, small furrows,
deep and wide troughs, or entirely missing enamel. Hypoplasias evident in fully
formed teeth result from disruptions of enamel formation which are thought to
reflect compromised nutritional status or developmental insults at the time of
crown formation. Although the position of a hypoplastic defect on the crown of a
tooth enables the timing of the insult to be inferred, the relative roles of genetic and
environmental factors in determining the expression of these defects is still unclear
(refer to Figure 1.20 in Chapter One). The detailed medical histories that we were

Figure 5.8
Professor Louise Brearley Messer obtaining standardised facial photographs of a twin
enrolled in Cohort 2.

127

Twin Studies

Figure 5.9
Dental models of a pair of monozygotic twins showing similar patterns of
tooth wear.

collecting on maternal health and postnatal development of the twins enabled

us to explore associations between developmental disturbances and expression of
hypoplastic defects.
As so often happens in longitudinal studies, fresh ideas are generated and
new initiatives developed during the course of an ongoing research project. As our
understanding of the role of genetic influences on variation in dento-facial features
improved, we became increasingly interested in the relationships between tooth
emergence and initial colonisation of bacteria in the mouth. There was evidence
that those individuals who became colonised with Streptococcus mutans at an earlier
age were more likely to suffer from dental decay subsequently. Thus it seemed to
us that studying the roles of genetic and environmental factors on the formation
and composition of dental plaque in twins offered great promise for the eventual
development of new, biologically based, preventive methods to protect against the
development of dental decay. These ideas stimulated us to decide to commence a
third major study of twins and their families, now referred to as Cohort 3. We will
discuss Cohort 3 further in the following chapter.

128

Cohort 2 A longitudinal study of dental and facial development

Some key findings of our studies involving Cohort 2

1. One of our first studies of the primary dentition of twins involved
recording the prevalence of spacing between the teeth of children between
the ages of 4 to 7 years. Our studies showed that spacing was present in
the primary dentition in most of the children examined (so it can be
considered a normal feature at these ages), and that there was a genetic
basis to the observed variation (Thomas and Townsend, 1999).
2. Fluctuating dental asymmetry (FDA) refers to the small, random
differences in size between corresponding teeth on opposite sides of the
dental arch. Increased levels of FDA have been reported in individuals
with congenital abnormalities and genetic syndromes. Associations have
also been noted with inbreeding and various environmental factors, such
as noise, temperature, and maternal smoking and alcohol consumption.
Interestingly, this study showed evidence of significant FDA in the sample
of twins studied, but there was also some evidence of directional dental
asymmetry, with some teeth being consistently larger on one side than
the other. This is a feature that continues to perplex researchers and is
currently under investigation. Our study failed to confirm the assertion of
Boklage that twins are more symmetrical in their dental dimensions than
singletons; but ours was only based on univariate analyses, rather than the
multivariate analysis undertaken by Boklage (Townsend etal., 1999).
3. As our sample of twins at the mixed dentition stage of development grew,
it became possible to study the expression of different dental features in
the primary and permanent dentitions of the same individuals for
example, Carabelli trait. This is a major advantage of studying the teeth
of children in the mixed dentition phase of development, as the primary
molars and the permanent first molar are present in the mouth at the
same time. Thus this offers a longitudinal view of dental development
in a single snapshot of time. Our studies confirmed that similar genetic
factors are likely to be involved in influencing the expression of Carabelli
trait on the upper molar teeth, but that the contribution of environmental
factors is likely to be more evident in the permanent first molar, which
develops over a longer period of time, than in the primary second molar,

129

Twin Studies
which completes its crown development by around twelve months
postnatally (Pinkerton etal., 1999).
4. One study that took advantage of the differences in birth dates of the
twins comprising Cohort 1 and those in Cohort 2 was a study of enamel
hypoplasia undertaken with Professor Rob Corruccini from the USA.
Enamel hypoplasias represent disruptions in the calcification process
during enamel formation, which are considered to reflect a response
to metabolic stress during the period of dental crown development. A
notable reduction in the frequency of hypoplasias was noted between
those twins born around 1965 (Cohort 1) and those born around
1990 (Cohort 2). While a reduction in childhood fevers and clinical
intervention to reduce stresses around birth may have contributed to
these findings, the strongest hypoplasia-preventing factor appeared
to be the introduction of water fluoridation into the water supply
(Corruccini and Townsend, 2003).
5. Another study looked at the prevalence of tooth grinding in young twins,
based on the presence of wear facets on the tips of the canine teeth.
Evidence of tooth grinding was found in all of the twins studied, and it
was often expressed more on one side than the other. There was also some
evidence of a mirror imaging effect for tooth grinding in some of the
monozygotic twin pairs (Dooland etal., 2006).
6. A series of papers with Toby Hughes as the first author provided a much
clearer picture of the role of genetic factors on observed variation in
the primary dentition than was available previously. This was due to
the application of modern methods of genetic model-fitting and the
availability of relatively large sample sizes. These findings have important
implications for dental anthropologists and clinicians (Hughes et al.,
2000; Hughes etal., 2001).
7. A study of the associations between birthweight and tooth size in twins
in Cohort 2 showed some evidence for a reduction in tooth size in the
female twins who were of low birthweight, but there was no evidence
of any reduction in the males. The reduction was small in magnitude,
being only 2 to 3 per cent in both the primary and the permanent incisor
teeth. These findings confirmed the general view that the developing

130

Cohort 2 A longitudinal study of dental and facial development

teeth are well protected from developmental disturbances during pre- and
postnatal periods (Apps etal., 2004).
8. Chorion type (that is, whether one or two placentas are present when
twins are born) is an important factor to remember when considering the
development of monozygotic twins, as vascular anastomoses (connections)
between monochorionic monozygotic twins can lead to an imbalance in
development between co-twins. In a study carried out by an Honours
student, Jonathan Race, it was found that maternal reports were unreliable
for determining chorion type, and hospital records often did not provide
enough information to be certain about chorionicity. Large birthweight
differences were found to occur more often in monochorionic twins pairs
than dichorionic pairs in the study sample (Race etal., 2006). Greater
emphasis is now being placed on accurate diagnosis of chorion type in
twin studies, as it is appreciated that not all monozygotic twins should
be lumped together for analysis. If we were commencing another twin
study now, we would certainly aim to include accurate information on
chorion type, and this has been made more feasible by the developments
in ultrasonography that enable chorion type to be determined noninvasively at around eleven to fourteen weeks in utero.
9. The aim of a study reported in the Australian Dental Journal in 2005
(Townsend etal., 2005) was to determine the prevalence of discordant
expression (that is, differences in expression) for missing teeth and extra
teeth in a sample of 278 monozygotic twin pairs, and to explain how
the differences in appearance (phenotypic differences) may have occurred
despite the similar genotypes of co-twins. At least one missing upper
lateral incisor or second premolar was noted in 24 of the 278 twin pairs
(8.6per cent), with 21 of these 24 pairs (87.5 per cent) showing discordant
expression. Nine of the 278 twin pairs had extra teeth (supernumeraries),
with 8 of the 9 pairs (88.9 per cent) being discordant. These findings
showed that differences in expression of missing or extra teeth are common
in monozygotic twin pairs, even though their genetic codes are identical.
We suggested that minor variations in epigenetic events during tooth
formation (that is, the way in which their genes are expressed) may lead to
quite distinct differences in their dental phenotypes (the number of teeth

131

Twin Studies
present). This was one of the first papers to raise the issue of epigenetic
influences on dental development based on studies of monozygotic twins.
10. A paper in the Journal of Dental Research, based on the PhD studies of
Daniela Ribeiro, was the first to investigate both primary and permanent
tooth sizes in females from opposite-sex dizygotic twin pairs compared with
females from dizygotic same-sex and monozygotic twin pairs to indicate
the intra-uterine influence of male hormones on dental development. This
paper built on the earlier work of Paula Dempsey, which concentrated on
the permanent dentition only (Dempsey et al., 1995). The findings of
Ribeiros study provide strong support for the Twin Testosterone Transfer
(TTT) hypothesis, and we have proposed that, together, the effects of
sex hormones and intra-uterine male hormone levels influence different
tooth dimensions and contribute differentially to sexual dimorphism in
the size of human teeth (Ribeiro etal., 2013).

132

Cohort 2 A longitudinal study of dental and facial development

References
Alvesalo L (2009). Human sex chromosomes in oral and craniofacial growth.
ArchOral Biol 54S:S18S24.
Alvesalo L (2013). The expression of human sex chromosome genes in oral and
craniofacial growth. In: Anthropological Perspectives on Tooth Morphology:
genetics, evolution, variation. Scott GR, Irish JD, editors. Cambridge:
Cambridge University Press, pp. 92107.
Apps MV, Hughes TE, Townsend GC (2004). The effect of birthweight on tooth
size variability in twins. Twin Res 7:415420.
Corruccini RS, Townsend GC (2003). Decline in enamel hypoplasia in relation to
fluoridation in Australians. Am J Hum Biol 15:795799.
Dempsey PJ, Townsend GC, Martin NG, Neale MC (1995). Genetic covariance
structure of incisor crown size in twins. J Dent Res 74:13891398.
Dooland KV, Townsend GC, Kaidonis JA (2006). Prevalence and side preference
for tooth grinding in twins. Aust Dent J 51:219224.
Ha D, RobertsThomson K, Armfield J (2011). The Child Dental Health Surveys
Australia, 2005 and 2006. Dental statistics and research series no. 54. Cat.
no.DEN 213. Canberra: Australian Institute of Health and Welfare. http://
www.aihw.gov.au/publicationdetail/?id=10737420637. Accessed 21 May
2015.
Hughes T, Dempsey P, Richards L, Townsend G (2000). Genetic analysis of
deciduous tooth size in Australian twins. Arch Oral Biol 45:9971004.
Hughes T, Thomas C, Townsend G (2001). A study of occlusal variation in
the primary dentition of Australian twins and singletons. Arch Oral Biol
46:857864.
Jreskog KG (1973). Analysis of covariance structures. In: Multivariate AnalysisIII
Proceedings of the Third International Symposium on Multivariate Analysis held
at Wright State University, Dayton, Ohio, June 1924. Krishnaiah PR, editor.
New York: Academic Press, pp. 263285.
Jreskog KG, Srbom D (1989). LISREL 7 users reference guide. Chicago: Scientific
Software Inc.

133

Twin Studies
Martin NG, Boomsma DI, Neale MC (1989). Foreword. Behav Genet 19:57.
Martin NG, Eaves LJ (1977). The genetic analysis of covariance structure. Heredity
38:7995.
Oldfield RC (1971). The assessment and analysis of handedness: the Edinburgh
Inventory. Neuropsychologia 9:97113.
Pinkerton S, Townsend G, Richards L, Schwerdt W, Dempsey P (1999). Expression
of Carabelli trait in both dentitions of Australian twins. Perspec Hum Biol
4(3):1928.
Race JP, Townsend GC, Hughes TE (2006). Chorion type, birth weight discordance
and toothsize variability in Australian monozygotic twins. Twin Res Hum
Genet 9:285291.
Ribeiro DC, Brook AH, Hughes TE, Sampson WJ, Townsend GC (2013).
Intrauterine hormone effects on tooth dimensions. J Dent Res 92:425431.
Thomas CJ, Townsend GC (1999). Anterior spacing in the primary dentition:
astudy of Australian twins and singletons. Perspec Hum Biol 4(3):2935.
Townsend G, Dempsey P, Richards L (1999). Asymmetry in the deciduous
dentition: fluctuating and directional components. Perspec Hum Biol
4(3):4552.
Townsend GC, Richards L, Hughes T, Pinkerton S, Schwerdt W (2005). Epigenetic
influences may explain dental differences in monozygotic twin pairs.
AustDent J 50:95100.
Varrela J, Alanen P (1995). Prevention and early treatment in orthodontics:
aperspective. J Dent Res 74:14361438.

