Molecular Genetics of Tooth Agenesis

Pekka Nieminen
Department of Orthodontics
Institute of Dentisty
and
Institute of Biotechnology
and
Department of Biological and Environmental Sciences
Faculty of Biosciences
University of Helsinki
Finland
Academic Dissertation
To be discussed publicly with the permission
of the Faculty of Biosciences of the University of Helsinki,
in the Main Auditorium of the Institute of Dentistry
on November 23
rd
2007 at 12 noon.
Helsinki 2007
Supervisors
Sinikka Pirinen, DDS, PhD
Professor emerita
Department of Pedodontics and Orthodontics
Institute of Dentistry, University of Helsinki, Finland
Irma Thesleff, DDS, PhD
Professor
Developmental Biology Programme
Institute of Biotechnology, University of Helsinki, Finland
Reviewed by
Jan Huggare, DDS, PhD
Professor
Department of Orthodontics
Karolinska institutet
Huddinge, Sweden
Anu Wartiovaara, MD, PhD
Professor
FinMIT, Research Program of Molecular Neurology
Biomedicum Helsinki
Finland
Opponent:
Heiko Peters
PhD, Reader
University of Newcastle
ISBN 978-952-10-4350-5 (nid.)
ISBN 978-952-10-4351-2 (PDF)
ISSN 1795-7079
Yliopistopaino Oy
Helsinki 2007
Contents
LIST OF ORIGINAL PUBLICATIONS 7
ABBREVIATIONS 8
SUMMARY 9
INTRODUCTION 10
REVIEW OF THE LITERATURE 11
OVERVIEW OF TOOTH DEVELOPMENT 11
Principles of development 11
Teeth and dentitions 13
Development of teeth 14
Commitment, morphogenesis and inductive interactions 19
Molecular regulation of tooth development 26
Reciprocal signaling and signaling centers 26
Transcription factors 27
MSX1 and PAX9 28
Initiation 29
Morphogenesis 32
Tooth replacement 34
TOOTH AGENESIS 36
Developmental anomalies 36
Developmental anomalies of teeth 37
Genetic traits of tooth number and shape 37
Supernumerary teeth 38
Tooth agenesis 39
Terminology 39
Diagnostic challenges 40
Prevalences 40
Patterns of agenesis 41
Tooth agenesis in syndromes 43
Dental anomalies associated with agenesis 43
Reduction of tooth size and morphology 44
Delayed development and eruption 45
Root abnormalities 46
Abnormal positions of teeth 47
Enamel defects 48
Etiology and pathogenesis of tooth agenesis 48
Environmental factors 48
Tooth size variation and heritability 50
Twin studies on agenesis 50
Segregation analyses in families 51
Molecular genetics 52
4
Pathogenesis of tooth agenesis 53
Tooth agenesis and cancer 56
HUMAN GENETICS AND GENE DEFECTS 57
The human genome 57
Variation 58
From genotypes to phenotypes 59
Gene identification 60
AIMS 64
MATERIALS AND METHODS 65
Subjects 65
DNA isolation 66
Genotyping 67
Linkage analysis (I, IV) 68
Sequencing (II) 68
FISH Analysis (III) 68
Gene expression data collection (V) 69
WWW implementation (V) 69
RESULTS AND DISCUSSION 70
MSX1 and PAX9 in dominantly inherited severe tooth agenesis (pub-
lications II and III) 70
Attempts to unravel the genetic basis of common tooth agenesis (incisor
and premolar hypodontia) (publications I, IV) 74
Construction of the gene expression database (publication V) 78
GENERAL DISCUSSION 80
Uncovering the genetic background of tooth agenesis 80
Implications for the pathogenetic mechanisms of tooth agenesis 82
CONCLUDING REMARKS 85
ACKNOWLEDGEMENTS 86
REFERENCES 88
5
6
List of original publications
This thesis is based on the following original articles, which are referred to in the text by
their roman numerals. In addition, some unpublished data are also presented.
I Nieminen P, Arte S, Pirinen S, Peltonen L, and Thesleff I (1995). Gene defect in hy-
podontia - exclusion of MSX1 and MSX2 as candidate genes. Human Genetics 96,
305-308.
II Nieminen P, Arte S, Tanner D, Paulin L, Alaluusua S, Thesleff I, and Pirinen S
(2001). Identification of a nonsense mutation in the PAX9 gene in molar oligodontia.
European Journal of Human Genetics 9, 743-746.
III Nieminen P, Kotilainen J, Aalto Y, Knuutila S, Pirinen S, and Thesleff I (2003).
MSX1 gene is deleted in Wolf-Hirschhorn syndrome patients with oligodontia. Jour-
nal of Dental Research 82 , 1012-1016.
IV Nieminen P, Arte S, Luonsi E, Pirinen S, Peltonen L, and Thesleff I. A genome-wide
search for hypodontia locus in families, manuscript.
V Nieminen P, Pekkanen M, berg T, and Thesleff I (1998). A graphical www-
database on gene expression in tooth. European Journal of Oral Sciences 106, 7-11.
7
ABBREVIATIONS
ADULT acro-dermato-ungual-lacrimal-tooth syndrome
AEC ankyloblepharon-ectodermal dysplasia-clefting syndrome
AI amelogenesis imperfecta
APC adenomatous polyposis coli
BMP/Bmp bone morphogenetic protein
CLPED cleft lip/palate-ectodermal dysplasia syndrome
DKK1/Dkk1 dickkopf-1
DLX/Dlx distalless homeobox homolog
DNA deoxyribonucleid acid
E embryonic day
EDA/Eda anhidrotic ectodermal dysplasia
EDAR/Edar EDA receptor
EDA-ID anhidrotic ectodermal dysplasia with immunodeficiency
EEC ectrodactyly-ectodermal dysplasia-clefting syndrome
EGF/Egf epidermal growth factor
ERS epithelial cell rests of Malassez
FAP familial adenomatous polyposis coli
FGF/Fgf fibroblast growth factor
FGFR/Fgfr fibroblast growth factor receptor
HERS Hertwigs epithelial root sheath
IP incontinentia pigmenti
LEF1/Lef1 lymphoid enhancer factor 1
LMS limb-mammary syndrome
mRNA messenger RNA
MSX/Msx muscle segment homeobox homolog
NMD nonsense mediated decay
OL-EDA-ID anhidrotic ectodermal dysplasia-immunodeficiency-osteopetrosis-
lymphoedema.
PAX/Pax paired box family member
PCR polymerase chain reaction
RNA ribonucleic acid
RUNX/Runx runt homolog
SHH/Shh sonic heghehog
SNP single nucleotide polymorphism
SRA short root anomaly
STRP short tandem repeat polymorphism
TGFA transforming growth factor o
TGF|/Tgf| transforming growth factor |
TNF/Tnf tumor necrosis factor
8
SUMMARY
Tooth agenesis is one of the most common developmental anomalies in man. The common
forms, in which one or a few teeth are absent, may cause cosmetic or occlusal harm, while
severe forms which are relatively rare require clinical attention to support and maintain the
dental function. Observation of tooth agenesis and especially the severe forms is also impor-
tant for diagnosis of malformation syndromes.
Some external factors like pollutants or cancer therapy may cause developmental defects and
agenesis in dentition. However, twin and family studies have shown the predominant role of
inheritance in the etiology of agenesis. Furthermore, studies on inherited tooth agenesis as
well as mouse null mutants have identified several of the genetic factors and helped to un-
derstand the molecular mechanisms of tooth development. However, so far success has only
been made in identifying the genes involved in syndromic or rare dominant forms of tooth
agenesis, while the genes and defects responsible for the majority of cases of tooth agenesis,
especially the common and less severe forms, are largely unknown.
In this study, different types of tooth agenesis were studied. It was shown that a dominant
nonsense mutation in PAX9 was responsible for severe agenesis (oligodontia) affecting espe-
cially permanent molars in a Finnish family. In a study of tooth agenesis associated with
Wolf-Hirschhorn syndrome, it was shown that severe tooth agenesis was present if the
causative deletion in the short arm of chromosome 4 spanned the MSX1 locus. A conclusion
from these studies was that severe tooth agenesis was caused by haploinsufficiency of these
transcription factors. During this work several other gene defects in MSX1 and PAX9 have
been identified by us and others, and according to an analysis of the associated phenotypes
presented in this thesis, similar but significantly different agenesis phenotypes are associated
with defects in MSX1 and PAX9, apparently reflecting distinctive roles for these two tran-
scription factors during the development of human dentition.
The original aim of this work was to identify gene defects that underlie the common incisor
and premolar hypodontia. For this purpose, several candidate genes were first excluded. Af-
ter a genome-wide search with seven families in which tooth agenesis was inherited in an
autosomal dominant manner, a promising locus in chromosome 18 was identified for second
premolar agenesis in one family. This finding was supported by results from other families.
The results also implied existence of other loci both for second premolar agenesis and for
incisor agenesis. On the other hand the results from this study did not lend support for com-
prehensive involvement of the most obvious candidate genes in the etiology of incisor and
premolar hypodontia. Rather, they suggest remarkable genetic heterogeneity of tooth agen-
esis.
Despite the increasing knowledge of the molecular background of tooth agenesis, the patho-
logical and developmental mechanisms of tooth agenesis have only become clarified in a
few cases. The available evidence suggests that human tooth agenesis usually is a conse-
quence of quantitative defects which predispose to a failure to overcome a developmental
threshold. However, the stages and causes may be different in the case of different genes.
9
INTRODUCTION
Mammalian teeth develop as ectodermal organs bearing many similarities to other such or-
gans like hair, feathers and mammary glands (Pispa and Thesleff, 2003). As such, teeth are
serially homologous and the developmental mechanisms that produce different tooth types in
an organized fashion have long been debated (Butler, 1939; Osborn, 1978; Weiss et al.,
1998). The positioning of teeth, their intricate and species-specific morphologies, timing of
development and regeneration imply stringent regulatory mechanisms of development and
make teeth a relevant and interesting model for several scientific disciplines. Basic problems
in developmental biology, including cell commitment, reciprocal tissue interactions, pattern
formation, positional information and development of complex morphologies may be ap-
proached using teeth and dentitions as a model system (Weiss et al., 1998; Thesleff and
Nieminen, 2005). Teeth are useful for the research into evolutionary mechanisms because of
the species-specific morphologies based on adaptations of the tooth forms to the changing
habitat and lifestyle as well as because of resilience of teeth among the fossil record
(Jernvall, 1995; Jernvall et al., 2000). The replacement of teeth and the existence of continu-
ously growing teeth offer a model for tissue regeneration and stem cell research (Huysseune
and Thesleff, 2004; Wang et al., 2007). Finally, the differentiation of the hard-tissue forming
cells and the coupling of the differentiation into the morphogenesis may be studied to answer
questions on regulation of cell differentiation (Wang et al., 2004b; Thesleff and Nieminen,
2005).
The strict genetic control of tooth development ensures that we all have a similar dentition
with anterior and posterior teeth of distinct shapes and times of eruption. However, despite
this similarity, all dentitions are unique and part of this individuality is created by variation
and features caused by genetic factors. Dental anthropologists have paid attention to various
morphological features with a hope that they could be used to clarify population history
(Dahlberg, 1945; Irish and Guatelli-Steinberg, 2003). The size and shape variation includes
all teeth but especially patterns of molar crowns (Dahlberg, 1945). The most salient features
involve abnormalities in tooth number. Developmental failure of one or more teeth, tooth
agenesis or hypodontia, is one of the most common anomalies in man, and depending on its
severity and location may be of aesthetic or clinical significance (Arte, 2001). Recently, a
connection between tooth agenesis and colorectal cancer was identified in a Finnish family,
suggesting that developmental anomalies of teeth may sometimes be signs of cancer predis-
position (Lammi et al., 2004).
As part of a research which aims to understand the molecular mechanisms and genetic net-
works regulating tooth development, a research project was started in 1992 to look for the
genetic factors that are responsible for tooth agenesis. During this project, different types of
familial tooth agenesis has been studied, and several gene defects and a new gene involved
in tooth agenesis identified. The original aim was to identify gene defects that underlie the
common type of tooth agenesis, incisor and premolar hypodontia. In this thesis, I present re-
sults from studies into rare forms of tooth agenesis, and summarize results from genome-
wide searches in several families with common incisor and premolar hypodontia.
10
REVIEW OF THE LITERATURE
OVERVIEW OF TOOTH DEVELOPMENT
Principles of development
Individuals of all animal species develop from a single cell, a fertilized oocyte. The devel-
opment includes a massive amount of cell divisions (proliferation), cell differentiation, mi-
gration and also cell death. The cells of an early embryo of higher animals are capable to
adapt all cell fates, and they may be regarded as embryonic stem cells. During further devel-
opment, the cells become parts of tissue layers and their options for regulative development
become more and more limited. Their fates are regulated by their interactions, limiting their
options and causing a stepwise commitment to more restricted cell fates (Gilbert, 2003).
However, the cells may still retain a capacity to regulation: cells that will contribute to a cer-
tain organ may be able to develop into a normal organ even though part of them is removed.
For example, if an early mouse tooth germ is split into two, both halves develop into teeth of
normal size and morphology (Glasstone, 1963). The terminal differentiation is associated
with a reduced capacity to proliferate. In many adult tissues, however, some cells have re-
tained stem cell-like properties and a capacity to provide new differentiated cells (Fuchs et
al., 2004).
In many animals, the unfertilized oocyte is polarized allowing the sperm entry only on cer-
tain regions (Gilbert, 2003). The site of the sperm entry further delineates the future devel-
opment, e.g. the planes of the first cell divisions, and creates the basis for polarity in the
growing embryo. Further guides for the prospective commitment of the cells is served by
their position in the growing embryo and by their interactions with other cell and tissues.
Commitment, morphogenesis and differentiation are regulated by inductive interactions be-
tween cells and groups of cells. The positional information may be conveyed from organiz-
ing tissues through gradients of inductive substances, often called morphogens, as well as of
their antagonists (Hogan, 1999; Gilbert, 2003). Inherent for development and morphogenesis
of many organs are self-organizing processes that are thought to act for example during for-
mation of somites from the paraxial mesoderm as well as during positioning of ectodermal
placodes and cusps of teeth (Weiss et al., 1998; Salazar-Ciudad and Jernvall, 2002; Giudi-
celli and Lewis, 2004; Sick et al., 2006)
In instructive interactions, the inducer dictates the commitment of a responder while in per-
missive interactions the properties of the inducer are needed to allow the commitment of the
responder (Gilbert, 2003). For an induction to happen, the responder must have previously
acquired a competence to respond. In the key inductive interaction called primary embryonic
induction the dorsal blastopore lip, the Spemann organizer, inducts the neural tube and the
dorsal axis. Subsequent inductive evens leading to the development of individual organs
have been called secondary inductions (Saxen and Thesleff, 1992; Gilbert, 2003). For many
organs, inductive interactions between epithelium and mesenchyme are important, and de-
velopment of teeth and hair are examples of reciprocal process of epithelial-mesenchymal
interactions (Mina and Kollar, 1987; Thesleff and Nieminen, 2005).
11
Figure 1. Scheme of principles of signal transduction. (1) Binding of a ligand to a receptor
may cause dimerization and phosphorylation of receptors (in the left) as in FGF, TGF| and
EGF signaling. Alternatively (to the right), it may trigger changes in the conformation of the
receptor proteins that cause changes in the protein-protein interactions inside the plasma
membrane as in hedgehog and canonical WNT signaling. (2) Dimerization and phosphoryla-
tion of the receptors may start a cascade of phosphorylation of signal transducing proteins. (3)
Receptor activation may lead to a release of an interaction that has inhibited an activity of a
signal transducer protein. (4) The active signal transducers enter the nucleus and participate in
the activation of transcription of target genes. (5) The target genes may code for antagonists,
that act either inside or outside the cell and attenuate the signal. L, ligand, i,e, the signaling
molecule; R, receptor; CoR, coreceptor necessary for ligand binding; SP, scaffolding protein;
K, kinase that phosphorylates the signaling transducer and renders it susceptible to degrada-
tion; ST, signal transducer; TF, transcription factor; I, antagonist; P, phosphate moiety.
Each cell has the same genome, but they express different sets of genes in different levels.
The morphology, behaviour and interactions with other cells as well as the commitment and
competence are based on the gene products the cell synthesizes. Aberrations of the regula-
tion of gene expression may lead to abnormal growth and cancer. The capacity to gene ex-
pression is largely executed through expression of transcription factors that are the proteins
regulating the expression of genes. Interactions between cells may be mediated by the adhe-
sion molecules in the cell surface and by the extracellular matrix that cells secrete (Gilbert,
2003; Thesleff et al., 1991). However, instructive interactions typically involve production
of signaling molecules ("signals"), often peptides or proteins, which are then bound to a spe-
cific receptor on the surface of (or in some cases, inside) the receiving cells (Gilbert,
2003; Pires-daSilva and Sommer, 2003; Wang and Thesleff, 2005). The signals may act in
12
paracrine fashion between neighbouring or close-residing cells but they may also exert their
effects on relatively long range and on a concentration dependent manner (Gilbert, 2003; Fan
et al., 1995; Gritli-Linde et al., 2001). Most important signals are peptide growth factors that
belong to the evolutionarily conserved Wnt, Heghehog and fibroblast growth factor (Fgf)
families as well as to the transforming growth factor-| (TGF|) superfamily including e.g.
TGF|s, bone morphogenetic proteins (BMPs), and activins (Logan and Nusse, 2004; Pires-
daSilva and Sommer, 2003; Kitisin et al., 2007). Other important signals include the tumor
necrosis factors (TNFs), epidermal growth factor (EGF) family, neurotrophins and Notch
ligands. In addition to these signals mediated by peptide ligands, retinoid acid has been con-
sidered as a morphogenic signal (Gilbert, 2003).
Cells that are competent to receive the signals must express receptors for each signaling pro-
tein (ligand) family (Fig. 1). Binding of a ligand to its receptor or receptor complex leads to
mediation of the signal into the cell which through protein interactions activates certain tran-
scription factors thus regulating gene expression (Gilbert, 2003) (Pires-daSilva and Sommer,
2003). The response of a cell to a signal depends on its competence and may be cell division,
apoptosis, change of commitment (cell fate), differentiation or production of a reciprocal sig-
nal, often of a different signal family, or an extracellular or intracellular antagonist of signal-
ing. Different signals may act synergistically or antagonistically and they may be attenuated
by signaling antagonists (Hogan, 1999; Wang and Thesleff, 2005). The signaling, the signal
transduction, activation of specific transcription factors, and subsequent responses are con-
served during the development of different organ systems and through evolution and can be
regarded to constitute modules of genetic networks which are used in variable manners and
in different combinations during different stages of organogenesis in different species
(Gilbert, 2003; Pires-daSilva and Sommer, 2003).
Teeth and dentitions
Vertebrate teeth may be used as weapons in fighting and self-defence, but they also provide
the vertebrates the first tool for feeding, making it possible to trap and swallow prey and, es-
pecially in the case of mammals, to render food more suitable for digestion in the gastro-
intestinal tract (Brown, 1983; Kardong, 1995). The teeth consist of a crown (protruding to
the mouth) and root (embedded or attached to the bone). The crown is composed of an ex-
ternal mineralized enamel (or enameloid) layer, the hardest mineralized tissue, and an inner
mineralized dentin which surrounds the pulpal cavity filled by living cells capable of dentin
regeneration and sensory function. In the roots of the mammalian teeth, the dentin and pulp
are surrounded by a mineralized cementum and a periodontal ligament that attaches the teeth
to the surrounding bone.
The whole dentition is composed of units of separate teeth of serial homology, i.e. having a
common evolutionary origin, and has been regarded as an example of merism (Butler, 1995;
Weiss et al., 1998). Teeth in various vertebrates may reside on the surfaces of mouth or phar-
ynx, but during the evolution they became restricted to a horseshoe-shaped dental arch lining
the oral cavity (Osborn, 1973; Brown, 1983). The fish and reptile teeth may be replaced sev-
eral, even hundreds of times during the lifespan of the animal (polyphyodont), but mammals
13
may replace some of them only once (diphyodont dentition). The teeth in different parts of
the mouth may have specialized forms in lower vertebrates, but the specialization to true
heterodonty with distinct tooth classes, as seen in modern mammalian species, started only
during the reptilian evolution (Brown, 1983). The heterodonty of mammals ncludes mor-
phologically and developmentally distinct tooth classes or types: the anterior incisors, ca-
nines and usually multicusped postcanine teeth, premolars and molars (Butler, 1978). In the
ancestral mammalian dentition, three primary incisors, one primary canine and four primary
postcanine teeth (premolars) developed in each jaw quadrant (Fig. 2). These could be re-
placed (in this case also called deciduous) with successional (secondary) teeth developing
from the dental lamina lingual to the predecessor (Butler, 1978; Brown, 1983; Luckett,
1993). In addition, three or more molars may develop posterior to these teeth and have no
deciduous predecessors. Together with the unreplaced and secondary teeth they constitute
the permanent dentition. Luckett (1993) and Butler (1978) considered the molars (e.g. hu-
man permanent molars) as primary teeth. Teeth may be regarded as primary or secondary
according to whether they develop from the surface epithelium or the dental lamina (Luckett,
1993). Most mammalian species, though, have reduced dentitions as they have lost some or
several of the ancestral teeth. Thus, mouse and other muroid rodents develop in each quad-
rant only one incisor and three molars, which are not replaced, the molars presumably being
homologous to the posterior-most postcanine teeth (molars) of other species (Cohn, 1957)
(Fig. 2). In human dentition, two primary incisors, a primary canine and two primary post-
canine teeth (called primary or deciduous molars) are replaced with two permanent incisors,
a permanent canine and two permanent premolars, and in addition three permanent molars
develop without deciduous predecessors (Ten Cate, 1994). Thus, during evolution, Homo
sapiens has lost one of the incisors and two anteriormost premolars.
Development of teeth
The mammalian teeth develop from the oral epithelium and the underlying mesenchyme.
Their development resembles that of the other ectodermal organs such as hair or the sweat
and mammary glands (Pispa and Thesleff, 2003). Tooth development has been studied ex-
perimentally in many vertebrate species such as dogs and amphibians (reviewed by Lewin,
1997; reviewed by Lumsden, 1988) but most of the recent knowledge relevant for under-
standing of the development of human dentition has been obtained from studies in rodents,
especially in the mouse.
Tooth development has been divided to distinct phases of initiation, morphogenesis, differ-
entiation and eruption. During each phase, different stages can be distinguished (Fig. 3).
The enamel-producing ameloblasts and Hertwigs epithelial root sheath originate in the epi-
thelium. The mesenchyme contributes to the dentin-forming odontoblasts, dental pulp, ce-
mentum and surrounding alveolar bone and originates in the cranial neural crest (for this rea-
son also called ectomesenchyme) (Lumsden, 1988). These cells migrate from the midbrain
and the hindbrain and populate the branchial arches and facial region before the tooth devel-
opment commences, in the mouse during embryonic days (E) 8-10 (Nichols, 1986; Imai et
al., 1996; Chai et al., 2000)
14
Figure 2. Comparison of dentitions. One quadrant from the upper jaw is shown. Uppermost, an-
cestral mammalian dentition. Middle, human dentition. Bottom, mouse dentition. Most common
designations of teeth are shown below the teeth. For human teeth, numbers according to the FDI
numbering system are shown inside the tooth crowns. Combinations of codes for different quad-
rants and numbers shown in figure are commonly used, e.g. 15 denotes maxillary tooth 5 on the
right, the second premolar (11 to 18, upper right; 21 to 28, upper left; 31 to 38, lower left; 41 to
48, lower right; 51 to 55, 61 to 65, 71 to 75, 81 to 85 primary teeth in the same order). In mouse,
the incisor is continuously growing and there is a toothless diastema between the incisor and the
first molar. Assumed evolutionary homologies are delineated by dotted lines. Please note, that
human premolars and their predecessors (deciduous molars) correspond to premolars 3 and 4 of
the ancestral mammalian dental formula. In human dentition the first postcanine tooth to initiate
development (key or stem tooth) is the first deciduous molar dM1, corresponding to dP3 of
the ancestral formula). dP1 of the ancestral formula is colored grey to indicate that a primary
tooth in this position may not be replaced. For incisors, it is assumed that mouse incisor corre-
sponds to the I2 of the ancestral formula. For references, see Butler (1978) and Luckett (1993).
15
The dental arches are formed along with the development of the oral cavity from the medial
nasal processes and maxillary and mandibular processes of the first branchial arch. In hu-
mans, the medial nasal and maxillary processes fuse on the sixth to seventh weeks of de-
velopment (Sadler, 1990) but the first signs of the future tooth positions, the thickening of
the epithelium to form the dental lamina may be seen even before that (Tonge, 1969). In
mouse, the dental lamina can be observed as a thickened epithelium on E12, but the specific
gene expression can be identified even earlier (Mina and Kollar, 1987; Cohn, 1957; Mina
and Kollar, 1987; Mucchielli et al., 1997).
Analogous to the development of the other ectodermal organs, the development of individual
teeth is initiated when the epithelial placodes form in the dental lamina (Pispa and Thesleff,
2003; Mikkola and Millar, 2006). In mouse, the first placodes appear in the molar and inci-
sor regions on E11.5-12. In humans, the placodes for the primary teeth have been observed
on the seventh week of gestation (Tonge, 1969).
The placode formation is accompanied with the commencement of the condensation of the
underlying mesenchymal cells (Cohn, 1957). Subsequently the epithelium grows into the
mesenchyme forming an epithelial bud consisting of outermost basal epithelial layer and in-
ner stellate reticulum and surrounded by condensating mesenchyme (bud stage). In the tip
of the bud the so-called enamel knot of non-dividing cells forms while the epithelium around
it continues the growth forming the so-called cervical loops (cap stage) (Jernvall et al.,
1994). In the mouse molars (and presumably in all multicusped teeth) additional, secondary
enamel knots develop in the epithelium to mark the sites of additional cusps (bell stage)
(Jernvall et al., 2000). The condensed mesenchyme delimited by the cervical loops forms the
dental papilla whereas the outermost mesenchyme surrounding the papilla and the cervical
loops forms the dental follicle. The basal epithelium becomes divided into the inner (facing
the papilla) and the outer enamel epithelium (facing the dental follicle) while the stratum in-
termedium forms between the inner enamel epithelium and the loose epithelium of the stel-
late reticulum.
