Genetic and Epidemiologic Studies of Oral Characteristics

in Hawaii's Schoolchildren. II. Malocclusion

C. S. CHUNG,1 J. D. NISWANDER,2 D. W. RUNCK,2,4
S. E. BILBEN,1,5 AND M. C. W. KAU3

Malocclusion may be defined as any disharmonious variation from the accepted or

theoretically normal arrangement of the teeth [ 1 ]. Undesirable deviations can arise
from a disharmonious relationship between the upper and lower jaws and/or
abnormal arrangements of the teeth within the jaws. Although the absence of a
clear delineation of normal or ideal occlusion has prevented a rigorous measurement of malocclusion, the method devised by Angle (see [2]) and its modifications have been extensively used in classifying malocclusion. Using these techniques, a number of investigators have separately reported the prevalence of malocclusion for different population groups.
Reported prevalences vary widely from population to population; for example,
a 95% prevalence of normal occlusion was reported for the Xavante Indians of
South America [3], compared with 18% for white schoolchildren in Maryland [4].
The prevalences estimated for other populations fall between these two extreme
values-for example, 44% for Eskimo children [5], 41% for Japanese children
[6], 34% for Chippewa Indian children [7], and 57% for American Negro children in the Chicago area [8].
The causes of the observed racial differences in the prevalences are unknown,
although part of the variation is undoubtedly due to differences in classification
and ages of the subjects studied. According to the hypothesis that malocclusion is
essentially a "disease of civilization" [5, 9-13], the etiological factors for the differences must be sought largely in the environment. Alternatively, there are indications that genetic factors are operative in the etiology of malocclusion. Schull
and Neel [6] showed a consistent adverse effect of inbreeding on malocclusion in
Japanese children, which suggests a strong possibility of involvement of recessive
Received December 10, 1970; revised February 19, 1971.
This investigation was supported in part by U.S. Public Health Service grants DE 02646,
FR 00247, and GM 15421 from the National Institutes of Health.
1 Departments of Public Health and Genetics, University of Hawaii, Honolulu, Hawaii 96822.
2 Human Genetics Branch, National Institute of Dental Research, N.I.H., Bethesda, Maryland
20014.
3 Division of Dental Health, Hawaii State Department of Health, Honolulu, Hawaii 96813.
4 Present address: School of Dentistry, University of Minnesota, Minneapolis, Minnesota 55455.
5 Present address: Walker, Minnesota 56484.
1971 by the American Society of Human Genetics. All rights reserved.

471

472

CHUNG ET AL.

genes in the etiology. Twin studies also indicate some degree of genetic determination in the variation of normal occlusion [ 14, 15] and malocclusion [ 16] .
In spite of the absence of a clearly established mode of inheritance, the notion
still persists among some dental practitioners that the increased frequency of
malocclusion in the modern population is due to disharmonious combinations of
genes resulting from admixture of diverse physical types. Thus, without presenting evidence, Graber [17, p. 255] states that "where there has been a mixture of
racial strains the incidence of jaw size discrepancies and occlusal disharmonies is
significantly greater." The notion was undoubtedly based on the classical observation of Stockard [18] on crossbreeding of dog strains, some of which had been
bred for special abnormal conditions.
The purposes of the present investigation of malocclusion in Hawaii are: (1) to
study possible effects of epidemiological and sociological factors on the risk of
malocclusion, (2) to detect and study racial variation in the prevalences, and (3)
to investigate possible effects of racial crossing as related to heterosis or recombination of genes. Hawaii is ideally suited for such a study because its population is
composed of diverse racial groups with a high frequency of racial crossing under
relatively uniform environmental conditions. The investigation covers schoolchildren aged 12-20 living primarily on the island of Oahu. The study dealing
with dental caries and periodontal disease of the same population has been re-

ported elsewhere [19].

SUBJECTS AND METHODS

Sample
In cooperation with the Hawaii Department of Education, 17,772 children, enrolled in
public schools were examined for dental and oral health during the period of September
1967-July 1968. The study covered 13 high schools (grades 10-12) and five intermediate
schools (grades 7-9) which, except for one school located on the island of Hawaii, were
widely scattered on the island of Oahu. An attempt was made to select schools with
higher proportions of Hawaii-born children to maximize the yield of record linkage of
dental data with birth records and to restrict the study to a population unexposed to
fluoridated water. The present study covers the analysis of malocclusion on 8,189 subjects
after the elimination of individuals not born in Hawaii, individuals with positive histories
of orthodontic treatment or extracted teeth, those with incomplete sociological and dental
histories, and those with unusual racial extraction.
In order to examine the possible effect of the exclusion of orthodontically treated
students from our sample, we obtained 562 pretreatment dental records from seven
practicing orthodontists in Honolulu. Pretreatment dental casts of these patients were
scored for malocclusion by the same procedure used in examining schoolchildren. The
data obtained from treated children could then be compared with the data from the
major sample of untreated children.
Examination
Prior to the dental examination, students were asked to fill out a questionnaire requesting the following information: name, parents' names, address, birth date, sex, birthplace,
father's occupation, races of parents, and history of orthodontic treatment and tooth
extraction. The maiden name of the mother was also requested to facilitate the location
of the birth certificate number for the purpose of record linkage. Dental examinations
were carried out by two dentists (authors Runck and Bilben) after numerous sessions