134

Chapter Six
COHORT 3 TOOTH EMERGENCE AND ORAL
HEALTH IN AUSTRALIAN TWINS AND THEIR
FAMILIES

Introduction
While the focus of our studies involving Cohorts 1 and 2 was on dental development
and morphology, we decided to concentrate more on oral health and disease,
particularly dental decay, when studying Cohort 3. The major developments in
molecular biology have also enabled research involving this cohort to make use of
new technologies and approaches to study genetic effects more directly.
Dental decay (caries) is the most common chronic disease affecting Australian
children, despite the implementation of public health initiatives, such as fluoridated
drinking water and toothpastes. The disease can cause pain and systemic infection,
lead to speech and learning problems, and is a predictor for poor general health.
Treatment for dental caries inflicts a huge economic burden on society, accounting
for 6.5 per cent ($AUS5.3 billion) of total health care expenditure in Australia per
year (Armfield etal., 2009; Ha etal., 2011).
In 2004, we submitted an application for funding to the NHMRC for a
new initiative involving Australian twins and their families. The title of this grant
application was Tooth emergence and oral streptococci colonisation: a longitudinal
study of Australian twins. Although the application was supported, funding was
only provided for three years rather than the five years that had been requested. The
study commenced in 2005, with the twins and their families comprising what is now

135

Twin Studies
referred to as Cohort 3. The chief investigators on this project were Grant Townsend,
Kim Seow, Theo Gotjamanos, Toby Hughes, Neville Gully and Lindsay Richards.
The first aim of the project was to clarify the influences of genetic and
environmental determinants on variation in the emergence (often referred to as tooth
eruption) of the human primary teeth by applying modern methods of genetic modelfitting to longitudinal data obtained from young monozygotic and dizygotic twin
pairs. The intention was to compare variability in both the timing and sequencing
of tooth emergence within and between the twins, and to relate these findings to
measures of physical development and other pre- and postnatal factors. It was also
planned to apply linkage analyses to detect quantitative trait loci (QTLs) for dental
development using genome scans of DNA derived from cheek cells.
QTLs refer to regions of the DNA which contain, or are linked to, genes that
influence a particular quantitative feature or trait. By statistically linking phenotypic
data (obtained through the analysis of trait measurements) and genotypic data (acquired
through the use of identifying molecular markers), it is possible to explain the genetic
basis of variation in complex traits, such as dental caries (Miles and Wayne, 2008).
The second aim of the project was to study the relationship between the timing
of emergence of the primary teeth and the colonisation of the oral cavity by mutans
streptococci, bacteria known to be important in the development of dental decay
(dental caries). It was also planned, subject to ongoing funding, to examine the twins
as they grew older to record the development of any dental decay or the presence of
developmental enamel defects.
In order to better understand how genetic factors contribute to dental
caries, it was decided to determine the degree to which genetic and environmental
factors influence microbial species associated with decay and oral health. Using the
traditional twin model method, comparisons of monozygotic and dizygotic twin
pairs would be used to investigate the role of genetic factors, as well as shared and
non-shared environmental factors, in contributing to phenotypic variation. This
model relies on the fact that monozygotic twins have identical genotypes, whereas
dizygotic twins share on average half their genes. It is usually assumed that for twins
who are living together, the effect of shared environment on both monozygotic and
dizygotic twins will be equivalent. Hence, any feature that shows greater associations
between pairs of monozygotic twins compared with dizygotic twins indicates the
influence of genetic factors.

136

Cohort 3 Tooth emergence and oral health in Australian twins

Professor Kim Seow and her team of researchers from Queensland had established
the timing of initial colonisation of mutans streptococci in the mouths of pre-term
and full-term children from birth to 24 months of age (Wan etal., 2001a,b; 2003).
These studies had shown that mutans streptococci colonisation steadily increases with
increasing age and number of teeth. They had also identified important infant and
maternal factors associated with the acquisition of mutans streptococci. So we were
very interested in seeing what sort of relationships might occur in monozygotic and
dizygotic twins in relation to colonisation, tooth emergence and oral health. Was there
evidence that genetic factors played an important role in these processes?
Another of our collaborators, Professor Theo Gotjamanos from the Fremantle
campus of the University of Notre Dame Australia, had noted that the primary
teeth of Australian children seemed to be erupting later than expected according
to published standards. A similar trend had also been reported for the permanent
teeth in Australian children (Diamanti and Townsend, 2003). Professor Gotjamanos
had suggested that delayed timing of emergence of the primary teeth might be a
contributory factor in an observed decline of dental caries affecting the primary teeth
of Australian children at that time. This altered window of infectivity, as it had been

Figure 6.1
Professor Kim Seow, University
ofQueensland.

Figure 6.2
Professor Theo Gotjamanos,
University of Notre Dame
WesternAustralia.

137

Twin Studies
termed by Page Caufield and colleagues (1993), was thought to be characterised by
delayed colonisation by mutans streptococci on newly emerged teeth.
Published literature at the time also suggested that children infected with
mutans streptococci before the age of 3 years had a greater prevalence of dental
caries compared with those who had been colonised later in childhood (Khler etal.,
1988). Prolonged infection with high levels of mutans streptococci had also been
associated with increased levels of dental caries in both the primary and permanent
teeth (Straetemans etal., 1998).
By obtaining plaque samples from twins and their parents and siblings,
it was aimed to find out whether mutans streptococci were acquired from both
mothers and fathers, or predominantly from mothers as reported in most previous
studies. Another aim was to determine whether acquisition of mutans streptococci
was associated with emergence of particular primary teeth, and whether there was
any relationship with subsequent caries experience. A further question that we
wanted to answer, using DNA fingerprinting techniques, was whether monozygotic
and dizygotic pairs of twins harboured the same or different strains of mutans
streptococci.
The plan was for the parents of the twins to record the timing of emergence
of all the primary teeth in their twins. A pilot study was carried out to ensure that
the recording sheets we were planning to use, and also the surveys about the health
and habits of the twins and their parents, were clear and unambiguous. The pilot
study also enabled us to confirm that the families could follow our instructions for
recording the emergence of teeth, as well as being able to collect samples of cheek cells
for zygosity testing and plaque samples for microbiological assessment. It was planned
to collect plaque samples every three months from the twins and every twelve months
from parents and other siblings. We also checked that the transportation of these
records to our laboratory was efficient and effective.
The recruiting phase of the study involved contacting mothers-to-be or mothers
of newborn twins throughout Australia and obtaining their permission to participate
in the study. Families were recruited through the NHMRC Twin Registry in
Melbourne and we also scanned through the birth columns of Australian newspapers
to identify newly born twins. The parents of the twins who agreed to participate
were asked to complete an initial questionnaire that provided information on the
pregnancy, maternal habits (such as smoking and drinking alcohol), birthweight

138

Cohort 3 Tooth emergence and oral health in Australian twins

Figure 6.3
Recording sheets for tooth emergence, including a pair of monozygotic twins (above)
and a pair of same-sex dizygotic twins (below).

139

Twin Studies

Figure 6.4
Examples of the collection kits for dental plaque, buccal cells and saliva
senttofamilies.

and length of the twins, and any illnesses. Parents were also given instructions and
forms (by email and hard copy) to record the times at which each of the twenty
primary teeth appeared in their twins mouths. We asked the parents to obtain cheek
cells of their twins for subsequent DNA analysis and zygosity testing, too, as well as
plaque samples for assessment of oral mutans streptococci levels and presence of other
microbes.
Scanning the birth columns of the Australian newspapers to look for births
of twins has proved to be a very fruitful method for recruiting families of twins to
Cohort 3, and our honorary research assistant, Ruth Rogers, has worked tirelessly
toidentify potential participants.
It was decided to give the parents another questionnaire when the twins were
around 12 months old. This survey focused on postnatal issues, including information
about any illnesses, medications, dietary habits, teething problems, and thumband finger-sucking habits. Measurements of the twins weight and height were also
obtained. The parents recordings of tooth emergence were checked by clinically
examining sub-samples of the twins. These examinations confirmed the validity of
the records being obtained (Hughes etal., 2007).

140

Cohort 3 Tooth emergence and oral health in Australian twins

The vagaries of the grant funding process

In 2007, we submitted an application to the NHMRC for a continuation of funding
for 2008-10, but our application was not successful. This represented a major blow
to our research momentum, as we were in the middle of a longitudinal study. During
the first two years of the project we had recruited over 400 pairs of twins and their
families Australia-wide, and had also commenced some analyses and submitted
papers for publication. The negative outcome of our application was a major shock,
given that no other study of this type had been undertaken previously, and given that
the reviewers comments were all very positive. The inclusion of twins and the use of a
longitudinal study design were enabling us to examine how an individuals genotype,
as well as his/her environment, acted upon both the timing and sequence of tooth
emergence and the likelihood of suffering dental decay from an early age. Although
a group of researchers in the USA was investigating the role of genetic factors in the
development of dental caries in Brazilian twins (Bretz et al., 2005a,b), they were
focusing neither on tooth emergence nor on how the timing of tooth emergence was
associated with colonisation with mutans streptococci.
With limited funding, progress on our study slowed considerably, although
we managed to keep the record collection ticking over. A grant of $AUS50 000 from
the Financial Markets Foundation for Children proved to be a lifeline for our study,
enabling us to continue to collect records from twins and their families; and our total
sample increased to over 600 families Australia-wide. We were also able to compile
and begin to administer a third questionnaire to gather more information on oral
hygiene, diet and dental disease in our cohort.

Getting beaten to the punch

We were well aware at the time of the major advances occurring in the field of
molecular genetics and the potential of genome-wide scanning approaches to identify
genes contributing to variation in complex multifactorial disorders and diseases, such
as hypertension and diabetes. We submitted grant applications to the NHMRC to
use linkage and association approaches to identify genes for dental development, but
our applications were unsuccessful.

141

Twin Studies
Table 6.1
Topics included in the questionnaires filled out by families of twins.
Questionnaire Headings

Questions relating to

Feeding Practice
Teeth and Oral Health Care

Breast- or bottle-fed, feeding times

Tooth loss
Tooth-brushing habits
Dentist visits and teeth condition
Teething
Thumb-sucking habits
Persons with whom twins spend most time
Food most commonly eaten
Twins height, weight and past illnesses
Parents smoking and drinking habits
Tooth-brushing habits
Medication taken
Dental visits and condition of teeth
Tooth charts to record the condition of twins and
parents teeth

Diet
General Health and Medical History
Smoking and Drinking
Parents Oral Health and Health Care

Optional

In 2010, the findings of a genome-wide association study (GWAS) of the

timing of primary tooth emergence in two large cohorts of children were published
(Pillas etal., 2010). The authors referred to our work, which had shown a very strong
genetic influence on the timing of emergence of the primary teeth (high heritability),
but we were very disappointed that we had not been the first group to report on
which genes seemed to affect tooth emergence.
Interestingly, five genetic loci were identified in the above-mentioned GWAS as
being involved in human dental development, with four of these also being implicated
in the development of cancer, while another was associated with occlusal anomalies in
the permanent dentition that required orthodontic treatment in later life. This latter
finding provided strong support for our contention that improved understanding
of the genetic, environmental and epigenetic influences on human primary tooth
emergence is needed to inform the clinical management of orthodontic problems
affecting not only the primary teeth but also the permanent teeth.
In addition to the GWAS of primary tooth emergence mentioned earlier,
a GWAS of permanent tooth emergence was carried out subsequently by an

142

Cohort 3 Tooth emergence and oral health in Australian twins

international team of researchers (Pillas et al., 2010; Geller et al., 2011). In
the study of primary tooth emergence, a variant of the HOXB gene cluster was
associated with alterations in dental occlusion of those study subjects who required
orthodontic treatment in later life (Pillas etal., 2010). The HOX genes are a group
of regulator genes that have been conserved throughout the course of vertebrate
evolution. They are involved in controlling the arrangement of body parts during
development, including patterning effects within the dentition for example,
the formation of incisors, canines and molars in their correct positions within the
dental arches.
Meanwhile, in the study of permanent tooth emergence, two identified loci
associated with stature and breast cancer were consistent with those identified for
primary tooth emergence, but the other loci had not been identified previously
(Geller etal., 2011).
In a recent study, a group of international researchers carried out a genomewide association study of facial morphology in nearly 10 000 individuals of European
descent, using 3D magnetic resonance images and 2D portrait images. Five
independent genetic loci were identified which were associated with different facial
phenotypes, suggesting that five candidate genes are involved in the determination of
facial morphology. Three of the candidate genes, namely PAX3, PRDM16 and TP63,
have been implicated previously in craniofacial development, whereas the other two
had not been identified as being directly involved in craniofacial development in the
past (Liu etal., 2012).
Genome-wide association studies in dentistry are now helping to identify
which particular genes are associated with dental development and oral health
(Stanley et al., 2014). Although these large-scale, multi-centre projects are still in
their infancy in dentistry, dental researchers have the advantage of being able to draw
on the experiences of geneticists and medical researchers, who have now overcome
many of the inherent difficulties and limitations of genome-wide association studies.
Traditionally, genome-wide association studies have been based on unrelated
case/control populations, but underlying stratification in the populations may lead to
spurious or misleading associations. By including family groupings in these types of
studies, particularly twins, some of the problems of population stratification can be
overcome (Hughes and Townsend, 2013).