16
Figure 3. Summary of tooth development and most essential known molecular regulation. Signals
emanating from the epithelium are shown above and signals from the mesenchyme below the scheme.
Stages when development is arrested in mouse null mutants are indicated (adapted from Thesleff,
2006).
Coupled to the process of morphogenesis, the differentiation of the hard tissue forming cells
starts at the tips of future cusps and extends to the cervical direction (Cohn, 1957; Ten Cate,
1994). The mesenchymal cells facing the basement membrane elongate, polarize and termi-
nally differentiate into odontoblasts starting to produce predentin matrix. The basement
membrane is digested and the epithelial cells differentiate into ameloblasts that also elon-
gate, polarize and start secreting enamel matrix. While the predentin layer thickens the odon-
toblasts withdraw, leaving behing processes called dentinal tubules, and trigger mineraliza-
tion of the predentin to form dentin. In the maturation of the enamel, the organic matrix is
processed by digestion and simultaneous mineralization. The differentiation of the hard tis-
sue producing cells marks also the fixation of the final form of the tooth crown, except for
the contribution by the increasing thickness of the enamel layer.
The morphogenesis of teeth is accompanied by alveolar osteogenesis in the surrounding
mesenchyme and the dental follicle and followed by innervation and vascularization of the
dental pulp (Cohn, 1957; Gaunt, 1964; Ten Cate, 1994; Luukko, 1997). Because of the for-
mation of the alveolar bone, teeth become enclosed in bony crypts delineated by the dental
follicle cells. Therefore, the eruption of teeth requires resorption of the alveolar bone.
In teeth that develop roots, as all human teeth and mouse molars, the differentiation to the
ameloblasts ceases when the differentiation front reaches the future cemento-enamel junc-
tion. The epithelium now forms a bilayer structure called Hertwigs epithelial rooth sheath
(HERS) which continues its growth into the underlying mesenchyme (Ten Cate, 1994;
Thesleff and Nieminen, 2005). The epithelial bilayer that is left behind becomes fragmented
and forms the so-called epithelial cell rests of Malassez (ERS). Along with the growth of
HERS, the differentiation of the dental papilla mesenchymal cells continues, leading to the
deposition and mineralization of the root dentin. Cells from the dental follicle differentiate
into cementoblasts that deposit cementum on the surface of the root dentin. Dental follicle
cells also form the fibrous periodontal ligament that connects the root to the bone and con-
17
tribute to the alveolar bone itself. In the multicusped teeth, the developing root may get bi-
furcated leading to the development of several separate root apices.
In different animal species, various modifications of the general process outlined above may
exist. In mouse and other rodents, the incisors grow continuously and only cells on the labial
aspect differentiate into ameloblasts (Tummers and Thesleff, 2003). For the continuous
growth of these teeth, new ameloblasts must differentiate continuously in the labial cervical
loop during the whole life span of the animal, i.e. the epithelium of the cervical loop is never
switched from the ameloblast forming fate to the root fate. In other rodents, such as sibling
voles and rabbits, also the molars may grow continuously (Tummers and Thesleff, 2003).
In humans and many other mammals, the secondary teeth develop from the lingual exten-
sions of the dental lamina that are connected to the enamel organ of the primary tooth
(Luckett, 1993; Ten Cate, 1994). According to Luckett (1993), the development of the sec-
ondary tooth usually becomes detectable after the primary predecessor has reached the bell
stage or after the onset of the terminal differentiation of odontoblasts and ameloblasts in the
primary tooth. A similar kind of relationship may be present between the developing molars.
Initiation of teeth of different tooth classes (i.e. incisors, canines and premolars/molars) tend
to follow a certain timetable and order in different species. Thus, thickenings for the central-
most incisor, the canine and a premolar appear first in different parts of the dental lamina. In
the incisor region the central-most incisors are initiated first, although the initiation of the
other incisors may happen almost simultaneously (Luckett, 1993). For the postcanine teeth,
the first teeth to be initiated are either the teeth corresponding to the third or fourth post-
canine teeth of the ancestral formula, and this is followed by initiation of the more anterior
and posterior teeth (Butler, 1978; Luckett, 1993). In humans and other primates, the first
postcanine tooth to be initiated is the anterior-most deciduous molar (corresponding to dP3
of the ancestral formula). The first permanent molars are initiated early, presumably before
the successional permanent teeth, while the more posterior molars develop postnatally from
a distal extension of the dental lamina (Ten Cate, 1994). The morphogenesis and the miner-
alization of the secondary teeth is slow and it takes years before the tooth erupts into the oral
cavity. The mineralization of all human deciduous teeth starts early during prenatal devel-
opment, while mineralization of first permanent molars starts perinatally and that of other
permanent teeth except third molars usually before three years of age (Pirinen and Thesleff,
1995). The deciduous teeth erupt during the first postnatal years and the permanent first mo-
lars in an age of six to seven years. There is individual variation in the ages of shedding of
the deciduous teeth and eruption of the secondary teeth but usually this happens between six
and twelve years of age, beginning from the incisors. Second permanent molars usually erupt
after 11 years of age. Mineralization of the third molars usually starts before age of 10 but
both the mineralization and eruption varies remarkably between individuals.
18
Commitment, morphogenesis and inductive interactions
For understanding the regulatory mechanisms of tooth development, it is relevant to compare
it to the development of other ectodermal organs, and to understand the teeth as units with
serial homology (Pispa and Thesleff, 2003; Butler, 1978; Weiss et al., 1998). Tooth devel-
opment shares many similarities with that of other ectodermal organs, including initiation
from an epithelial placode, and, analogous to a mammary line, a preceding epithelial thick-
ening, reciprocal interactions of the epithelial and mesenchymal component, activa-
tion/inhibition mechanisms to create the separate meristic units, and, analogous to hair cy-
cling, renewal (reviewed by Mikkola and Millar, 2006). As distinctive features, teeth de-
velop complex and genetically stable morphologies, and contain cells that are able to pro-
duce specialized mineralized hard tissues.
After comparative anatomical examination of dentitions and morphology of teeth in different
species, Butler (1939) proposed the so-called field model. According to Butlers model, de-
velopment of mammalian dentitions in each jaw quadrant is dictated by the existence of
morphogenetic fields for each tooth class, incisors, canines and molars/premolars which co-
incide with a series of tooth forming locations (Butler, 1978). Different mammalian dental
formulas and different morphologies could be explained by alterations of strengths and rela-
tive placement of the morphogenetic field and the tooth forming locations. The concept ex-
plains why morphological features usually exhibit a gradient inside a tooth class and why a
morphological alteration usually affects several teeth although to a different extent. The con-
cept also predicts that no separate genes are needed for each tooth but that the different tooth
types and morphologies are created by differential regulation of one set of genes (Butler,
1978; see also Miles and Grigson, 1990).
As an experimental support for the existence of a dental morphogenetic field, Glasstone
(1963; 1967) showed that teeth developed in tissue culture of parts of mouse mandibles from
an E11 embryo, i.e. when the culture was started before tooth initiation. The experiments
also showed that the identities and locations of the incisors and molars were already at that
time determined (Glasstone, 1963; Glasstone, 1967; Miller, 1969). Glasstone (1963) also
showed that individual cap stage tooth germs from various species developed teeth with
normal morphology in culture, as did even teeth cut in two halves. Thus, tooth development
from at least from cap stage onwards was shown to be independent of the surrounding tissue
and teeth showed capacity to regulation, which are the key features of the morphogenetic
field concept (see Gilbert, 2003). The commitment of dental cells for tooth development has
also been shown by development of tooth-like structures after reaggregation of dissociated
cells from tooth germs (e.g. Slavkin et al., 1968; Duailibi et al., 2004).
Knowledge from the development of other ectodermal appendages (reviewed by Hardy,
1992; Pispa and Thesleff, 2003; Gilbert, 2003), as well as from tissue implantation studies in
amphibians (reviewed by Lumsden, 1988; MacKenzie et al., 1992), suggested that neural
crest-derived mesenchyme contained the instructive potential for tooth development. In sup-
port for the instructive role of the dental mesenchyme in tooth development, cultures of re-
combined tissues showed that mouse E13 or older mandibular mesenchyme recombined with
limb bud epithelium was able to instruct tooth development and that incisor or molar mesen-
19
chyme recombined with enamel organs instructed the development of a tooth type according
to their source (Kollar and Baird, 1969; Kollar and Baird, 1970).
Lumsden (1979) cultured mouse first molar germs in the anterior chamber of the mouse eye
and showed that E12 or older germs were able to give rise also to the second and third mo-
lars. He concluded that the results supported an intrinsic control of development and there-
fore a morphogenetic gradient field was not necessary. Accordingly, Osborn (1978) pre-
sented a new model explaining the development of different dentitions, which, according to
him, could better explain the diverse morphological aspects in different species (see criticism
by Butler, 1978; see also Miles and Grigson, 1990). The clone model suggested the pres-
ence of specific determined cells, presumably in the mesenchyme of the neural crest origin,
that contained the information for the development of the different tooth classes. These cells
were able to form and instruct the development of teeth by clonal expansion regulated by
inherent inhibition mechanisms. The limited capacity of these cells to expand would be re-
sponsible for limiting the extent of tooth rows, and the gradual diminishing of the capacity
would be reflected as progressively simplified morphology of the later developing teeth.
The role of the mesenchyme as the instructive tissue was challenged by Miller (1969) who
showed that the E11 to E12 mouse incisor or molar dental epithelium was able to instruct the
tooth type in the recombination tissue culture on the chick chorioallantoic membrane. Mina
and Kollar (1987) recombined the first and second branchial arch epithelia and mesenchyme
from mouse embryos and cultured them in the anterior eye chamber. They showed that the
first arch epithelium instructed the tooth development with the second branchial arch ec-
tomesenchyme until E11.5, but not thereafter, whereas the first arch mesenchyme instructed
tooth development with the second arch epithelium in E12,5 or older embryos. Thus, the in-
structive potential was present in the oral epithelium until first signs of tooth development,
but shifted to the dental mesenchyme at the time when the dental placodes are formed. Con-
temporarily, Lumsden (1988) showed that the cultured mouse E9 or E10 mandibular epithe-
lia together with cranial neural crest cells allowed tooth development, confirming the induc-
ing role of the early epithelium and the odontogenic capacity of mouse neural crest cells.
Furthermore, his results showed that the odontogenic capacity was largely limited to the cra-
nial neural crest, and that any instructive interactions during the neural crest cell migration
were not necessary. The capacity of the early epithelium to instruct tooth type specification
has also been shown (Kollar and Mina, 1991). More recently, the instructive role of early
mandibular epithelium has also been shown in cell reconstitution experiments with bone
marrow cells (Ohazama et al., 2004; Li et al., 2007). The instructive potential of the mouse
dental tissues have also been shown by recombination experiments with chick tissues in
which variable stages of morphogenesis and differentiation have been observed (Mitsiadis et
al., 2003 and references therein).
Tissue interactions are crucial also during later stages for differentiation of hard tissue form-
ing cells and for the development of the alveolar bone (reviewed by Thesleff and Nieminen,
2005). Recently, stem cell properties have been described for ameloblast, odontoblast and
periodontal ligament forming cells (Harada et al., 1999; Gronthos et al., 2002; Sonoyama et
al., 2006; Wang et al., 2007).
20
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Molecular regulation of tooth development
During the last two decades after the advent of molecular biology and genetics, the new tech-
nologies have been extensively used to elucidate developmental mechanisms and the genetic
regulation of tooth development. The most usual model has been the mandibular molar teeth
of the mouse, the most practical laboratory animal that develops teeth. Immunohistology and
in situ hybridization have been used to study gene expression during mouse tooth develop-
ment and differentiation. Natural and transgenic mutant mice have been utilized to reveal
gene function. Tissue culture of whole tooth or jaw explants as well as culture of recombined
tissues has been used to study effects of proteins and mutations. This knowledge is applica-
ble to humans and other mammals because of the conservation of the basic genetic and de-
velopmental mechanisms. However, the molecular genetic studies in humans, including the
positional cloning of several genes that cause different developmental dental anomalies, have
significantly contributed to understanding of the genetic regulation of development and pat-
terning of the human dentition (Table 1).
Reciprocal signaling and signaling centers
Molecular studies have revealed that the instructive and permissive tissue interactions during
mouse tooth development described above are mainly mediated by growth factor signaling
(reviewed by Thesleff and Mikkola, 2002; Wang and Thesleff, 2005). Development from
initiation to eruption is governed by a sequential and reciprocal signaling process rather than
simple one-way messages (Fig. 3). The signaling involves all major signaling pathways, in-
cluding TGF|, FGF, Shh and Wnt as well as Eda, Notch, and EGF signaling, and studies
with mouse mutants have shown that they are needed simultaneously during critical stages of
development (Table 1). Expression of signals is often redundant: several FGFs are expressed
in the initiation stage epithelium (Fgf8, -9), in the enamel knot (Fgf3, -4, -9, -20) and in the
dental mesenchyme (Fgf3, -10) and they signal to receptors expressed differentially by mes-
enchymal and epithelial cells (Kettunen et al., 1998; Kettunen et al., 2000; reviewed by
Wang and Thesleff, 2005). Similar co-expressions are evident for BMP and Wnt signals
(berg et al., 1997; Sarkar and Sharpe, 1999).
The signaling pathways act in an hierarchical, interactive and iterative manner. One pathway
often elicits a reciprocal signal of another pathway or different pathways antagonize each
other to limit the extent of the cellular response. For example, Wnt signaling is needed for
the expression of Fgf4 in the enamel knots as well as Eda in the early epithelium, which sub-
sequently works upstream of Shh and BMP antagonists (Kratochwil et al., 2002; Pummila et
al., 2007). Antagonism of FGF and BMP signaling is thought to act to delineate the positions
of tooth initiation, to specify tooth identity and to regulate cusp morphogenesis (Neubuser et
al., 1997; Tucker et al., 1998; Peters and Balling, 1999; Salazar-Ciudad and Jernvall, 2002).
Induction of specific inhibitors have been shown to be important for the fine-tuning of the
signaling effects and proper morphogenesis and possibly to tooth renewal (Wang et al.,
2004a; Wang et al., 2004b; Kassai et al., 2005; Lammi et al., 2004). BMP4 acts as an itera-
tive signal early in the determination of the tooth positions, has a critical role during morpho-
26
genesis, and finally as an inducer of the differentiation of both odontoblasts and ameloblasts
(Neubuser et al., 1997; Vainio et al., 1993; Jernvall et al., 1998; Wang et al., 2004b; re-
viewed by Wang and Thesleff, 2005).
During development, some parts of an organ rudiment may organize patterning and morpho-
genesis by active signaling (Hogan, 1999; Gilbert, 2003). Well-characterized examples of
such organizers or signaling centers from vertebrates are the dorsal blastopore lip, the
notochord, the zone of polarizing activity in the limb buds, and the isthmus between the de-
veloping midbrain and hindbrain. In ectodermal organs, the epithelial placodes that initiate
hair, tooth and gland development are thought to signal to the underlying mesenchyme and
instruct condensation and gene expression as well as to the surrounding epithelium to pattern
the positioning of neighbouring placodes (reviewed by Pispa and Thesleff, 2003; Mikkola
and Millar, 2006). In teeth, the enamel knots that form in the late bud stage epithelium signal
to the surrounding epithelium to activate proliferation and to the mesenchyme to induce re-
ciprocal signals and inhibitors (reviewed by Thesleff et al., 2001; Wang and Thesleff, 2005).
Through this activity, enamel knots mark and stimulate the formation of tooth cusps and pat-
tern tooth crown morphogenesis presumably by regulating formation of additional (secon-
dary) enamel knots (Jernvall et al., 2000; Salazar-Ciudad and Jernvall, 2002).
Transcription factors
Transcription factors are intracellular proteins that bind to DNA and regulate expression of
the target genes. They typically contain one or more protein motifs that are able to bind to
specific sequence motifs in DNA or to interact with other proteins that are necessary for the
activation of transcription. Especially the DNA-binding motifs are conserved and used to
classify different factors.
Hox proteins contain a DNA-binding homeobox. The nested expression of the genes of the
Hox clusters define the anterio-posterior identities in the trunk and neural tube as well as the
proximo-distal and anterio-posterior axes in the limbs (Gilbert, 2003). The homeobox is pre-
sent also in many transcription factors coded by genes outside the Hox clusters. These genes
have important roles in the development for example in the craniofacial region where the
genes of the Hox clusters are not expressed (reviewed by Jernvall and Thesleff, 2000; De-
pew et al., 2005). Other DNA-binding motifs of the transcription factors taking part in cell
regulation during development include e.g. helix-loop-helix, leucine zipper, paired, fork-
head, T-box, LIM and runt motifs (reviewed by Dahl et al., 1997; Packham and Brook, 2003;
Friedman and Kaestner, 2006; Gilbert, 2003).
Adding or removing expression of a single transcription factor may change a cell's commit-
ment or capacity for differentiation. Manipulations of expression of the Hox genes may lead
to changes in the identity of body parts, the so-called homeotic changes. Nested expression
of the Dlx homeobox genes specifies the identities of cell populations in the developing jaws
(Depew et al., 2002). Inactivation of the Runx2 gene blocks all bone differentiation (Otto et
al., 1997). As described below, expression of specific transcription factors during different
stages of tooth development is necessary for the competence, commitment and signaling. It
27
is apparent that expression of specific transcription factor genes are needed for the dental
specification of the early epithelium and for the regulation of the instructing signaling activ-
ity. On the other hand, expression of several transcription factors in the mesenchyme, regu-
lated by signals from the epithelium, are needed for the activation of the odontogenic net-
works in the mesenchyme. Furthermore, a central role for specific transcription factors has
been shown in mediation of the reciprocal signaling networks critical for the tooth morpho-
genesis and cellular differentiation (reviewed by Peters and Balling, 1999; Jernvall and
Thesleff, 2000; Tucker and Sharpe, 2004).
MSX1 and PAX9
MSX1 and PAX9 are transcription factors intimately involved in the genetic networks regu-
lating tooth development. MSX1 contains a homeobox which binds to specific target se-
quences in the DNA but is also capable to protein-protein interactions. MSX1 has often been
considered rather as a repressor than activator of gene expression (Catron et al., 1995; re-
viewed by Bendall and Abate-Shen, 2000). The mouse Msx1 gene codes also for an an-
tisense transcript which may have a role in the regulation of Msx1 expression (Blin-Wakkach
et al., 2001). Mouse Msx1 is expressed during the development and migration of the neural
crest as well as during craniofacial and limb development (Tribulo et al., 2003; Monsoro-
Burq et al., 2005; reviewed by Bendall and Abate-Shen, 2000). Msx1 is induced by epithelial
signals in the dental mesenchyme (Vainio et al., 1993; Kettunen et al., 1998; Tucker et al.,
1998; Kettunen et al., 2005), where it is necessary for the expression of the reciprocal sig-
nals, especially Bmp4 and Fgf3, as well as for expression of the Shh receptor Patched and
the transcription factors Lef1 and Runx2 (Chen et al., 1996; Zhang et al., 1999; berg et al.,
2004). MSX1 is able to activate transcription from the Bmp4 promoter in vitro (Ogawa et al.,
2006). Msx1 null mutant mice exhibit a cleft palate and other craniofacial anomalies as well
as a lack of teeth, the development of which is arrested at the bud stage (Satokata and Maas,
1994). In these mice the condensation of the ectomesenchymal cells is impaired. In double
null mutants of Msx1 and its homolog Msx2 tooth development usually does not reach the
placode stage suggesting that earlier than the bud stage Msx1 function may be redundant
with Msx2 (Satokata et al., 2000).
PAX9 belongs to the paired-box containing transcription factor family, and is one of the ear-
liest mesenchymal markers of the future tooth forming positions in mouse (Neubuser et al.,
1997). Pax9 is regulated by epithelial signals, especially FGF8, and it apparently regulates
reciprocal signaling from the mesenchyme (Neubuser et al., 1997; Peters and Balling, 1999).
In the Pax9 null mutant mice, expression of mesenchymal Bmp4 is impaired at the bud stage
and that of Msx1 and Lef1 slightly later (Peters et al., 1998). It has been shown that PAX9 is
capable to bind the MSX1 protein and synergistically with MSX1 activate Msx1 and Bmp4
transcription in vitro (Ogawa et al., 2006). In mouse null mutants of Pax9, tooth develop-
ment is arrested at the bud stage, the condensation of the ectomesenchymal cells is reduced,
and, in addition to tooth agenesis and cleft palate, several derivatives of the pharyngeal
pouches fail to develop and limb abnormalities are observed (Peters et al., 1998). In mice
with hypomorphic Pax9 mutations, a partial failure of tooth development was observed, af-
28
fecting in a dose-dependent manner the third molars and incisors and to a smaller extent the
other molars. The ameloblast differentiation and dentinogenesis were also affected (Kist et
al., 2005).
It has been suggested that the key role of Msx1 and Pax9 is to facilitate the bud to cap stage
transition (Peters and Balling, 1999; Thesleff, 2006). Mesenchymal Msx1 expression is ini-
tially activated by the epithelial BMP4 signal, and needed for a reciprocal BMP4 signal from
the mesenchyme. Bmp4 and Msx1 thus form an autoregulatory loop (Chen et al., 1996). The
BMP4 signal to the epithelium is crucial for the formation of the epithelial signaling center,
the enamel knot, and the arrest of the development in Msx1 null mutant teeth can be rescued
by external BMP4 or transgenically activated Bmp4 expression (Chen et al., 1996; Bei and
Maas, 1998; Zhang et al., 2000). The expression of Pax9 is apparently needed to maintain
and, by the synergism with Msx1, to enhance this loop. However, as shown by the mice with
hypomorphic mutations, Pax9 is also needed later in tooth development (Kist et al., 2005).
Loss of function defects in MSX1 and PAX9 in humans cause partial failure of tooth devel-
opment, tooth agenesis. As described in the Results and discussion, these defects are selec-
tive: defects in MSX1 associate especially with agenesis of second premolars and third mo-
lars, whereas the defects in PAX9 affect particularly the permanent molars. The size of the
permanent teeth may also be reduced. In one of the families with a defect in MSX1, some
patients also presented with nail dysplasia and in another family with oral clefts (Jumlongras
et al., 2001; van den Boogaard et al., 2000). Several other sequence changes in MSX1 have
also been described in connection with oral clefting (Jezewski et al., 2003; Suzuki et al.,
2004). In addition, a microsatellite allele in the intron of MSX1 has been associated with both
tooth agenesis and oral clefting, and two promoter region SNP alleles of PAX9 with tooth
agenesis (Lidral et al., 1998; Suzuki et al., 2004; Vieira et al., 2004; Peres et al., 2005).
Initiation
In mammals, teeth develop on a special horseshoe-shaped area of a thickened epithelium, the
dental lamina (Cohn, 1957; Tonge, 1969). The lamina spans epithelia originating in separate
facial processes. The identity of these processes is instructed by specification of neural crest
cells by pharyngeal endoderm during their migration (Couly et al., 1998). On the other hand,
the growth and identity of these processes is also under the control of signaling from the sur-
face epithelium (Lee et al., 2001; Stottmann et al., 2001; reviewed by Richman and Lee,
2003). It is also assumed that the regional specification of the processes is associated with
differential expression of epithelial signals (Tucker et al., 1998; Trumpp et al., 1999; Ha-
worth et al., 2004). As reflections of the specification and signaling, several transcription
factors show selective or graded expression patterns during the early jaw development
(reviewed by Jernvall and Thesleff, 2000; Tucker and Sharpe, 2004; Depew et al., 2005).
The dental lamina apparently defines the region for future tooth development, and subse-
quently individual dental placodes are initiated at specific positions along the lamina. For
hair and mammary glands, it has been assumed that the initial, perhaps permissive, signal is
provided by the mesenchyme (Hardy, 1992; reviewed by Pispa and Thesleff, 2003; Mikkola
29
and Millar, 2006). As described above, initial instructive capacity for tooth development ap-
pears to reside in the oral epithelium (Mina and Kollar, 1987). However, it is apparent that
both epithelial and mesenchymal signaling are needed for the formation of the dental pla-
codes. In several mouse mutants, formation of the placodes is impaired and it appears that in
the initiation several signaling pathways interact (reviewed by Mikkola and Millar, 2006).
It has been suggested that the position of odontogenic epithelium is originally defined by sig-
naling organized by the oral-aboral boundary (Harris et al., 2006). Neubuser and colleagues
(1997) suggested that tooth positions are defined by antagonistic interactions of FGFs and
BMPs, perhaps under organizing control of the ectodermal-endodermal boundary. The ex-
pression of Pitx2 becomes restricted to the lamina in mouse embryos at E10.5 (St Amand et
al., 2000). Its expression is dependent on Fgf8 (agonist) and Bmp4 (antagonist) (St Amand et
al., 2000). Pitx2 is itself needed for the restriction of the epithelial Fgf8 expression to the
lamina as well as for tooth development past the placode stage (Lin et al., 1999; Lu et al.,
1999). In man, defects in PITX2 cause selective tooth agenesis in the Rieger syndrome
(Semina et al., 1996). In addition, it has been shown that e.g. signaling genes Shh, Bmp2 and
Wnt10b become expressed early in the odontogenic epithelium, and subsequently upregu-
lated in the placodes (Dassule and McMahon, 1998; reviewed by Wang and Thesleff, 2005).
Interestingly, Wnt7b and Shh showed complementary expression patterns in the oral epithe-
lium, and forced expression of Wnt7b antagonized expression of Shh and arrested future
tooth development, suggesting that antagonism between Wnt and Shh signaling is involved
in positioning of the tooth placodes (Sarkar et al., 2000).