MALOCCLUSION IN HAWAII

473

to calibrate the examination techniques. In addition, dual examinations were conducted

daily on several individuals to assure continuous consistency between the two examiners.
Occlusion characteristics of the permanent dentition were scored and measured after
the techniques of Grainger [1]. The buccal segment relationship (BSR), or the anteroposterior relationship between the upper posterior teeth and the lower posterior teeth,
was scored by observing the position of the lower first molar in relation to the upper first
molar. The relationship was scored separately for the right and left sides according to
the following criteria:
1. Severe mesioclusion: the lower tooth displaced mesially (toward the front) a full
cusp distance or more
2. Moderate mesioclusion: the lower tooth displaced mesially less than a full cusp
distance
3. Neutroclusion: normal
4. Moderate distoclusion: the lower tooth displaced distally (toward the back) less than
a full cusp distance
5. Severe distoclusion: the lower tooth displaced distally a full cusp distance or more
Rotation or displacement of the individual tooth from its ideal position within a jaw
was measured by malalignment score, which was further divided into minor and major
malalignment. Minor malalignment was measured by the number of teeth rotated to
450 or displaced up to 2 mm from their ideal alignment positions. The count of teeth
rotated or displaced beyond this specified level constituted the major malalignment score.
Overjet was measured as the distance in millimeters from the labial surface of the
upper central incisor to the labial surface of the corresponding lower central incisor.
The measurement was taken horizontally, parallel to the occlusal plane, with the jaws in
the normal bite position (centric occlusion). The value assumes a negative number when
the lower incisor is positioned anterior to the upper incisor in centric occlusion (anterior

crossbite).
Overbite was measured as the distance in millimeters from the incisal edge of the
upper central incisor to that of the corresponding lower central incisor, with the jaws
in centric occlusion. Thus the measurement can assume positive, zero (end-to-end bite),
or negative (open bite) value.
Crowding of the teeth was estimated as total space deficiency (in millimeters) of the
anterior teeth (incisors, canines, and cuspids). This was done by observing overlappings
of the teeth.
Spacing estimated the total amount of space in excess of normal proximity of the
anterior teeth.
Crossbite measured the buccal-lingual (lateral) relationship of the upper and lower
teeth in the posterior segment (bicuspids, first and second molars). The deviation had
to be a cusp to cusp or beyond to be scored and had to involve the entire tooth (not
just a rotation). Thus the score was a count of the upper teeth displaced toward the
buccal region (buccal crossbite) and a count of the upper teeth displaced toward the
lingual region (lingual crossbite). The possible range of values of crossbite is 0 to 12.
Finally, the width of the upper central incisors was measured with a special caliper
(in 0.1 mm) at the region of greatest mesiodistal distance. The examiners also recorded
the presence of deciduous teeth, unerupted teeth, or congenitally missing teeth on the
basis of clinical examination.

Analysis of Orthodontically Treated Children

Our main analysis of racial incidence of malocclusion was based on the sample of
individuals not disturbed by orthodontic treatment. The proportion of children with
positive histories of orthodontic treatment, including simple tooth extraction, amounted
to 22% of the total sample. The proportion varied considerably among racial groups;
adjustment for this factor in the analysis of the main data will be discussed later. How-

474

CHUNG ET AL.

ever, racial analysis of orthodontically treated individuals relative to frequencies of

different types of malocclusion will provide useful information in interpreting the findings
from the main analysis.
Table 1 shows the racial means and frequencies of occlusion characteristics of orthodontically treated individuals as measured from pretreatment casts at offices of cooperating orthodontists. Since no Hawaiians were represented in this sample, part-Hawaiians
were excluded from the following analysis along with "other races" of mixed origin; thus
the analysis includes only Caucasians and Orientals (Chinese, Filipino, Japanese, and
Korean). The effect of Oriental race was studied as a deviation from Caucasian race,
which was taken as the base; the value of 1 was assigned to Oriental race and 0 to the
Caucasian race. Differences among Orientals were then studied by examining deviations
of Chinese, Filipino, and Korean from Japanese by three variables for the three racial
groups. These design variables are illustrated in table 2.
A stepwise multiple regression of the dental variable of interest on the racial variables
was performed after fitting the effects of age and sex (1 = male, 0 = female). The
results are shown in table 3. Oriental patients tended to have a higher frequency of
normal occlusion or mesioclusion than Caucasians, with the possible exception of Filipino
children, who had a higher frequency of distoclusion. Undoubtedly associated with the
above observations are significantly lower frequencies of overjet and overbite for Japanese and Chinese patients than for Caucasians. Overjet was observed more frequently
among Korean and Filipino patients, and overbite among Filipino patients, than among
patients of other racial groups. In general, significant lack of spacing was also noted for
Oriental patients. The implications of these findings relative to the main source of the
data will be discussed presently.

Statistical Methods
The analysis of our main data was carried out in three steps with the use of a multiple
regression method. The method is essentially the same as that used in a previous study
on dental caries and periodontal disease [19], with minor modifications. The procedure
was (1) to study effects of epidemiological factors within racial groups, (2) to study
additive effects of the races of the parents and maternal effects, and (3) to assess the
effects of racial crossing.
The epidemiological factors studied were age in years, sex (1 = male, 0 = female),
father's occupational status (1 = high, 2 = middle, 3 = low), maternal age in years at
birth of child, maternal residence at birth (1 = urban, 0 = rural), and birth order of
child counting all previous pregnancies of mother. All of the information except age and
sex was obtained from the earlier data [20] and linked with the present data by computer. Quadratic terms were added for age, occupational status, maternal age, and birth
order to allow for possible nonlinear effects. Thus the regression of the dental variable
of interest was fitted on these 10 variables by use of the stepwise multiple regression
program [21] based on the matrix of pooled sums of squares and products formed
within racial groups. Significance of an independent variable was tested by F. Only
significant epidemiological factors were fitted in the model in studying the racial variables.
It should be pointed out that possible difference between examiners was tested in
the preliminary analysis by the introduction of a dummy variable. There was little or
no systematic difference between the examiners in the traits studied. Since the two
dentists examined approximately equal numbers of subjects every day, no confounding
effect of examiner on the social variation was expected even if the effect of examiner
were significant. For this reason, the examiner difference was not considered further.
There was considerable variation among racial groups in the frequency of individuals
with positive histories of orthodontic treatment (ranging from the wearing of appliances
for long periods to simple tooth extraction). In studying the racial effects on occlusion
characteristics, we attempted to remove possible bias due to the exclusion of treated