143

Twin Studies

An exciting new collaboration

Although the outcome of our NHMRC grant application in 2007 was a major
disappointment, the year marked the beginning of an exciting new and continuing
collaboration involving our studies of twins. Grant Townsend spent a period of
sabbatical leave in Liverpool with Professor Alan Brook and his research team, who
had recently relocated from Sheffield. Over 200 sets of vacuum-formed plastic
impressions had been made of selected dental models of twins in Adelaide and these
were then shipped to Liverpool, where they were poured up in stone. This provided
a duplicate set of dental models that could then be studied in Liverpool. Alan Brook
and Richard Smith had set up state-of-the-art imaging equipment, both 2D and 3D,
to enable novel measurements of the teeth to be made, including areas, perimeters
and volumes.
During this time, a workshop was held in Liverpool to establish an International
Collaborating Centre in Oro-facial Genetics and Development, with Alan Brook,
Lassi Alvesalo and Grant Townsend as co-directors. A special issue of the journal
Archives of Oral Biology was subsequently published, containing refereed papers
arising from the workshop (Brook, 2009). The aim of the International Collaborating
Centre was to bring together colleagues from different centres around the world who
were using different approaches, so that existing collaborations could be developed
further and new collaborations established.
It was decided to purchase similar imaging equipment to that in Liverpool for
our laboratory in Adelaide so that we could ensure a standardised approach to future
studies. Alan Brook then came to Adelaide to consolidate the links that had been
established. Indeed, he is now spending most of his time in Adelaide as an Adjunct
Professor in the School of Dentistry, and as a key member of our research group. The
Collaborating Centre has been developed as a Collaborating Network, and a special
issue of the Australian Dental Journal, edited by Grant Townsend and Alan Brook,
which contains several papers from members of the Craniofacial Biology Research
Group and the International Collaborating Network, was published in June 2014
(Townsend and Brook, 2014).

144

Cohort 3 Tooth emergence and oral health in Australian twins

Figure 6.5
Some of the initial members of the International Collaborating Centre in Oro-facial
Genetics and Development, with Professor Alan Brook in the centre.

Developments in epigenetics
The field of epigenetics has developed exponentially over the past decade or so, but
epigenetics is not a new concept. Phenotypic discordance in monozygotic co-twins
that is, differences in appearance of various features between pairs of monozygotic
twins was traditionally interpreted as indicating the influence of environmental
factors on the feature or trait being investigated. However, more recently, evidence
has accumulated that epigenetic modifications of DNA, such as methylation of DNA,
can influence the expression of genes.
Although molecular geneticists have tended to focus on processes such as
the methylation and acetylation of segments of DNA when referring to the term
epigenetics, we have used a broader interpretation of the term, following on from

145

Twin Studies
the pioneering work of Conrad Waddington (1957). We consider that the term
epigenetics can be used to refer to all of the processes by which the genotype
gives rise to the phenotype (Townsend etal., 2009). For example, epigenetic effects
may involve modification of DNA through methylation or alteration in histone
packaging through acetylation, but they may also refer to the interactive processes
that occur between cells at the local tissue level during development (Williams
etal., 2014).
Waddington provided a fascinating visual metaphor to illustrate the concept
of an epigenetic landscape, representing the processes by which cells make decisions
during development. He likened the different stages of cellular decision-making during
development to a ball rolling down an undulating landscape of interconnecting hills
and valleys. At various stages on this landscape, the ball (or cell) could take specific
permitted trajectories that would lead to different outcomes or cellular fates. We have
extended this metaphor to include the influence of epigenetic processes on a pair of
monozygotic twins (Figure 6.6).
This metaphor would seem to be very appropriate when considering the
developmental processes involved in odontogenesis, or tooth formation. Minor
variations in the timing and/or spatial relationships of interacting cells have the
potential to lead to quite different phenotypic outcomes for example, the absence
of a tooth rather than its presence, or the development of an extra tooth. Small
differences in the epigenetic landscape between right and left sides of the dentition
may also lead to distinct or subtle differences in the morphology of antimeric teeth
(that is, corresponding teeth on opposite sides of the dental arch). We would contend
that differences in the epigenetic landscape between monozygotic co-twins are likely
to account for some of the differences in dental phenotypes we have observed in these
twin pairs.
Waddingtons concept of epigenetics is compatible with the apparent dynamic
self-organising nature of tooth formation (also referred to as odontogenesis), which
leads to the unfolding of each tooths morphology. More recently, with our colleague
Professor Alan Brook, we have been investigating the development of teeth as an
example of a Complex Adaptive System (Brook etal., 2014).
Studies of epigenetic differences between monozygotic twin pairs are now
helping to explain phenotypic differences between monozygotic co-twins. Mario
Fraga and colleagues (2005) assessed the extent of two important epigenetic

146

Cohort 3 Tooth emergence and oral health in Australian twins

Figure 6.6
Waddingtons epigenetic landscape is a metaphor for how gene regulation modulates
development. Imagine a number of marbles rolling down a hill towards a wall. The
marbles will compete for the grooves on the slope, and the ridges between the grooves
represent the increasing irreversibility of cell type differentiation. Each marble will come
to rest at the lowest possible point, representing eventual cell fates, or tissue types.
Reproduced with permission from the Australian Dental Journal (Hughes etal., 2014).

modifications, DNA methylation and histone acetylation, in the genomes of forty

pairs of monozygotic twins. They found that the epigenetic profiles of monozygotic
co-twins were almost identical in 65 per cent of the twin pairs, whereas there
were significant differences in the other 35 per cent of twin pairs. Intriguingly,
the amount of epigenetic difference was directly related to the age of the twins, as

147

Twin Studies
well as to the amount of time co-twins had spent apart. The epigenetic differences
between co-twins were also greater in those pairs who had different medical
histories. These findings may explain why some MZ co-twins seem to become
less alike with age. They also suggest that environmental disturbances are likely
to contribute to epigenetic changes that accumulate over time. A recent review by
Jordana Bell and Tim Spector (2011) provides further details about how large-scale
epigenetic studies of twins promise to provide important insights into the way that
genetic, environmental and stochastic (random) factors influence epigenetics and,
in turn, variation of complex traits.
Research following the completion of the Human Genome Project has
demonstrated that the aetiology of complex diseases cannot be explained by genetics
alone. Much research is now looking at epigenetics in an effort to elucidate how the
environment interacts with our genes to bring a phenotype or disease process into
being. One aspect of current research in the Craniofacial Biology Research Group
involves investigating whether a discordant epigenetic profile may be associated
with discordant expression of dental developmental anomalies in Australian
monozygotic twins. We have subjected sixty DNA samples from thirty monozygotic
twin pairs to epigenetic analysis (genome-wide microarray methylation profiling).
A control group of concordant monozygotic pairs was compared with a group of
discordant pairs for missing and extra teeth. All groups were ascertained across a
broad range of tooth sizes, and an approximately equal distribution of males and
females was selected.
DNA samples were taken at the time of phenotyping, approximately twenty
years ago. Although a degree of degradation was evident, our samples are still of
high quality. Preliminary results have shown that there is a substantial degree of
discordance in epigenetic profiles between many monozygotic twin pairs, and
that this discordance may be greater for twins with discordant dentitions. Our
preliminary analysis suggests that, at a genome-wide level, there may be an influence
of methylation status on tooth formation, manifesting in variation in the presence
or absence of teeth. Further analyses are required to investigate effects on tooth size,
and more sophisticated site-specific analyses are also required to investigate specific
genes. Epigenetics research is now being applied in several areas of dentistry, and
promises to have far-reaching clinical implications in the future (Williams etal.,
2014).

148

Cohort 3 Tooth emergence and oral health in Australian twins

Next-generation sequencing
The advent of next-generation sequencing methods is providing enormous power
to genetically characterise diverse biological samples without needing any prior
information about the actual DNA sequences present. In collaboration with Dr
Christina Adler and Professor Neil Hunter at the University of Sydney, we are now
sequencing microbial DNA extracted from the dental plaque samples being collected
from the twins and family members in Cohort 3. The depth of sequencing provided
by next-generation methods enables sensitive detection and discrimination of a wide
diversity of microbes. In addition, this method also enables the relative abundance
of different bacterial components of the sequenced microbial community to be
determined.
Our aim, using these state-of-the-art methods, is to demonstrate the degree to
which genetic and environmental factors influence variation in the oral microbiota.
We have, therefore, extended our microbiological studies to include other bacteria
apart from mutans streptococci.
The current consensus is that dental decay is caused by a microbial shift
in oral biofilms (dental plaque) due to carbohydrate consumption, leading to
demineralisation of the tooth surface. This hypothesis is referred to as the extended
ecological plaque hypothesis (Takahashi and Nyvad, 2008). It views dental plaque as
being composed of a dynamic microbial ecosystem in which there are many different
bacteria, with the non-mutans bacteria being key organisms in maintaining dynamic
stability. With increasing numbers of non-mutans bacteria that can thrive in a lowpH environment, the microbial composition of the plaque can become destabilised,
leading to an increase in mutans streptococci that have the potential to promote the
development of carious lesions.
This hypothesis, however, does not consider the role of host genetic factors in
the development of dental caries an effect we demonstrated through our study of
oral microbiota in twins belonging to Cohort 3 (approximately 300 monozygotic
and 300 dizygotic twin pairs). Furthermore, it is unclear whether caries is associated
with an enrichment of a small number of cariogenic (decay-producing) species or
a change in the overall structure of the oral microbiota. As a result, it is unclear
exactly how the oral bacteria of a child with dental decay differ from those of a
healthy individual.

149

Twin Studies
Figure 6.7 shows an intra-oral photograph of one member of a pair of
monozygotic twins enrolled in Cohort 3 who shows extensive dental decay. One focus
of our current research is to record the expression of dental decay in pairs of monozygotic
twins, as we have already noted examples where the patterns of expression are very
similar (concordant) and other examples where they differ considerably (that is, they
are discordant). We have also noted discordance in expression of other dental features
in monozygotic twin pairs for example, in tooth emergence and also gingival health.
Figure 6.8 shows the anterior teeth of a pair of monozygotic twins enrolled in
Cohort 3. Twin A displays accumulation of dental plaque around the necks of the

Figure 6.7
An example of extensive dental decay affecting the anterior primary teeth of one of
the twins enrolled in Cohort 3.

Figure 6.8
Different expressions of dental problems in a pair of monozygotic twins.

150

Cohort 3 Tooth emergence and oral health in Australian twins

primary lower left incisors associated with gingival inflammation. These teeth are
loose, whereas Twin B has a permanent lower central incisor erupting behind the
retained primary incisor.

A new NHMRC grant

An application to the NHMRC by Christina Adler, Toby Hughes, Grant Townsend
and Manish Arora for a research project entitled Determining how genetic and
environmental factors influence the developing oral microbiota and drive disease
in early childhood was successful in receiving funding and commenced in 2014.
Christina Adler undertook her PhD with Professor Alan Cooper and his group in
the Centre for Ancient DNA at the University of Adelaide, and we have established a
collaboration with them to explore the oral microbiome of prehistoric humans, based
on DNA analysis of dental calculus, also referred to as tartar. After her PhD, Christina
took up an academic position in the Dental School at the University of Sydney.
A key focus of this new project is to extend our understanding of childhood
caries by revealing how genetic, epigenetic and environmental factors drive variation
in the composition of the developing oral microbiota through in-depth genetic
analyses. Using approaches described in a recent paper in Nature Genetics (Adler
etal., 2013), it is planned to provide a more sophisticated understanding of how the
whole oral microbial community contributes to the maintenance of oral health and
also to the development of dental decay.
Two of the research questions we are addressing are:
1. Is dental caries associated with the enrichment of a few cariogenic species
or a range of species that cause a change in the overall community
structure of the oral microbiota?
2. Are the oral microbial species that are enriched in caries as well as in
health influenced mainly by environmental or genetic factors?
The human mouth contains between 102 and 103 different species of bacteria
that can contribute to both health and disease. It is known that colonisation of
the mouth with these different types of bacteria commences at birth, and that the
composition of the oral microflora (or oral microbiota) is influenced by environmental
influences during infancy, such as diet and the use of antibiotics. Generally, the
microbiota tend to reach stable levels by early childhood.