The epithelial transcription factor p63 is indispensable for tooth development because in the
p63 null mutant mice both tooth and hair placodes fail to form (Mills et al., 1999; Yang et
al., 1999). In man, mutations in P63 cause tooth agenesis associated with ectrodactyly-
ectodermal dysplasia-clefting (EEC) and other allelic syndromes (Celli et al., 1999; reviewed
by van Bokhoven and McKeon, 2002). The expression of mouse p63 is not limited to the
tooth forming areas, and normal Fgf8 and Bmp4 expression was observed in the null mutants
(Laurikkala et al., 2006). However, p63 is upstream of several signaling molecules including
Bmp7, Fgfr2, |-catenin and Edar, thus regulating the signaling that is involved in the initia-
tion and positioning of the dental placodes (Laurikkala et al., 2006).
The formation of the epithelial dental placodes is marked by the expression of several genes,
including transcription factor genes Msx2 and Lef2 and signaling genes Shh, Bmp2, Fgf8,
Fgf20, Wnt10a, Wnt10b, and Edar (reviewed by Wang and Thesleff, 2005). The role of these
genes is apparently to regulate gene expression in the placodes themselves, and signal to the
surrounding epithelium and mesenchyme. Shh and FGFs also stimulate the proliferation in
the epithelium, presumably promoting the growth of the tooth bud (Hardcastle et al., 1998;
Cobourne et al., 2001; Kettunen et al., 1998).
In the mesenchyme, Pax9 is localized to the future tooth forming position already at the E9.5
(molars) to E10 (incisors) in mouse (Neubuser et al., 1997). As shown by inactivating Fgf8
in the epithelium or using an antagonist of FGF signaling in tissue culture, early expression
of Pax9 as well as several other transcription factor genes in the mesenchyme is dependent
on FGF signaling from the epithelium, but becomes independent of FGFs already before the
30
formation of the dental placodes and the observed shift of the odontogenic potential to the
mesenchyme (Trumpp et al., 1999; Mandler and Neubuser, 2001). In tissue culture experi-
ments, it has been shown that FGFs, BMPs, Wnts and Shh, that are expressed in vivo in the
epithelium and the placodes, are able to induce expression of specific transcription factor
genes in the mesenchyme. FGF8-containing beads induced Msx1, Pax9, Barx1, Dlx1, Dlx2,
Lhx6, and Lhx7 (Neubuser et al., 1997; Kettunen and Thesleff, 1998; Tucker et al., 1998;
Grigoriou et al., 1998), BMP4 and WNT4 induced Msx1, and Shh induced Gli1 as well as its
own receptor, Patched (Vainio et al., 1993; Kettunen et al., 2005; Dassule and McMahon,
1998; Hardcastle et al., 1998). Tooth development may be arrested already prior the placode
stage in the double null mutants of Msx1;Msx2, Dlx1;Dlx2 and Gli2;Gli3, which is explained
by the need of these transcription factors for induction of reciprocal signals in the mesen-
chyme (Satokata et al., 2000; Thomas et al., 1997; Hardcastle et al., 1998).
One of the earliest placodal markers, Edar, is originally expressed throughout the oral epi-
thelium and epidermis, but becomes limited to the placodes at an early stage (Laurikkala et
al., 2001). In Tabby, the mouse mutant devoid of the function of Eda, the Edar ligand, the
limitation to the hair placodes does not happen (Laurikkala et al., 2002). In these mice as
well as in mutants of Edar and Edaradd, a gene coding for an Eda signal transduction pro-
tein, however, the placode development is not completely inhibited. On the other hand, when
Eda was overexpressed in the epithelium, the hair and tooth placodes became larger, proba-
bly due to an increased amount of the cells destined to become placode cells (Mustonen et
al., 2004). Thus, Eda signaling probably acts rather as a modulator of ectodermal placode
formation than as an initiator. Eda signaling may be important as a mediator of effects of
Wnts to activate Shh and antagonize BMPs (Pummila 2007). Mutations in the EDA, EDAR
and EDARADD genes in humans cause X-linked and autosomal anhidrotic ectodermal dys-
plasias (EDAs) characterized by sparse hair, failure of sweat gland development, tooth agen-
esis and size reduction of teeth (microdontia) (reviewed by Mikkola and Thesleff, 2003).
For several reasons, Wnt signaling has been a strong candidate for an ectodermal placode
initiator. Wnt reporters become activated in the hair and mammary placodes, and several
Wnt ligands are expressed in the dental tissues (Sarkar and Sharpe, 1999; reviewed by Pispa
and Thesleff, 2003; Wang and Thesleff, 2005; Mikkola and Millar, 2006). Necessity of Wnt
signaling for placode formation was shown by epithelial expression of a Wnt antagonist
Dkk1 under the keratin 14 promoter which arrested tooth as well as hair development before
the placode stage (Andl et al., 2002). On the other hand, experimental accumulation of the
intracellular Wnt signaling mediator, |-catenin, under the keratin 14 promoter in epithelium
lead to de novo formation of hair follicles (Gat et al., 1998). Forced overexpression of Lef1
in ectoderm caused extra tooth-like budding in oral epithelium (Zhou et al., 1995). Further-
more, the expression of Eda was induced by Wnts in mouse tissue culture and absent in the
early dental epithelium of the Lef1 null mutant mice (Laurikkala et al., 2001).
As a summary, it appears that different signaling pathways have different and partially re-
dundant roles in the initiation of dental placodes. It is assumed that FGFs and Wnts as well
as Eda promote placode formation, and BMPs and TGF|s antagonize it, analogous to the
formation of other ectodermal placodes (reviewed by Wang and Thesleff, 2005; Mikkola and
Millar, 2006).
31
Morphogenesis
The most complex morphological variation in mammalian teeth involves the crown patterns
of multicusped teeth. The regulatory and molecular basis of morphogenesis of multicusped
teeth as well as establishing different cusp arrangements have begun to be understood
(Jernvall et al., 2000; Salazar-Ciudad and Jernvall, 2002). Even a quantitative manipulation
of one or a few gene activities during molar tooth development may lead to remarkably dif-
ferent cusp arrangements and crown patterns (Kangas et al., 2004; Wang et al., 2004a; Kas-
sai et al., 2005).
In the late bud stage, a group of cells at the tip of the epithelial bud, the primary enamel knot,
cease to proliferate and are later removed by apoptosis (Jernvall et al., 1994; Vaahtokari et
al., 1996). The enamel knot deviates significantly from the surrounding epithelium because
of its gene expression. It expresses several transcription factors and numerous signaling
molecules as well as signaling inhibitors with a specific schedule of appearance, thus having
potential to act as a signaling center that orchestrates the development of the surrounding
tissues (reviewed by Thesleff et al., 2001; Wang and Thesleff, 2005). The primary enamel
knot is apparently induced and maintained by signals emanating from the underlying mesen-
chyme (Jernvall et al., 1998; Kratochwil et al., 2002). On the other hand, formation of the
primary knot seems to be a prerequisite for the advancing of the tooth development to the
cap stage. This is suggested by several mouse null mutants (Msx1, Pax9, Runx2, Lef1,
FGFR2IIIb, Bmpr1a) in which tooth development is arrested at the bud stage, apparently
because of a failure of formation or function of the primary enamel knots (van Genderen et
al., 1994; Satokata and Maas, 1994; Peters et al., 1998; berg et al., 2004). In the Msx1,
Pax9, and Runx2 mutants, the mesenchyme fails to activate signaling to the epithelium and
to induce or maintain the enamel knot (Chen et al., 1996; Jernvall et al., 1998; Bei and Maas,
1998; berg et al., 2004). In the Lef1 mutants, the epithelium fails to activate the expression
of Fgf4, which leads to a failure of growth of the cervical loops and reciprocal signaling with
the mesenchyme (Kratochwil et al., 2002). Shh expressed by the enamel knot induced prolif-
eration in the epithelium, probably by inducing mesenchymal signals, and FGFs both in the
epithelium and the mesenchyme (Jernvall et al., 1994; Kettunen et al., 1998; Cobourne et al.,
2001; Gritli-Linde et al., 2002). Thus, the enamel knot has potential to guide the formation
of the epithelial cervical loops and the dental papilla, the landmarks of the cap stage of tooth
development.
In mouse molars, similar structures called secondary enamel knots are formed subsequently
in certain positions in the epithelium undergoing folding morphogenesis and these appar-
ently correspond to the positions of the later forming cusps of the molar teeth (Jernvall et al.,
2000). It is assumed that the formation and positions of the secondary knots are dependent
on the signaling activity of the primary knot, possibly via induction of signals in the mesen-
chyme (Salazar-Ciudad and Jernvall, 2002). The size of the primary enamel knot and the de-
velopment of the mouse molar cusps are dependent on Eda signaling (Pispa et al., 1999;
Kangas et al., 2004) as well as on normal amounts of follistatin and ectodin, inhibitors of
activin, BMP, and Wnt signaling (Wang et al., 2004a; Kassai et al., 2005). Modelling of the
molar tooth development has also suggested that positions and sizes of the secondary knots
32
are dependent on slight alterations in the concentrations and diffusion properties of distinct
activators and inhibitors of knot differentiation (Salazar-Ciudad and Jernvall, 2002). Quanti-
tative adjustment of these parameters may be sufficient to change a mouse type of molar
tooth to resemble the molars of another rodent, the vole.
The main difference between the premolars and molars and the other tooth types, incisors
and canines, is in the amount of cusps, suggesting that the tooth type specification is associ-
ated with the capacity to form the secondary enamel knots. As known from the tissue recom-
bination studies, at the morphogenetic stages the dental mesenchyme is able to instruct tooth
development also in a heterologous epithelium as well as to determine the tooth type (Kollar
and Baird, 1969). Accordingly, the mesenchyme apparently is competent to instruct whether
the secondary enamel knots are induced. However, as the epithelium is able to instruct the
tooth type specification during the early stages (Kollar and Mina, 1991), it appears that the
early epithelium instructs the dental mesenchyme competent to decide whether and how the
secondary knots will de induced. This competence of the mesenchyme could be dependent
on specific transcription factor activities. Although the serial homology of teeth suggests that
no separate genetic programs exist for each tooth, differences of gene activities must exist
during development of teeth of different classes. These differences may be mainly quantita-
tive but at least some genes show specific expression only during development of one tooth
class. A LIM-domain transcription factor gene Islet1 appears to be expressed only in the epi-
thelium of the developing incisors, whereas e.g. Barx1, a homeobox transcription factor
gene, is specific for the presumptive molar mesenchyme (Mitsiadis et al., 2003; Tissier-Seta
et al., 1995).
Inactivations of both Dlx1 and Dlx2, members of the Dlx homeobox gene family, caused an
arrest in the development of mouse upper molar teeth only (Thomas et al., 1997), which was
suggested to support the concept of an odontogenic homeobox-code (Sharpe, 1995; Tho-
mas et al., 1997). However, as described above, the expression of the mesenchymal tran-
scription factors is dynamic and dependent on various epithelial signals. Furthermore, in the
Dlx1;Dlx2 null mutant, there is no homeotic change of a molar to an incisor. The normal de-
velopment of lower molars can be explained by redundancy, i.e. the expression of other Dlx
genes in the mandibular mesenchyme (Peters and Balling, 1999). The insensitivity of the in-
cisors to inactivation of the Dlx genes suggests that the latter are not critical for the incisor
development. Thus, Dlx activity appears to be needed not to determine a molar tooth identity
but to make it possible to develop any tooth at a molar location. Interestingly, inactivation of
activin|A signaling arrests the development of all mandibular teeth and upper incisors
(Matzuk et al., 1995a; Ferguson et al., 2001). The insensitivity of the upper molars may be
explained by redundancy of signaling pathways (Ferguson et al., 2001).
Barx1 has been suggested to be a candidate for a factor mediating tooth type determination
(Tissier-Seta et al., 1995; Tucker et al., 1998). It is normally expressed only in the presump-
tive molar region and inducible by FGF8. However, if the epithelial BMP4 activity is
blocked by application of an inhibitor Noggin, the expression domain of Barx1 is expanded
to the presumptive incisor region (Tucker et al., 1998). Incisor tooth germs cultured in the
presence of Noggin grew large, showing resemblance to molar tooth germs. Similar change
has been described after injection of Barx1 cDNA to the incisor region (Miletich et al.,
33
2005). Thus, it appears that Barx1 activity would be able to mediate the effect of epithelial
gradients of Bmp4 anf Fgf8 expression on tooth type specification (Tucker et al., 1998).
However, a reciprocal change of a molar to an incisor in absence of Barx1 has not been re-
ported.
It is reasonable to assume that the epithelial signaling gradients are involved in tooth type
specifications, i.e. in the basis of heterodonty (Tucker et al., 1998). Differential signaling
may be mediated to the specification of tooth identity by specific expression of transcription
factors as described above. The differential timing of the interactive processes during the ini-
tiation may also be involved. Pax9 becomes expressed slightly earlier in the presumptive
molar region than in the incisor region (Neubuser et al., 1997). On the other hand, Shh ex-
pression appears to become prominent earlier in the incisor region than in the molar region
(Dassule and McMahon, 1998). Still, the question remains how the epithelial gradients are
created. Organizing activity of the ectodermal-endodermal boundary has been suggested
(Neubuser et al., 1997). Some evidence suggests that the epithelial cells become specified
before the growth of the facial processes, possibly by the endoderm (Haworth et al., 2004;
Haworth et al., 2007). Furthermore, the gradients should be able to create three separate
specifications, i.e. one for each tooth class, e.g. during human tooth development, and the
gradients should lead to similar patterning in the maxilla and mandible even though these are
formed from fusing facial processes in a different way.
Tooth replacement
Relatively little is known about the molecular regulation of tooth renewal, i.e. shedding of
the deciduous teeth and development and eruption of the secondary teeth. There appears to
exist a regulatory relationship between the development of the primary teeth and the succes-
sor (Luckett, 1993), and it may be possible that both activating and inhibitory effects are in-
volved.
Within the hair follicle, a specific epithelial compartment, a hair bulge, contains cells with
stem cell-like properties. These cells are activated in a certain stage of hair cycling to make it
possible for the hair papilla to activate the follicle to start new anagen stage of cycling
(reviewed by Blanpain et al., 2007). Existence of a similar stem cell compartment has been
suggested to make tooth renewal possible in fish and possibly in other vertebrates
(Huysseune and Thesleff, 2004).
Wnt signaling is involved in the activation of the cells of the hair bulge (reviewed by Alonso
and Fuchs, 2003). Several observations suggest the involvement of Wnt signaling also to the
regulation of the secondary tooth development. Mutations in the human AXIN2 gene that
presumably affect the intracellular negative feedback regulation of Wnt signaling, i.e. |-
catenin degradation, cause severe tooth agenesis that affects almost exclusively the perma-
nent teeth (Lammi et al., 2004). In the human disease adenomatous polyposis coli, a cancer
syndrome with massive colon polyposis caused by deregulation of |-catenin level as a con-
sequence of lack of the functional APC gene product, development of supernumerary teeth is
often observed (Ida et al., 1981; Jrvinen et al., 1982). Finally, forced overexpression of the
34
epithelial |-catenin disturbs the mouse molar morphogenesis by creating supernumerary
budding of the molar epithelium in vivo and, in the kidney capsule culture, numerous tooth
structures resembling compound odontomas (Jrvinen et al., 2006).
Supernumerary teeth are a regular feature of cleidocranial dysplasia, a syndrome caused by
defects in the transcription factor gene RUNX2 (Jensen and Kreiborg, 1990; Mundlos et al.,
1997). Whether these teeth reflect a failed suppression of an ancient tooth renewal program
is not clear because the teeth seem to develop occlusally to the normal permanent successors.
It has been suggested that the development of the supernumerary teeth follows from a failure
of degradation of the dental lamina (Jensen and Kreiborg, 1990). Although Runx2 activity is
mandatory for tooth development, a reduced amount of RUNX2 may also release the inhibi-
tion of tooth renewal, as rudimentary epithelial outgrowths have been observed in the molars
of Runx2 null mutant heterozygotes (berg et al., 2004).
35
TOOTH AGENESIS
Developmental anomalies
The development of an individual from an fertilized egg to an adult is a tightly regulated
process requiring coordination of the patterning, organogenesis, morphogenesis and differen-
tiation. Deviations from normal development may lead to anomalies of structure or function,
which when present at birth either as visible or hidden are called birth defects. Structural or
anatomical malformations and abnormalities present at birth as signs of abnormal prenatal
development are also called congenital anomalies (Gilbert, 2003; Kotilainen, 1996). How-
ever, in the case of teeth the development and differentiation continues long after birth, and
instead of congenital many anomalies could rather be called developmental anomalies.
Dysmorphic features that may only require cosmetic concern are considered minor anoma-
lies, whereas anomalies that require clinical or cosmetic attention are considered major
anomalies (Kotilainen, 1996). Minor anomalies are rather common, and a figure of 15 % was
presented by Marden et al (1964), whereas major anomalies are present in 1-2 % of new-
borns (Marden et al., 1964; Sadler, 1990; Gilbert, 2003). Observation of several minor
anomalies increases the risk for presence of one or more major anomalies. Presence of sev-
eral anomalies may be called a syndrome (Kotilainen, 1996).
Congenital or developmental anomalies may be caused by external factors such as terato-
genic agents, radiation, viral infections and even hyperthermia or mechanical forces, and in
this case they are called disruptions or deformations (Kotilainen, 1996). These effects may
vary depending on the time of the exposure, and therefore often manifest in an organ- and
time-specific fashion (Sadler, 1990). Thalidomide, a drug that was used by pregnant women
in the 1950s, caused ear defects, truncations of hands and truncations of feet depending on
the time of exposure during the fourth and fifth weeks of gestation (Sadler, 1990; Gilbert,
2003). As teeth develop during a long period from six weeks of embryonal development to
early adulthood, they are also subject to time-specific effects, which are characterized by dif-
ferent defects on the tooth development or the hard tissue formation depending on the time
and nature of the deleterious agent (Alaluusua et al., 1999; Hltt, 2005). Indeed, because
hard tissues of teeth are not remodelled or repaired after eruption, anomalies of hard tissues
may serve as biomarkers of an experienced environmental insult (Alaluusua et al., 1999).
Normal development may also by affected by genetic causes, and it has been suggested that
the term malformation would be reserved for these anomalies (Kotilainen, 1996; Gilbert,
2003). They may affect only one organ system but often a genetic factor has a pleiotrophic
effect on many organs (multiorgan malformation syndrome). These may be related or inde-
pendent, reflecting the roles of a certain molecular mechanism in the development of multi-
ple organ systems (Gilbert, 2003). A term trait has also been used to describe inherited phe-
notypes, which may be regarded either normal variation but may in some cases be classified
as anomalies (Guttman et al., 2002).
Especially syndromes may result from large-scale chromosomal abnormalities such as dele-
tions, translocations or abnormal chromosome number, which affect the functions of several
36
genes. However, syndromes, anomalies, and many other genetic diseases can also be caused
by sequence defects in single genes, while other genes may have a modifying effect
(Strachan and Read, 1999; Gilbert, 2003). The relationship between a genotype and a pheno-
type may be rather complex. The dependence of the phenotype on other genetic factors, the
genetic background, as well as epigenetic and external factors results in variable expressiv-
ity, i.e. different phenotypes among affected individuals, and often as reduced penetrance,
i.e. some healthy individuals who have the defective genotype.
Developmental anomalies of teeth
Developmental anomalies of the teeth include deviations in tooth number (agenesis or super-
numerary teeth), abnormalities of size and form, failure of eruption or precocious or delayed
eruption, malpositions, as well as defects of dental hard tissues. Well-known external factors
affecting the dental hard tissue formation are vitamin D deficiency in rickets and excess
fluor. Apparently many other environmental factors in modern society may cause defects in
the maturation of hard tissues (Alaluusua et al., 1999). Alleged increased occlusal deviations
as well as increased prevalence of impaction of third molars considered as a result of modern
diets may also be regarded as defects caused by environmental factors (Corruccini, 1984;
Sengupta et al., 1999). On the other hand, both normal quantitative and qualitative variation
as well as many developmental anomalies have been attributed to inheritance (Bailit, 1975;
Townsend et al., 1998; Thesleff and Pirinen, 2002). Several gene defects are known that af-
fect the formation of the dental hard tissues. Amelogenesis imperfecta is a failure of normal
formation of enamel and it may result from defects in the structural genes of enamel or in
proteases and regulatory genes (Wright, 2006; Hu and Simmer, 2007). Dentinogenesis im-
perfecta and dentin dysplasia that primarily affect dentin deposition and mineralization are
known to be caused by defects in the genes that code for the structural components of the
dentin matrix, collagen I and dentin sialophosphoprotein (Waltimo, 1996; MacDougall et al.,
2006; Kim and Simmer, 2007). Anomalies and variation observed in the morphology, size
and number of teeth will be discussed below in more detail.
Genetic traits of tooth number and shape
Most of us develop a similar set of teeth, with similar shapes and timing of the development,
but also many kind of individual variation exists. The variation may be quantitative or quali-
tative, i.e. continuous or discreet, and it is apparent that extremes of quantitative variation
may turn into qualitative changes, regarded either as variation or anomalies (Miles and Grig-
son, 1990; Bailit, 1975).
Quantitative variation is observed e.g. in the tooth size, the root length and the timing of
tooth development, shedding and eruption. Many authors have reported population values
and observed variation of tooth sizes (Jensen et al., 1957; Garn et al., 1968) (Steigman et al.,
1982; Lysell and Myrberg, 1982) as well as standards and methods of estimation of the tim-
ing of development and eruption (Moorrees et al., 1963; Haavikko, 1970; Demirjian, 1978;
Kataja et al., 1989). Tooth size, tooth maturation and times of eruption display some differ-
37
ences between populations and men generally have larger teeth than women (Bailit, 1975).
On the other hand, different teeth show different magnitudes of size variation.
Qualitative deviations are observed in tooth number, either as agenesis of one of more teeth
or as development of extra (supernumerary) teeth (Fig. 4), in cusp and root number as well
as in presence of abnormal shapes or positions. Several studies have addressed cusp number
and morphology of permanent molar crowns (Dahlberg, 1945; Jrgensen, 1955; Davies,
1968; Lavelle et al., 1970). Considerable variation exist in terms of molar crown shapes and
reduction of cusp number among Caucasian populations and also ethnic differences may ex-
ist. Other common morphological features include presence of extra cusps in molars, e.g. the
so-called Carabellis cusp in the medial lingual aspect of the maxillary molars, as well as
morphological variation of incisors including shovel-like shape, talon cusps, dens-in-
dente/dens invaginatum in the lingual aspect of upper lateral incisors and peg-shape of these
teeth (Dahlberg, 1945; Ooshima et al., 1996; Tsai and King, 1998; Alvesalo and Portin,
1969).
Supernumerary teeth
Development of supernumerary teeth is observed in some syndromes, but they also occur in
the permanent dentition of about 2-3.5 % of otherwise healthy individuals, with perhaps a
slightly higher prevalence among Asian populations than in Caucasians, and in most studies
a two-fold higher prevalence among males (Niswander and Sujaku, 1963; Haavikko, 1970;
Brook, 1974; Bckman and Wahlin, 2001; reviewed by Zhu et al., 1996). In the deciduous
dentition the occurrence is about one fifth of that in the permanent dentition (Zhu et al.,
1996). In Finland the reported prevalences in the permanent and primary dentition are 1.6 %
and 0.4 %, respectively (Haavikko, 1970; Jrvinen and Lehtinen, 1981). Four fifths of the
cases present with one supernumerary tooth and in only 1 % more than two are observed
(Zhu et al., 1996). Supernumerary teeth are classified according to their time and place of
appearance as well as to their morphology (reviewed by Miles and Grigson, 1990; Zhu et al.,
1996; Rajab and Hamdan, 2002). They may be normal by size and morphology (eumorphic
or supplemental supernumerary teeth) or they may be rudimentary (conical, tuberculate or
molariform). Most commonly the supernumerary teeth develop in the incisor region, and a
typical supernumerary tooth is a mesiodens, an extra peg-shaped incisor in the midline be-
tween the normal incisors (Russell and Folwarczna, 2003). The majority of anterior super-
numerary teeth remain unerupted. Other common findings are supernumerary mandibular
premolars, and molars between the normal molars (paramolars) or posterior to the third mo-
lar (distomolar), more commonly in the maxilla (Zhu et al., 1996).
Supernumerary teeth have been considered as reflections of atavism, i.e. reappearance of
teeth lost during evolution (reviewed by Miles and Grigson, 1990; Zhu et al., 1996; Rajab
and Hamdan, 2002). This is based on an idea that in some cases an ancestral developmental
program that is normally suppressed during the development of human dentition becomes
activated. Another suggestion is that supernumeraries develop from local overactivity of the
dental lamina or from a dichotomous tooth bud. A third suggestion considers supernumerary
teeth as an expression of a quantitative variation, which in the other end leads to agenesis or
38
size reduction of teeth (Brook, 1984). Support for this view is offered by an observation that
supernumerary teeth are often associated with teeth that are bigger than normal in size
(Khalaf et al., 2005). These explanations may to some extent represent different aspects
(evolutionary, developmental and genetic) of the same explanation, e.g. overactivation of
genetic pathways the activity of which may have been reduced during evolution. Studies of
mouse mutants have shown that increased quantitative level of signaling may lead to super-
numerary teeth (Mustonen et al., 2004; Kassai et al., 2005; Klein et al., 2006).
Development of supernumerary teeth is observed in some syndromes like cleidocranial dys-
plasia and familial adenomatous polyposis coli (FAP, also called Gardner syndrome}
(Jensen and Kreiborg, 1990; Ida et al., 1981; Wolf et al., 1986) in which the causative genes
are known. Gene defects in RUNX2 are responsible for cleidocranial dysplasia and gene de-
fects in APC for FAP (Mundlos et al., 1997; reviewed by Jrvinen and Peltomki, 2004).