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CHUNG ET AL.
TABLE 2
DESIGN VARIABLES FOR RACIAL COMPARISONS IN ORTHODONTICALLY TREATED SAMPLE
XI

X2

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(Oriental)

(Chinese)

(Filipino)

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Filipino ...................
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Korean ...................
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individuals by considering the racial frequency of orthodontically treated individuals

among our examined children as a covariate.
The racial analysis on the incidence of the dental trait was based on an extended
model of a diallel cross in which the race of a child was expressed as a function of
parental races [20]. The basis of the model was seven major unmixed races (Caucasian,
Hawaiian, Chinese, Filipino, Japanese, Puerto Rican, and Korean), 21 biracial combinations derived from them, and one group referred to as part-Hawaiian (unspecified).
Thus, of a total of 29 X 29 =841 possible racial combinations, 248 groups were represented in our data.
After the model of the earlier study [20], we introduced three sets of racial variables
in order to study (1) maternal effects, (2) general racial effects, and (3) effects of racial
crossing. The maternal variables were designed to measure the special effects of the
maternal constitution including possible cytoplasmic or environmental factors independent
of genotype of the child. The variables were defined as the proportion of Hawaiian,
Chinese, Filipino, Puerto Rican, and Korean ancestry and the proportion of Pacific
race ancestry (Hawaiian, Chinese, Filipino, Japanese, and Korean) in the mothers.
Thus, taking the Caucasian group as the base, we could study maternal effects of other
races as deviations from the Caucasian base, and then differences in Pacific mothers
as deviations from the Japanese base. Each racial variable ranges from 0 to 1. On the
previous evidence [20], a biracial parent was considered made up of one-half of each
race, and a part-Hawaiian (unspecified) parent, made up of one-half Hawaiian, one-fourth
Caucasian, and one-fourth Chinese.
General racial effects are expected to measure the additive effects on the child of genes
contributed by both parents, and that part of the possible nongenetic effect confounded
with parental races but not controlled by the covariance analysis by fitting significant
epidemiological factors. Thus the general racial variables were defined as half of the sum
of the corresponding maternal and paternal races. As in the maternal variables, the
Caucasian race was taken as the base of all the data, and the Japanese as the base of the
Pacific populations.
The third set of racial variables is considered the most critical for our study, since
our hypothesis is whether racial crossing produces any phenomena unusual beyond the
observed general racial and maternal effects. Six variables of racial crossing were introduced to study the effects of maternal hybridity, recombination, and hybridity of the
child. Hybridity was further divided into major and minor categories. Major hybridity
results from a cross between the two major population groups, the Caucasoid (Caucasian
and Puerto Rican) and the Pacific (Hawaiian, Chinese, Filipino, Japanese, and Korean),
whereas minor hybridity is represented by crosses within these two major groups. These
variables are defined in table 4. The hybridity variable measures the effect of heterozygosity in the mother or in the child, whereas the recombination variable was designed
to measure the effect of reassortment of genes in the child due to parental hybridity. Al-

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TABLE 4
VARIABLES OF RACIAL CROSSING
Name

Major maternal hybridity .......

maternal hybridity .......
recombination .........
recombination .........
hybridity of child ........
Minor hybridity of child ........

Minor
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EPiMi + Y:Pimj, i # j

proportion of ith Atlantic race (Caucasian and P'uerto Rican) in father and mother, respectively
= proportion of ith Pacific race in father and mother, respectively (i - 1,
5).
.

1, 2); pi, 1ni

though these variables are expected to represent the genetic effects, the variables may
include environmental factors peculiar to hybrid parents or children.
In the racial analysis, the dental variable of interest was regressed on the maternal
and general parental variables simultaneously after significant epidemiological variables
and the treatment variable were fitted. After fitting significant maternal and general
racial variables plus significant epidemiological variables, the variables of racial crossing
were studied. Significance of racial variables was tested by the residual term based on
the sums of squares and the product matrix among mating types (racial combinations).
It is known that some of the dental variables considered are significantly correlated
with each other and that the information contributed by each factor is not independent.
Consequently, we may attempt to summarize the information in the total number of
variables into a smaller number of independent variables that are simple linear functions
of the original variables. Thus the new composite variables so formed may bear a more
direct relationship to the etiological factors of malocclusion. For this purpose we have
used the technique of principal components F22]. After three major principal components
were extracted, the individually computed component scores were analyzed in the same
manner as the individual dental variables above.
RESULTS

Buccal Segment Relationship

In the analysis of buccal segment relationship (BSR), six contrasts were made,
based on the original BSR scores on the right and left sides. These are: first,
the presence (1) or absence (0) of the extreme form of mesioclusion (BSR 1);
second, presence or absence of any form of mesioclusion (BSR 1 or 2); third,
presence or absence of the extreme form of distoclusion (BSR 5); fourth,
presence or absence of any form of distoclusion (BSR 4 or 5); fifth, presence or
absence of bilateral neutroclusion (BSR 33); and sixth, the presence or absence
of "good" occlusion. "Good" occlusion is defined as (1) bilateral neutroclusion,
(2) absence of major malalignment, (3) measurements in buccal and lingual
crossbites, overjet, and overbite falling within one standard deviation above and
below the means, and (4) crowding and spacing scores, based on x + s, below
4.53 mm and 1.90 mm, respectively.
Table 5 presents the results of a regression analysis of epidemiological factors
within mating types, and table 6 shows the analysis of racial factors. The means
or frequencies of the dental characteristics for representative racial groups are
given in table 7.

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CHUNG ET AL.