151

Twin Studies
Apart from environmental influences, it is suspected that each individuals
genetic make-up (their genotype) plays a role in determining the overall composition
of the oral microbiota, as family members have been shown to have more similar
microbial profiles than non-related individuals. Heritable components of the oral
microbiota are thought to play a role in the development of dental decay, with
studies showing that the similarity of caries experience in monozygotic co-twins is
greater than that in dizygotic co-twins. In fact, estimates of heritability for dental
caries experience range from 30 per cent to 60 per cent (Boraas etal., 1988; Wang
etal., 2010). However, it is still unclear what the relative contributions of genetic
and environmental influences are to observed variation in the composition of the
oral microbiota, and this is one of the key questions we are addressing from both
anthropological and genetic viewpoints (Kaidonis and Townsend, 2015).
Collection of plaque and saliva samples from Cohort 3 is ongoing, as well as
clinical examinations to detect evidence of dental caries and developmental abnormalities of the teeth and oral soft tissues (Figure 6.9).

Figure 6.9
Clinical examinations of twins.

152

Cohort 3 Tooth emergence and oral health in Australian twins

Apart from the new records being collected from the participants in
Cohort 3, including plaque and saliva samples and buccal cells for epigenetic
testing, we are continuing to obtain dental impressions to enable stone models
of the teeth to be constructed. We are also obtaining fingerprints, carrying out
laterality tests and recording heights and weights. Some other new recordings
being obtained in collaboration with colleagues in Melbourne include blood
pressure readings. Figure6.10 shows various records being obtained from twins in
Cohort 3.

Figure 6.10
Various tests and measurements are performed during the visits.

153

Twin Studies

Figure 6.10 continued.

We have now reached a stage where children of twins who were enrolled in our
second cohort are involved in Cohort 3 (Figure 6.11).

The future
With the development of new equipment for measuring teeth and components of
teeth, it is now becoming possible to define more biologically meaningful dental
phenotypes. Following on from the establishment of the International Collaborating
Network in Oro-facial Genetics and Development in Liverpool in 2007, we have now

154

Cohort 3 Tooth emergence and oral health in Australian twins

Figure 6.11
Two generations of twins enrolled in our ongoing studies. The twins who are seated
behind participated in Cohort 2, and the children in front are the twin monozygotic
daughters and son of one of the twins, who are now participating in Cohort 3.

set up two-dimensional (2D) and three-dimensional (3D) imaging equipment in our

laboratory in Adelaide. We have confirmed that these systems have high accuracy and
reliability, and research projects to clarify how genetic, epigenetic and environmental
factors contribute to morphological variation within the dentition are both underway
and planned. Figure 6.12 shows how 2D imaging enables defects in enamel to be
quantified from study models.
Figure 6.13 shows 3D models of teeth and dental arches generated by a laser
scanner.
Advances in the fields of micro- and nano-imaging are also opening up new
avenues to explore the internal structure of teeth, as well as their physical and chemical
properties. We have now collected a large number of exfoliated (shed) primary teeth,
which are providing an opportunity to further study tooth structure (Figure 6.14).
Figure 6.15 shows 3D micro-CT images of teeth from a pair of monozygotic
twins where there is evidence of Carabelli trait at the dentino-enamel junction as well

155

Twin Studies

Figure 6.12
2D imaging of enamel defects. Reproduced with permission from the Australian
Dental Journal (Yong etal., 2014).

Figure 6.13
3D models of teeth (Townsend etal., 2012).

156

Cohort 3 Tooth emergence and oral health in Australian twins

Figure 6.14
Exfoliated primary teeth from a pair of twins.

Figure 6.15
3D micro-CT images of teeth from a pair of monozygotic twins. The 3D models were
generated by Dr Jeremy Deverell at the South Australian node of the Australian National
Fabrication Facility under the National Collaborative Research Infrastructure Strategy.
Reproduced withpermission from the Australian Dental Journal (Hughes etal., 2014).

157

Twin Studies
as on the enamel surface. Planned studies based on these types of images offer great
promise to link observed expression of dental features on the external surfaces of
teeth to events occurring at the site of the future dentino-enamel junction, where the
developing tooth folds to produce its crown shape.
We continue to pursue new opportunities to undertake collaborative, multicentre research in orofacial growth and development and oral health. Some recent
examples include:

a grant application to the NIH with Professor Walter Bretz from New
York University to analyse genes associated with salivary proteins in two
national twin cohorts, one from Brazil and one from our Cohort 3 from
Australia

early dialogue to undertake GWAS for orofacial phenotypes in a

consortium of twin cohorts, including Cohorts 1, 2 and 3 from our group,
various twin cohorts from Professor Nick Martins genetic epidemiology
group at the Queensland Institute of Medical Research, and several twin
cohorts from Professor Alex Vieiras group at the University of Pittsburgh

a collaborative effort between our group, Associate Professor Jeff Craigs

group at the Melbourne Childrens Research Institute and the J Craig
Venter Institute in the USA to undertake next-generation sequencing of
DNA and RNA from oral microbiome samples of twins

two new initiatives with dental anthropologists from the USA, Kathleen
Paul and Richard Scott. Paul will spend time in Adelaide examining
dental models of twins to test the performance of several dental features
in reconstructing genetic relationships for bioarcheological applications.
Scott will work on a new edition of the classic text The Anthropology
of Modern Human Teeth in Adelaide with Grant Townsend, and will
examine the twins dental models.

Some of the key findings relating to Cohort 3

1. Accurate and up-to-date data on the timing and sequence of tooth
emergence are important for researchers, clinicians and parents. Based on
data collected from Cohort 3, updated tables have been produced for the
timing and sequence of primary tooth emergence in Australian children.

158

Cohort 3 Tooth emergence and oral health in Australian twins

The first and last primary teeth emerged, on average, at 8.6 months and
27.9 months, respectively. The order of emergence, based on average
values, was central incisor, lateral incisor, first molar canine, and second
molar. However, there was considerable variation in the sequence of
emergence between individuals. Around 35 per cent of all corresponding
teeth on opposite sides of the arch emerged within two weeks of each
other. These findings indicate that primary tooth emergence is occurring
later than reported previously for Australian children but the sequence
has remained the same. Another study of the patterns of asymmetry
in primary tooth emergence showed relatively low levels of fluctuating
asymmetry throughout the dentition (minor differences between right
and left sides without any tendency for one side to be consistently earlier
in emergence than the other), with the maxillary and mandibular lateral
incisors displaying the highest values (Mihailidis etal., 2009; Woodroffe
etal., 2010).
2. Our finding that there is a very high genetic influence on variation in
primary tooth emergence in Australian twins was the first report to be
published based on sophisticated genetic modelling methods and it
spurred on the race to identify the genes associated with tooth eruption
using genome-wide association studies (Hughes etal., 2007; Bockmann
etal., 2010).
3. A paper entitled Genetic and environmental influences on human dental
variation: a critical evaluation of studies involving twins, arising from the
International Workshop on Oral Growth and Development, which was
held in November 2007 in Liverpool, was published in a special issue of
Archives of Oral Biology in 2009. This paper discusses the different methods
of analysis which can be carried out using data derived from twins, and
considers the advantages and disadvantages of these different approaches.
Results from our studies of Cohorts 1, 2 and 3 are summarised and some
of the opportunities for future research explored (Townsend etal., 2009).
4. In a study of primary tooth emergence and timing of oral colonisation
of Streptococcus mutans, it was found that approximately 20 per cent
of monozygotic twin pairs were discordant (that is, they differed) for
the timing of colonisation, in terms of whether colonisation occurred

159

Twin Studies
before or after the first primary tooth had emerged. This suggests that
environmental or epigenetic factors are likely to influence the timing of
tooth emergence, or the colonisation by Streptococcus mutans, or both
of these variables. These findings provide hope that it may be possible
to develop strategies to prevent or delay infection of children with
Streptococcus mutans and, therefore, to reduce the likelihood of future
dental disease in other words, dental decay (Bockmann etal., 2011).
5. Two areas of research that we have pursued in recent times have been those
of phenomics and epigenetics. We believe that these areas will become
increasingly important in the future. Recently, Grant Townsend and Alan
Brook edited a special issue of the Australian Dental Journal entitled: The
face, the future, and dental practice: how research in craniofacial biology
will influence patient care. This issue includes several papers that refer
to our ongoing studies of Australian twins, including papers that are
devoted to the topics of dental phenomics and epigenetics. Readers are
directed to this volume if they would like to learn more about these topics
(Townsend and Brook, 2014; Hughes etal., 2014; Williams etal., 2014;
Yong etal., 2014).

160

Cohort 3 Tooth emergence and oral health in Australian twins

References
Adler CJ, Dobney K, Weyrich LS, Kaidonis J, Walker AW, Haak W, etal. (2013).
Sequencing ancient calcified dental plaque shows changes in oral microbiota
with dietary shifts of the Neolithic and Industrial revolutions. Nat Genet
45:450455.
Armfield JM, Spencer AJ, Brennan DS (2009). Dental health of Australias teenagers
and preteen children: the Child Dental Health Survey, Australia 200304.
Dental statistics and research series no. 52. Cat. no. DEN 199. Canberra:
Australian Institute of Health and Welfare.
Bell JT, Spector TD (2011). A twin approach to unravelling epigenetics. Trends
Genet 27:116125.
Bockmann MR, Harris AV, Bennett CN, Odeh R, Hughes TE, Townsend GC
(2011). Timing of colonization of cariesproducing bacteria: an approach
based on studying monozygotic twin pairs. Int J Dent Article ID 571573,
7pages, doi:10.1155/2011/571573. Accessed 19 May 2015.
Bockmann MR, Hughes TE, Townsend GC (2010). Genetic modeling of
primary tooth emergence: a study of Australian twins. Twin Res Hum Genet
13:573581.
Boraas JC, Messer LB, Till MJ (1988). A genetic contribution to dental caries,
occlusion, and morphology as demonstrated by twins reared apart. J Dent Res
67:11501155.
Bretz WA, Corby PM, Hart TC, Costa S, Coelho MQ, Weyant RJ, etal. (2005a).
Dental caries and microbial acid production in twins. Caries Res 39:168172.
Bretz WA, Corby PM, Schork NJ, Robinson MT, Coelho M, Costa S, etal.
(2005b). Longitudinal analysis of heritability for dental caries traits. J Dent
Res 84:10471051.
Brook AH (2009). Editorial. Research collaborative initiative. Arch Oral Biol
54S:S1S2.
Brook AH, Brook ODonnell M, Hone A, Hart E, Hughes TE, Smith R, etal.
(2014). General and craniofacial development are complex adaptive processes
influenced by diversity. Aust Dent J 59 (1 Suppl):1322.