Common to both genes is that they affect well-known signaling pathways and both teeth and
the bone. Mouse studies have shown that Runx2 function is obligatory for bone development
and that some Runx2 expression is needed for the normal tooth development (Otto et al.,
1997; berg et al., 2004). Paradoxically, Runx2 null mutant mice do not develop teeth at all,
while reduced RUNX2 dosage in humans causes supernumerary teeth. As discussed earlier,
Runx2 function may be associated with the prevention of tooth renewal (Wang et al., 2005).
In FAP, apparently as a result of overactivation of the intracellular Wnt-signaling (reviewed
by Giles et al., 2003; reviewed by Segditsas and Tomlinson, 2006), jaw osteomas and odon-
tomas or supernumerary teeth are observed in 80 % and 20-30 % of the cases, respectively
(Ida et al., 1981; Wolf et al., 1986)..
Tooth agenesis
Terminology
Failure to develop all normally developing 20 deciduous and 32 permanent teeth, tooth
agenesis, is a common phenomenon and various terms have been used to describe it
(reviewed by Schalk-van der Weide, 1992) (Fig. 4). The layman way of speaking about
missing teeth is prone to cause misunderstandings because teeth may be lost by dental dis-
ease or trauma or extracted on clinical grounds. Congenitally missing teeth is also prob-
lematic, because some teeth start their development only after birth and because of the pres-
ence of most of the permanent teeth germs can only be verified during childhood. Tooth
aplasia and agenesis have been used to describe developmentally missing teeth. Tooth agen-
esis is the suitable term because it directly refers to the developmental failure. To be exact it
should need to be complemented e.g. with partial or selective tooth agenesis (Vastardis
et al., 1996). In the literature, the term anodontia (ano, Greek for none) has sometimes
been used to describe tooth agenesis in general even though it should be restricted to the very
rare cases of agenesis of whole the dentition. Hypodontia (hypo, Greek for less) is the
most commonly used term even though it may sound like a scientifically sounding simile of
missing teeth or may be mixed with reduced size of teeth. The term has been used for
tooth agenesis in general, but recently in particular for the common, mild forms. The term
oligodontia (oligo, Greek for few) has been used for describing more severe forms of
39
agenesis, usually of at least six teeth excluding third molars (Schalk-van der Weide, 1992;
Arte, 2001). This definition is, however, somewhat arbitrary, often causes misunderstandings
and may not properly reflect the severity of the phenotype as the third molars are excluded.
Diagnostic challenges
The reliability of the diagnosis of tooth agenesis is dependent on a reliable history of dental
treatment, trauma and tooth extractions. Therefore, most studies on the prevalence of tooth
agenesis focus on children and adolescents. However, for young subjects, radiographic ex-
amination is critical for the diagnosis but not always possible, and even then the late-
developing teeth may be sometimes scored developmentally missing. Agenesis of the pri-
mary teeth can be diagnosed without radiographic examination in three to four year old chil-
dren, because all primary teeth are at that age normally visible in mouth. Permanent teeth
cannot be studied reliably even with radiological methods before the age of six years, and
even at that age all the second premolars may not have started mineralization (Arte, 2001).
Obviously, the diagnosis of agenesis of third molars is subject to errors caused by a large
variation of the onset of mineralization and rather common extractions of these teeth.
Prevalences
Prevalence of tooth agenesis has been addressed by numerous studies (reviewed by Arte,
2001; Polder et al., 2004; Mattheeuws et al., 2004). The reported prevalences show a rather
large variation. Extremes are found in some isolated populations (Mahaney et al., 1990), but
in most populations the reported prevalences of agenesis of permanent teeth, excluding third
molars, varies from 2.2 to 10.1 % (reviewed by Arte 2001; Polder et al., 2004). In their meta-
analysis of 33 studies, Polder and collaegues (2004) did not find any significant increase in
prevalences when samples from seven year olds or younger were included. Instead, they de-
cided to exclude one study reporting low prevalence because of a possible error due to an
exceptionally large sample size. Inspection of the data from the meta-analysis suggests a
tendency of lower prevalences also in other studies with large sample sizes, and because
some of these are from USA, this may undermine their conclusion that tooth agenesis shows
a lower prevalence in Northern America. They also noticed signs of an increasing trend in
agenesis during the 20
th
century, a notion also advocated by Mattheeuws and colleagues
(2004). While the available data are not sufficient for confirmation of this trend, the data
support the conclusion that in Caucasian populations the prevalence of permanent tooth
agenesis apart from the third molars is generally in a range of 5 to 8 %. The data also support
the conclusion that the prevalence is higher among females than among males (Polder et al.,
2004). In the two studies of African Americans, the prevalences were comparable to those of
White subjects, whereas in two studies from Saudi-Arabia prevalences of 2.2 and 4 % were
reported (Polder et al., 2004). Studies among Japanese and among school children of Chi-
nese origin in Hongkong reported prevalences of 6.6 % and 6.9 %, respectively (Niswander
and Sujaku, 1963; Davis, 1987).
40
Figure 4. Panoramic tomographies of developmental dental anomalies. Asterisks mark de-
velopmentally missing teeth. A. Agenesis of the mandibular second premolars and the right
maxillary third molar in a 15 years old boy. B. Agenesis of the left mandibular central incisor
and a peg-shaped right maxillary lateral incisor (arrow) in a nine years old girl. C. Severe
agenesis (oligodontia) in a six years old boy. D. Unerupted supernumerary incisor, so-called
mesiodens, between the maxillary central incisors (arrow) in a nine years old boy.
Agenesis of third molars is much more common than that of other teeth, but because of prob-
lems referred above, also much more challenging to study. The reported figures suggest that
one or more third molars fail to develop in more than 20 % in populations of Caucasian ori-
gin (Grahnen, 1956; Haavikko, 1971). On the other hand, agenesis of deciduous teeth is
much more rare, the prevalences among Caucasian populations ranging from 0.3 to 0.9 %,
the highest prevalence being reported among Finnish 3-4 year olds (Jrvinen and Lehtinen,
1981; reviewed by Arte, 2001). In a study from Japan, a remarkably higher prevalence of 2.4
% was reported (Yonezu et al., 1997).
Thus, tooth agenesis is a very common developmental anomaly. However, if the absense of
more than a few teeth is considered, the prevalences become progressively smaller. There-
fore, agenesis of more than two teeth (third molars excluded) happens in ~1 % of the popula-
tion, while the prevalences are in a range of 0.1 to 0.3 % for agenesis of at least six teeth
(Grahnen, 1956; Hunstadbraten, 1964; Haavikko, 1971; Rlling, 1980; Rlling and Poulsen,
2001; reviewed by Polder et al., 2004). In the primary dentition, the distribution is similar
with the majority of cases lacking only one tooth (Daugaard-Jensen et al., 1997a).
Patterns of agenesis
No general difference in the frequency of agenesis between the left and right sides exists,
and for permanent teeth no significant difference between maxilla and mandible has been
reported although for individual teeth in different jaws the frequencies differ. For the pri-
mary teeth, agenesis is more common in the maxilla (Daugaard-Jensen et al., 1997a).
41
Apart from the third molars, many studies among Caucasian populations have scored the
lower second premolars most commonly affected, followed by upper lateral incisors and up-
per second premolars, while some studies have found that upper lateral incisors are most of-
ten affected (Grahnen, 1956; Haavikko, 1971; reviewed by Graber, 1978; Arte, 2001; Polder
et al., 2004) (Fig. 5). These differences may reflect diagnostic or real population differences.
Among Asian populations agenesis of lower central incisors is much more common than
among Caucasians, this tooth actually being the most often affected, and also in the primary
dentition (Yonezu et al., 1997). The third molars may account for about 75 % of all affected
teeth (Haavikko, 1971). If they are not considered, agenesis of second premolars and upper
lateral incisors account for 85 % of all affected teeth among Caucasian populations (as calcu-
lated from data by Polder et al., 2004), and their proportion is still higher if cases with agen-
esis of only one or two teeth are considered. Prevalences of agenesis for all other permanent
teeth, third molars excluded, are less than 0.36 % or as proportions of all affected teeth, 3.5
% or less. The most commonly affected other teeth are, in order, lower incisors, maxillary
first premolars, mandibular first premolars, maxillary canines and mandibular second mo-
lars. Prevalences of agenesis of all other teeth are less than 0.075 %, corresponding to pro-
portions below 0.7 %, and the most stable teeth are maxillary central incisors (prevalence of
agenesis 0.016 %) and mandibular first molars and canines (prevalences of agenesis about
0.03 %).
In the primary dentition, the maxillary lateral incisors account for over 50 % and together
with mandibular incisors for 90 % of all affected teeth (Daugaard-Jensen et al., 1997a; Jr-
vinen and Lehtinen, 1981; Magnusson, 1984; Whittington and Durward, 1996). A correla-
tion of agenesis of primary and secondary teeth also exist: agenesis of a primary tooth is
nearly always followed by agenesis of the corresponding secondary tooth (Daugaard-Jensen
et al., 1997b; Whittington and Durward, 1996).
Bilateral agenesis is observed for most teeth in almost half of the possible occurrences, i.e.
when at two teeth are affected (Grahnen, 1956; Haavikko, 1971; Davis and Brook, 1986;
Rasmussen, 1999; Polder et al., 2004; Kirkham et al., 2005). Bilaterality may be more com-
mon for maxillary lateral incisors than for premolars in either jaw (Thompson and Popovich,
1974; Davis and Brook, 1986; Polder et al., 2004). In families the occurrence of agenesis
within one tooth class appears more common than agenesis of different tooth classes
(Grahnen, 1956; Chosack et al., 1975; Arte et al., 2001). However, if agenesis of third mo-
lars were taken into account, the tendencies to bilaterality and familial concordance would
probably be weakened. According to Grahnen (1956), agenesis of third molars was observ-
able in approximately half of the subjects with agenesis of other teeth.
The teeth that are most often affected, i.e. the third molars as well as the second premolars
and upper lateral incisors of the permanent dentition, are the last to develop in their respec-
tive tooth classes. This suggests that quantitative mechanisms are involved in the pathogene-
sis (see below). The tendency to bilaterality and familial concordance, on the other hand,
support the existence of mechanisms that tend to affect different tooth classes differentially.
42
Figure 5. Prevalences of agenesis of different
tooth types. Prevalences from teeth on the left
and right are combined. Figures indicate per-
centages. Darkness of color indicates the
prevalence. Figures inside the crowns of the
maxillary permanent teeth are the second dig-
its of the FDI codes. Prevalences of permanent
teeth except third molars according to table 4
in Polder et al., 2004.
Tooth agenesis in syndromes
As can be reasoned from the prevalence figures, tooth agenesis is usually an isolated anom-
aly, without any other observable malformations. It is, however, a constant feature associated
with oral clefts and tens of well-defined malformation syndromes (Schalk-van der Weide,
1992; Arte, 2001) (Table 1). In association with oral clefts, agenesis may happen in the re-
gion of the cleft, but agenesis in other regions of the mouth is also more common than in the
general population, reflecting common etiology (Ranta, 1986). Tooth agenesis that is associ-
ated with different malformation syndromes vary in severity but syndromic agenesis ac-
counts for a remarkable proportion of all cases of severe agenesis (Schalk-van der Weide,
1992). In many syndromes there is a typical pattern of agenesis and in some cases it is strik-
ingly different from the frequencies in non-syndromic cases (Table 1). On the other hand, in
the association of severe agenesis, occurrence of minor ectodermal anomalies is often ob-
served (Schalk-van der Weide, 1992; Pirinen et al., 2001; Nordgarden et al., 2001).
Dental anomalies associated with agenesis
For dental clinicians, it is familiar that tooth agenesis is associated with other anomalies of
teeth. Tooth agenesis is prone to cause abnormal occlusion, the severity of which is depend-
ent on the amount of missing teeth. Agenesis may also affect craniofacial development, and
especially maxillary retrognathism and reduced anterior facial height have been reported
(Mattheeuws et al., 2004; Nodal et al., 1994; Endo et al., 2006). A reduction in jaw size has
also been described (Lavelle et al., 1970). However, as these may be considered secondary to
agenesis, they will not be discussed further here. Several studies have addressed associations
of agenesis and other dental anomalies (Lai and Seow, 1989; Schalk-van der Weide, 1992;
Ooshima et al., 1996; Baccetti, 1998; Bjerklin et al., 1992; Bckman and Wahlin, 2001).
Agenesis is often associated with reduction in tooth dimensions and morphology, delays of
development, root anomalies, abnormal positions and also enamel hypoplasia (Ahmad et al.,
1998; Baccetti, 1998) (Table 2). However, these studies have not, with some exceptions,
considered different subtypes of agenesis. While the following refers to studies concerning
43
isolated tooth agenesis, these anomalies are rather often present in syndromic forms of tooth
agenesis (reviewed by Arte, 2001).
Reduction of tooth size and morphology
The term microdontia has been used for occurrence of teeth with reduced tooth size (Brook,
1984), but some authors have reserved this term to extreme size reduction, e.g. to a reduction
observable without measurements (Hltt, 2005), or defined a limit for the deviation
(Ooshima et al., 1996). Small but measurable decreases of mesio-distal tooth dimensions
were reported in association with the agenesis of the third molars (Garn et al., 1961; Garn et
al., 1964; Lavelle et al., 1970), but these were on the average only in a range of a few per-
cent. Somewhat more remarkable decreases of size have been observed in association with
agenesis of other teeth, and correlations between the amount of missing teeth and the extent
of size reduction have been reported (Lysell, 1953; Garn and Lewis, 1970; Baum and Cohen,
1971; Rune and Sarns, 1974; Schalk-van der Weide, 1992; Brook et al., 2002). Even then,
the tooth sizes were reduced less than 20 % of the normal size. The labio-lingual/palatal di-
mensions have also been shown to be reduced in association with agenesis (Baum and
Cohen, 1971; Schalk-van der Weide, 1992; McKeown et al., 2002). Reduced tooth sizes
have also been observed within the healthy relatives of patients with severe tooth agenesis
(Schalk-van der Weide and Bosman, 1996; McKeown et al., 2002). From several of these
studies it appears that the size reduction affects most strongly the anterior teeth, even in as-
sociation with the third molar agenesis (Garn and Lewis, 1970; Schalk-van der Weide, 1992;
Brook et al., 2002), and, on the other hand, that agenesis is accompanied by an increase of
the tooth size variability, and especially that of the posterior teeth (Garn and Lewis, 1970;
Schalk-van der Weide, 1992). Reduced tooth size of affected family members has also been
reported in association of identified gene defects in MSX1 and PAX9 (see Results).
In addition to reduction in tooth dimensions, agenesis is also associated with changes of
tooth crown morphology, especially with simplification of tooth shapes. The occurrence of
peg-shaped upper lateral incisors is associated with the absence of a contralateral tooth and
occurrence of agenesis of upper lateral incisors among relatives (Mandeville, 1949; Grahnen,
1956; Chosack et al., 1975; Alvesalo and Portin, 1969; Arte et al., 2001), and association of
peg-shaped laterals has also been reported to be assosiated with agenesis of other teeth
(Grahnen, 1956; Baccetti, 1998). Alvesalo and Portin (1969) concluded that peg shape and
agenesis of laterals incisors are different expressions of the same genetic trait while the re-
duction of mesio-distal size is not. They also proposed that in different populations a com-
bined frequency of missing and peg-shaped teeth may be of the same magnitude while pro-
portions of individual defects may vary.
Several studies have addressed the lower molar cusp patterns in relation to agenesis. Some
studies have found that reduction of cusp number from 5 to 4 is increased in association with
agenesis (Garn et al., 1966; Davies, 1968) while others have failed to confirm this (Lavelle et
al., 1970). Other morphological features possibly associated with agenesis include conicality
of canines and reduction of cusps of premolars (Schalk-van der Weide, 1992).
44
Table 2. Anomalies associated with tooth agenesis
cont-
rols
agene-
sis
group
agene-
sis
among
*)
sample notes
% % %
Peg or small maxillary lateral incisors
Grahnen, 1956 1.7 50
Swedish schoolchildren and
students
agenesis of contralateral
incisor
Alvesalo and Portin, 1969 1.3 50 43 Finnish island population
Lai and Seow, 1989 0 8.9
**)
Australian pediatric dentistry
patients
mean n of missing teeth 4.7
Baccetti, 1998 4.7 18 42 Italian orthodontic patients agenesis of 2nd premolars
Short root anomaly
Lind, 1972 2.4 46 Swedish schoolchildren
max incisors; crown/root >
1.1
Apajalahti et al., 1999 1.3 12 Finnish university students
all teeth; crown/root > 1 on
both sides
Taurodontism
Seow and Lai, 1989 7.5 35
Australian pediatric dentistry
patients
mandibular 1st molars
Schalk-van der Weide, 1992 9.9 22
Dutch patients with severe
agenesis
Arte et al., 2001 22 41 Finnish 6-21 y
1st and 2nd permanent
molars
Ectopic canines
Bjerklin et al., 1992 1.8 7.2 5.5 Swedish schoolchildren
Palatally displaced canines
Baccetti, 1998 5.2 16 18 Italian orthodontic patients agenesis of 2nd premolars
Pirinen et al., 1996 8 36 Finnish orthodontic patients
Infrapositioned/ankylosed primary molars
Lai and Seow, 1989 1.5 66
Australian pediatric dentistry
patients
mean n of missing teeth 4.7
Bjerklin et al., 1992 10.3 19.6 19.4 Swedish schoolchildren
Baccetti, 1998 5.6 15 20 Italian orthodontic patients agenesis of 2nd premolars
Ectopic eruption of first molars
Bjerklin et al., 1992 4.3 3.1 6.5 Swedish schoolchildren
Baccetti, 1998 4.6 11 12 Italian orthodontic patients agenesis of 2nd premolars
Enamel hypoplasia
Lai and Seow, 1989 0 12
Australian pediatric dentistry
patients
mean n of missing teeth 4.7
Baccetti, 1998 4.2 11 16 Italian orthodontic patients agenesis of 2nd premolars
*) percentage of subjects with tooth agenesis among subjects with the anomaly
**) bold indicates statistical significance as evaluated by the authors
Delayed development and eruption
Delayed development of posterior permanent teeth in association with the third molar agen-
esis was reported by Garn and colleagues (Garn et al., 1961). Rune and Sarns (1974) re-
ported an average delay of two years, however with great variation, in a group of 85 patients
with agenesis of on the average seven permanent teeth. They also reported excessive retarda-
tion of development of teeth contralateral to missing teeth. Schalk-van der Weide (1992) re-
45
ported a tendency of early developing teeth of males to be retarded in association with severe
agenesis, and in females with severe agenesis second mandibular molars to be significantly
delayed in development (only mandibular teeth were studied). In a sample of 135 cases, 50
% of whom had agenesis of one or two permanent teeth, an average delay of 1.5 years was
recorded (Uslenghi et al., 2006), and this delay correlated with the extent of agenesis and
was most prominent in positions next to the teeth that had failed to develop.
Root abnormalities
Two types of root abnormalities have been described in association with tooth agenesis. The
roots may be shorter which with certain criteria is defined as short root anomaly (SRA).
The prevalence of SRA was reported as 2.4 % among Swedish school children, 2.7 % among
British school children and 1.3 % among Finnish university students (Lind, 1972; Brook and
Holt, 1978; Apajalahti et al., 1999). The Swedish and British studies considered only the
maxillary central incisors and applied a criteria of crown to root ratio bigger than 1.1, while
the Finnish study measured also other permanent teeth, but required that the teeth on both
sides would fill a less stringent crown to root ratio of 1. In another abnormality of root de-
velopment, so-called taurodontism, root bifurcation in molars is observed on an abnormally
apical level. Different methods of diagnosing taurodontism have been used and modified
(Seow and Lai, 1989; Shifman and Chanannel, 1978), the main difference being the selection
of reference points for the crown height and the level of root bifurcation. The reported popu-
lation prevalences show a considerable variation from 7.5 to 22 %, reflecting probably dif-
ferences in the study plans more than in real frequencies, i.e. whether only mandibular first
molars or all molars were studied (Seow and Lai, 1989; Schalk-van der Weide, 1992; Arte et
al., 2001).
Regardless of different ways of measurement and definitions, both root shortening and tauro-
dontism have been reported to be more common in association with tooth agenesis. Tooth
agenesis was reported in 46 % of Swedish school children and in 12 % of Finnish students
with SRA (Lind, 1972; Apajalahti et al., 1999). In the Australian study, taurodontism was
almost five and in a Finnish study two times more frequent among subjects with tooth agen-
esis (Seow and Lai, 1989; Arte et al., 2001), while among Dutch patients with severe agen-
esis it was three times more common than among controls (Schalk-van der Weide, 1992)
Root abnormalities have been attributed to an epithelial defect and more specifically to a de-
fect of the function of the Hertwig's epithelial root sheath (Hamner et al., 1964; Seow and
Lai, 1989; Apajalahti et al., 1999; Arte et al., 2001). The association between root abnor-
malities and tooth agenesis suggests the existence of a common primary defect. It may exert
its effect independently on different processes or root abnormalities may follow secondarily
from an earlier defective event. So far, taurodontism has been associated with defects in the
homeobox gene DLX3 in the tricho-dento-osseous-syndrome (TDO) and defects in the EVC,
presumably a Shh signaling regulator, in Ellis-van Creveld syndrome (Price et al., 1998;
Ruiz-Perez et al., 2007). Shortened roots are observed in association with developmental de-
fects of dentin formation, caused by defective collagen I and DSP/DPP. Increased frequency
of tooth agenesis has also been observed in connection with osteogenesis imperfecta
46
(Lukinmaa et al., 1987). Abnormalities of root development were observed in the NFI-C null
mutant mice as well as in mice with defective Patched, the Shh receptor (Steele-Perkins et
al., 2003; Nakatomi et al., 2006).
Abnormal positions of teeth
Teeth developing in an abnormal position in relation to the dental arch, i.e., ectopically posi-
tioned teeth, have been associated with tooth agenesis. Prevalence of ectopically erupted
teeth has been estimated to be 4 to 7.8 % in the general population (Bergstrm, 1977;
Kimmel et al., 1982; Bjerklin et al., 1992). The prevalence of ectopic maxillary canines has
been reported as about 2 % (Shah et al., 1978; Ericson and Kurol, 1986), and the prevalence
of palatally displaced canines among Israeli teenagers as 1.5 % (Brin et al., 1986). A longi-
tudinal Swedish study reported that in the last examination (mean age 17.8 years) impacted
canines were found in 1.8 % of study subjects, and that half of them were palatally displaced
(Thilander and Jakobsson, 1968). According to this study, dental crowding was mostly re-
lated to the buccal displacement of a canine, and the persistence of a deciduous canine seen
in six of the 10 cases was rather a consequence than reason for displacement of the perma-
nent successor. Becker and colleagues (1981) showed that the risk for palatal displacement
of a maxillary canine was six times higher in association with an abnormal (absent, peg-
shaped or mesiodistally reduced) adjacent lateral incisor (Becker et al., 1981; Brin et al.,
1986), and that the association was also detected among the relatives of the probands
(Zilberman et al., 1990). On the basis of these observations, the palatal displacement was
suggested to be based on local etiology, possibly due to the disturbed role of the lateral inci-
sor root in the guidance of eruption of the maxillary canine, rather than general malocclusion
or crowding (Brin et al., 1986; Brin et al., 1986; Zilberman et al., 1990).
Palatal displacement of permanent maxillary canines is associated with a four-fold higher
prevalence with agenesis of second premolars (Bjerklin et al., 1992; Baccetti, 1998). Palatal
canines did also occur in families together with agenesis of incisors, premolars and third mo-
lars (Svinhufvud et al., 1988; Pirinen et al., 1996). Thus, a general and presumably genetic
etiology related to tooth agenesis, was suggested.
Rotation of premolars and that of maxillary lateral incisors have been found to be associated
with the agenesis of the same teeth (Baccetti, 1998; Arte, 2001). Half of the patients with
transposition of maxillary canines and first premolars may also present with tooth agenesis
(Peck et al., 1993; Camilleri, 2005).
In the molar region, agenesis of permanent premolars and infraposition of primary molars
are associated (Bjerklin et al., 1992; Baccetti, 1998). Malposition of first permanent molars
occurs with a prevalence of 4.3 % (Bjerklin and Kurol, 1981) and may show familial accu-
mulation (Kurol and Bjerklin, 1982). It has been shown to be increased among patients with
premolar agenesis (Bjerklin et al., 1992; Baccetti, 1998). However, eruption failure of first
molars was reported to have a significant association with rotated lateral incisors, malposi-
tions of canines, and infraposition of the primary molars, but not with tooth agenesis or peg-
shaped lateral incisors (Baccetti, 2000).
47
Enamel defects
Some authors have reported a high incidence of enamel hypoplasia among patients with
tooth agenesis (Lai and Seow, 1989; Baccetti, 1998). Enamel hypoplasia was also described
as a phenotypic feature in a family with recessive inheritance of tooth agenesis (Ahmad et
al., 1998). The co-occurrence of enamel hypoplasia and agenesis could be explained by an
underlying defect in the epithelium or a defect in signaling between the tissue layers. Failure
of tooth development and enamel defects has been linked e.g. by mutants of Msx2 and Pax9
and disruption of the epithelial Shh signaling affect both tooth formation and ameloblast dif-
ferentiation in mouse (Aioub et al., 2007; Kist et al., 2005; Gritli-Linde et al., 2002).
Etiology of tooth agenesis
While several potential and verified environmental (postgenetic) etiological factors for tooth
agenesis have been presented, there is definitive proof that genetic factors play a major role
in the etiology (reviewed by Burzynski and Escobar, 1983; Graber, 1978; Vastardis, 2000).
The role of the genetic factors was suggested by observed familial occurrence, prevalence
differences between populations, and association with heritable syndromes as well as by
twin and family studies, but definitive evidence has been acquired during the molecular ge-
netic era: defects in several genes have been shown to cause agenesis and anomalies in size
and morphology (Table 1). On the other hand, the findings have also confirmed the complex-
ity of the relations between genotypes and phenotypes. Postgenetic events are important
even for the final manifestation of truly dominant gene defects and it is obvious that they are
even more critical for action of predisposing variants considered as risk alleles.