The mean frequency of uni- or bilateral extreme distoclusion (BSR 5) was 6.2%
for the sample. The condition was found more often in boys than in girls (table 5).
The Pacific racial groups, with the possible exception of Filipinos, have lower
frequencies of this type of malocclusion than Caucasians (tables 6 and 7), indicating that this condition is more characteristic of Caucasoid children. When all types
of distoclusion (BSR 4 or 5) were considered, a decreasing effect of age was also
detected, consistent with the developmental pattern [17, chap. 2]. The mean frequency of BSR 4 or 5 for all racial groups was 19.4%o. The same racial variation
was observed for BSR 4 and 5 as for extreme distoclusion; in addition, Puerto
Rican children showed a significantly lower frequency of BSR 4 and 5 than Caucasians. Chinese parentage, especially the maternal component, tended to increase
the frequency of distoclusion more than Hawaiian, Japanese, and Korean parentage
(tables 6 and 7). However, the significant effect of the Chinese maternal component
was no longer noted when the Chinese parental variable was introduced. No
significant effects of the factors of hybridity or recombination were found.
The severe form of mesioclusion (BSR 1) had a mean frequency of 3.4% and
was less frequent than that of distoclusion in the sample. As expected from the
finding in distoclusion, this condition tended to increase with age and was found
more frequently among children of Pacific parents than among Caucasian children,
with no additional variation due to maternal race or racial crossing. All forms of
mesioclusion (BSR 1 or 2) were found among 26.1% of children over all racial
groups. The condition increased with age and was more prevalent among boys in
our sample. Its relationship to maternal age at birth was curvilinear. Children of
Japanese and Chinese parents had the highest frequencies (>30% for the unmixed
groups), significantly different from Caucasians (18.2%). Children of Korean and
Filipino parents had lower proportions than Japanese and Chinese, as did Hawaiian
children, whose lower frequency appeared to be influenced more by Hawaiian
mothers than fathers. However, the significant maternal effect disappeared when
the Hawaiian parental variable was fitted. There was a borderline significance of
major maternal hybridity.
The proportion of neutroclusion (BSR 33) in the entire sample was 55.4%
and was less in boys than in girls, with a negligibly small age effect. Filipino
children had a lower frequency of neutroclusion (52.2%) than did Caucasian
children (56.7%o). Korean mothers and Puerto Rican parents tended to have a
higher proportion of children with neutroclusion. However, the Korean maternal
effect was no longer significant when the Korean parental variable was fitted.
"Good" occlusion as defined was relatively uncommon; 16.2 %o of the total
sample belonged in this category. This form of occlusion appears more stable than
other types of occlusion in that the only significant factors detected were sex and
Pacific parents; girls in the sample more frequently had good occlusion, and children of Pacific parentage exhibited only a slightly lower frequency of good occlusion than Caucasian children.

Malalignment
Independent of major-minor class, there was a tendency for malalignments to
occur more frequently among children of fathers with lower occupational status,

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TABLE 7
MEANS OR FREQUENCIES OF OCCLUSION CHARACTERISTICS FOR MAJOR RACIAL GROUPS
Racial
Combination
(d X ?)
......
Caucasian X Caucasian
.......
Hawaiian X Hawaiian
Chinese X Chinese ...... ....
Filipino X Filipino ..........
Japanese X Japanese ........
Puerto Rican X Puerto Rican .
Korean X Korean ...... .....
.......
Caucasian X Japanese
.......
Japanese X Caucasian
Chinese X Japanese ...... ....
Japanese X Chinese ...... ....
Caucasian X part-Hawaiian*
Part-Hawaiian X Caucasian
Hawaiian X part-Hawaiian ...
Part-Hawaiian X Hawaiian ...
Filipino X part-Hawaiian ....
Part-Hawaiian X Filipino ....
Part-Hawaiian X partHawaiian .................
All groups ......... .....

(cX D)

Caucasian X Caucasian .......

Hawaiian X Hawaiian ........
Chinese X Chinese ...... ......
Filipino X Filipino ...... .....
Japanese X Japanese .........
Puerto Rican X Puerto Rican ..
Korean X Korean ...... ......
Caucasian X Japanese ........
Japanese X Caucasian ........
Chinese X Japanese ...... ....
Japanese X Chinese ...... ....
Caucasian X part-Hawaiian*
Part-Hawaiian X Caucasian
Hawaiian X part-Hawaiian ....
Part-Hawaiian X Hawaiian ...
Filipino X part-Hawaiian
.....
Part-Hawaiian X Filipino
Part-Hawaiian X partHawaiian ..................
groups

.......

Age

BSR 1

BSR 1 or 2

BSR 5

BSR 4 or 5

BSR 33

379

15.93
14.67

0.018
0

0.045

0.106
0.028
0.059
0.083
0.049
0.089
0.028
0.047
0.034
0.060
0.030
0.103
0.087
0.052
0.058
0.044
0.065

0.264

16.08
15.29
15.88
15.56
15.89
15.98
15.21
15.76
15.85
15.69
15.46
15.15
14.90
15.28
15.45

0.182
0.083
0.305
0.226
0.309
0.111
0.139

0.202
0.208

0.567
0.750
0.515
0.522
0.537
0.733
0.750
0.574
0.690
0.522
0.515
0.575
0.543
0.574
0.596
0.516

0.258

0.484

0.220

0.581
0.554

36
489
517

3,555

45
36
129
29
67

33
261
12 7

115
104

159
31

740
8,189

15.29
15.68

0.031
0.043
0
0.028
0.031
0
0.090
0.061

........