161

Twin Studies
Caufield PW, Cutter GR, Dasanayake AP (1993). Initial acquisition of mutans
streptococci by infants: evidence for a discrete window of infectivity. J Dent
Res 72:3745.
Diamanti J, Townsend GC (2003). New standards for permanent tooth emergence
in Australian children. Aust Dent J 48:3942.
Fraga MF, Ballestar E, Paz MF, Ropero S, Setien F, Ballestar ML, etal. (2005).
Epigenetic differences arise during the lifetime of monozygotic twins.
ProcNatl Acad Sci U.S.A. 102:1060410609.
Geller F, Feenstra B, Zhang H, Shaffer JR, Hansen T, Esserlind AL, etal.
(2011). Genomewide association study identifies four loci associated with
eruption of permanent teeth. PLoS Genet 7:e1002275 doi:10.1371/journal.
pgen.1002275. Accessed 19 May 2015.
Ha D, RobertsThomson K, Armfield J (2011). The Child Dental Health Surveys
Australia, 2005 and 2006. Dental statistics and research series no. 54. Cat. no.
DEN 213. Canberra: Australian Institute of Health and Welfare.
Hughes TE, Bockmann MR, Seow K, Gotjamanos T, Gully N, Richards LC, etal.
(2007). Strong genetic control of emergence of human primary incisors.
JDent Res 86:11601165.
Hughes T, Townsend G (2013). Twin and family studies of human dental crown
morphology: genetic, epigenetic, and environmental determinants of
the modern human dentition. In: Anthropological Perspectives on Tooth
Morphology: genetics, evolution, variation. Scott GR, Irish JD, editors.
Cambridge: Cambridge University Press, pp. 3168.
Hughes TE, Townsend GC, Pinkerton SK, Bockmann MR, Seow WK, Brook AH,
etal. (2014). The teeth and faces of twins: providing insights into dentofacial
development and oral health for practising health professionals. Aust Dent J
59 (1 Suppl):101116.
Kaidonis J, Townsend G (2015). The SialoMicrobialDental Complex in oral
health and disease. Ann Anat. doi:10.1016/j.aanat.2015.02.002. Accessed
19May 2015.
Khler B, Andren I, Jonsson B (1988). The earlier the colonization by mutans
streptococci, the higher the caries prevalence at 4 years of age. Oral Microbiol
Immunol 3:1417.

162

Cohort 3 Tooth emergence and oral health in Australian twins

Liu F, van der Lijn F, Schurmann C, Zhu G, Chakravarty MM, Hysi PG, etal.
(2012). A genomewide association study identifies five loci influencing facial
morphology in Europeans. PLoS Genet 8:e1002932 doi:10.1371/journal.
pgen.1002932. Accessed 19 May 2015.
Mihailidis S, Woodroffe SN, Hughes TE, Bockmann MR, Townsend GC (2009).
Patterns of asymmetry in primary tooth emergence of Australian twins.
In: Comparative Dental Morphology. Koppe T, Meyer G, Alt KW, editors.
Frontiers in Oral Biology, Basel: Karger, 2009, vol 13, pp. 110115.
Miles CM, Wayne M (2008). Quantitative trait locus (QTL) analysis. Scitable by
Nature Education 1:208. Accessed 30 July 2014.
Pillas D, Hoggart CJ, Evans DM, OReilly PF, Sipil K, Lhdesmki R, etal.
(2010). Genomewide association study reveals multiple loci associated
with primary tooth development during infancy. PLoS Genet 6:e1000856
doi:10.1371/journal.pgen.1000856. Accessed 19 May 2015.
Stanley BO, Feingold E, Cooper M, Vanyukov MM, Maher BS, Slayton RL, etal.
(2014). Genetic association of MPPED2 and ACTN2 with dental caries.
JDent Res 93:626632.
Straetemans MM, van Loveren C, de Soet JJ, de Graaff J, ten Cate JM (1998).
Colonization with mutans streptococci and lactobacilli and the caries
experience of children after the age of five. J Dent Res 77:18511855.
Takahashi N, Nyvad B (2008). Caries ecology revisited: microbial dynamics and the
caries process. Caries Res 42:409418.
Townsend G, Bockmann M, Hughes T, Mihailidis S, Seow WK, Brook A (2012).
New approaches to dental anthropology based on the study of twins. In:
NewDirections in Dental Anthropology: paradigms, methodologies and outcomes.
Townsend G, Kanazawa E, Takayama H, editors. Adelaide: University of
Adelaide Press, pp. 1021.
Townsend GC, Brook AH (2014). The face, the future, and dental practice: how
research in craniofacial biology will influence patient care. Aust Dent J 59
(1Suppl):15.
Townsend G, Hughes T, Luciano M, Bockmann M, Brook A (2009). Genetic and
environmental influences on human dental variation: a critical evaluation of
studies involving twins. Arch Oral Biol 54S:S45S51.

163

Twin Studies
Waddington CH (1957). The strategy of genes: a discussion of some aspects of
theoretical biology. London: Allen & Unwin.
Wan AKL, Seow WK, Purdie DM, Bird PS, Walsh LJ, Tudehope DI (2003). A
longitudinal study of Streptococcus mutans colonization in infants after tooth
eruption. J Dent Res 82:504508.
Wan AKL, Seow WK, Walsh LJ, Bird P, Tudehope DI, Purdie DM (2001a).
Association of Streptococcus mutans infection and oral development nodules
in predentate infants. J Dent Res 80:19451948.
Wan AKL, Seow WK, Purdie DM, Bird PS, Walsh LJ, Tudehope DI (2001b). Oral
colonization of Streptococcus mutans in sixmonthold predentate infants.
JDent Res 80:20602065.
Wang X, Shaffer JR, Weyant RJ, Cuenco KT, DeSensi RS, Crout R, etal. (2010).
Genes and their effects on dental caries may differ between primary and
permanent dentitions. Caries Res 44:277284.
Williams SD, Hughes TE, Adler CJ, Brook AH, Townsend GC (2014). Epigenetics:
a new frontier in dentistry. Aust Dent J 59 (1 Suppl):2333.
Woodroffe S, Mihailidis S, Hughes T, Bockmann M, Seow K, Gotjamanos T, etal.
(2010). Primary tooth emergence in Australian children: timing, sequence
and patterns of asymmetry. Aust Dent J 55:245251.
Yong R, Ranjitkar S, Townsend GC, Smith RN, Evans AR, Hughes TE, etal.
(2014). Dental phenomics: advancing genotype to phenotype correlations in
craniofacial research. Aust Dent J 59 (1 Suppl):3447.

164

Chapter Seven
PUBLICATIONS AND THESES RELATING TO
THEADELAIDE TWIN STUDIES

Publications
1980s
Brown T, Townsend GC, Richards LC, Travan GR (1987). A study of dentofacial
morphology in South Australian twins. Aust Dent J 32:8190.
Sekikawa M, Namura T, Kanazawa E, Ozaki T, Richards LC, Townsend GC,
BrownT (1989). Threedimensional measurement of the maxillary first
molar in Australian Whites. Nihon Univ J Oral Sci 15:457464.
Townsend G (1988). Research in dentistry: growth and development. Aust Dent J
33:375378.
Townsend GC, Corruccini RS, Richards LC, Brown T (1988). Genetic and
environmental determinants of dental occlusion variation in South Australian
twins. Aust Orthod J 10:231235.
Townsend GC, Richards LC, Brown T, Burgess VB (1988). Twin zygosity
determination on the basis of dental morphology. J Forensic Odontostomatol
6:115.
Townsend GC, Brown T, Richards LC, Rogers JR, Pinkerton SK, Travan GR,
Burgess VB (1986). Metric analyses of the teeth and faces of South Australian
twins. Acta Genet Med Gemellol 35:179192.

165

Twin Studies
Travan GR, Townsend GC, Brown T, Richards LC, Burgess VB (1987). Application
of the SIR system in a study of South Australian twins. Proceedings of the
Annual Conference USIR Australasia.

1990s
Brown T, Townsend GC, Richards LC, Travan GR, Pinkerton SK (1992). Facial
symmetry and mirror imaging in South Australian twins. In: Craniofacial
Variation in Pacific Populations. Brown T, Molnar S, editors. Adelaide:
Anthropology and Genetics Laboratory, The University of Adelaide,
pp.7998.
Corruccini RS, Townsend GC, Richards LC, Brown T (1990). Genetic and
environmental determinants of dental occlusal variation in twins of different
nationalities. Hum Biol 62:353367.
Dempsey PJ, Townsend GC, Martin NG (1999). Insights into the genetic basis of
human dental variation from statistical modelling analyses. Perspec Hum Biol
4(3):917.
Dempsey PJ, Townsend GC, Richards LC (1999). Increased tooth crown size in
females with twin brothers: evidence for hormonal diffusion between human
twins in utero. Am J Hum Biol 11:577586.
Dempsey P, Schwerdt W, Townsend G, Richards L (1999). Handedness in
twins: the search for genetic and environmental causes. Perspec Hum Biol
4(3):3744.
Dempsey PJ, Townsend GC, Martin NG, Neale MC (1995). Genetic covariance
structure of incisor crown size in twins. J Dent Res 74:13891398.
Kapali S, Townsend G, Richards L, Parish T (1997). Palatal rugae patterns in
Australian Aborigines and Caucasians. Aust Dent J 42:129133.
Kasai K, Richards LC, Townsend GC, Kanazawa E, Iwasawa T (1995). Fourier
analysis of dental arch morphology in South Australian twins. Anthropol Sci
103:3948.
Mealey L, Townsend GC (1999). The role of fluctuating asymmetry on judgements
of physical attractiveness: a monozygotic cotwin comparison. Perspec Hum
Biol 4(1):219224.

166

Publications and theses relating to theAdelaide Twin Studies

Mealey L, Bridgstock R, Townsend GC (1998). Symmetry and perceived facial
attractiveness: a monozygotic cotwin comparison. J Pers Soc Psychol
76:151158.
Pinkerton S, Townsend G, Richards L, Schwerdt W, Dempsey P (1999). Expression
of Carabelli trait in both dentitions of Australian twins. Perspec Hum Biol
4(3):1928.
Richards LC, Townsend GC, Brown T, Burgess VB (1990). Dental arch
morphology in South Australian twins. Arch Oral Biol 35:983989.
Richards LC, Townsend GC, Kasai K (1997). Application of the Fourier method
on genetic studies of dentofacial morphology. In: Fourier Descriptors and their
Application in Biology. Lestrel PE, editor. Cambridge: Cambridge University
Press, pp. 189209.
Springbett SM, Townsend GC, Kaidonis J, Richards LC (1999). Tooth wear in the
deciduous dentition: a crosscultural and longitudinal study. Perspec Hum
Biol 4(3):93101.
Thomas CJ, Townsend GC (1999). Anterior spacing in the primary dentition:
astudy of Australian twins and singletons. Perspec Hum Biol 4(3):2935.
Townsend GC (1992). Genetic and environmental contributions to morphometric
dental variation. In: Culture, Ecology and Dental Anthropology. Lukacs JR,
editor. Delhi: KamlaRaj, pp. 6172.
Townsend G (1994). Understanding the nature and causes of variation in
dentofacial structures. Proc Finn Dent Soc 12:642648.
Townsend G, Richards L (1990). Twins and twinning, dentists and dentistry.
AustDent J 35:317327.
Townsend GC, Martin NG (1992). Fitting genetic models to Carabelli trait data in
South Australian twins. J Dent Res 71:403409.
Townsend GC, Richards LC, Brown T (1992). Mirror imaging in the dentitions
of twins what is the biological basis? In: Craniofacial Variation in Pacific
Populations. Brown T, Molnar S, editors. Adelaide: Anthropology and
Genetics Laboratory, The University of Adelaide, pp. 6778.
Townsend GC, Aldred MJ, Bartold PM (1998). Genetic aspects of dental disorders.
Aust Dent J 43:269286.

167

Twin Studies
Townsend G, Dempsey P, Richards L (1999). Asymmetry in the deciduous
dentition: fluctuating and directional components. Perspec Hum Biol
4(3):4552.
Townsend G, Dempsey P, Richards L (1999). Causal components of dental variation:
new approaches using twins. In: Dental Morphology 1998: Proceedings of 11th
International Symposium on Dental Morphology. MayhallJT, Heikkinen T,
editors. Oulu: University of Oulu Press, pp. 464472.
Townsend G, Richards L, Brown T, Pinkerton S (1994). Mirror imaging in twins:
some dental examples. Dent Anthropol Newsl 9:25.
Townsend G, Rogers J, Richards L, Brown T (1995). Agenesis of permanent
maxillary lateral incisors in South Australian twins. Aust Dent J 40:186192.
Townsend GC, Richards LC, Sekikawa M, Brown T, Ozaki T (1990). Variability of
palatal dimensions in South Australian twins. J Forensic Odontostomatol 8:314.
Townsend G, Dempsey P, Brown T, Kaidonis J, Richards L (1994). Teeth, genes
and the environment. Perspec Hum Biol 4:3546.
Townsend GC, Richards LC, Brown T, Burgess VB, Travan GR, Rogers JR
(1992). Genetic studies of dental morphology in South Australian twins.
In: Structure, Function and Evolution of Teeth. Smith P, Tchernov E, editors.
London: Freund Publishing House, pp. 501518.
Vanco C, Kasai K, Sergi R, Richards LC, Townsend GC (1995). Genetic and
environmental influences on facial profile. Aust Dent J 40:104109.