As described above, agenesis and reduction of tooth sizes are associated. As this association
is relevant from the pathogenetic point of view, some etiological factors that affect tooth size
will also be discussed in the following.
Environmental factors
Tooth agenesis and tooth size reductions have been related to trauma, maternal systemic dis-
ease and various external factors (reviewed by Grahnen, 1956; Schalk-van der Weide, 1992;
Arte, 2001; Hltt, 2005). Among the maternal systemic disease, diabetes and different in-
fections have been suggested. For example, developmental dental anomalies and tooth size
reduction have been described in association of maternal rubella infection during pregnancy
(Kraus et al., 1969). Maternal diabetes and hypothyroidism as well as high birth weight and
length have been associated with an increase in tooth size and hypertension and low birth
weight and length with a decrease in tooth dimensions (Garn et al., 1979). Small mesio-distal
dimensions of the primary teeth among low birth-weight children has been described (Fearne
and Brook, 1993; Seow and Wan, 2000) whereas contradictory results were obtained when
permanent teeth were studied (Harila-Kaera et al., 2001; reviewed by Paulsson et al., 2004).
In animal experiments, maternal low-protein diet were shown to decrease molar size and
cusp number of the third molars as well as cause a delay of eruption (Holloway et al., 1961).
48
Definitive evidence for the involvement of environmental pollutants has been presented after
studies of the victims of the dioxin accidents in Italy, Taiwan and Japan (Rogan et al., 1988;
Wang et al., 2003; Alaluusua et al., 2004). The observed anomalies included natal teeth, de-
layed eruption of permanent teeth, disturbed root development, agenesis of permanent teeth
and enamel defects. In utero or lactational exposure for dioxins leads to increased agenesis
of the third molars as well as reduction of the size of other molars in rats (Lukinmaa et al.,
2001; Kattainen et al., 2001) and increase of tooth agenesis and anomalies in rhesus mon-
keys (Yasuda et al., 2005). Maternal tobacco smoking has been associated with small but
statistically significant reduction of tooth size (Heikkinen et al., 1994). Same kind of effects
of other toxic compounds produced in urban society may be suspected.
The sensitivity of tooth development for childhood anti-cancer treatment by radiotherapy,
chemotherapy and stem cell transplantation conditioned by whole body irradiation has been
shown in many studies (Jaffe et al., 1984; Nsman et al., 1997; Hltt, 2005; reviewed by
Dahllf and Huggare, 2004). The dental effects may include agenesis, microdontia (i.e. con-
siderable size reduction), developmental delays, root anomalies and calcification defects.
The effects are dependent on the age when the treatment is given. A retrospective study by
Hltt (2005) showed a correlation between the age of the anticancer therapy and the effect
on specific teeth. Agenesis of first premolars was mostly observed in the patients, who had
received treatment before the age of two years, whereas agenesis and microdontia of second
premolars and second molars were common in the patients who were treated before the age
of five years. However, in the youngest recipients under the age of two, second molars ap-
peared unharmed. Advancing mineralization may protect the tooth from agenesis, even
though a therapy coinciding with a late stage of development of a specific tooth may lead to
microdontia. The correlations seem to show that the treatments are most deleterious at a
rather late stage of development at the time of differentiation, suggesting that the tooth germ
may regress although the morphogenesis has been nearly completed.
Is is generally held that while tooth development is under strict genetic control, jaw growth
is dependent on functional demands, principally masticatory activity and needs, and also
modified in the case of incomplete dentition (e.g.Brown, 1983). However, some authors con-
sider agenesis of third molars as secondary to a reduction in jaw size (e.g. Kajii et al., 2004).
Sengupta et al (1999) presented that, presumably as a result of more processed food, the fail-
ure of eruption (impaction) of the third molars has significantly increased since the Medieval
Ages and especially since prehistoric times. The prevalence of agenesis could not be studied
in the prehistoric samples, and they could not find a significant difference in the agenesis
between the Medieval and modern samples even though the data they presented showed
higher prevalence for agenesis in the modern samples. It is difficult to envision an evolution-
ary process or even relaxed selection acting on human dentition in such a short length of
time. While the reduction of size of the second and third molars during the hominid evolu-
tion has been suggested to be driven by adaptation to the limitation of the available space in
the jaws, this process has been considered as a result of selection of genotypes during a con-
siderable length of time (e.g. Sofaer et al., 1970; Sofaer et al., 1972; see also Graber, 1978).
49
Tooth size variation and heritability
Tooth dimensions show some variation in the normal populations. The relative contributions
to this variation of genetic and environmental (postgenetic) causes have been estimated ei-
ther by studying correlations between first degree relatives (Sofaer et al., 1970; Alvesalo and
Tigerstedt, 1974; Townsend, 1980; Potter et al., 1983) or differences in the correlations be-
tween mono- and dizygotic twins (Osborne et al., 1958; Potter et al., 1976; Dempsey et al.,
1995; Boraas et al., 1988; Dempsey and Townsend, 2001). Generally, the studies among the
first degree relatives have shown a considerable genetic component for both mesio-distal and
labio-lingual/palatal dimensions but the heritability estimates have been rather variable.
Some studies suggested lowest heritability estimates as well as higher size variation for the
late developing teeth, suggesting that environmental factors would be more significant in the
determination of the size of these teeth (Sofaer et al., 1970; Alvesalo and Tigerstedt, 1974).
However, heritability estimates from twin studies have not supported specifically small
heritabilities for the size of the later-developing teeth (Dempsey et al., 1995; Dempsey and
Townsend, 2001). In their studies with 149 monozygotic and 149 dizygotic twin pairs from
Australia, Dempsey and collaegues (1995; 2001) estimated that the additive genetic compo-
nent would in most cases account for over 80 % of the tooth size variation. Interestingly,
they found only a 60 % genetic component for first molar dimensions, explained mostly by
the relatively large contribution of shared environment. For the teeth most often affected by
agenesis, they found only slightly less than average heritabilities for mesio-distal dimensions
of maxillary second premolars (mean 76 %) and for labio-palatal dimensions of maxillary
lateral incisors (mean 72 %). These estimates imply that agenesis of these teeth is predomi-
nantly genetically determined and that the size of these teeth can independently be affected
by selection and by an evolutionary process.
Twin studies on agenesis
Several studies have described tooth agenesis in identical (monozygous) and non-identical
(dizygous) twins (Table 3). From these studies, it is obvious that non-identical twins have
more disconcordant phenotypes. However, in several studies at least some pairs of identical
twins were disconcordant for agenesis. Boruchov and Green (1971), and Townsend and col-
laegues (1995; 2005) found that in majority of pairs of identical twins they studied, only one
of the twins presented with tooth agenesis. In addition, if monozygotic twins were concor-
dant for agenesis, they could have had different teeth missing. In a study by Townsend
(2005), three of the pairs had identical phenotypes, eight pairs had different agenesis pheno-
types and in 13 pairs only one of the twins was affected. Interestingly in all 11 pairs concor-
dant for agenesis, teeth of the same class were affected, suggesting a genetic component un-
derlying the phenotype. These studies showed that tooth agenesis cannot be fully explained
by genotype. The variability of phenotypes of identical twins suggests a relatively low pene-
trance of agenesis and rather high variability of phenotypic expression. Some authors have
suggested that the role of genes has been overestimated (Boruchov and Green, 1971), while
others consider the heredity as the most important factor but stress the variable expression
and reduced penetrance. The latter has been explained by maternal factors as well as by the
50
Table 3. Twin studies on tooth agenesis
n pairs
1)
p
r
e
v
a
l
n
c
e

o
f
a
g
e
n
e
s
i
s

(
%
)
n
c
o
n
c
o
r
d
a
n
t
c
o
n
c
o
r
d
a
n
t

w
i
t
h
v
a
r
i
a
b
l
e

e
x
p
r
e
s
s
i
o
n
c
o
n
c
o
r
d
a
n
t

f
o
r
t
o
o
t
h

g
r
o
u
p
d
i
s
c
o
n
c
o
r
d
a
n
t
n
c
o
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Boruchov and Green, 1971 369 5.7 USA 9 2 2 ?
2)
5 32 3 3 26
Gravely and Johnson, 1971 3 UK 3 0 3 2 0
Markovic, 1982 99; 66 Yugoslavia 9 ? 8
2)
? 1 5 0 0 5
Markovic, 1992 11 Yugoslavia 6 6
3)
0 6 0 6 0 0 6
Townsend et al., 1995
4)
122; 101 2.2 Australia 5 3
3)
0 3 2 3 0 0 3
Kotsomitis et al., 1996
5)
59; 42 8.4
Australia,
Belgium
8 2 6 ? 0
Townsend et al., 2005
6)
278 6.3 Australia 24 3 8 11 13
1)
pairs of monozygotic twins; pairs of dizygotic twins. In three studies, only monozygotic twin pairs were examined.
2)
identities of affected teeth not available
3)
identities of affected teeth identical if peg shape included
4)
includes agenesis of incisors only
5)
dizygotic twins significantly less correlated, but exact figures were not reported
6)
includes agenesis of maxillary lateral incisors and second premolars only
monozygotic dizygotic
intrinsic randomness of the developmental process, and especially by its self-organizing na-
ture (Gravely and Johnson, 1971; Townsend et al., 1995; Townsend et al., 2005).
Segregation analyses in families
Different modes of inheritance for tooth agenesis have been suggested . For a definite
evaluation of modes of inheritance, a segregation analysis in a large population sample to-
gether with the access to phenotype data from first degree relatives is mandatory. Grahnen
(1956) performed a segregation analysis of 171 families with tooth agenesis and found that
altogether 26 % of sibs and 41 % of parents of the probands were affected and that in 73 %
of the families at least one of the parents was affected. He concluded that the data were most
compatible with an autosomal dominant inheritance with reduced penetrance and variable
expression. His data have been revisited, however, with contradictory conclusions. Suarez
and Spence (1974) concluded that Grahnens data was best fitted to a polygenic inheritance
model, while Burzynski and Escobar (1983) reinstated Grahnens original conclusions.
A segregation analysis by Chosack and collaegues (1975) concluded that tooth agenesis was
determined by polygenic inheritance. The conclusion was based on segregation of agenesis
of distinct tooth classes. Thus, agenesis of incisors or premolars were considered as separate
traits even inside a family.
Schalk-van der Weide (1992) analysed segregation with cases of severe agenesis as probands
while family members with any type of agenesis and even microdontia were considered as
affected. Thus, severe agenesis, observed only in some family members, did not segregate in
51
the families. The conclusions were compatible with Grahnen (1956), even though the author
made reservations in favor for the polygenic inheritance model.
Special attention has also been paid to agenesis and reduced maxillary lateral incisors. Man-
deville (1949) and Alvesalo and Portin (1969) concluded that agenesis of these teeth fol-
lowed autosomal dominant inheritance and regarded peg shape as variable expression of the
same gene.
Based on prevalence and family studies, Brook (1984) presented a modification of the etio-
logical model of Bailit (1975) combining tooth agenesis with a quasicontinuous variation of
tooth size. In this model, variation of tooth size is considered to be determined by a quantita-
tive trait. Overcoming certain thresholds leads to agenesis or formation of supernumerary
teeth, i.e. continuous quantitative variation predisposes to discreet qualitative phenomena.
Observations on which the model was based include association of reduced tooth dimensions
(microdontia") with agenesis and macrodontia with supernumerary teeth formation, de-
pendence of magnitude of tooth size deviation on the amount of agenetic teeth, and a higher
risk for the relatives of patients of multiple agenesis (Brook, 1984). Brook modified the
model to take into account the sex differences, i.e. smaller tooth dimensions and higher
prevalence of agenesis in females and higher prevalence of supernumerary teeth in males, by
including separate curves of variation and separate thresholds of agenesis and supernumerary
teeth formation for males and females. While proposing that the model is able to accommo-
date the observations, he also made a reservation that in some cases a dominant inheritance
may be involved (Brook, 1984).
Arte and colleagues (2001) presented the dental characteristics in eleven Finnish families
with apparent autosomal dominant inheritance of agenesis of one or more permanent teeth
called incisor and premolar hypodontia (IPH). The characteristics of these families included:
- An apparent autosomal dominant inheritance, however with cases of obligatory gene car-
riers who had normal dentition, especially in older generations, reflecting either reduced
penetrance or difficulties of ascertainment.
- Concordance of agenesis phenotypes. In all families except two, primarily or exclusively
either incisor, usually maxillary lateral incisors, or second premolars were affected.
- Association of dental anomalies with agenesis. In addition to peg-shape of maxillary lat-
eral incisors, especially taurodontic molars, ectopic canines and rotated premolars were
found to be associated with agenesis in these families.
Molecular genetics
The most compelling evidence for the genetic etiology of tooth agenesis has been provided
by the identification of gene defects associated with different types of tooth agenesis (Table
1 and references therein). In many cases, these results are complemented by experimental
mouse mutants. So far, gene defects have been identified that either cause severe tooth agen-
esis (oligodontia) as a sole malformation (isolated or non-syndromic agenesis) or agenesis in
association with multiorgan malformation syndromes. The tooth agenesis phenotypes associ-
ated with syndromes in which the causative genes are known vary from extremely severe
52
e.g. in anhidrotic ectodermal dysplasias (EDAs) to phenotypes in which tooth agenesis re-
sembling common hypodontia is observed only in a subgroup of patients.
Dominant defects in MSX1, PAX9 and AXIN2 have been described in families with isolated
severe tooth agenesis (see Results and discussion). However, in association with defects in
MSX1, nail dysplasia and some patients with oral clefts have each been described in single
families (Jumlongras et al., 2001; van den Boogaard et al., 2000). In addition to causing se-
vere tooth agenesis phenotype, a defect in AXIN2 also predisposed to colorectal cancer
(Lammi et al., 2004). Recently, two defects that affected only dentition were also described
in EDA (Tao et al., 2006; Tarpey et al., 2007). All these gene defects cause severe types of
agenesis. However, evidence for association of specific intragenic polymorphisms to tooth
agenesis, apparently consisting mostly of common types of tooth agenesis, has been pre-
sented for MSX1, PAX9, AXIN2, TGFA, IRF6 and FGFR1 (Vieira et al., 2004; Peres et al.,
2005; Mostowska et al., 2006; Vieira et al., 2007).
The syndromes include, among others, ectodermal dysplasias and syndromes with oral cleft-
ing, revealing common genetic pathways for development of teeth and other ectodermal or-
gans as well as teeth and craniofacial structures. Striking examples are EDAs, in which de-
fects in genes coding for the signaling ligand, its receptor and intracellular mediators of the
signal cause rather similar clinical phenotypes affecting teeth, hair and ectodermal glands
(reviewed by Mikkola and Thesleff, 2003).
Observation of syndromic features in association with oligodontia in general (Schalk-van der
Weide, 1992; Pirinen et al., 2001; Nordgarden et al., 2001) and with defects in MSX1 sug-
gests that especially from the etiological point of view it is difficult to make strict distinction
between syndromic and isolated types of tooth agenesis. Furthermore, as described above,
e.g. in the Msx1 and Pax9 null mutant mice several other defects besides tooth agenesis are
observed, and so far a regulatory gene that would affect only tooth development has not been
identified. Therefore, a qualitative distinction between syndromic and isolated phenotypes
can be made mainly concerning individual phenotypes, which may reflect different positions
on an etiological scale.
In general, the identified genes that are affected in isolated or syndromic agenesis, are almost
exclusively regulatory genes the functions of which in many cases have been studied in
mouse. Together, identified human and mouse genes in which defects affect tooth develop-
ment involve all major signaling pathways and the transcription factors mediating these sig-
nals.
Pathogenesis of tooth agenesis
While the studies described above have shown that genetic factors are most critical in the
etiology of tooth agenesis in humans, they have not clarified the pathogenetic mechanisms.
The studies in mouse mutants have helped to understand the underlying genetic networks
and developmental consequences of disturbed gene function.
53
It has been suggested that specific vulnerability of certain teeth is explained by their ana-
tomical position either in the distal end of the dental lamina (second premolars) or in the ar-
eas of fusion of the facial processes (maxillary lateral incisors and mandibular central inci-
sors) (Svinhufvud et al., 1988). On the other hand, it is also well-recognized that those teeth
in each tooth class are most often affected that are initiated and develop latest (Dahlberg,
1945; Clayton, 1956; Miles and Grigson, 1990). In accordance with the morphogenetic mod-
els, this suggests that agenesis follows from a quantitative defect. In terms of Butlers field
theory, agenesis can be regarded as a critical decrease of the morphogenetic potential in the
periphery of the field, following either from decrease of the field strength in general or
change of the steepness of the field gradient. Analogously, in terms of the clone theory,
agenesis may be interpreted to follow from a decrease of odontogenic potential of the initial
clones or a change in how this potential is consumed or regulated by activation or inhibition.
Reduction of tooth number during evolution usually also affects the teeth that are initiated
latest (Miles and Grigson, 1990; Weiss et al., 1998), suggesting that mechanisms affected in
the evolutionary change may also underlie tooth agenesis. Indeed, some authors have re-
garded the teeth that are affected by agenesis as vestigial organs (Clayton, 1956).
Mechanisms dependent on quantitative aspects are also suggested by associations of tooth
size reduction to tooth agenesis, as described above. This association and observed features
of quantitative trait genetics in familial tooth agenesis were used as foundations for the mod-
els presented by Bailit (1975) and Brook (1984), which explained tooth size variation by an
underlying multifactorial quantitative trait and tooth agenesis and supernumerary teeth for-
mation mainly as extreme expressions of this variation. These concepts were supported by
observations of Grneberg (1951) in an inbred mouse strain. In this strain, the variation of
the size of the third molars, determined by a quantitative trait, extended to such exceptionally
small values that predisposed for agenesis, apparently precipitated by prenatal conditions.
However, tooth agenesis and reduction of tooth sizes are linked also in association of defects
in single genes, e.g. in EDA and also in families with mutations in PAX9 (e.g. Lammi et al.,
2003). Thus, it is clear that tooth agenesis may not be solely explained by predisposition be-
cause of quantitative variation, acknowledged also by reservations made by Brook (1984).
Instead, it is probable that in the pathogenesis of tooth agenesis quantitative aspects play an
important role, both on the level of tooth classes and on the level of individual teeth.
Tooth size variation is limited to a certain range, apparently by regulative developmental
mechanisms capable also to compensate for earlier deviations (Glasstone, 1963). Occurrence
of truly microdontic teeth as observed after childhood cancer treatments (Hltt, 2005) ap-
pears to be rather rare (personal communications). Thus, if agenesis follows from a quantita-
tive failure, the quantitative defect must somehow be converted to a qualitative change dur-
ing development. Regressing rudimentary tooth germs in wild-type animals suggests exis-
tence of developmental thresholds that need to be overcome for the development to proceed
(Tureckova et al., 1995; Kernen et al., 1999). Developmental thresholds are also recognized
from experimental mouse null mutants in which inactivation of specific genes arrest tooth
development at specific stages (Table 1). In many of these mutants, complete inactivation of
a gene arrested the development of all teeth or a whole tooth class, while heterozygotes for
these mutants usually develop normal dentition. Transgenic mice with hypomorphic alleles
of Pax9 showed that quantity of activity of a single gene is critical for tooth development
54
and that decreasing this activity leads to gradually more severe phenotypes, the most sensi-
tive teeth being the ones that develop latest. These mice also connected retarded develop-
ment to agenesis and suggested that developmental arrest may happen at several stages, even
at late bell stage (Kist et al., 2005).
Models for the effects of a quantitative change in the amount of a single gene product are
also provided by mutants, in which a signaling gene is overactivated or the level of an an-
tagonist is manipulated (Table 1). Particularly interesting are mutants in which Eda is over-
expressed in the epithelium or in which signaling antagonists ectodin (antagonist of BMP
and Wnt signaling), Sprouty2 or Sprouty4 (antagonists of FGF signaling) are inactivated
(Mustonen et al., 2004; Kassai et al., 2005; Klein et al., 2006): in these mice supernumerary
teeth develop from rudiments that are arrested in wildtype mice, thus overcoming develop-
mental thresholds. Arrest of organ development at certain stages have been seen as a mecha-
nism for evolutionary change in dentition (Kernen et al., 1999; Peterkova et al., 2002; Klein
et al., 2006) but these mice may also serve as useful models for tooth agenesis in humans
and for the role of individual genes and genetic networks.
The pathogenesis of human tooth agenesis is perhaps best understood in anhidrotic ectoder-
mal dysplasias. In this case the molecular pathogenesis and the phenotypes in human patients
and mouse mutants are directly comparable. The gene defects in EDA, EDAR, EDARADD,
IKK and their mouse homologs, i.e. the signaling ligand, its receptor and the intracellular
mediators of the signaling, cause complete inactivation of this signaling pathway (reviewed
by Mikkola and Thesleff, 2003). In the mutant mice, incisors and third molars commonly fail
to develop and first molars are hypoplastic, while in the patients with anhidrotic ectodermal
dysplasia, both dentitions are severely affected and tooth morphology is simplified (Pispa et
al., 1999; Prger et al., 2006; Lexner et al., 2007). The phenotypes of the mice with impair-
ment or overexpression of Eda signaling suggest that early defects of ectodermal placodes
and, in teeth, the enamel knots would explain the ectodermal defects in human patients
(Pispa et al., 1999; Mustonen et al., 2004). Thus, failure of signaling at an early stage leads
to anomalies that are present also in the deciduous dentition. On the other hand, as the mu-
tant and disease phenotypes are caused by complete inactivation of the signaling pathway,
the partial albeit severe tooth agenesis phenotypes suggest redundancy in the function of the
signaling pathways, i.e. that different signaling pathways have overlapping functions. This
redundancy adds a further element explaining how different gene defects may cause partial
agenesis.
In the report of the first identified gene defect in MSX1, the authors suggested that the partial
and selective tooth agenesis reflected a patterning defect possibly related to the odontogenic
homeobox code underlying the development of different teeth (Vastardis et al., 1996). They
suggested that the defect had a dominant negative effect but showed later that it caused loss
of function (Hu et al., 1998). As described later (see Results and discussion), the gene de-
fects in human MSX1 and PAX9 are essentially loss of function mutations and cause haploin-
sufficiency by reducing the amount of the functional protein to one half (Hu et al., 1998; Das
et al., 2002; Nieminen et al., 2003). Thus, it is probable that the selective tooth agenesis is
explained by differential sensitivity to gene dosage. The phenotypes of the hypomorphic
Pax9 mutants (Kist et al., 2005) show that the late developing posterior molars are especially
55
sensitive for a reduced Pax9 dose. The functions of mouse Msx1 and Pax9 are best under-
stood as regulators of the signaling needed for the formation of the enamel knots (Peters and
Balling, 1999; Jernvall and Thesleff, 2000), and this function has been connected with tooth
agenesis in humans (Thesleff, 2006). It is not clear, however, how this relates to the selective
tooth agenesis that affects mainly some teeth in the permanent dentition, i.e. secondary teeth
and permanent molars. The pathogenesis of MSX1 and PAX9 defects will be discussed fur-
ther in the General discussion.
The phenotypes in the family segregating a nonsense mutation of AXIN2 are striking in a
sense that even in the two cases when only three permanent teeth had developed, the primary
dentition was intact (Lammi et al., 2004). This suggested that AXIN2 function is especially
important for the processes involved in tooth replacement and development of the permanent
molars. So far, excess |-catenin levels have been mainly associated with enhancement of
development and renewal of ectodermal organs (Gat et al., 1998; Alonso and Fuchs, 2003;
Jrvinen et al., 2006; Blanpain et al., 2007). The function of AXIN2 as a negative feedback
regulator suggests that it is needed at defined stages of tooth development to downregulate
|-catenin activity. However, no data exist on the consequences of overactivation of |-
catenin activity in the dermis or dental mesenchyme. Furthermore, it has been shown that the
Axin2 null mutant mice develop a craniosynostosis phenotype as a result of increased prolif-
eration and differentiation potential of calvarial osteogenic cells (Yu et al., 2005). AXIN2
haploinsufficiency may affect the regulation of the relationship between the tooth germs and
the bone which may be critical for the long development of the teeth that were affected in
association with the AXIN2 gene defects.
Tooth agenesis and cancer
The connection between tooth agenesis and cancer predisposition as a consequence of
AXIN2 defects is explained by the critical role of Wnt signaling in tooth development (Andl
et al., 2002; van Genderen et al., 1994; Jrvinen et al., 2006) and the major contribution of
the deregulation of intracellular |-catenin levels to carcinogenesis (reviewed by Segditsas
and Tomlinson, 2006; Giles et al., 2003). It is intriguing to consider a more general connec-
tion between tooth agenesis and cancer predisposition and that tooth agenesis could in some
cases be an indication of the latter.
Importance of epigenetic events for the outcome of tooth agenesis suggests that agenesis
may in some cases reflect inherited developmental instability. Increased cancer risk has been
associated with developmental instability, developmental anomalies and evolutionary change
(Narod et al., 1997; Galis, 1999; Galis and Metz, 2003). On the other hand, it has been sug-
gested that major hereditary contribution to cancer is given by largely unknown alleles of
low penetrance (Amundadottir et al., 2004; de la Chapelle, 2004), and some of these alleles
may also contribute to the background of tooth agenesis. It is conceivable that defects in
other genes, in addition to AXIN2, involved in Wnt signaling and regulation of |-catenin
level may also link tooth agenesis and cancer predisposition. Interestingly, it has been shown
that expression of MSX1 is reduced in cervical cancer cells and that MSX1 stabilizes p53, a
well known tumor suppressor protein (Park et al., 2005).