0.225
0.207

0.019
0.019
0.065

0.299
0.242
0.180
0.268
0.261
0.202
0.2 77
0.323

0.026

0.208

0.034

0.261

0.027
0.008

0.070

All
Major
"Good" Mlalalign- AMalalignment
ment
Occlusion

Racial
Combination

All

1.96

0.620

3.13

0.250
0.176
0.151
0.146
0.178

1.25
2.56
2.53
2.57

0.472
0.885

2.72
2.86

0.961
0.903
0.311
0.806
0.760
0.310

3.23

0.222

0.186
0.172
0.134
0.242
0.203
0.142

0.217
0.221
0.157
0.129

1.71
1.47
1.82
2.32

0.188
0.261
0.163
0.156
0.111
0.202
0.138
0.194
0.242
0.257
0.213

0.174

0.194

Anterior Anterior
Overjet Overbite Crowding Spacing
(mm)
(mm)
(mm)
(mm)

0.171

1.42
2.44
2.29
1.93
2.34
2.24
1.96
1.84

0.065
0.062

0.167

2.75

0.701
0.727
0.579
0.551

3.16
3.25
2.86
2.93
2.91
3.03
3.03
2.91

0.409

2.70

0.317
0.692
0.903

3.00
2.88
3.10

2.87
2.06
2.56
2.65
2.37
2.27
2.56
2.70
3.28
2.42
2.18
2.69

2.67
2.08
2.55
2.45

2.65

2.06

0.731

0.64

1.806
0.303

2.43
2.42
2.48
1.24
2.17
2.29
2.00
2.40
1.88
1.91
1.80
1.26
1.31
1.70
2.19

0.507
0.303

1.267
0.222
0.388
0.241

0.522
0.545
0.816
0.606
1.009
1.2 78

0.723
0.548

0.181

1.68

0.512

2.95

2.43

1.36

0.873

0.162

2.30

0.786

2.89

2.47

2.19

0.493

NOTE.-BSR = buccal segment relationship (see text for explanation).

* Sum of part-Hawaiian unspecified and all other Hawaiian biracial combinations.

MALOCCLUSION IN HAWAII

485

TABLE 7 (Continued)

Racial
Combination
(3 X i)

Caucasian X Caucasian .......

Hawaiian X Hawaiian ........
Chinese X Chinese ...... ......
Filipino X Filipino ...... .....
Japanese X Japanese .........
Puerto Rican X Puerto Rican ..
Korean X Korean ...... ......
Caucasian X Japanese ........
Japanese X Caucasian ........
Chinese X Japanese ..........
Japanese X Chinese ..........
Caucasian X part-Hawaiian* ..
Part-Hawaiian X Caucasian ...
Hawaiian X part-Hawaiian ....
Part-Hawaiian X Hawaiian ...
Filipino X part-Hawaiian
.....
Part-Hawaiian X Filipino
.....
Part-Hawaiian X partHawaiian ..................
All groups ...............

Buccal
Crossbite

Total CongeniLingual Incisor tally

Cross- Width MIissing
bite
(mm) Incisors

Com-

Com-

ponent

ponent

0.069
0.090
0.121
0.107
0.063
0.026
0.048
0.113
0.065

0.269
0.361
0.288
0.221
0.238
0.244
0.083
0.116
0.241
0.209
0.091
0.146
0.268
0.748
0.260
0.239
0.355

17.2
16.8
17.2
17.3
17.2
17.1
16.7
17.3
17.3
17.3
17.1
17.3
17.4
17.2
16.9
17.1
17.1

0.019
0.008
0.035
0.038
0.069
0

0.393
-1.532
0.150
0.737
-0.025
-0.561
0.270
0.228
0.279
-0.065
-0.172
0.194
-0.103
-1.254
-0.703
-0.458
0.101

0.072
0.125

0.359
0.259

17.2
17.2

0.032
0.043

-0.519
0

0.108
0.028
0.123
0.209
0.143

0.111
0.167
0.101

0.042
0
0.053
0.039
0.055

0
0.056
0.031
0
0.060
0.061

-0.735
-1.770
0.379
-0.063
0.485

-1.411
-0.462
-0.128
-0.512
0.202
-0.302
-0.799
-0.456
-0.184

-1.376
-0.622
0.013
-0.813

Component
3

0.083

0.322
0.030
0.103
0.0002
0.001
-0.150
-0.288
-0.532
0.076
-0.027
-0.056
-0.265
0.400
0.288
0.173
0.017

0.050
0

and among urban-born children. Malalignments were observed distinctly more

often in children of Oriental parentage than in children of other racial groups.
This is clearly seen by the mean numbers of teeth in the all-malalignment category:
2.56, 2.53, 2.57, and 2.44 for the unmixed Chinese, Filipino, Japanese, and Korean
children, respectively, compared with 1.96 for unmixed Caucasian children (table
7). However, Hawaiian descendants had the lowest frequency of the condition;
unmixed Hawaiians had a mean number of 1.25. Hawaiian mothers independent
of Hawaiian fathers had a barely significant effect on the all-malalignment
category. However, no such effect was observed in the category of major malalignment. No significant effect of the variables of racial crossing was detected.

Overjet
Overjet decreased with age and was found more frequently among boys in the
sample. The effects of age and sex are consistent with the finding on distoclusion
(BSR 4 or 5). There was an association between overjet and birth order in that
later-born children tended to have slightly less overjet.
Children of Japanese and Hawaiian ancestry had less overjet than those of
Caucasian ancestry. The mean measurements for the respective unmixed groups
were 2.75 mm, 2.72 mm, and 3.13 mm (table 7). There was increased overjet in
children of Filipino, Korean, and Chinese parentage (3.23 mm, 3.25 mm, and
2.86 mm for respective incrosses). This appeared to be determined more by the
mother in each respective race. However, the observed effects of the mother were

486

CHUNG ET AL.

no longer significant when the respective parental variables were fitted in the
model. There was no significant effect of the hybridity or recombination variables.