2000s
Apps MV, Hughes TE, Townsend GC (2004). The effect of birthweight on
toothsize variability in twins. Twin Res 7:415420.
CheginiFarahini S, Fuss J, Townsend G (2000). Intra and interpopulation
variability in mamelon expression on incisor teeth. Dent Anthropol 14:16.
Corruccini RS, Townsend GC (2003). Decline in enamel hypoplasia in relation to
fluoridation in Australians. Am J Hum Biol 15:795799.
Corruccini RS, Townsend GC, Schwerdt W (2005). Correspondence between
enamel hypoplasia and odontometric bilateral asymmetry in Australian twins.
Am J Phys Anthropol 126:177182.

168

Publications and theses relating to theAdelaide Twin Studies

Darwis WE, Messer LB, Thomas CDL (2003). Assessing growth and development
of the facial profile. Pediatr Dent 25:103-108.
Dempsey PJ, Townsend GC (2001). Genetic and environmental contributions to
variation in human tooth size. Heredity 86:685693.
Dooland KV, Townsend GC, Kaidonis JA (2006). Prevalence and side preference
for tooth grinding in twins. Aust Dent J 51:219224.
Eguchi S, Townsend GC, Richards LC, Hughes T, Kasai K (2004). Genetic
contribution to dental arch size variation in Australian twins. Arch Oral Biol
49:10151024.
Eguchi S, Townsend GC, Hughes T, Kasai K (2004). Genetic and environmental
contributions to variation in the inclination of human mandibular molars.
Orthod Waves 63:95100.
Higgins D, Hughes TE, James H, Townsend GC (2009). Strong genetic influence
on hypocone expression of permanent maxillary molars in South Australian
twins. Dent Anthropol 22:17.
Hughes T, Richards L, Townsend G (2001). Dental arch form in young Australian
twins. In: Dental Morphology 2001. Brook A, editor. Sheffield, England:
Sheffield Academic Press, pp. 309319.
Hughes T, Richards L, Townsend G (2002). Form, symmetry and asymmetry of the
dental arch: orthogonal analysis revisited. Dent Anthropol 16:38.
Hughes T, Thomas C, Richards L, Townsend G (2001). A study of occlusal
variation in the primary dentition of Australian twins and singletons.
ArchOral Biol 46:857864.
Hughes T, Dempsey P, Richards L, Townsend G (2000). Genetic analysis of
deciduous tooth size in Australian twins. Arch Oral Biol 45:9971004.
Hughes TE, Bockmann MR, Seow K, Gotjamanos T, Gully N, Richards LC,
Townsend GC (2007). Strong genetic control of emergence of human
primary incisors. J Dent Res 86:11601165.
Kondo S, Townsend GC (2006). Associations between Carabelli trait and cusp areas
in human permanent maxillary first molars. Am J Phys Anthropol 129:196203.
Kondo S, Townsend GC, Yamada H (2005). Sexual dimorphism of cusp
dimensions in human maxillary molars. Am J Phys Anthropol 128:870877.

169

Twin Studies
Liu P, Ranjitkar S, Kaidonis JA, Townsend GC, Richards LC (2004). A system
for the acquisition and analysis of threedimensional data describing dental
morphology. Dent Anthropol 17:7074.
Medland SE, Duffy DL, Wright MJ, Geffen G, Hay DA, Levyl F, Catherina EM,
vanBeijsterveldt CEM, Willemsen G, Townsend GC, White V, Hewitt AW,
Mackey DA, Bailey JM,. Slutske WS, Nyholta DR, Treloar SA, Martin NG,
Boomsma DI (2009). Genetic influences on handedness: data from 25 732
Australian and Dutch twin families. Neuropsychologia 47:330337.
Mihailidis S, Woodroffe SN, Hughes TE, Bockmann MR, Townsend G (2009).
Patterns of asymmetry in primary tooth emergence of Australian twins.
In: Comparative Dental Morphology. Koppe T, Meyer G, Alt KW, editors.
Frontiers in Oral Biology, Basel: Karger, 2009, vol 13, pp. 110115.
Race JP, Townsend GC, Hughes TE (2006). Chorion type, birth weight discordance
and toothsize variability in Australian monozygotic twins. Twin Res Hum
Genet 9:285291.
Smith RN, Townsend G, Chen K, Brook A (2009). Synetic superimposition
of dental 3D data: application in twin studies. In: Comparative Dental
Morphology. Koppe T, Meyer G, Alt KW, editors. Frontiers in Oral Biology,
Basel: Karger, 2009, vol 13, pp. 142147.
Smith R, Zaitoun H, Coxon T, Karmo M, Kaur G, Townsend G, Harris EF,
BrookA (2009). Defining new dental phenotypes using 3D image analysis
to enhance discrimination and insights into biological processes. Arch Oral
Biol 54S:S118S125.
Taji S, Hughes T, Rogers J, Townsend G (2000). Localised enamel hypoplasia of
human deciduous canines: genotype or environment? Aust Dent J 45:8390.
Takahashi M, Kondo S, Townsend GC, Kanazawa E (2007). Variability in cusp size
of human maxillary molars, with particular reference to the hypocone. Arch
Oral Biol 52:11461154.
Tangchaitrong K, Messer LB, Thomas CDL, Townsend GC (2000). Fourier analysis
of facial profiles of young twins. Am J Phys Anthropol 113:369379.
Townsend G (2006). Comparing identical twin pairs a research model for busy
clinicians. Dental Insights 19:1113.

170

Publications and theses relating to theAdelaide Twin Studies

Townsend G, Brook A (2008). Genetic, epigenetic and environmental influences on
the human dentition. Ortho Tribune 3:36.
Townsend G, Alvesalo L, Brook A (2008). Variation in the human dentition: some
past advances and future opportunities. J Dent Res 87:802805.
Townsend GC, Hughes T, Richards L (2005). The dentitions of monozygotic
twin pairs: focussing on the differences rather than the similarities. In:
Current Trends in Dental Morphology Research. Refereed full papers, 13th
International Symposium on Dental Morphology. Zadzinska E, editor.
Poland: University of Lodz, pp. 337352.
Townsend G, Hughes T, Richards LC (2006). Gaining new insights into how
genetic factors influence human dental development by studying twins.
Int J Anthropol 21:6774.
Townsend G, Richards L, Hughes T (2003). Molar intercuspal dimensions: genetic
input to phenotypic variation. J Dent Res 82:350355.
Townsend G, Harris EF, Lesot H, Clauss F, Brook A (2009). Morphogenetic fields
within the human dentition: a new, clinically relevant synthesis of an old
concept. Arch Oral Biol 54S:S34S44.
Townsend G, Hughes T, Bockmann M, Smith R, Brook A (2009). How studies of
twins can inform our understanding of dental morphology. In: Comparative
Dental Morphology. Koppe T, Meyer G, Alt KW, editors. Frontiers in Oral
Biology, Basel: Karger, 2009, vol 13, pp. 136141.
Townsend G, Hughes T, Luciano M, Bockmann M, Brook A (2009). Genetic and
environmental influences on human dental variation: a critical evaluation of
studies involving twins. Arch Oral Biol 54S:S45S51.
Townsend GC, Richards L, Hughes T, Pinkerton S, Schwerdt W (2003). The value
of twins in dental research. Aust Dent J 48:8288.
Townsend GC, Richards L, Hughes T, Pinkerton S, Schwerdt W (2005). Epigenetic
influences may explain dental differences in monozygotic twin pairs. Aust
Dent J 50:95100.
Townsend G, Richards L, Messer LB, Hughes T, Pinkerton S, Seow K,
GotjamanosT, Gully N, Bockmann M (2006). Genetic and environmental
influences on dentofacial structures and oral health: studies of Australian
twins and their families. Twin Res Hum Genet 9:727732.

171

Twin Studies

2010 to 2015
Ashar A, Hughes T, James H, Kaidonis J, Khamis F, Townsend G (2012). Dental
crown and arch size in Europeans and Australian Aboriginals In: New
Directions in Dental Anthropology: paradigms, methodologies and outcomes.
Townsend G, Kanazawa E, Takayama H, editors. Adelaide: University of
Adelaide Press, pp. 6580.
Bockmann MR, Hughes TE, Townsend GC (2010). Genetic modeling of
primary tooth emergence: a study of Australian twins. Twin Res Hum Genet
13:573581.
Bockmann MR, Harris AV, Bennett CN, Odeh R, Hughes TE, Townsend GC
(2011). Timing of colonization of cariesproducing bacteria: an approach
based on studying monozygotic twin pairs. Int J Dent, Article ID 571573,
7pages, doi:10.1155/2011/571573. Accessed 19 May 2015.
Chan E, Bockmann M, Hughes T, Mihailidis S, Townsend G (2012). Do feeding
practices, gestation length, and birth weight affect the timing of emergence of
the first primary tooth? In: New Directions in Dental Anthropology: paradigms,
methodologies and outcomes. Townsend G, Kanazawa E, Takayama H, editors.
Adelaide: University of Adelaide Press, pp. 3545.
Hasegawa Y, Rogers J, Scriven G, Townsend G (2010). Carabelli trait in Australian
twins: reliability and validity of different scoring systems. Dent Anthropol
23:714.
Hughes T, Townsend G (2012). Genes for teeth drawing inference from family
data. In: New Directions in Dental Anthropology: paradigms, methodologies
and outcomes. Townsend G, Kanazawa E, Takayama H, editors. Adelaide:
University of Adelaide Press, pp. 2234.
Hughes T, Bockmann M, Mihailidis S, Bennett C, Harris A, Seow WK, Lekkas D,
Ranjitkar S, Rupinskas L, Pinkerton S, Brook A, Smith R, Townsend GC
(2013). Genetic, epigenetic, and environmental influences on dentofacial
structures and oral health: ongoing studies of Australian twins and their
families. Twin Res Hum Genet 16:4351.
Hughes TE, Townsend GC (2013). Twin and family studies of human dental
crown morphology: genetic, epigenetic and environmental determinants

172

Publications and theses relating to theAdelaide Twin Studies

of the modern human dentition. In: Anthropological Perspectives on Tooth
Morphology: genetics, evolution, variation. Scott GR, Irish JD, editors.
Cambridge: Cambridge University Press, pp. 3168.
Hughes TE, Townsend GC, Pinkerton SK, Bockmann MR, Seow Wk, Brook AH,
Richards LC, Mihailidis S, Ranjitkar S, Lekkas D (2014). The teeth and faces
of twins: providing insights into dentofacial development and oral health for
practicing oral health professionals. Aust Dent J 59 (1 Suppl):101116.
Hughes T, Bockmann M, Townsend G (2015). An overview of dental genetics. In:
A Companion to Dental Anthropology. Irish JD, Scott GR, editors. Hoboken,
NJ: John Wiley & Sons Inc. (in press).
Kondo S, Townsend G, Matsuno M (2014). Morphological variation of the
maxillary lateral incisor. Jpn Dent Sci Rev 50:100107.
Mihailidis S, Scriven G, Khamis M, Townsend G (2013). Prevalence and patterning
of maxillary premolar accessory ridges (MxPARs) in several human
populations. Am J Phys Anthropol 152:1930.
Mihailidis S, Ashar A, Hughes T, Bockmann M, Brook A, Townsend G (2013).
Dental phenomics: hightech scans reveal similarities and differences in
monozygotic twins. Dental Tribune US Edition April:A4A5.
Mihailidis S, Bockmann M, McConnell E, Hughes T, van Beijsterveldt TCEM,
Boomsma DI, McMaster M, Townsend G (2015). The influence of chorion
type on health measures at birth and dental development in Australian and
Dutch twins: a comparative study. Twin Res Hum Genet 18:368-374.
Odeh R, Mihailidis S, Townsend G, Lhdesmki R, Hughes T, Brook A (2015).
Prevalence of infraocclusion of primary molars determined using a new 2D
image analysis methodology. Aust Dent J (in press).
Odeh R, Townsend G, Mihailidis S, Lhdesmki R, Hughes T, Brook A (2015).
Infraocclusion: dental development and associated dental variations in
singleton and twins. Arch Oral Biol 60:1394-1402.
Ooi G, Townsend G, Seow WK (2014). Bacterial colonization, enamel defects and
dental caries in 46yearold mono and dizygotic twins. Int J Paediatr Dent
24:152160.
Ribeiro DC, Brook AH, Hughes TE, Sampson WJ, Townsend GC (2013).
Intrauterine hormone effects on tooth dimensions. J Dent Res 92:425431.