56
HUMAN GENETICS AND GENE DEFECTS
The human genome
During the last hundred years, significant understanding of the basis and mechanisms of he-
redity has accumulated. Major steps in this process include recognition of the significance of
Mendels laws, understanding that chromosomes carry the heritable determinants, discovery
of the structure of DNA and deciphering of the genetic code, development of the recombina-
tion DNA technology, and, finally, ability to catalogue whole genomes at the DNA sequence
level (reviewed by Dunwell, 2007). Application of increasingly powerful genetic mapping
and positional cloning methodology has led to the identification of thousands of disease
causing loci, and tens of thousands of individual gene defects. The international efforts to
catalogue the DNA sequence of the whole human genome, first drafts of which were pub-
lished in 2001, made identification of disease causing gene defects even more straightfor-
ward, and have made it possible to understand genotype-phenotype relationships at a higher,
whole genome level. This is facilitated by technological as well as conceptual advances re-
garding the genome structure and abilities to consider, in addition to single genes, whole
gene networks, and to extract information based on conservation of sequences in the ge-
nomes of different species (reviewed by Kidd et al., 2004; Boffelli et al., 2004).
Human genome consists of 22 pairs of autosomes, two sex-determining chromosomes, and
the mitochondrial DNA. One of the sex-chromosomes with one from each autosome pair
constitute a haploid genome, which is inherited from each parent and after random segrega-
tion and crossover events transferred to a child. MtDNA is inherited in the ovum from the
mother to the child. In a process of producing gametes, meiosis, approximately 35 crossover
events reshuffle parts of the parental chromosome pairs, and the resulting jigsaws become
transmitted to the progeny, thus determining the so-called genetic length of the genome as 35
Morgans. A haploid genome of a gamete contains approximately 3.1 * 10
9
basepairs. Ac-
cording to current statistics, the human genome contains approximately 20000-25000 pro-
tein-coding genes (Little, 2005; see also http://www.ensembl.org). In addition, the gene
maps in public access internet databases contain a lot of potential predicted genes. The usage
of alternative transcription start sites and an alternative mRNA-processing (splicing)
makes it possible to produce a much larger amount of different proteins than is the amount of
genes in the genome. The gene content is also complemented by an increasing amount of
non-protein-coding RNA genes including the micro-RNAs (Cobb and Duboule, 2004;
Hobert, 2007). The genomic length covered by the genes accounts only for one fourth of the
whole genome length, and the actual protein coding sequence has been estimated as only two
% of the genome length. However, the non-coding sequence contains important regulatory
and structural elements affecting gene expression and genome maintenance, and also a lot of
conserved elements of as yet unknown significance. Remarkable part of the genome is cov-
ered by different types of repeat elements (Levy et al., 2007). Several gene families exist
where extensive gene duplications create variation between individuals (Freeman et al.,
2006). Finally, whole genome sequencing has revealed the extent of genetic variation, rang-
ing from large sequence blocks to single nucleotide changes (reviewed by Kidd et al., 2004;
Feuk et al., 2006).
57
Figure 6. Common types of sequence changes in an idealized gene (exons and introns are
usually significantly longer!). Exonic sequences are written with capital letters and promoter
and introns with lowercase. Examples of sequence changes are shaded. Codons and a CA-
repeat in the intron are underlined. Sequence changes that do NOT change an amino acid, af-
fect the reading frame or create a stop codon, may affect regulation of the gene activity or
mRNA processing (splicing). Appearance of a termination (stop) codon as a result of a mu-
tation often leads to degradation of the mRNA instead of translation to a truncated protein.
Variation
Chromosomal aneuploidies and major chromosomal abnormalities account for the most
gross, usually rare forms of genetic variation. While aneuploidies and most abnormalities
(large deletions, partial trisomies and most translocations) are not inheritable, some of the
less deleterious deletions and translocations may be transmitted to progeny. The genetic
variation transmitted from a generation to another includes duplications and deletions of
large sequence segments as well as repeat elements (Kidd et al., 2004; reviewed by Feuk et
al., 2006; Levy et al., 2007). The repetitive sequences are common in the centromeric re-
gions of chromosomes (satellite DNA) but they may also exist in regions of euchromatic
DNA, and involve functional genes. Repetitive sequences of short fragments from two to a
few basepairs (short tandem repeat polymorphisms, STRPs, also called microsatellites) have
been extensively used as genomic markers in construction of genetic maps and in localiza-
tion (mapping) of disease genes (Weissenbach et al., 1992; Dib et al., 1996). Most abundant
variation, however, consists of single nucleotide polymorphisms (SNPs), insertions and dele-
tions (Kidd et al., 2004) (Fig. 6). The human genome contains over 10 million SNPs (Feuk et
al., 2006; Estivill and Armengol, 2007). On the average a polymorphic SNP occurs once in
300 basepairs (Feuk et al., 2006). In the genome of one individual more than two million
sites may be heterozygous (Levy et al., 2007). Different genomic variants and alternative
58
sequences of the polymorphisms are called alleles. While only a small fraction of the varia-
tion affects protein structure (variation in exons affecting codons), silent changes and varia-
tion outside the coding regions are regarded potentially important for gene regulation and
evolutionary change.
Sequencing of whole human genomes has also revealed a substructure of chromosomes,
called haplotype blocks (reviewed by Wall and Pritchard, 2003). These blocks reflect differ-
ent magnitudes of linkage disequilibrium between SNPs made possible by uneven distribu-
tion of meiotic crossing-over events during generations.
Already before the whole genome sequencing, the observed sequence variation made it pos-
sible to construct high density genetic maps of the human genome to serve as frameworks in
the disease gene mapping (Donis-Keller et al., 1987; Weissenbach et al., 1992; Dib et al.,
1996). The first maps were based largely on restriction length polymorphisms, usually
caused by SNPs (Donis-Keller et al., 1987), followed by microsatellite maps (Weissenbach
et al., 1992; Dib et al., 1996). These were followed by the physical maps and subsequent
whole genome sequencing (Cohen et al., 1993). Along with the whole genome sequencing,
SNP-based mapping methodology has become reasonable (Kruglyak et al., 1997).
From genotypes to phenotypes
Malformations and other genetic diseases may be caused by a defect (mutation
1
) in a sin-
gle gene and usually then follow Mendelian inheritance (OMIM, http: //www.ncbi.nlm.nih.
gov/OMIM; Fig. 6). Gene defect may cause a disorder either when present as one copy, i.e.
in a heterozygous state (dominant diseases) or only when both gene copies are defective (ho-
mozygotes or compound heterozygotes in recessive disorders). The consequence of a gene
defect may be loss of function, gain of a new function or it may also prevent the function of
the unaffected allele (dominant negative). The genetic factors present in an individual consti-
tute the individuals genotype. The phenotype (the appearance, fitness and health of an in-
dividual) is a result of an interplay of the genotype and postgenetic factors, i.e. epigenetic,
maternal, and environmental factors.
Similar phenotypes may be caused by defects in different genes (genetic heterogeneity) as
seen in many malformation syndromes such as craniosynostosis syndromes or anhidrotic
ectodermal dysplasias (reviewed by Wilkie, 1997; Mikkola and Thesleff, 2003). Allelic het-
1
Sequence variants that cause a phenotype and are rare (e.g. gene frequency less than 0.01) have traditionally
been called mutations, whereas more common variants have been classified as polymorphisms. This relates to
the thinking that rare causative sequence variants are considered results of recent mutation events because due
to harmfulness they tend to vanish from the population gene pool. However, recessive gene defects can be very
old because of no selection against them. Furthermore, all sequence variants are results of mutations. A fre-
quency criterium does neither reflect the real contribution of a sequence variant to the pathogenesis. For this
reason, it could be more appropriate e.g. to use terms gene defect for variants that have high penetrance and
risk allele for variants that have low penetrance (and may be common in the population). Still, there remains
the problem of determining the limit between high and low penetrance. One criterium could be whether the
disease phenotype caused by the variant can or can not be shown, respectively, to follow Mendelian inheri-
tance.
59
erogeneity, a form of genetic heterogeneity in which a disease may be caused by different
gene defects in a single gene, is according to current view rather a rule than exception when
malformations or single gene diseases are considered (Weiss, 1996; Wilkie, 1997). In some
cases, allelic or even identical - gene defects may also cause phenotypes or diseases that
are or have been considered separate entities as in the case of gene defects in p63, IRF6 and
the genes for the FGF receptors (reviewed by van Bokhoven and McKeon, 2002; Kurotaki et
al., 2002; reviewed by Wilkie, 1997). For example, defects in the FGFR2 have been found in
several craniosynostosis syndromes, and in some cases identical amino acid changes have
been identified in patients with diagnoses of different syndromes (Wilkie, 1997).
In many diseases, the correlation between the genotype and phenotype is strong and they fol-
low Mendelian inheritance. In these cases, such as many diseases of the so-called Finnish
disease inheritage, it has been relatively straigthforward to localize the disease-causing gene.
However, the relationship between a genotype and a phenotype may also be rather complex.
The dependence of the phenotype on other genetic factors (modifier genes or genetic
background), epigenetic and external factors is reflected as different degrees of variable
expressivity (different phenotypes among individuals) and often as reduced penetrance
(some individuals with no disease even though the individual carries the gene defect or geno-
type associated with the disease). Redundancy between genes and genetic pathways may
mask the effects of loss of function mutations. Diseases, in which a single gene has a major
effect, usually follow Mendelian inheritance patterns (exceptions are diseases with genomic
imprinting, i.e. effect of a parent's sex, and diseases caused by repeat expansion), albeit often
with reduced penetrance and variable expressivity. These may include hypomorphic defects
that by definition cause only a partial loss of function of the affected allele (Strachan and
Read, 1999). It is thought that non-Mendelian or "complex" diseases are caused by defects
(or rather risk variants or risk alleles
1
) that have low penetrance which may be considered
as having only a predisposing effect and usually require contribution of other genetic factors
(polygenic diseases) or extrinsic factors (multifactorial diseases) to cause the disease
(Strachan and Read, 1999; Reich and Lander, 2001; Peltonen et al., 2006). The borderline
between "Mendelian diseases" and "complex diseases" may often be, however, rather arbi-
trary, as are borderlines between alleles of "high" and "low" penetrance. It is assumed that
defects in single gene diseases usually reside in the protein coding region, affecting the read-
ing frame or the protein sequence, while risk variants rather affect the sequences important
for the regulation of gene expression (Reich and Lander, 2001; Peltonen et al., 2006) (Fig.
6). Genes, in which coding region defects have been identified, are often first candidates also
in search of the risk variants.
Gene identification
To identify gene defects that cause a genetic disease, two approaches exist. It is possible ei-
ther to study candidate genes or perform a genome-wide search. Candidate genes can be sub-
jected to sequence analysis, either by sequencing or indirect methods, or, if possible, the ex-
pression levels in the patients can be compared to those of healthy controls. Candidate genes
can also be studied by genetic analysis based on linkage or association. Genetic analysis is
usually able to detect also the involvement of sequence variants that reside outside the cod-
60
ing region and may affect the regulation of gene expression. However, genetic analysis is
possible only if a reasonable amount of patients is available. If the candidate gene approach
has not provided positive results or is not feasible and a suitable sample of patients is avail-
able, a genome-wide search, also called positional cloning, can be performed.
Figure 7. Recombinants and non-recombinants.
During meiosis, parental chromosomes are ran-
domly segregated to the gametes. An individual
is a recombinant with respect to two genes or
polymorphisms (A and B) if he or she inherits
alleles (A/a and B/b) originating in different
grandparents. Expected proportion of recombi-
nant progeny decreases from 50 % if the loci are
located so near each other that the expected
amount of crossovers of the parental chromo-
somes between the loci during meiosis de-
creases.
Two properties (diseases, phenotypes, sequence variation) are segregated randomly if their
genotypic determinants reside in different chromosomes or in the same chromosome but rea-
sonably far from each other, allowing a good chance for crossover events between them
(Terwilliger and Ott, 1994; Strachan and Read, 1999). In this case, recombinant and non-
recombinant progeny are observed with similar frequency (individual who inherits alleles of
two genes from one parent that originated in different grandparents is called a recombinant,
see Fig. 7). If they are located relatively near each other in a chromosome, crossovers be-
tween them are rare. As a result, they will segregate nonindependently, i.e. be in linkage,
and a fraction of recombinants will be less than one half. Thus, the estimate of the recombi-
nation fraction can be used to estimate the genetic distance of two genotypic determinants,
forming the basis of linkage analysis (Terwilliger and Ott, 1994).
With experimental or domestic animals, the recombination fraction can be estimated simply
by counting the progeny with different phenotypes and evaluating the statistical significance
of the observations. In human genetics, for diseases following (reasonably closely) Mende-
lian inheritance, a mathematical method based on evaluating observations from pedigrees
may be used. In this method, a total likelihood is calculated for the observations assuming
different hypotheses, these in this case being different recombination fractions, i.e. distance
of the disease locus and the analysed DNA marker. A 10-based logarithm of a likelihood ra-
tio assuming linkage (recombination fraction less than 0.5) and non-linkage (recombination
fraction 0.5), usually called the lod (logarithm of odds) score is used as an indicator of sig-
nificance of results (Terwilliger and Ott, 1994). A lod score > 3 was initially considered sig-
nificant, this score meaning that, with a given recombination fraction, a linkage is 1000
61
times more probable than the null hypothesis of non-linkage. A more stringent limit than e.g.
the commonly used limit of p-value of 0.05 is necessary because of the inherent multiple
testing. Even more stringent limits for significance have been suggested, based on experi-
ence and theoretical considerations, especially in complex diseases (Strachan and Read,
1999).
In practice, the lod score method of gene mapping can be utilized if a reasonably large single
family or many separate families are available (the lod scores are additive if the families
share a common genetic background). For traits following dominant inheritance, it may be
possible to obtain significant evidence for linkage with a single pedigree of 10-15 affected
individuals, or alternatively, with several pedigrees. Recessive traits require several families
with at least two affected children. Increasing the sample size provides better possibilities for
limiting the locus size in terms of a recombinant free region. The locus identification be-
comes less cumbersome, if a founder effect can be assumed in the history of the population
or as a verified consanquinity loop (Terwilliger and Ott, 1994; Kere, 2001). In these cases
linkage disequilibrium may be utilized. In recessive traits with a founder effect, regions of
homozygosity have been searched utilizing samples of just a few affecteds (Nikali et al.,
1995; Pekkarinen et al., 1998). Etiologic or genetic heterogeneity and high disease gene fre-
quency, on the other hand, tend to make the analysis less straightforward. The same follows
from reduced penetrance. The stringency of a genotype to a phenotype relation becomes
weaker, decreasing the power of the statistical analysis.
Several computer programs have been developed for the estimation of the recombination
fraction. The popular programs were based on the algorithm by Elston and Stewart (Lathrop
et al., 1984). However, more effective algorithms have been developed for purposes of mul-
tipoint analysis that evaluate linkage along a haplotype rather than with a single polymorphic
marker. These are implemented e.g. in GeneHunter and Simwalk (Kruglyak et al., 1996; So-
bel and Lange, 1996).
In the case of the so-called complex diseases, the penetrance is so low that an inheritance
pattern can not be determined (Strachan and Read, 1999; Freimer and Sabatti, 2004). In
these situations the so-called non-parametric methods of analysis can be applied. These are
based on estimations of allele sharing among affecteds, either as identical-by-state (ibs) or as
identical-by-descent (ibd). Software packages such as Mendel, GeneHunter and Simwalk
implement these algorithms to offer elaborate statistical indicators for linkage (Kruglyak et
al., 1996; Sobel and Lange, 1996).
Within complex phenotypes or diseases, because of a low occurrence of affecteds in one
family, a different kind of strategy based on analysis of allelic association may be used
(Strachan and Read, 1999; Freimer and Sabatti, 2004). A presumption for this analysis is that
the affected individuals to a large extent share same predisposing genetic factors, i.e. ances-
tral sequence variants. Instead of collecting large families, allele and genotype frequencies
may be measured in a large sample of unrelated affected individuals and compared to fre-
quencies among an equivalent sample of unaffected controls (case-control-design). Devia-
tions from expected frequencies may be taken as proof of a causative role of the studied vari-
ant itself or of a linkage disequilibrium with a causative genetic factor. An inherent problem
62
of the selection of an adequate control group can be avoided if instead of allele frequencies,
frequencies of transmission of alleles from parents to offspring is estimated (e.g. transmis-
sion disequilibrium test, TDT). The results of association analyses should be regarded criti-
cally, and for reliable results, large samples shall often be studied, or positive results repli-
cated in other studies.
A further methodology in genetic reseach involves mapping of quantitative traits. The sam-
pling strategies are similar as in association analysis but instead of discrete phenotypes, cor-
relations of quantitative measures to the observed allele frequencies are estimated (Mackay
2001).
Technological development has greatly increased the possibilities for genome-wide studies.
Instead of microsatellites, SNP genotyping using DNA-arrays is becoming a method of
choice (Carlson et al., 2004). The final step of the process, sequence analysis, has also be-
come fast and economical and new technologies are emerging. Thus the greatest limitation,
in addition to funding, most probably is the identification and recruiting of a reasonable large
sample of patients.
63
AIMS
The aim of the present study was to identify genes and gene networks that participate in the
development of teeth and dentition. For this purpose, the study into the congenital defects of
human dentition was undertaken. More specifically, the aim was to study
- the inheritance of the incisor and premolar hypodontia, one of the most common con-
genital malformations in humans, and identify causative genes
- the involvement of candidate genes into the etiology of the incisor and premolar hypo-
dontia
- the involvement of the candidate genes into the severe tooth agenesis in humans
- the co-expression of genes during tooth development by developing a bioinformatic tool
for this purpose.
64
MATERIALS AND METHODS
Subjects
The criterion (I, IV) for selecting persons with hypodontia (probands) was the congenital ab-
sence of one to six permanent teeth or the presence of peg-shaped permanent upper lateral
incisors. The probands were non-syndromic patients at the Department of Pedodontics and
Orthodontics, Institute of Dentistry, University of Helsinki. The probands and/or their par-
ents were interviewed of the occurrence of hypodontia in their families. The study popula-
tion comprised nine probands with hypodontia and their family members, totaling 149 indi-
viduals in nine Finnish families (Fig. 8; Table 4). From these, five families with 42 family
members participated in the study on involvement of MSX1 and MSX2 to tooth agenesis (I).
Seven families were selected for the genome wide search (IV).
Information concerning general health was obtained by interview. A clinical dental examina-
tion of the probands and their family members was performed by three experienced ortho-
dontists (S.A., S.P., I.T.). In addition to hypodontia, other visible dental abnormalities were
recorded. Panoramic radiographs were taken, if this was necessary for the diagnosis. In some
cases, information on hypodontia was confirmed from documents and radiographs in dental
files. In addition, retrospective dental data were collected by questionnaires and from dental
files. Agenesis of the third molars was excluded because reliable retrospective data on them
were incomplete. Children under six years of age were excluded from the study.
The proband of family 1 in (II) was originally referred for treatment to the Pediatric Dental
Department of the Hospital for Children and Adolescents, Helsinki University Central Hos-
pital. The proband of family 2 was referred for consultation and treatment to the Department
of Pedodontics and Orthodontics. The diagnosis of missing teeth was based on clinical and
radiographic examinations. Retrospective dental information was collected from dental files.
Agenesis of third molars was not possible to diagnose in the proband and in two brothers of
the proband in family 1 because of their young ages.
We studied eight individuals with a deletion in the short arm of chromosome 4 (III). Seven
of them had been diagnosed as Wolf-Hirschhorn syndrome patients while one was included
in the study because of the presence of a 4p deletion. Their ages ranged from 5.8 to 21.7 yrs.
Initial diagnoses had been made in the University Hospitals of Helsinki, Turku, or Tampere
and been confirmed in early childhood with cytogenetics or fluorescence in situ hybridiza-
tion (FISH). Congenitally missing teeth were assessed from panoramic radiographs. Of two
patients from Rinnekoti Central Institute, two panoramic radiographs with several years' in-
terval were available. In case of obscure regions in radiographs, the number of erupted teeth
was confirmed in clinical examination. Signs of enamel hypoplasia and severely worn denti-
tion were also recorded. The anatomy of the palate and structure of hair and nails were re-
corded in a clinical examination or obtained from patient records.
The studies were approved by the Ethics Committee of the Institute of Dentistry, University
of Helsinki. The study was conducted with the consent of the parents and the Rinnekoti Cen-
tral Institute.
65
Table 4. Agenesis phenotypes in the incisor and premolar hypodontia families
family gen:id*) agenesis**) family gen:id*) agenesis
1 II:1 15 9 IV:6 peg 12
1 II:4 35 9 IV:8 35
1 II:6 35 9 IV:10 35
1 III:1 25, 35, 45 9 IV:11 15
1 III:2 35 9 IV:13 35
1 III:4 45 9 IV:17 35, 45
1 IV:1 35, 45 11 II:2 25
2 II:3 31, 41 11 II:4 35, 45
2 III:3 peg 12, peg 22 11 III:2 12, 22, 15, 25, 35, 45
2 IV:2 12, 22 11 III:3 35, 45
2 IV:3 12, 22 11 III:5 45
3 II:2 31 12 II:4 35, 45, peg 12, 22
3 III:1 peg 12 12 II:6 premolars
6 I:1 12, 25, peg 22 12 II:8 13, premolars
6 II:2 12, peg 22 12 II:10 15, 25, 35, 45
6 II:4 15, 35 12 II:12 14, 15, 25, 31, 35, 41, 45
6 II:5 peg 12, 22 12 III:4 35, peg 15
6 III:3 15, 35, 45 12 III:8 12, 22, 53, 63
7 I:1 peg 22 12 III:10 35, 45
7 II:1 15, 25 12 III:11 12, 22, 41, peg 31
7 III:1 15, 25 12 III:12 31, 41, 35
7 III:2 25 12 IV:1 15, 25, 35, 45, 27, 34
9 II:2 35 20 I:2 15, 25
9 III:4 peg 12 20 II:5 15, 25, 35
9 III:9 35, 45 20 II:7 15, 25
9 III:13 15, 25, 35 20 III:2 12, 35, 45
9 III:15 35 20 III:3 15, 25
9 III:18 14, 15, 24, 25, 35, 45 20 III:7 35
9 III:19 15, 25 20 IV:1 35, 45
9 III:22 35 20 IV:2 35, 45, cleft soft palate
9 IV:1 25 20 IV:3 peg 22
9 IV:3 31, peg 12 20 IV:4 15, 35, 45
*) generation:subject in order from the left (compare to Fig. 8)
**) missing teeth expressed as the FDI notation; peg, peg shaped incisor
DNA isolation
Venous blood samples, 10 to 20 ml, were taken for DNA analyses from all available family
members. DNA was extracted from leukocytes according to standard procedures (Vanden-
plas et al., 1984). DNA-samples of family 12 were isolated from venous blood samples by
the DNA isolation service of the National Public Health Institute of Finland, Biomedicum,
Helsinki, using a Autopure TM DNA purification system (Gentra, Minneapolis, MN, USA).
66
Figure 8. Pedigrees of families with autosomal dominant inheritance of incisor and premolar
hypodontia. Squares, males; circles, females, black, affected; open, unaffected; ?, possibly af-
fected; dot, carrier. For description of phenotypes, see table 4. Please note that different num-
bers for families were used in Arte, 2001, and Arte et al., 2001.
Genotyping
The polymerase chain reaction (PCR) with amplifiable microsatellite markers was used for
assessing the genotypes of the individuals (I, IV). PCR primers were obtained from Ge-
nethon, France, or from the Department of Clinical Genetics, University Hospital of Upp-
sala, Sweden, or they were synthesized in the Laboratory of Human molecular genetics of
the National Public Health Institute, Finland, or bought from TAGC, Copenhagen, Denmark
or Oligomer Oy, Helsinki, Finland. When radioactive detection of PCR products was used,
one of the primers was 5- endlabeled with
32
P-phosphate with T4 kinase (Amersham, UK;
Pharmacia, Sweden). PCR reactions were done in a Perkin-Elmer Cetus Thermal Cycler 480
(Norwalk, CT, USA) or DNA Engine (MJ Research, MA, USA) in a total volume of 15 l
containing 4 ng/ul chromosomal DNA, 0.4 uM of each of the primers, 0.2 mM of each of the
deoxynucleotides, 0.25 U of enzyme, and 1.5 mM MgCl2 in a standard PCR buffer. Either
Taq-polymerase (Amplitaq, Perkin Elmer Cetus, Ca), Dynazyme II or Dynazyme Ext (Finn-
zymes, Finland) were used.
32
P-labeled PCR products were made 50% of formamide and 10
mM of EDTA, pH 8.0, and separated in a 5% sequencing gel with 7.5 M urea in an IBI gel
apparatus. Alleles were detected by autoradiography with Kodak films exposed for 15 to 48
hours and analyzed manually. Fluorescently labeled PCR products were analyzed in an ABI
377 sequencer (Applied Biosystems, Foster City, CA). Fluorescent alleles were detected
67
with ABI Genescan software and identified with ABI Genotyper software. For families 11,
12, and 20 genome-wide genotyping of 365 microsatellites was provided by the Finnish Ge-
nome Center, Biomedicum, University of Helsinki, Finland. The genotype data were stored
and organized with dBase IV 5.0 for Windows software (Borland International, USA).
Linkage analysis (I, IV)
In the linkage studies (I, IV), the lod score method served for evaluation of the existence of
linkage (Ott, 1974). The hypodontia locus was modeled as an autosomal dominant, two-
allele system with a gene frequency of the hypodontia allele of 8%. A penetrance of hypo-
dontia of 86% was used (Burzynski and Escobar, 1983). The informativeness of the family
material was evaluated with the Slink software package, assuming an autosomal dominant
model and gene homogeneity (Ott, 1989). Allele frequencies for marker alleles were calcu-
lated from observed genotypes if data from a reasonable amount of founders was available,
otherwise equal allele frequencies were used. The pairwise lod scores for different recombi-
nation fractions were estimated by the Mlink and Ilink options of the Linkage package, ver-
sion 5.1 7 (Lathrop et al., 1984). The multipoint location scores (corresponding to lod scores)
were estimated with Simwalk software (Sobel and Lange, 1996) which was also used for
testing of genetic heterogeneity. In affecteds-only analyses, the phenotypes of the unaffected
individuals were coded as unknowns.