Overbite
As with overjet, overbite was associated with age, birth order, and sex. Hawaiian
children had probably the least amount of overbite (2.06 mm for the unmixed
group), followed by children of Japanese extraction (2.37 mm for unmixed
Japanese) and Puerto Rican extraction (2.27 mm). All of these groups had significantly less overbite than the Caucasian group. On the other hand, Chinese,
Korean, and Filipino children were intermediate between the Caucasian and the
other Pacific racial groups.
Anterior Crowding
Anterior crowding was found to be associated with sex and birth order. The
mean measurement of crowding was 2.19 mm for the entire sample. Children of
Oriental origin had clearly increased levels of anterior crowding compared with
Caucasians, with no evidence of heterogeneity among the different Oriental groups.
The mean measurement of crowding was 2.06 mm for Caucasians, compared with
2.43 mm, 2.42 mm, 2.48 mm, and 2.17 mm for the unmixed Chinese, Filipino,
Japanese, and Korean groups, respectively. The Hawaiian children, unmixed or
mixed, had the distinctly lowest level of crowding among all the racial groups.
The unmixed Hawaiian group had a mean measurement of crowding of 0.64 mm.
The factors of racial crossing showed no significant effect.
Anterior Spacing
Spacing in the anterior teeth showed a tendency to decrease with age and tended
to increase in males and individuals whose fathers had lower occupational status.
There was a negligible association with birth order. In general, the trend of racial
variation of this condition was complementary to the observation on anterior
crowding. Children of Oriental ancestry, with the exception of Filipinos, had the
least amount of spacing. Thus the mean measurements were 0.303 mm, 0.303 mm,
and 0.222 mm for the unmixed Chinese, Japanese, and Korean groups, respectively,
compared with 0.731 mm for the Caucasian group. The Filipino group was intermediate between the Caucasian and the three Oriental groups (0.507 mm for
unmixed Filipinos). Most notable was the Hawaiian parental effect, which led to
increased spacing. For example, the mean measurements in children from the
matings of Hawaiian 8 X Hawaiian 9, Hawaiian e X part-Hawaiian 9, and
part-Hawaiian 8 X Hawaiian 9 were 1.81 mm, 1.01 mm, and 1.28 mm, respectively. None of the variables of hybridity or recombination was significant.
Buccal Crossbite
Buccal crossbite was found more frequently in boys than in girls, and it increased slightly with birth order. Hawaiians and part-Hawaiians had lower frequencies relative to Caucasians, and Filipino children had the highest prevalence
of the condition. The mean numbers were 0,108, 0.028, and 0.209 for the un-

MALOCCLUSION IN HAWAII

487

mixed Caucasian, Hawaiian, and Filipino groups, respectively. There was no indication that other Oriental groups were different from Caucasians.

Lingual Crossbite
Lingual crossbite tended to increase with age and showed some association with
sex and paternal occupational status. The condition increased in children of
Hawaiian parentage, depending specifically on whether the father was of Hawaiian
extraction. The trend can be clearly seen in the reciprocal matings of Caucasian
X part-Hawaiian, Hawaiian X part-Hawaiian, and Filipino X part-Hawaiian
(table 7). None of the variables of racial crossing was significant.
Incisor Width
In order to minimize measurement errors, mesiodistal diameters of the right and
left upper central incisors were summed for incisor width. Incisor width showed a
very slight but significant decrease with age, probably indicating the effect of
attrition and/or dental caries. Boys had somewhat larger incisors than girls (about
0.25 mm per tooth). There was a barely significant negative association between
birth order and incisor width.
A marked uniformity was noted in incisor width among racial groups except
for some groups with Hawaiian ancestry, who tended to have lower diameters
than all other groups. The Hawaiian effect depended more on Hawaiian mother
than father. The Hawaiian maternal effect still remained significant (P < .05) even
after the Hawaiian parental variable was fitted in the model. Major maternal
hybridity showed an effect, significant at the 5% level.

Congenitally Missing Teeth

Since the present study involved some children with mixed dentition (deciduous
and permanent) and included no radiological examination of the teeth, we decided
to limit our analysis to permanent incisors (central and lateral) in both jaws. An
incisor was considered congenitally missing when the tooth was missing, the subject
had no history of tooth extraction, and no deciduous tooth was present in that
tooth position.
The frequency of missing incisors classified this way would have underestimated
the true frequency of the condition because we did not consider the permanent
tooth missing when the deciduous incisor was present. It is known that prolonged
retention of deciduous teeth is often due to congenitally missing permanent teeth.
The mean number of missing incisors for Japanese children in the sample was
0.055 compared with 0.075 for Japanese children in Japan examined by X-ray
[23].
The only significant epidemiological factor was sex; boys had missing teeth
less frequently than girls. Children of Oriental parentage were in general at higher
risk than Caucasian children for congenitally missing incisors. The mean numbers
of missing incisors were 0.053, 0.039, 0.055, and 0.056 for the unmixed Chinese,
Filipino, Japanese, and Korean groups, respectively, compared with 0.042 for the
Caucasian group. Children of Hawaiian origin had the lowest probability of

488

CHUNG ET AL.