173

Twin Studies
Ribeiro D, Sampson W, Hughes T, Brook A, Townsend G (2012). Sexual
dimorphism in the primary and permanent dentitions of twins: an
approach to clarifying the role of hormonal factors. In: New Directions in
Dental Anthropology: paradigms, methodologies and outcomes. Townsend G,
KanazawaE, Takayama H, editors. Adelaide: University of Adelaide Press,
pp. 4664.
Taji SS, Seow WK, Townsend GC, Holcombe T (2010). A controlled study of
dental erosion in 2 to 4yearold twins. Int J Paediatr Dent 20:400409.
Taji SS, Seow WK, Townsend GC, Holcombe T (2011). Enamel hypoplasia in
the primary dentition of monozygous and dizygous twins compared with
singleton controls. Int J Paediatr Dent 21:175184.
Townsend GC, Brook AH (2013). Genetic, epigenetic and environmental
influences on human tooth size, shape and number. In: eLS. Chichester:
John Wiley & Sons, Ltd. doi:10.1002/9780470015902.a0024858. Accessed
19May 2015.
Townsend GC, Brook AH (2014). The face, the future, and dental practice: how
research in craniofacial biology will influence patient care. Aust Dent J 59
(1Suppl):15.
Townsend G, Bockmann M, Hughes T, Brook A (2012). Genetic, environmental
and epigenetic influences on variation in human tooth number, size and
shape. Odontology 100:19.
Townsend G, Bockmann M, Hughes T, Mihailidis S, Seow WK, Brook A (2012).
New approaches to dental anthropology based on the study of twins. In:
NewDirections in Dental Anthropology: paradigms, methodologies and outcomes.
Townsend G, Kanazawa E, Takayama H, editors. Adelaide: University of
Adelaide Press, pp. 1021.
Townsend G, Brook A, Yong R, Hughes T (2015). Tooth classes, field concepts,
and symmetry. In: A Companion to Dental Anthropology. Irish JD, Scott GR,
editors. Hoboken, NJ: John Wiley & Sons Inc. (in press).
Woodroffe S, Mihailidis S, Hughes T, Bockmann M, Seow WK, GotjamanosT,
Townsend G (2010). Primary tooth emergence in Australian children:
timing, sequence and patterns of asymmetry. Aust Dent J 55:245251.

174

Publications and theses relating to theAdelaide Twin Studies

Yong R, Ranjitkar S, Townsend GC, Smith RN, Evans AR, Hughes TE,
Lekkas D, Brook AH (2014). Dental phenomics: advancing genotype
to phenotype correlations in craniofacial research. Aust Dent J 59 (1
Suppl):3447.

Theses
Richmond D (1990). An assessment of dental occlusion in a sample of South Australian
twins. BScDent (Hons) Thesis, The University of Adelaide.
Rogers JR (1990). Tooth size variability in South Australian twins. BScDent (Hons)
Thesis, The University of Adelaide.
Townsend GC (1994). Genetic studies of morphological variation in the human
dentition. DDSc Thesis, The University of Adelaide.
Dempsey P (1998). Genetic and environmental contributions to morphological
variation in the permanent dentition a study of Australian twins. PhD
Thesis, The University of Adelaide.
Tangchaitrong K (1998). Fourier shape analysis of facial profiles of twins. MDS
Thesis, The University of Melbourne.
Thomas C (1998). Occlusal variation in the primary dentition: a study of Australian
twins and singletons. MDS Thesis, The University of Adelaide.
CheginiFarahani A (1999). Incisor mamelon morphology: how important are genetic
factors. BScDent (Hons) Thesis, The University of Adelaide.
Darwis WE (2002). Fourier analysis: assessment of facial profile variation with time in
young twins. MDS Thesis, The University of Melbourne.
Loo SM (2003). Growth of facial features in young twins: assessment by Fourier shape
analysis. MDS Thesis, The University of Melbourne.
Chiam S (2004). Superimposition of computergenerated overlays of anterior teeth in
pairs of identical twins. Grad Dip Forensic Odont Thesis, The University of
Adelaide.
Apps M (2005). Effect of birthweight on tooth size variability in twins. BScDent
(Hons) Thesis, The University of Adelaide.
Dooland K (2005). Is there a side preference for bruxing? BScDent (Hons) Thesis,
The University of Adelaide.

175

Twin Studies
Race J (2005). Birthweight discordance and chorion type in monozygotic twins.
BScDent (Hons) Thesis, The University of Adelaide.
Ramadas Y (2005). Longitudinal studies of facial growth of twins. DClinDent Thesis.
The University of Melbourne.
Mahmood Z (2006). Age changes in dental arch shape in twins. MDS Thesis, The
University of Adelaide.
Ismail Z (2006). Hypocone expression in Australian twins. Grad Dip Forensic Odont
Thesis, The University of Adelaide.
Woodroffe S (2006). Factors influencing tooth emergence in young twins. BScDent
(Hons) Thesis, The University of Adelaide.
Odeh R (2008). Mutans streptococci and their relationship with primary tooth
emergence. BScDent (Hons) Thesis, The University of Adelaide.
Smythe L (2008). Identification of individuals by superimposition of dental structures.
Grad Dip Forensic Odont Thesis, The University of Adelaide.
Taji S (2010). A controlled study of oral health in twin children. DClinDent Thesis,
The University of Queensland.
Bermann H (2011). Variation in human palatal rugae and their use as a forensic
marker. BScDent (Hons) Thesis, The University of Adelaide.
Chan E (2011). Effect of feeding habits on primary tooth emergence. BScDent (Hons)
Thesis, The University of Adelaide.
Handayani A (2011). Validation of an Optix 400S 3D laser scanner for use in forensic
odontology. Grad Dip Forensic Odont Thesis, The University of Adelaide.
McConnell E (2011). The influence of chorion type on the emergence of first primary
tooth in Australian twins. BScDent (Hons) Thesis, The University of Adelaide.
Ribeiro D (2012). Increased tooth crown size in females from oppositesex dizygotic
twins: a possible intrauterine hormonal influence on dental development. PhD
Thesis, The University of Adelaide.
Williams S (2012). Epigenetic influences on dental development. BScDent (Hons)
Thesis, The University of Adelaide.
Bullens L (2013). Evidence of tooth grinding patterns in twins side preference,
mirrorimaging and handedness. Masters Thesis, Academisch Centrum
Tandhellkunde Amsterdam.

176

Publications and theses relating to theAdelaide Twin Studies

Cheshire K (2013). Tooth grinding in the primary and permanent dentitions of twins.
Masters Thesis, Academisch Centrum Tandhellkunde Amsterdam.
Gagliardi A (2013). A genetic analysis of the Curve of Spee. DClinDent Thesis, The
University of Adelaide.
Odeh R (2013). Infraocclusion of primary molars and associated dental anomalies
in twins and singletons: what is the underlying aetiology. PhD Thesis, The
University of Adelaide.
Ashar A (2015). The individuality of the human dentition: implications for forensic
odontology. PhD Thesis, The University of Adelaide.
Patel P (2015). Intrauterine male hormone effects on dental dimensions of females from
dizygotic oppositesex twin pairs. BScDent (Hons) Thesis, The University of
Adelaide.
Lam F (ongoing). Exploring further the different effects of the Y chromosome and male
hormones on tooth size and shape by 3D measurement and analysis on twin study
models. BScDent (Hons) Thesis, The University of Adelaide.
Taduran RJ (ongoing). The nature and extent of sexual dimorphism in dental and
dermatoglyphic traits of twins. PhD Thesis, The University of Adelaide.
Williams S (ongoing). Epigenetic studies of dental development and the oral
microbiome. PhD Thesis, The University of Sydney.
Waller D (ongoing). Sequence of primary tooth emergence in twins. BScDent (Hons)
Thesis, The University of Adelaide.
Ribeiro D (ongoing). Development of dental occlusion and speech in Australian twins.
DClinDent Thesis, The University of Adelaide.

177

GLOSSARY OF TERMS

Acetylation

The process or formation of an acetyl (an acetic acid molecule)

derivative. Acetylation of histone proteins reduces the affinity
between these proteins and DNA in the nucleus of the cell and
is another epigenetic mechanism (in addition to methylation)
to control gene expression.

Aetiology

The cause or set of causes of a disease or disorder.

Agenesis

Absence or failure of a structure to develop, e.g. a tooth.

Algorithm

A process or set of rules used in problem-solving calculations

and operations.

Amniotic

Relating to the amnion, a membrane that envelops the embryo

in utero.

Androgens

Androgens (which include testosterone) are often referred to

as male hormones, although males and females both produce
androgens. They are present in higher levels in males and play
an important role in male traits and reproductive activity.

Anthropometric

Related to measurements of the human body.

Biofilm (oral)

A thin coating that contains bacteria and forms over structures

in the mouth, e.g. teeth.

Buccal

Relating to the cheeks.

Buccolingual
crown diameter

The distance between the buccal (cheek) and lingual (tongue)

surfaces of a dental crown. For anterior teeth, the term
labiolingual is often used, where labial refers to the lips.

178

Glossary of terms

Cariogenic

Producing dental decay.

Cerebral
lateralisation

Refers to specialisation of the two halves of the brain, with

one side carrying out certain functions and the other side
performing different functions. For example, the right side has
been linked to language production and the left side to visuospatial perception.

Chi-square test

Statistical test whereby variables are categorised to determine

whether an observed distribution of scores differs from those
expected according to a certain hypothesis.

Chorion

One of the foetal membranes.

Chromosome

One of the rod-shaped structures situated in the nucleus of a

cell that carries genes. There are usually 22 pairs of autosomes
(numbered 1 to 22) and one pair of sex chromosomes (X and
Y) in humans, making 23 pairs or 46 chromosomes in total.

Cohort

A collection of people sharing similar characteristics.

Congenital

Refers to conditions which are present at birth and may be either

hereditary or due to an influence occurring during gestation.

Correlation
coefficient

A statistical measure of the strength of the association between

two variables, often denoted by the symbol r. Values can range
from -1 to +1 with a value of 0 indicating no association.

Covariance

Statistical measure of how much two variables change together.

Deciduous
(primary)

Teeth that are shed (exfoliated) and replaced by permanent

teeth.

Dental caries

The process involving loss of mineral from the teeth due to acid
production by bacteria within dental plaque (oral biofilm).

Dental lamina

A curved band of epithelium in the upper and lower developing

jaws with growths (or swellings) at the sites where future
deciduous teeth will form.

Dental papilla(e)

Clump(s) of mesenchymal cells which give rise to the dentine

and pulp of the teeth. Neural crest cells contribute to the dental
papilla, so the cells are often referred to as ecto-mesenchymal,
referring to the ectodermal origin of the neural crest.

179

Twin Studies

Dermatoglyphics

The study of fingerprints.

Dichorionic

Showing evidence of two chorions (foetal membranes) which

enclose the foetus. Some monozygotic (so-called identical) twin
pairs are dichorionic, whereas others are monochorionic.

Digitiser

Equipment that has the ability to locate features on images or

models and convert the data generated into a digital format for
storage on a computer.

Ectoderm

The outer layer of cells in an embryo.

Enamel organ

Refers to the epithelially derived component of the developing

tooth germ which eventually forms the enamel of the crown.

Endoderm

The innermost of the three primary layers of cells in an embryo.

Epidemiology

The study of the patterns, causes and outcomes of conditions

affecting health and disease in human populations.

Epigenetics

Refers to the regulation of gene expression without changing

the genetic code.