Sequencing (II, IV)
For the sequencing analysis, exons of MSX1, PAX9, AXIN2 and TGFA were amplified in
PCR by Dynazyme Ext polymerase (Finnzymes, Espoo, Finland). For analysis of exons of
PAX9 in II, PCR products were purified from agarose gels by Qiaquick gel extraction kit
(Qiagen, Bothell, Wa). Both strands of the PCR products were sequenced in both directions
with ABI BigDye terminator chemistry (Applied Biosystems, Foster City, CA) and analyzed
on an ABI 377XXL DNA sequencer. For other sequencings, PCR products were purified
with ExoSAP-it reagent (USB, Cleveland, Ohio) and sequenced in both directions with ABI
BigDye v.3.1 sequencing reagents. Sequencing products were analysed in the ABI 3730 cap-
illary instrument in Molecular Medicine Sequencing laboratory, Biomedicum Helsinki.
Primers as well as PCR and sequencing conditions were as described earlier (Nieminen et
al., 2001; Lammi et al., 2003; Lammi et al., 2004) or as summarized in Table 7. Sequencing
results were compared by BLAST2 (http://ncbi.nlm.nih.com/gorf/ bl2.html) with EMBL en-
tries M76731, M76732 (MSX1), AJ238381, AJ238382, and AJ238383 (PAX9) as well as ge-
nomic sequence entries from NCBI NT_010783.13 (AXIN2) and NT_022184.14 (TGFA).
FISH Analysis (III)
Chromosome preparations for FISH were made from cultures of blood lymphocytes. DNA
samples from cosmid clones 2A1 and 15A2, spanning a region of 40 kb and containing the
entire MSX1 coding region (gift from Dr. Jane E. Hewitt), were labeled with biotin 14-dATP
by means of a BRL-nick translation kit (Bethesda Research Laboratories, Gaithersburg, MD,
USA). Denaturation of the target cells, hybridization, and detection were carried out as de-
scribed elsewhere (el-Rifai et al., 1995).
68
Table 7. Conditions and primers for the sequence analysis of MSX1 and TGFA
exon primer sequence*)
ann. T,
cycles**)
add
DMSO
ann.
T***)
add
MSX1 1 F CCCGGAGCCCATGCCCGGCGGCTG hot 64 32x 5 % 60
R CTCCCTCTGCGCCTGGGTTCTGGCT
2 F ACTTGGCGGCACTCAATATC hot 59 32x 2 % 59
R AGAGGCACCGTAGAGCGAG
TGFA 1 F GGTAGCCGCCTTCCTATTTC hot 58 32x 58
R GCAGCCAGGTAAGCAGGTAG
2 F GTGCTTTTCATGGGCATTTT hot 58 32x 58
R GAGCTCTTGAGGAGCCACAC
3 F TGGAAAGCACGCTATACAGG hot 58 32x 58
R CCATGAGTGACCTGAGATGC
4 F CTCCAGGATTTGGCACAGTC hot 58 32x 58
R ATACTGCGGATGTCCCTGGT
5 F GGGTAGCCAACAGATGCTTT hot 58 32x 58
R TTCCTTTTCTCCTCTCTTCCTG
6 F CCACCCCTTACAGGATCTGA hot 58 32x 58
R CCGTCTCTTTGCAGTTCTTTT
*) all primers were used in the final concentration of 1 uM
**) hot start, annealing temperature, number of cycles
***) annealing T, 25 cycles
sequencing PCR
1 M
Betaine
Gene expression data collection (V)
The data on expression of genes were collected mostly from published literature and to a
smaller extent from direct submissions from the researchers. The data was first collected to a
form on paper and subsequently stored to tables designed in dBase 5.0 for Windows soft-
ware. Standardized schematic drawings were used to indicate subtissue-level resolution and
gradients of expression when unambiguous illustrations were available. The drawings were
made in CorelDraw v. 5 to 8 (Corel Corporation, Ottawa, Canada) and exported in JPEG
format.
WWW implementation (V)
dBase 5.0 for Windows scripts were written to produce WWW-pages in HTML format for
gene lists, pages for individual genes and notes. The pages were stored in the WWW-server
of the Institute of Biotechnology, University of Helsinki, Finland, and updated with regular
basis.
69
RESULTS AND DISCUSSION
MSX1 and PAX9 in dominantly inherited severe tooth agenesis (publica-
tions II and III)
During the studies described in this thesis, researchers elsewhere made important contribu-
tions to clarify the genetic basis of human tooth agenesis. It was shown that the mouse null
mutants of Msx1 and Pax9 did not develop any teeth, but development was arrested at an
early stage (Satokata and Maas, 1994; Peters et al., 1998). Vastardis and collaegues in the
Harvard university (1996) identified a missense mutation in the MSX1 homeobox that was
associated with dominantly inherited severe tooth agenesis (oligodontia) in a family of Afri-
can origin. Later this mutation was shown to disturb the three-dimensional folding of the
MSX1 protein and its ability to bind to its cognate DNA sequences (Hu et al., 1998). A few
years later, Stockton and collaegues (2000) identified a frameshift mutation within the DNA-
binding paired domain of the human PAX9 gene in an American family segregating severe
agenesis. These first findings suggested that defects in these two genes were associated with
somewhat different types of agenesis. In the family segregating the MSX1 mutation, the
agenesis rather uniformly affected second premolars and third molars, in addition to variable
agenesis of some other teeth. On the other hand, the PAX9 mutation was strikingly associ-
ated with agenesis of permanent molars, however, with variable agenesis of other teeth in
this case, too.
These findings inspired the studies of dominant severe tooth agenesis in Finnish families.
First families to be studied were two small nuclear families with one of the parents and one
or two of the children affected (Table 1 and Fig.1 in II). In a family with predominantly per-
manent molar agenesis, resembling the phenotypes in the family described by Stockton et al
(2000), a c. 1143A>T mutation creating a nonsense change Lys144Stop was identified in the
paired box domain (Fig.2 in II). The same mutation was later identified in another Finnish
oligodontia patient with no known relationship to the original family (unpublished). As the
stop codon appeared in the middle of the DNA binding paired box, it was reasoned that it
would cause loss of function. In another family no defects in MSX1 or PAX9 were identified.
However, further family members were later recruited and a genome-wide scan with samples
from this family was conducted in collaboration with the Finnish Genome Center. This work
led to the identification of a nonsense mutation in the AXIN2 gene (Lammi et al., 2004).
In another line of investigation of the genetic basis of tooth agenesis, the involvement of
MSX1 to the tooth agenesis phenotype in association with the Wolf-Hirschhorn syndrome
was investigated (III). This syndrome is caused by deletions in the short arm of chromosome
4, and involves craniofacial abnormalities and mental retardation as the most prominent fea-
tures. In some patients, tooth agenesis had also been reported, while on the other hand dental
features may in many cases have become overlooked (Burgersdijk and Tan, 1978). The
strong candidate for causation of tooth agenesis in Wolf-Hirschhorn syndrome patients was
MSX1 in 4q32 (Ivens et al., 1990). A group of Finnish patients with Wolf-Hirschhorn syn-
drome was studied and tooth agenesis recorded (Table 1 and Fig. in III). In a subsequent
FISH analysis with a genomic MSX1 probe, it was shown that in all five patients affected by
severe agenesis, the observed deletion spanned the MSX1 locus, presumably causing MSX1
70
haploinsufficiency (Table 1 in III). In one patient with a less severe agenesis, both copies of
the MSX1 gene were found to be present. The severe agenesis phenotypes of the five patients
roughly correlated with previous findings from families with defects in MSX1. This study
offered direct evidence that the tooth agenesis associated with MSX1 defects was a result of
reduced amounts of the MSX1 protein, i.e. haploinsufficiency, thus corroborating the results
from functional studies of the MSX1 protein with a missense mutation R196P in the ho-
meobox (Hu et al., 1998).
Table 6. Gene defects in MSX1 , PAX9 and AXIN2 that cause tooth agenesis
gene exon type DNA (coding region) protein
Nieminen et al., 2004 gene deletions
1 Kim et al., 2006 insertion 62-63insG G22RfsX168
1 Lidral et al., 2002 missense 182T>A M61K
1 van den Boogaard et al., 2000 nonsense 314C>A S105X
2 de Muynck et al., 2004 nonsense 559C>T Q187X
2 Vastardis et al., 1996 missense 587G>C R196P
2 Jumlongras et al., 2001 nonsense 605C>A S202X
2 Arte et al. (unpublished) deletion 690delG K231SfsX232
2 Chishti et al., 2006 missense 655G>A A219T
Das et al., 2002 gene deletion
Devos et al., 2006 gene deletion
1 Klein et al., 2005 nonsense 1A>G M1V
2 Das et al., 2003 missense 62T>C L21P
2 Lammi et al., 2003 missense 76C>T R26W
2 Jumlongras et al., 2004 missense 83G>C R28P
2 Zhao et al., 2005 insertion 109-110insG I37SfsX41
2 Zhao et al., 2005 missense 139C>T R47W
2 Mostowska et al., 2003 missense 151G>A G51S
2 Tallon Walton et al. (in press) nonsense 175C>T R59X
2 Das et al., 2003 insertion 175-176ins288bp R59QfsX177
2 Stockton et al., 2000 insertion 218-219insG S74QfsX317
2 Kapadia et al., 2006 missense 259A>T I87F
2 Das et al., 2003 missense 271A>G K91E
2 Nieminen et al., 2001 nonsense 340A>T K114X
2 Mostowska et al., 2005 delins 619_621delATCins24bp I207Y_X211
4 Frazier-Bowers et al., 2002 insertion 792-793insC V265RfsX315
7 Lammi et al., 2004 nonsense 1966C>T R656X
7 Lammi et al., 2004 insertion 1994-1995insG N666QfsX706
MSX1
PAX9
AXIN2
71
Figure 9. Genomic structures and known gene defects in MSX1, PAX9, and AXIN2. Num-
bers below the schemes indicate amino acid positions. Standard amino acid codes are used
in the description of mutations. X, appearance of a stop codon (nonsense or frameshift mu-
tations); fs, a frameshift as a result of an insertion or a deletion; light grey, exons; medium
grey, coding region; dark grey, code for the DNA binding domain; hb, code for the ho-
meobox.
Until today, altogether 24 different sequence defects in addition to whole gene deletions in
PAX9 and MSX1 have been published in association with dominant severe tooth agenesis
(Fig. 9; Table 6). Our laboratory has been involved in identification of five mutations in
PAX9, (II , Lammi et al., 2003; Klein et al., 2005; Tallon-Walton et al, in press; unpublished)
and two in MSX1 (unpublished), in addition to the syndromic deletions described above. The
defects have included nonsense and frameshift as well as missense mutations. In PAX9,
whole gene deletions in two families and a mutation destroying the start codon in one family
have been described (Das et al., 2002; Klein et al., 2005; Devos et al., 2006). For the first
described defect, a frameshift in the paired box (Stockton et al., 2000), the mutated protein
was shown to be unable to bind to known PAX target DNA sequences and to activate tran-
scription (Mensah et al., 2004). Inability to bind to target DNA was also shown for two mis-
sense defects (Jumlongras et al., 2004; Kapadia et al., 2006). For the mutation affecting the
exon 2 intron 3 junction, no mRNA carrying the mutated sequence was found in patient
lymphocytes, presumably because of the degradation of the abnormal RNA by the nonsense
mediated decay (NMD) mechanism (Mostowska et al., 2005). Although not studied, all mis-
sense defects in exon 2 of PAX9 are susceptible to NMD (Wilusz et al., 2001). These results
strongly suggest that, analogous to the defects in MSX1, the principal effect of known PAX9
mutations is to reduce the amount of functional PAX9 protein, i.e. haploinsufficiency. This
is also supported by the essential similarity of the associated phenotypes. Recognizing hap-
72
loinsufficiency as the cause of severe tooth agenesis implicates a dose effect of MSX1 and
PAX9 protein in the pathogenetic mechanism.
The summary that can be built from the phenotypes associated with these mutations supports
the conclusion drawn from the families first described: defects in MSX1 are characteristically
associated with agenesis of second premolars and third molars (frequencies of agenesis over
80 %) whereas defects in PAX9 affect most strongly all the permanent molars (except for
mandibular first molar, frequencies of agenesis are over 80 %)(Fig. 10; Table 7). It is also
probable that even though tooth size within the affecteds has been commented in only a few
reports (Nieminen et al., 2001; Jumlongras et al., 2001; Lammi et al., 2003; Jumlongras et
al., 2004; Klein et al., 2005; Chishti et al., 2006), reduced dimensions, shortened roots and
simplified forms are common in association with the defects in MSX1 and PAX9.
The increased amount of agenesis phenotypes associated with different mutations provides a
possibility to attempt statistical analysis. Such an attempt is presented in Table 7, consisting
of 39 patients with 7 defects in MSX1 and 63 patients with 13 defects in PAX9. As no sig-
nificant differences between the frequency of agenesis in the left and right sides were ob-
served, the frequencies from both sides were combined. Significant differences (p<0.001)
were found between the maxilla and the mandible. For phenotypes associated with defects in
MSX1, the first premolars in the maxilla were missing significantly more often than in the
mandible, whereas in association with defects in PAX9, the second premolars and the first
molars were missing significantly more often in the maxilla than in the mandible. In the inci-
sor region, the central incisors were much more often affected in the mandible and the lateral
incisors in the maxilla in association with the defects of both genes, a difference observed
also in the general population. In association with the defects in MSX1, agenesis of the lat-
eral incisors in the manbible was almost as frequent as that of the central incisors, but this
may reflect difficulties in identifying the missing tooth in the mandible.
When the phenotypes associated with the defects in different genes were compared, a sig-
nificantly higher frequency of agenesis was found for the maxillary first and second premo-
lars and the mandibular second premolars in association with defects in MSX1 than with de-
fects in PAX9, whereas agenesis of the maxillary first and second molars and the mandibular
second molars was significantly more common in association with defects in PAX9. In addi-
tion, the mandibular central incisors were significantly more frequently affected in associa-
tion with defects in PAX9 than in MSX1, but as the relationship was the opposite in the case
of the mandibular lateral incisors, these differences may again be explained by difficulties to
distinguish agenesis of mandibular central and lateral incisors.
Results of this part of the analysis are similar to those presented by Kim et al (2006). In addi-
tion to the results provided by Kim et al (2006), a significantly (p<0.001) higher frequency
of agenesis of maxillary first molars in association of defects in PAX9 was observed. Thus,
the most salient differences between the phenotypes are observed in the agenesis of premo-
lars, especially the maxillary first premolars (higher frequency in association with defects in
MSX1), and the second molars in both jaws as well as the maxillary first molars (higher fre-
quency in association with defects in PAX9). These differences may be useful when differen-
tiating severe agenesis caused by defects in PAX9 and MSX1. However, a further comment
73
concerning the agenesis of the third molars is warranted. Kim and collaegues (2006) did not
take the agenesis of the third molars into account on the basis that because of the high fre-
quency of the third molar agenesis in the population, it would be redundant for the purposes
of the analysis. However, in view of the reported phenotypes in the literature (Table 7),
agenesis of third molars is clearly an essential feature of phenotypes in association with de-
fects in MSX1 or PAX9. While some patients who have defects, especially in MSX1, have
developed at least some of the third molars, it is also possible that published reports may un-
derestimate the third molar agenesis because of problems in diagnosis. This probably also
explains the observed significant difference for agenesis of mandibular third molars in asso-
ciation with defects in MSX1 (Table 7). It appears that the agenesis of third molars is
strongly associated with defects in both genes, and presence of third molars should cause
doubt whether these genes are involved in etiology.
It is also relevant to compare phenotypes in association with different defects in MSX1 and
PAX9, i.e. to look for genotype-phenotype correlations. In the case of PAX9, the whole gene
deletions and the start codon mutation appear to cause the most severe defects extending to
the premolars and primary molars (Das et al., 2002; Klein et al., 2005). It has also been pre-
sented earlier that missense defects in PAX9 are associated with slightly different phenotypes
than other defects in this gene (Lammi et al., 2003). The analysis of figures in Table 7 (see
also Fig. 10) shows that agenesis of the first and second molars is significantly less common
in association with missense defects in PAX9 than in association with other kinds of defects
(p<0.05 for the mandibular second molars, p<0.001 for the other molars). Interestingly,
agenesis of the maxillary canines appears to be more common in association with missense
defects. Thus, the missense defects more often leave the first permanent molars unaffected
(Lammi et al., 2003). The differences may be explained by the assumption that in the case of
nonsense, frameshift and especially missense defects, some functional activity of the protein
is retained, possibly through a residual DNA-binding ability and especially through protein-
protein interactions. For different mutations in MSX1, the genotype-phenotype correlations
are less straightforward although also in this case it appears that deletion and nonsense muta-
tions are associated with more severe phenotypes than missense mutations (Table 7).
Attempts to unravel the genetic basis of common tooth agenesis (incisor
and premolar hypodontia) (publications I, IV)
The research summarized in this thesis was started with an effort to identify the genetic fac-
tors, i.e. causative genes, that cause dominantly inherited common tooth agenesis, incisor
and premolar hypodontia. Originally five Finnish families (1 ,2, 3, 6 and 7 in Fig. 8) were
recruited into the study (I). In these families agenesis of one or a few second premolars,
mandibular central incisors or upper lateral incisors, or in some cases, peg-shaped upper lat-
eral incisors, had been observed to follow an apparently dominant inheritance. In one of
these original families, only second premolars, and in two only incisors were affected, while
in the remaining families both classes of teeth could be affected (Table 4). One obligatory
carrier was observed in these initial families, reflecting the reduced penetrance.
74
Table 7. Summary of tooth agenesis phenotypes associated with defects in MSX1 and PAX9
n /
teeth
n / 3rd
molars
maxilla 1 2 3 4 5 6 7 8
MSX1 all 78 72 0 27 5.1 72 94 18 12 85
MSX1 missense 28 24 0 18 0 68 93 0 0 100
PAX9 all 126 122 1.6 22 9.5 21 70 81 91 98
PAX9 missense 50 48 0 36 24 26 60 62 80 96
mandible
MSX1 all 78 72 21 19 3.8 14 90 40 22 92
MSX1 missense 28 26 7.1 21 0 14 93 32 7.1 96
PAX9 all 126 122 47 7.1 1.6 6.3 45 40 88 97
PAX9 missense 50 48 62 4 4 8 54 22 78 92
p values from chi
2
tests
1 2 3 4 5 6 7 8
MSX1, maxilla v. mandible
<0.001 ns ns <0.001 ns <0.05 ns ns
PAX9, maxilla v. mandible
<0.001 <0.001 <0.05 <0.001 <0.001 <0.001 ns ns
max ns ns ns <0.001 <0.001 <0.001 <0.001 <0.001
mand <0.001 <0.05 ns ns <0.001 ns <0.001 ns
max ns ns ns ns ns <0.05 <0.05 <0.05
mand <0.05 ns ns ns ns ns <0.05 ns
max ns <0.05 <0.001 ns ns <0.001 <0.001 ns
mand <0.05 ns ns ns ns <0.001 <0.05 <0.05
*) bold, frequency of agenesis > 60 %
**) non-missense: deletions, frameshifts, nonsense, splicing mutations
MSX1 missense v. non-missense**)
PAX9 missense v. non-missense**)
MSX1 v. PAX9
agenesis % *)
As the first step, involvement of the most promising candidate genes was studied. In the ini-
tial analysis, microsatellite markers in the MSX1 and MSX2 genes were genotyped in all
available DNA samples (I). These paralogous genes were obvious candidate genes because
of the known expression patterns of them during the mouse tooth development, also suggest-
ing functional redundance (MacKenzie et al., 1991; MacKenzie et al., 1992). Further support
for the role of these genes was provided by the findings that a mutation in MSX2 was respon-
sible for the Boston-type craniosynostosis in man (Jabs et al., 1993). After the completion of
our analysis, it also became known that inactivation of Msx1 in mouse leads to an arrest of
tooth development at an early stage (Satokata and Maas, 1994).
Using the five families and intragenic microsatellite polymorphisms in the MSX1 and MSX2
genes, exclusively negative total lod scores were obtained for the total family material, and
no significant support for linkage was either observed in the individual families (Table 2 in
I). When the segregation of the microsatellite alleles in the pedigrees was inspected, it was
observed that in most families the affected family members had inherited different alleles for
these markers (Fig. 1 in I).
Subsequently, we presented a similar study on the involvement of other candidate genes,
EGF, EGFR, FGF3 and FGF4. In this study, a few additional families (including family 9 in
Fig.8) with comparable phenotypes were included. Also in this study the principal conclu-
sion was that these genes did not explain tooth agenesis in the families studied (Arte et al.,
1996).
75
Figure 10. Comparison of phenotypes
associated with gene defects in MSX1
and PAX9. Only permanent teeth are
shown. Darkness of the color ex-
presses the frequency of agenesis.
PAX9 missense includes only mis-
sense defects, i.e. single amino acid
changes. Compare to table 7.
The investigation was expanded to other known candidate genes and finally to genome-wide
efforts to identify causative loci (IV). For a genome-wide genotyping, only samples from the
most informative families (1, 2, 6 and 9 in Fig. 8) and even a reduced set of samples from
these families were used. After recruiting a further set of families (11, 12 and 20), samples
from these families were subjected to total genome wide genotyping in the Finnish Genome
Center. In addition to markers included in the genome-wide searches with intervals from 10
to 20 cM, results from candidate gene loci as well as from fine mapping of the most promis-
ing regions were used in calculation of the results described below. For these reasons,
marker maps and densities for individual families are not identical. Samples of family 12
were analysed for 418 microsatellite markers, those from family 9 with 552 markers and
those of the other families with 450-520 markers. However, multipoint analysis offers link-
age estimates also from the marker intervals and makes it possible to compare and summate
results from different families.
The location score charts from the multipoint analysis by Simwalk showed that only rela-
tively low scores were obtained when all the families were considered together, i.e. a genetic
homogeneity was assumed (Fig. 2a,b in IV). The highest scores from the analyses of indi-
vidual families are given in Table 8 and the genome-wide location score charts in Figs. 2c-l
in IV. The highest scores obtained for family 9, the largest family, were also relatively low
as compared to the expectations of the informativeness (Fig. 2i in IV). Indeed, no recombi-
nant-free locus in the genome was found in this family, i.e. an area where all affected family
members would have inherited a shared allele or haplotype. This probably reflected the pres-
ence of multiple causative factors in this family, and accordingly the analyses were also con-
ducted for subfamilies "91", "93" and 9p (Fig. 8).
In most families (1, 2, 6, 11, 91, 93, and 9p) multiple positive but insignificant scores in the
range of 0.7-2 were obtained (Figs. 2a,b,c,d,j,k,l in IV; Table 8) both in the normal and in the
affecteds-only analyses, reflecting the fact that because of the moderate size of the families
several recombinant-free areas existed in the genome.
76
Table 8. Highest location scores from multipoint analysis by Simwalk
all family members
family
chromo-
some
cM score
chromo-
some
cM score
1 2 87 1.801 2 87 1.801
2 5 28 1.606 5 23 0.781
6 7 98 1.691 several 0.778
11 7 44 1.567 several 1.045
12 12 56 2.431*) 2 59 1.336
12 13 30 1.459
20 18 39 3.059**) 18 39 2.009**)
20 6 5 1.621
9 12 88 1.263 21 10 1.609
91 5 108 1.710 several 1.237
93 1 225 1.576 several 0.797
9pm 8 138 1.804 several 1.168
*) affecteds-only analysis: location score for this locus 0,946; **) see text
affecteds-only
In family 12, the highest peaks in chromosomes 2, 12, and 13 were all obtained in areas,
where also at least some recombinant affected family members were observed (Fig. 2g in
IV). In family 20, the most promising locus was initially identified in chromosome 6 (Fig. 2h
in IV) but after the fine mapping an affected recombinant family member (IV:4) was ob-
served in this locus. Subsequent fine mapping of other promising regions led to an identifica-
tion of a locus in chromosome 18, in which all the affected family members except IV:3 had
inherited the same haplotype (location score 1.970). As IV:3 presented with a different phe-
notype (one peg-shaped lateral incisor) than other affected family members and especially
his sibs (one or multiple missing second premolars), his phenotype was marked as unknown
and a significant location score 3.059 was obtained (Figs. 2h and 3 in IV).
When the results from all the families were compared, there were some overlap of the sug-
gested loci. The chromosome 2 locus where the highest score in family 1 was obtained over-
lapped peaks from families 11 and 91. The locus in chromosome 18, that was identified in
family 20, was recombinant-free for the affecteds also in family 11, and the analyses of
families 12 and 9p also gave positive scores in this region. Overlap of positive peaks were
also observed in 8qtel, 10p and 17q. When gene heterogeneity was allowed in the analysis of
all the families in these regions, support for linkage was obtained in chromosome 18 from
the analysis that included family 9p (Fig. 3 in IV). In the other regions, allowing gene het-
erogeneity gave suggestive but not significant scores (data not shown).
Results from the genome-wide search were also studied in relation to the known candidate
genes, implicated either by known gene defects in man or by mouse mutants. While identi-
fied defects in several of these genes show a strong dominant effect, it has been suggested
that common types of tooth agenesis, such as incisor and premolar hypodontia in the families
described in this study, could result e.g. from hypomorphic alleles, and perhaps from alleles
considered only as risk alleles (Vieira, 2003). For 6 cM wide regions around the most obvi-
ous candidate genes, only negative or non-supporting scores were usually obtained (Table 4
77
in IV). The results excluded MSX1 and several other genes. AXIN2 could not be excluded in
families 2 and 11, and MSX2 and PAX9 in family 6. For families 1, 2, 6, 11, 91 and 93, re-
gions of at least one studied candidate gene gave suggestive scores. The highest peak from
family 1 overlapped the TGFA locus, and the highest peak from family 11 with the AXIN2
locus. However, as described above, in both families several other regions were identified in
which affected family members had inherited a shared haplotype.