agenesis of incisors. None of the unmixed Hawaiian children had any incisor
missing; however, the sample involved was small.
Principal Components
Thus far we have considered single occlusion characteristics individually, independent of others. It may, in fact, be that correlations among these characteristics
would yield a number of more meaningful composite variables, fewer than the total
number of individual traits considered. Such composite variables must be independent of each other. For this purpose we have used principal component analysis
based on the correlation matrix derived from the pooled "within-race" sum of
squares and products.
In this situation, the jth principal component of the sample of p-variate observations is the linear compound
yj - aljxl + ... + apjxp,

where the coefficients are the elements of the eigen vector of the sample correlation
matrix corresponding to the jth largest eigen value, and xi is the standardized observation of the ith occlusion variable.
For this analysis, we have taken 11 individual variables, as given in table 8. The
definitions of all variables considered are the same as those discussed above except
for BSR 1 or 2 and BSR 4 or 5. For BSR 1 or 2, we assigned 2 to the observation
with at least one BSR 1, 1 to that with BSR 2 (but not 1), and 0 otherwise.
Similarly, for the BSR 4 or 5 variable, the scores 2, 1, and 0 were assigned to the
observations with at least one BSR 5, BSR 4 (but not 5), and otherwise, respectively.
The vectors of coefficients for three major principal components corresponding
to the three largest eigen values are given in table 8. The proportion of the total
variance explained by these three components was 48.7%o. Each of the remaining
eight principal components accounted for less than 10%o of the variance. There was
no particular component that explained an overwhelmingly large proportion of the
total variance. The results of regression of individual component scores on epidemiological factors and racial variables are given in tables 5 and 6, respectively.
Table 7 shows mean scores for the major racial groups.
The first component characterized individuals on the basis of overjet accompanied by distoclusion, overbite, and increased malalignment and crowding. The
component explained 19.7%o of the variance and could be called the distoclusion
factor. The component decreased with age up to about age 17.5 and was higher
for boys, as was BSR 4 or 5. The composite trait was found somewhat less frequently for children with higher birth order (table 5). It tended to decrease with
Hawaiian and Puerto Rican parentage relative to Caucasian. The effects of Chinese
and Korean parents had a marginal significance (tables 6 and 7).
The second component, which explained 18.3%o of the variance, appeared to
classify individuals on the basis of malalignment and crowding accompanied by
mesioclusion and lingual crossbite (table 8). The component may be called the
mesioclusion factor. The composite condition increased with age up to about age 18

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490

CHUNG ET AL.

and showed a slight increase in males and later-born children. There was considerable racial variation in this component (tables 6 and 7). Children of Japanese and
Chinese parentage had a higher prevalence of the composite condition than
Caucasian children. Individuals of Filipino and Korean ancestry were intermediate
between the above two groups, with some suggestion of maternal effects which,
however, disappeared when the corresponding parental variables were included in
the model. The lowest component scores were found among children of Hawaiian
ancestry, particularly when the mother was Hawaiian or part-Hawaiian. The
effects of major maternal hybridity and major recombination were significant at
the 5% level; the former was associated with higher risk and the latter with lower
risk to the trait.
The third component accounted for 10.7% of the total variance and appeared to
classify individuals on the basis of missing incisors and more spacing (table 8).
The component may be called the missing-incisor factor. The composite condition
was apparently insensitive to environmental factors, as seen by the negligibly small
effects of epidemiological factors (table 5). There appeared to be little distinct
racial variation for the component. The missing-incisor factor appeared to be more
rare in Koreans than Caucasians. The variable representing major hybridity of
child was significant, although at the 5% level and in the direction indicating that
the condition was less frequent among hybrid children resulting from the crossing
of major races. This aspect will be discussed further.
DISCUSSION

Malocclusion can be characterized either by a single measurable trait, such as

overjet or malalignment, or by a group of observable traits that tend to go together.
The classical method of the Angle classification [2] is based on the latter approach
and groups malocclusion into the broad categories of Angle I (neutroclusion), II
(distoclusion), and III (mesioclusion) with appropriate subdivisions depending on
the presence of other abnormalities. The empirical method, although used widely
by dental practitioners, needs more rigorous quantitative assessment.
Using multiple group factor analysis, Grainger [1] was able to extract seven
"syndromes" out of 10 malocclusion traits. Some of these syndromes were characterized by only one or two malocclusion traits. Thus his analysis suggests that
the causes of malocclusion are multiple and complex. Bearing this in mind, we have
approached interracial comparison of malocclusion in two ways: first, by comparison of individual malocclusion traits, and second, by factor approach using
principal components.
Our first component corresponds very well to the first factor identified by
Grainger-"syndrome of distoclusion with overjet"; the second component of
our data is analogous to his second factor, called "syndrome of mesioclusion with
lower overjet." Our third component appears to correspond to his fourth factor,
designated as "congenitally missing incisors syndrome."
In general, the effects of epidemiological factors on occlusion traits were relatively small, although often statistically significant. The values of the multiple

MALOCCLUSION IN HAWAII

491

correlation squared (R2) were in most cases smaller than 1 %. Those characters
with R2 larger than 1 o were overjet, overbite, incisor width, and component 1.
It is not known to what extent the sex differences detected can be explained by
the possibility that more girls receive orthodontic treatment and are therefore
excluded from the sample. However, if there were such an effect in the present
analysis, it must have been very small, since the sex ratio of our data (52.0%)
was fairly comparable with 51.5% for the unselected newborn population in
Hawaii [20].
Age of the subjects was found to be associated with a number of occlusion
variables, especially with the first and second components or their constituent
characters, indicating the occlusion pattern changes with age until age 17-18. The
associations of other epidemiological factors with occlusion characteristics are
sporadic and more difficult to interpret. However, the fact that these factors were
statistically significant suggests that environmental agents are playing an appreciable role in the etiology of malocclusion. The present finding should be contrasted with the result of a study of cleft lip and/or cleft palate in Hawaii [24] in
which none of 16 epidemiological variables studied was significantly related to the
risk of oral clefts in the sample of about 145,000 Caucasians and Japanese analyzed
using a comparable method.
It would be informative to discuss briefly those factors which showed significance at the 1% level or less. Children with higher birth order showed a decrease in overjet, overbite, anterior crowding, and component 1. Buccal crossbite
increased with birth order. It is not known to what extent the birth order effect is
due to prenatal factors. Maternal age had a generally negligible effect on all the
dental traits except minor mesioclusion, which showed an increase with maternal
age after about age 24.
Our code of father's occupational status is crude, and its relationship to the
occlusion traits is somewhat confusing. The children from families with lower
occupational status had more anterior spacing and yet had an elevated frequency
of major malalignment. Malalignment was also found more commonly among urban
residents. It is not known whether the observed associations of occlusion pattern
with occupation and residence of the parents reflect the difference claimed to exist
between the "civilized" and "uncivilized" population groups [13].
The racial comparison of the various occlusion variables was based on a model
in which additive racial effects were studied by including maternal and parental
variables together using the stepwise regression method. Under such a condition,
a possible maternal effect is competing with the possible general combining effect
of parents. For this reason, whenever a maternal effect was found significant, the
corresponding parental variable was fitted to retest the maternal effect.
When this procedure was followed, significant maternal effects, all involving
Hawaiian mothers, were found in only four occlusion variables; these were all
types of malalignment and incisor width at the 5% level and lingual crossbite
and component 2 at the 1% level. It is recalled that children of Hawaiian ancestry had the lowest mean values of malalignment and component 2 (mesioclu-