Ethnicity

Related to a group of people who share a distinctive social and

cultural tradition, often established by their origin at birth.

Eugenics

The study of, or the belief in, improving the genetic quality of
human populations. There have been attempts at both positive
eugenics (by selective breeding of those with desirable
features), and negative eugenics (by eliminating those with
undesirable features).

Exfoliation

The normal process of loss of deciduous (primary) teeth, which

occurs as their roots are resorbed.

Extrinsic

Coming from outside, e.g. extrinsic factors coming from

outside the body, such as trauma, may damage tooth structure.

Genome

The complete set of genes which constitute an organism.

Genotype

The genetic constitution of an individual.

Gingivitis

Inflammation of gingival tissue as a response to products of

bacteria in dental plaque around the necks of teeth.

Homeostasis

The process through which bodily equilibrium is maintained.

Homologous

Corresponding or similar in position, structure or function, e.g.

homologous chromosomes form pairs.

180

Glossary of terms

Hydroxyapatite

Natural mineral structure which is the principal inorganic

component of bones and teeth.

Hypodontia

A congenital or acquired condition where there is less than the

normal complement of teeth.

Hypoplasia

Condition illustrating defective or incomplete tissue. Enamel

hypoplasia refers to a condition where the enamel of teeth is
thinner than normal. It may present as linear grooves or pits on
the tooth surface.

Hypothesis

A proposed explanation which is either retained or rejected

depending on the outcomes of testing.

In utero

Within the womb.

Intercorrelated
variables

Variables showing a mutual relationship or association.

Internal enamel
epithelium

An epithelial layer in the developing tooth germ which folds

to produce the basic shape of the future dental crown. The
epithelial cells differentiate into ameloblasts that lay down
enamel.

Intra-uterine

Within the womb.

Intrinsic

Coming from inside, e.g. intrinsic factors, such as proteins

produced by the body.

Locus (plural is
loci)

A particular position, point, place or location. In genetics, a

locus refers to the specific location of a gene or DNA sequence
on a chromosome.

Lupus
erythematosus

A chronic inflammatory autoimmune disease that can affect

various parts of the body, including the skin and joints.

Malocclusion

Term used to describe a variation from the ideal or normal

relationship of the upper and lower teeth, e.g. crooked teeth,
protruding buck teeth.

Milieu intrieur

The environment within (French).

Mesenchyme

Embryonic connective tissue consisting of cells, fibres and

ground substance.

Mesial surface

The surface of a tooth nearest to the midline of the dental arch.

181

Twin Studies

Mesiodistal crown
diameter

The distance between the mesial (nearest to the midline) and

distal (furthest from the midline) surfaces of a dental crown.

Mesoderm

The middle layer of cells in an embryo.

Methylation

Addition of a methyl group, e.g. DNA methylation is one of

the epigenetic mechanisms cells use to control the expression
of genes.

Microbiome (oral)

The aggregate or community of micro-organisms found in the

oral cavity.

Microbiota

A collective term for all of the micro-organisms found within a

given environment.

Mirror imaging

Two images or structures, with one being the reverse of the

other (as if seen in a mirror).

Modularity

The arrangement of a system into discrete units.

Monochorionic

Evidence of one chorion (also see dichorionic).

Morphogenesis

The development of a distinct shape during embryological

development.

Morphology

The study of the form of living organisms.

Multiparous

Giving birth to more than one offspring at a time.

Multivariate
analysis

Statistical term used for analyses involving more than one

variable at a time.

Neural crest cells

Ectodermal cells derived from the developing neural tube.

These cells have the potential to develop into a variety of tissues,
including all of the tissues of teeth, except for the enamel.

Occlusion (dental)

Simply, dental occlusion refers to the contact between maxillary

and mandibular teeth. More broadly, it refers to understanding
of the structure and function of the masticatory system and
managing problems within this system. In this sense, occlusion
is basic to dentistry.

Odontogenesis

Tooth formation.

Odontometrics

The measurement and study of tooth size.

Orthopantomogram (OPG)

A panoramic radiograph used to provide an image of all of the

teeth and the surrounding oral and facial structures.

182

Glossary of terms

PCR (Polymerase
Chain Reaction)
amplicons

The multiple segments of DNA replicated from a template

during a Polymerase Chain Reaction process for amplifying
DNA material.

Pergamon

Ancient city situated in Aeolis, an area once established along

the north-western coastline of Asia Minor.

Periodontal disease

An inflammatory disease of the gingival tissues (gums) and

supporting structures (periodontium) of teeth associated
with the production of bacterial products from dental plaque
aroundthe necks of the teeth. This disease leads to loss of bone
around the roots of teeth (alveolar bone) and to loosening
(mobility) of the teeth.

Phenomics

The measurement of phenomes that are usually associated

with the physical and biochemical traits of organisms. Dental
phenomics refers to measurement of variables of interest in
dentistry, e.g. tooth size.

Phenotypes

Those observable characteristics of an individual which have

been shaped from genetic, epigenetic and environmental
influences.

Phylogenetics

Studies of evolutionary relationships among groups of organisms

or populations.

Pleiotrophy

A situation where a gene appears to affect multiple features or

traits.

Polyembryony

Development of more than one embryo from a fertilised egg.

Polygenic

Referring to more than one gene affecting a character or trait.

Sexual dimorphism The difference in expression of a feature between males and

females of the same species, e.g. males have larger teeth, on
average, than females.
Sine/cosine

Mathematical function concerning angles.

Standard dental
plaques

Standardised models that illustrate different expressions of

dental traits to facilitate scoring of the features, e.g. the Arizona
State University (ASU) plaques and the Dahlberg plaques.

183

Twin Studies

Stereophoto
grammetry

A method of identifying landmarks and making measurements

from two photographs taken from known positions in relation
to the object of interest, e.g. a persons face.

Stochastic process

Random process.

Streptococcus
mutans

Cariogenic (decay-producing) bacteria commonly found in

dental plaque. The term Streptococcus mutans is used to refer to a
single species of bacteria whereas the term mutans streptococci
refers to a group of the streptococcal species.

Syndrome

A group of signs and symptoms that consistently occur together.

Systemic

Relating to, or affecting, the body as a whole, as distinct from a

local effect or disease.

Teratology

The study of abnormalities of development.

Variable

Feature being studied that can take on different values.

Vedic

The period and religion associated with ancient Indo-European

speaking people who migrated to India from 1500 BC.

Zygosity

Refers to the degree of identity in the genome of twins.

Monozygotic twins share the same genes, whereas dizygotic
twins share, on average, half their genes.

184

APPENDIX 1

The original research team

Grant Townsend
Lindsay Richards
Tasman Brown
Sandy Pinkerton
George Travan

Craniofacial Biology and Dental Education Group 2015

Abdulaziz Almajed
Poppy Anastassiadis
Peter Anderson
Nor Atika Md Ashar
Manpreet Bariana
Corinna Bennett
John Berketa
Vishesh Bhojwani
Michelle Bockmann
Alan Brook
Tasman Brown
Ketki Chandewar
Anh Diep
Mohamed El-Kishawi

Frances Greenwood
Linda Hassanali
Toby Hughes
Helen James
John Kaidonis
Sophie Karanicolas
Kenneth Koh
Felicity Lam
Dimitra Lekkas
Chelsea Mann
Mustafa Mian
Suzanna Mihailidis
Ruba Odeh
Premal Patel

185

Caroline Petroff
Rene Phillips
Sandy Pinkerton
Rabiah Rahmat
Sarbin Ranjitkar
Chris Redwood
Daniela Ribeiro
James Rogers
Ruth Rogers
Graham Scriven
Komal Shah
Catherine Sims
Vicki Skinner
Catherine Snelling

Twin Studies
Karen Squires
Richard Jonathan Taduran
Vivian Toh
Ikuko Tomo
Soichiro Tomo

Grant Townsend
Ryuji Ueno
Daniel Waller
Abbe White
Tom Wilkinson

Scott Williams
Tracey Winning
Robin Yong

Visiting researchers, collaborators and other key contributors

Wadian Abdul-Wahed
Hiro Aboshi
Christina Adler
Michael Aldred
Lassi Alvesalo
Mary Apps
Peter Arrow
Mark Bartold
Hannah Berman
Jasmine Blight
Lucas Bockmann
Dorret Boomsma
Louise Brearley Messer
Walter Bretz
Gary Briscoe
Bridget Brown
Gina Browne
Lotte Bullens
Viv Burgess
Hanny Calache
Angus Cameron
Emmanuel Chan
Ke Chen
Rebecca Chen
Kitty Cheshire
David Chubb
John Clement
Deborah Cole
Robert Corruccini

Tom Coxon
Jeffrey Craig
Paula Dempsey
John Diamanti
Kim Dooland
Craig Dreyer
Shosei Eguchi
Tennent Emerson
Alistair Evans
Luca Fiorenza
Judy Ford
Antonio Gagliardi
Jinlong Gao
Rakesh Garayia
Evangeline Gotjamanos
Theo Gotjamanos
Neville Gully
Edward Harris
Yuh Hasegawa
Shirley Hastings
David Hay
Tuomo Heikkinen
Denice Higgins
Jenny Hong
John Hopper
Neil Hunter
Tadashi Ideguchi
Elka Johansson
Ikuo Kageyama

186

Voula Kaidonis
Eisaku Kanazawa
Sunita Kapali
Kazutaka Kasai
Samvit Kaul
Mohd Fadhli Bin Khamis
Nima Kianoush
John Kibble
Jules Kieser
Nicky Kilpatrick
Inger Kjaer
Shintaro Kondo
Raija Lhdesmki
Herve Lesot
Judith Littleton
Helen Liversidge
Pamela Long
Michelle Luciano
Lucy Ludlow
David Madsen
Zuliani Mahmood
Nick Martin
Judith May
John Mayhall
Elise McConnell
Linda Mealey
Sarah Medland
Pascale Mehanna
Marion Morgenstern

Appendix 1
John Mulley
Sen Nakahara
Koh Nakajima
Mike Neale
Leanne Ng
Ruba Odeh
Greg Ooi
Richard Osborne
Tadashi Ozaki
Tracey Parish
Kathleen Paul
Brian Penhall
Liu Ping
Pertti Pirttiniemi
Ron Presswood
Kris Anne Pulanco
Josephine Quinn
Jonathan Race
Quentin Rahaus
David Richmond
Jackie Rovensky

Fiona Rowett
Loreta Rupinskas
Richard Saffery
Wayne Sampson
Bhim Savara
Wendy Schwerdt
Richard Scott
Mitsuo Sekikawa
Tsuneo Sekimoto
Kim Seow
Rob Sergi
Tarciso Sindeaux
Patricia Smith
Richard Smith
Lyndall Smythe
John Spencer
Sue Springbett
Lauren Stow
Smitha Sukumar
Sue Taji
Masami Takahashi

Adelaide Dental School staff and students

Australian Multiple Birth Association staff
Australian NHMRC Twin Registry staff
Colgate Australian Clinical Dental Research Centre staff
Colgate Oral Care Australia staff
Dental Health Services Victoria
Institute for Medical and Veterinary Science staff
Melbourne Dental School staff and students
Royal Dental Hospital of Melbourne staff
School of Dental Therapy Melbourne staff
South Australian Dental Service
Sydney Dental School staff and students
Western Sydney Local Health District
Westmead Centre for Oral Health staff
Womens and Childrens Hospital Adelaide staff

187

Kanokwan Tangchaitrong
Lydia Tarnowskyj
Peter Telfer
Candy Thomas
David Thomas
Maureen Tremaine
Penny Tsoutouras
Christy Turner
Kuljeet Vaid
Melanie Van Altena
Con Vanco
Juha Varrela
John Wetherell
Ted Wild
Grace Wong
Sabrina Woodroffe
Hiroyuki Yamada
Xiaoyan Zhou
Peter Zilm

Twin Studies

A gallery of researchers, twins and their families

188

Appendix 1

189

Twin Studies

190

Appendix 1

191

Twin Studies

192

Appendix 1

193

Twin Studies

194

Appendix 1

195

Twin Studies

196

Appendix 1

197

Twin Studies

198

Appendix 1

199

This book is available as a free fully-searchable ebook from

www.adelaide.edu.au/press