Sequence variants that have a strong dominant effect usually severely affect the coding se-
quence whereas sequence variants for risk alleles affect the gene regulation and tend to re-
side outside the coding region. Linkage analysis reveals also the involvement of sequence
variants in non-coding regions. To complement the results from the linkage analysis, we also
performed sequence analyses of exons and flanking sequences of MSX1, PAX9, AXIN2 and
TGFA in the samples of the probands and some other affected family members. No sequence
alterations besides common SNPs were identified in this analysis. This is in line with some
previous studies, in which no sequence alterations were found in the coding regions of MSX1
and PAX9 in association with common types of tooth agenesis (Scarel et al., 2000; Frazier-
Bowers et al., 2003).
In conclusion, the results from the genome-wide search do not support the existence of a sin-
gle or a major locus for incisor and premolar hypodontia or involvement of several candidate
genes, especially MSX1. On the other hand, the results are most compatible with existence of
several loci, some of which may contain a previously known candidate gene. However, most
candidate genes could be excluded in our families. The strongest support was provided to a
novel locus in chromosome 18. While it was initially presumed that incisor and premolar
hypodontia would be caused by one or only a few causative genes, the results imply a re-
markable genetic heterogeneity of incisor and premolar hypodontia, a fact that also signifi-
cantly reduced the possibilities for identification of the loci.
Construction of the gene expression database (V)
The amount of data on gene expression in the developing tooth has increased rapidly since in
situ hybridization methodology began to be applied in several laboratories. This created a
need to collect existing data into a database which would help researchers to easily find data
on gene expression, often published in papers not necessarily concentrating on tooth devel-
opment, and to enable detection of co-expression of genes. As an additional benefit, collect-
ing the data according to common principles and storing it in a common, formalized struc-
ture, would also help to assess the quality of the data. To make it possible for everyone to
browse the collected data, a WWW-based solution was the natural choice.
We fitted the data into six developmental stages: initiation, bud, cap, bell, differentiation and
secretory stages. Later a specific stage covering root development was added. In the tables of
the database, the expression data was coded for each tissue present during different stages of
tooth development. However, when unambiguous visual view of the expression was avail-
able, e.g. as illustrations of the publications, additional standardized schematic drawings
were used to indicate subtissue-level resolution and gradients of expression. The data was
78
presented as lists selected from different viewpoints (tissue, stage, species, molecule class,
methodology) and as separate pages for each gene containing the schematic illustrations and
notes. In addition to minimum information, we included data on the methodology, properties
of genes and literature references as well as on functional and experimental data, if available.
Several links to other internet databases were added later.
The data was stored as tables in Borland dBase 5.0 for Windows software, and the WWW-
pages in HTML format were produced by dBase-scripts. The schematic drawings were in-
cluded to the WWW pages in the JPG format. Thus the WWW-site presented static, but
regularly updated and intuitively organized pages.
The Gene expression in tooth (http://bite-it.helsinki.fi) site was first published on the eve of
the 6
th
Tooth morphogenesis and differentiation meeting in Gothenburg 1998, and was posi-
tively received by the researchers in the field. Currently the database contains altogether 435
gene expression records, but because of separate pages for different species and for expres-
sion on the mRNA and protein levels, the amount of different gene homologs is smaller, cur-
rently 330. 267 of them describe expression in mouse, while other species included are rat,
human, sibling vole, cow, hamster and pig, listed in the order of the amount of the genes
from each species. 323 pages describe expression on the mRNA level and 118 on the protein
level. Half of the genes are signaling genes and one fourth transcription factors, reflecting
the interests of the researchers in the field.
During recent years, biological data in the internet accessible databases have remarkably in-
creased, especially accelerated by the genome projects. Most of the data concern DNA and
protein sequences and derived information, but also an increasing amount of expression data
that have been produced by DNA-microarray methodology is available. So far, microarray
expression data from developing teeth has not been made available in public databases. Re-
cently a database offering in situ expression data has been launched by researchers in the
Max-Planck-Institute (http://Genepaint.org). This database offers primary in situ hybridiza-
tion views into gene expression in whole embryos with spatial resolution high enough to re-
veal details in the the craniofacial region. Expression in teeth has been annotated. While of-
fering data of a large amount of genes, ultimately covering all mouse genes, the database is
so far limited to only certain stages of development. Thus, in terms of coverage of different
stages and annotations, Gene expression in tooth has still retained an important function.
79
GENERAL DISCUSSION
Uncovering the genetic background of tooth agenesis
In the work presented in this thesis, we have clarified the genetic basis of dominantly inher-
ited severe tooth agenesis (oligodontia). We have identified a nonsense loss of function mu-
tation in PAX9 that segregated with agenesis in a Finnish family and shown that deletions of
MSX1 are associated with severe agenesis. These findings contribute to the understanding
that reduced amount of functional PAX9 or MSX1 protein, haploinsufficiency, is able to
cause the severe, partial agenesis. On the other hand, we have studied the genetic back-
ground of the common type of tooth agenesis, incisor and premolar hypodontia, in a set of
Finnish families where hypodontia phenotype follows autosomal dominant inheritance. As
conclusions of this study, we found no support for the remarkable role of the most important
candidate genes but found strong support for existence of at least one novel locus involved in
the etiology of this phenotype.
The results confirm the heterogeneous genetic etiology of tooth agenesis. Together with
other results from our and other laboratories, they help to clarify the genetic background of
tooth agenesis in general.
So far, gene defects have been identified in association of either well-defined multiorgan
syndromes or non-syndromic severe agenesis, oligodontia. For the latter, gene defects have
been identified from families with fully penetrant oligodontia, that follows either dominant
inheritance or results from de novo, dominantly acting, mutations. Gene defects associated
with syndromes usually also have a strong effect on the molecular level, i.e. result in loss of
function, dominant negative effect or possibly gain of function, but in different syndromes
the effect on tooth development may be strong or less penetrant and variable (Table 1). Re-
gardless of the incomplete penetrance of tooth agenesis, diagnosis of a syndrome has been
possible because of other salient features. Thus, it is common for the identified gene defects
that they generally have a strong effect on the molecular function and have been identified
from patients with relatively unequivocal diagnosis and mode of inheritance.
In our laboratory we have identified the causative gene defect in seven Finnish families with
severe agenesis, oligodontia (II; Lammi et al., 2003;.Lammi et al., 2004; unpublished). In
addition, mutational analysis of MSX1, PAX9 and AXIN2 as well as of some other genes has
been conducted with negative results in several other families with dominantly inherited se-
vere agenesis. As our mutational screening covers only the exons, the immediate flanking
sequences and immediate promoter regions, mutations in the important regulatory regions
may have been left undetected. However, the sequence variation in the non-coding region
has rather been associated with risk alleles (Reich and Lander, 2001), and it may be consid-
ered unlikely that non-coding regulatory region sequence variants would remarkably con-
tribute to this phenotype. Thus, it is premature to evaluate the relative contribution of MSX1,
PAX9, or AXIN2 to the dominantly inherited non-syndromic severe tooth agenesis (see also
Kapadia et al., 2007). It seems likely that as yet unrecognized genes defective in this kind of
families will be identified in the future. EDA and its downstream partners may belong to
these as shown by the recent reports (Tao et al., 2006; Tarpey et al., 2007).
80
In an ongoing study (unpublished), we have also studied a large group of patients whose par-
ents or other family members did not present with severe agenesis. In fact, these constitute a
bigger group than the probands of families with dominant inheritance. So far we have been
able to identify three gene defects in these probands. However, these represent either uncer-
tainties of the parenthood or de novo mutations, which most probably are dominant by na-
ture.
The majority of genetic causes of tooth agenesis remain largely unidentified. These include a
remarkable fraction of severe agenesis, and especially those with no apparent dominant in-
heritance, as well as all cases of common, less severe types of agenesis, including incisor and
premolar hypodontia. Apparently, in the latter cases, defects and variants in genes in which
strong defects already have been identified are most tempting candidates for causative fac-
tors (Vieira, 2003). These could be hypomorphic defects (reduced activity instead of com-
plete loss of function), or variants considered to represent "risk alleles". Studies exploring
the polymorphisms in MSX1, TGFo, PAX9, AXIN2, IRF6 and FGFR1 in association with
tooth agenesis have reported associations with variable significance to specific alleles and
haplotypes (Vieira et al., 2004; Peres et al., 2005; Mostowska et al., 2006; Vieira et al.,
2007). So far, it is reasonable to wait whether these results can be confirmed by further stud-
ies. However, especially the associations of third molar agenesis to SNPs in the PAX9 pro-
moter and tooth agenesis to SNPs in the exon 7 and intron 2 of AXIN2 seem promising
(Peres et al., 2005; Mostowska et al., 2006). It is possible that these SNPs exert their effect
either by affecting the binding of transcription factors or splicing efficiency, and would con-
form to the idea that common phenotypes are caused by changes that affect the regulation of
gene expression rather than the structure of the protein. Interestingly, the 169 bp allele of the
intragenic microsatellite in the MSX1 gene appears to be associated with both tooth agenesis
and oral clefting (Vieira et al., 2004; Suzuki et al., 2004), although the functional explana-
tion remains obscure.
Our results from the families with apparent autosomal dominant inheritance of incisor and
premolar hypodontia do not lend strong support for the involvement of the MSX1, TGFo,
PAX9, AXIN2, IRF6 and FGFR1 or several other loci. Rather, our results suggest the exis-
tence of previously unidentified loci for tooth agenesis. The strongest evidence is shown for
such a locus in chromosome 18, but further studies are needed to confirm and map this locus
more precisely as well as to confirm the involvement with tooth agenesis of the other ge-
nomic regions indicated in this study.
The molecular nature of the genetic factors residing in the loci we identified remains un-
known. They may represent hypomorphic defects (or high risk alleles) that however by
themselves have a major effect. They may also represent stronger defects, e.g. with loss of
function and haploinsufficiency, as shown by the identification of such defects in the asso-
ciation with syndromic phenotypes that resemble common types of tooth agenesis (e.g. van
der Woude and Kallmann syndromes, see table 1). Functional redundancy between different
genes and genetic pathways may limit the consequences of a haploinsufficient defect, thus
allowing the effect to become visible only as a relatively mild form of tooth agenesis. Con-
sidering the phenotypes in syndromes as well as in the families studied by us and in other
81
family studies (Grahnen, 1956; Chosack et al., 1975), it is also probable that the effects of
many of such genetic factors would be selective, i.e. primarily affect only one class of teeth.
Evidence of tooth agenesis as a result of a combination of genetic factors has been provided
by cases of severe agenesis where both parents have presented with less severe tooth anoma-
lies ("non-dominant severe agenesis") or from reports of recessive inheritance (Schalk-van
der Weide, 1992; Lyngstadaas et al., 1996; Ahmad et al., 1998; Pirinen et al., 2001; Chishti
et al., 2006). Taking the already verified genetic heterogeneity into account, it appears that it
is much more frequent to find cases with defects or risk alleles of two or more genes than to
find recessive inheritance, even as compound heterozygotes of allelic defects. Recessive in-
heritance is most probable in consanguinous situations (Ahmad et al., 1998; Chishti et al.,
2006) or in populations with a strong possibility of a founder effect (Pirinen et al., 2001).
Depending on the effect on the regulatory pathways, all combinations of alleles of different
genes may not necessarily be additive as may be expected for the recessive inheritance, and
one allele may have a major contribution while the other has a modifying function. Combi-
nations of different kind of alleles may largely satisfy the premises on which the quasicon-
tinuous quantitative trait models of polygenic/multifactorial etiology were based (Bailit
1975; Brook, 1984).
In summary, non-syndromic tooth agenesis may follow from different genotypes. Strong de-
fects in critical genes, often loss of function defects that cause haploinsufficiency, cause
dominantly inherited severe agenesis. Similar defects, either present in less critical genes or
masked by redundancy, may also underlie more common types of dominantly inherited tooth
agenesis such as incisor and premolar hypodontia. The latter kind of phenotypes may also be
caused by hypomorphic defects or high risk alleles. Tooth agenesis without dominant inheri-
tance may follow from combinations of haploinsufficient, hypomorphic or risk alleles, in-
cluding recessive inheritance.
Implications for the pathogenetic mechanisms of tooth agenesis
One of the main conclusions from the results presented in this thesis is that defects in PAX9
and MSX1 exert their effect through haploinsufficiency. Reduced amount of functional
MSX1 or PAX9 protein in the tooth forming cells is able to cause severe and selective tooth
agenesis. Another conclusion, based on the analysis of the phenotypes associated with the
known defects in these genes, is that the phenotypes associated with the defects in MSX1 and
those associated with the defects in PAX9 are different. Despite the similarities, there are
clearcut differences in the frequency of agenesis of specific teeth.
As described in the Review of the literature, most types of tooth agenesis can be considered
to be caused by quantitative mechanisms affecting especially those teeth that are initiated
and develop latest in their respective tooth class. In terms of the morphogenetic field and
clone theories this can be regarded as exhaustion or change of the field strength or odonto-
genic potential. Historically, critically reduced size of the dental lamina or tooth germs have
been considered as causes of agenesis (Grneberg, 1951; Bailit, 1975; Brook, 1984). How-
ever, in modern thinking based on the molecular and genetic studies of tooth development,
82
tooth agenesis is a consequence of a qualitatively or quantitatively impaired function of ge-
netic networks, which regulate tooth development (Thesleff, 2006). Understanding a regula-
tory failure as a cause of agenesis is in line with the concepts implying morphogenetic fields
and self-organizing cell populations.
As shown by studies in mouse, impaired functions of the genetic networks are reflected as
reduced signaling or impaired signal regulation, cell proliferation, migration, commitment
and differentiation. The most critical are the stages of formation of the signaling centers that
have an organizing role for the future development. It is conceivable that these and other
critical stages of tooth development may work as thresholds at which a somehow reduced
tooth forming potential of the regulatory networks is converted to partial tooth agenesis.
The other stages may include e.g. differentiation and activation of a program for secondary
tooth formation. Overcoming the thresholds appears more critical in the late developing
teeth. The reduction of the tooth forming potential may follow from a reduced functional
activity of a single gene as in the case of the heterozygous defects in MSX1 and PAX9. It
may also result from complete inactivation of a single signaling pathway the function of
which is partially redundant as in the case of impaired EDA signaling. Thus, reduced size
and function of the dental signaling centers as a result of impaired EDA signaling has been
suggested as a major cause of tooth defects in anhidrotic ectodermal dysplasias (Mustonen et
al., 2004). AXIN2 haploinsufficiency may specifically affect the onset of the program needed
for secondary tooth development (Lammi et al., 2004).
In the case of MSX1 and PAX9, tooth agenesis has been related to the critical function of the
mouse homologues of these genes in the formation of the enamel knot and the subsequent
transition from bud to cap stage (e.g. Thesleff, 2006). The MSX1 haploinsufficiency, how-
ever, appears to affect only the secondary teeth and permanent molars, and it is not obvious
how a weakened enamel knot function, which presumably follows from a reduced amount of
functional MSX1 protein, is linked to impaired secondary tooth development. It is possible
that the late developing teeth are more sensitive to impaired enamel knot function. The de-
velopment of these teeth normally is a long lasting process and happens surrounded by the
alveolar bone. It can also be speculated that enamel knots may somehow regulate the pro-
gram leading to the secondary tooth formation.
Both Msx1 and Pax9 are also needed for the mesenchymal cell condensation around the
growing epithelial bud (Satokata and Maas, 1994; Peters et al., 1998). The reduced conden-
sation which is also seen in the Pax9 hypomorphic mutants, perhaps indicating a decreased
amount of committed dental mesenchymal cells, may be related to tooth agenesis (Kist et al.,
2005). As Msx1 is known to be important for the commitment of the neural crest, an early
defect in the commitment or migration of the neural crest cells could also be responsible for
the tooth agenesis, if it caused a reduction in the amount of competent ectomesenchymal
cells.
The analysis presented in this thesis shows that MSX1 and PAX9 haploinsufficiency and dif-
ferent types of PAX9 defects are associated with slightly but distinctly different agenesis
phenotypes. While third molars are affected in the association with defects in both genes, the
most essential differences between the phenotypes are that premolars are more often affected
83
in association with defects in MSX1 and first and second molars in association with defects
in PAX9. As PAX9 apparently is upstream of MSX1 and acts synergistically with it (Peters et
al., 1998; Ogawa et al., 2006), it is conceivable that the effect of PAX9 haploinsufficiency is
mediated by reduced MSX1 activity. However, the differences in phenotypes suggest that
PAX9 also has functions not mediated by MSX1.
In patients with defects that reduce the amount of PAX9 mRNA and protein, the agenesis
appears to grow in a posterior-to-anterior direction in a way that agenesis of a tooth is as-
sociated with the agenesis of all the more posterior teeth. The whole gene deletions and the
start codon mutation affected all the postcanine teeth, including the primary molars showing
that the whole postcanine dentition is sensitive to the PAX9 dose, and that a posterior-to-
anterior sensitivity gradient (Kist et al., 2006) may extend to the anterior-most of these teeth,
the primary first molar which is regarded as the key or stem tooth of the human post-
canine dentition. The less severe agenesis phenotypes observed in association with the mis-
sense defects in PAX9 may relate to the fact that while these defects reduce or impair the
DNA binding ability of the PAX9 protein, the protein still is capable to protein-protein inter-
actions. As shown by Ogawa and colleagues (2006), such mutated PAX9 protein was able to
bind MSX1, but its capacity to transcriptional activation alone or in synergism with MSX1
was remarkably reduced. It is possible that the observed residual transcriptional activation
capacity accounts for the less severe phenotypes. Alternatively, these may be explained by
interactions of PAX9 with other protein partners.
The pathogenetic mechanisms that mediate the effect of reduced amounts of functional
MSX1 and PAX9 protein may serve as models for pathogenesis of tooth agenesis caused by
other gene defects. These may exert their effect by affecting MSX1 or PAX9 function or the
same genetic networks. Further research of genetic and pathogenetic mechanisms of MSX1
and PAX9 is warranted to shed light into the pathogenesis of tooth agenesis in general. This
is especially true for MSX1 because defects in this gene affect the teeth that are most often
affected in the population.
84
CONCLUDING REMARKS
The studies summarized in this thesis were started with an aim to identify genes that affect
human tooth development and are involved in inherited tooth anomalies. More specifically,
we wanted to identify the gene defect that caused a common type of tooth agenesis, domi-
nantly inherited incisor and premolar hypodontia, in a group of Finnish families. Originally,
it was presumed that agenesis in these families would share a common genetic background,
i.e. to be caused by defects in one or a few genes. During the work it became obvious that
this was not the case, but instead, the genetic background of this phenotype was rather het-
erogeneous, which was one of the main conclusions of these studies. The heterogeneity
hampered the possibilities to identify causative loci and to pinpoint the defective genes. The
observed heterogeneity is in line with the increasing understanding of the complex genetic
networks regulating the development of dentition. This understanding, however, also sup-
ports the idea that gene defects with dominant effects may be responsible for the incisor and
premolar hypodontia.
In this work evidence was presented for novel causative loci, especially in chromosome 18.
Further studies will be required to confirm and refine these results and eventually to identify
the causative sequence variants. Basic approaches for this end would be to recruit additional
patients and families as well as to take advantage of an eventual common ancestral etiology,
which would allow the utilization of single nucleotide polymorphisms to fine-map the dis-
ease loci. The causative defects may rather affect the expression than the protein structure
and reside outside the coding regions. Therefore, mutational analysis could be comple-
mented by analysis of RNA expression.
In an other line of investigation into the genetics of tooth agenesis presented in this thesis,
causes of dominantly inherited severe tooth agenesis, oligodontia, were identified. It was
shown that haploinsufficient defects of PAX9 and MSX1 cause tooth agenesis with specific
patterns. Thus, the pathogenesis of specific types of tooth agenesis involves reduced activity
of these important regulatory genes, which presumably affects the essential genetic networks
necessary for normal development of dentition. During the work it has also become obvious
that defects in the so far identified three genes MSX1, PAX9 and AXIN2 may not explain all
cases of non-syndromic oligodontia with dominant inheritance. Furthermore, mutational
analysis of these genes in other patients with severe tooth agenesis, i.e. patients without fa-
milial background of this phenotype, has been successful in only a few cases. Etiology of
this kind of severe tooth agenesis may largely be explained by combinations of genetic fac-
tors, i.e. polygenic inheritance. One way to clarify the etiology in these cases is to identify
factors that cause common familial incisor and premolar hypodontia.
The results presented in this thesis, especially those on severe tooth agenesis, provide tools
for diagnosis, genetic counseling and planning of treatment. However, the main impact of
the results is to provide insights into the biological mechanisms that underlie normal and ab-
normal development of teeth and development in general. Thus, the results contribute to the
biological basis of dental science, and eventually to development of diagnosis and therapy.
85
ACKNOWLEDGEMENTS
My part in the work presented in this thesis was started in 1993 at the sixth floor laboratory
of the Institute of Dentistry in Ruskeasuo. I also visited the Department of Pedodontics and
Orthodontics at the third floor as well as the Laboratory of Human molecular genetics at the
nearby building of the National Public Health Institute. From 1996, I mostly worked in the
Institute of Biotechnology at the new Biocenter in Viikki. In 2001, I set up a corner of a
laboratory in Biomedicum, brand new, under the auspices of the Institute of Dentistry.
I am greatly indebted to professor Sinikka Pirinen whose scientific work, aspirations and vi-
sions at the Department of Pedodontics and Orthodontics were the foundations to start the
molecular genetic studies of human tooth agenesis. During these years she has been not only
the Professor but also a friend, whose ability to encourage and take you over the critical
moments has been invaluable.
I entered the laboratory of professor Irma Thesleff even some years before the start of the
work with tooth agenesis. During the completion of my studies in biochemistry, I greated an
interest in developmental biology. I have retained this interest, even though I became routed
to the world of human molecular genetics. Irma has been the most essential person for the
work I have done: she inspired and guided the work with her scientific knowledge and vision
and provided the bulk of the basic support. She has shown an encouraging trust without
which my work, including this thesis, wouldnt have been possible.
At the very beginning of the project, I became to know Sirpa Arte, then a dentist finishing
her specialization in orthodontics. Sirpa recruited and examined most of the patients and has
thus been elementary for the investigation. During the years we have spent a lot of time with
pipetting, scoring alleles, and discussing. Although Sirpa now has a busy position as a senior
orthodontist, she still finds time to participate in the research and share her specialist knowl-
edge. Im especially grateful to Sirpa for the friendship and support.
In the beginning of these studies, I had the pleasure to get acquainted with Leena Peltonen-
Palotie, then a professor of human molecular genetics in the National Public Health Institute.
She took a personal and warm interest in our efforts, gave me wonderful supervision, al-
lowed the use of many of her facilities and introduced me to a lot of helpful people in her
laboratory.
Im grateful to professor Satu Alaluusua for all the support, scientific, economical and social,
during my years in Biomedicum as well as for her scientific alertness which opened new
avenues for my research.
I warmly thank Johanna Kotilainen whose work offered us the possibility to study an inter-
esting group of patients with Wolf-Hirschhorn syndrome. I want also express my gratitude to
professor Sakari Knuutila and to Yan Aalto in his laboratory for the FISH analysis of sam-
ples from these patients.
86
I thank all the people in the tooth development group for their help and companionship. I
want especially to thank Johanna Pispa for discussions and help, Thomas berg for joint ac-
tivities and friendship, David Rice for the excursions to sporting events, Maija Kaski for her
friendship and the contribution to the Gene expression database, and Merja Mkinen and
Riikka Santalahti for all the help I have received during these years. Im grateful to Jukka
Jernvall for discussions and his readiness to share his scientific knowledge. I greatly appreci-
ate the help of Lars Paulin in the sequencing laboratory of the Institute of Biotechnology. I
thank professor, director Mart Saarma for the support and all encouraging words.
My warm thanks go to Carin Sahlberg for her company at the laboratory and during travels,
and also for her advice how to care Tommi, my cat. I wish to thank Janna Waltimo-Siren,
Pirjo-Liisa Lukinmaa and Anna-Maija Partanen for all the discussions and support. Im
grateful to Laura Lammi, Elina Luonsi and other young dentists for their contributions in
many projects as well as for refreshing the life in the laboratory. My warmest thanks go to
Annikki Siren and Anneli Sinkkonen for their help in the laboratory and especially to Mar-
jatta Kiveks and Maarit Hakkarainen for their invaluable help in many respects. Im grate-
ful to Kirsti Kari for her help and support in the laboratory. I thank professor Jarkko Hieta-
nen for support and appreciation of my work.
Im grateful to Raila Salminen and Elina Waris for their help and friendliness. I also thank
all the people in the computer support at the Institutes of Dentistry and Biotechnology.
Numerous people in the laboratory of the National Public Health Institute and in the Molecu-
lar Medicine Sequencing Laboratory have helped me during these years: Johanna Aaltonen,
Anne Vikman, Iiris Hovatta, Petra Pekkarinen, Joe Terwilliger, Teppo Varilo, Maija Parkki-
nen, Mari Sipil, Pekka Ellonen, Elli Kempas, Heli Kernen and Susanna Anjala. I also
thank Pivi Lahermo and Aarno Palotie at the Finnish Genome Center for the invaluable
help in the genome-wide searches.
Many times during the work I have tempted to ignore my friends. The friendship of Mervi
and Petra Erkkil in all the turns of life during these years has helped me enormously. The
company of Ilkka Leskinen and all the travels together have been essential for survival, and
so have the activities organized by Cetin Sahin, Ilppo Kivivuori and Anne Ojanper.
Im fully aware of the importance of my late father in waking my interest in studies and edu-
cation. Im grateful for my mother for all the care and love.
In addition to the Institutes and the grants of the seniors, I have received financial support
from the Finnish Cultural Foundation, the University of Helsinki funds and HUCH EVO.
Finally, Im indebted to Jan Huggare and Anu Wartiovaara who as reviewers gave a remark-
able contribution to this thesis.
Vantaa, November 2007
Pekka Nieminen
87
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