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CHUNG ET AL.

sion factor) among all races, and Hawaiian or part-Hawaiian mothers contributed
more than Hawaiian or part-Hawaiian fathers to the reduction of malalignment
in the hybrid children. In the case of lingual crossbite, Hawaiian or part-Hawaiian
fathers contributed more to the increase of the condition, or the corresponding
mothers were less contributory. For incisor width, the mother of Hawaiian origin
tended to contribute more to the reduction of tooth size in the hybrid. Interestingly, a maternal effect of tooth size has been clearly demonstrated in mice,
although the magnitude of the observed effect was even smaller in that experiment
[25].
We have found variable differences among racial groups in the occlusion characteristics studied. In general, children of Pacific racial groups had a higher
prevalence of mesioclusion than Caucasian children. Caucasian children had a
tendency toward more distoclusion compared with children of all other racial
origins except for Filipino. The higher prevalence of distoclusion of Caucasians
was accompanied by a higher degree of overjet and overbite, although there was
considerable heterogeneity among the Pacific racial groups in overbite.
Oriental children, with the exception of Filipinos, tended to suffer from the
lack of tooth space and malalignment, and incisors were more frequently missing.
It is of interest to note that a small group of Puerto Ricans appeared to differ from
Caucasians in that they had less distoclusion and overbite and more spacing. The
Hawaiian groups characteristically had the most tooth space, the smallest incisor
width, and the least congenitally missing teeth, malalignment, and overbite. However, they had a uniquely high prevalence of lingual crossbite. The Filipino
children appeared to differ from other Oriental groups in that they had more tooth
space and the highest frequency of buccal crossbite.
By comparing the results of racial analysis of the patient sample with that of
the main data, we find racial differences fairly comparable between the two
samples, although the patient sample has limitations in composition and size.
Compared with Caucasians, Oriental children, with the possible exception of
Filipinos, had increased frequency of mesioclusion and decreased overjet and overbite with reduced space between teeth. The higher proportion of neutroclusion observed in the Oriental patients was probably due to the likelihood that they more
often sought orthodontic attention for crowded or malaligned teeth.
Now we can turn to the critical question: is there any evidence of heterosis or
recombination of genes in these occlusion traits? To answer this question, we introduced six outcrossing indicators. Of the 114 (6 X 19) possibilities (not necessarily
independent), we found five values significant at the 5%o level (i.e., 4.3%o of all the
possibilities). They were major maternal hybridity factor for BSR 1 or 2, incisor
width, and component 2 (mesioclusion factor), major recombination factor for
component 2, and major hybridity factor for component 3. Component 2 and BSR
1 or 2 are closely related, as pointed out earlier.
Since a disproportionately large amount of information on hybridity of parents
came from part-Hawaiians, whose racial composition has more ambiguity than
other hybrids, we fitted two additional variables to further study the effects of
major maternal hybridity and recombination. These variables are the "part-

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493

Hawaiian mother" factor (1 for part-Hawaiian mother, 0 for other) and the "partHawaiian parent" factor (0, 0.5, 1 for none, one, or both parents part-Hawaiian).
When this was done, the effects of major maternal hybridity still remained significant for BSR 1 or 2 and component 2. However, it is difficult to interpret this
association, since we have detected no clear-cut maternal effect on these traits. The
practical importance of the significant effect of major hybridity on component 3
(missing-incisor factor) is questionable.
Thus we can conclude that there were no major consequences of heterosis or
recombination of genes in the interracial crosses in Hawaii. On the basis of the
inbreeding effect on the proportion of "normal" occlusion demonstrated in Japan
[6], a significant effect of hybridity of child was anticipated in BSR 33 or "good"
occlusion in our data. However, no such effect was detected in the present investigation. It would be informative to study another population to test the consistency of the inbreeding effect.
Regardless of the method of measurement of malocclusion, the racial effects
were largely additive in the racial crosses, with no significant indication of dominance or overdominance, as seen by the lack of effect of hybridity of child.
Furthermore, the notable absence of recombination effect (if any occurred, it was
in the wrong direction in component 2) indicates that gene recombination imposed
no adverse influence on the hybrid populations in occlusion pattern as far as could
be measured by the present technique. It is concluded that interracial crosses in
Hawaii have presented no additional problem over and above intraracial crosses.
All of the present findings indeed refute the applicability to humans of inferences
drawn from the experiments on dogs [18, 26]. The argument, based on the dogbreeding experiment, is that because of "independence in genetic constitution of
the maxillary structures from the mandible and the independence of the teeth
from both," an increased frequency of malocclusion is expected in the segregating
F2 generation when two morphologically diverse breeds are crossed [26].
It should be recalled that the experiments on dogs involved crossing of breeds
that had been bred for special (pathological) mutations and other desirable traits;
the former is likely to have been due to major (recessive) genes and the latter
to genes with minor effects. Thus when a breed with abnormal mutant traits was
bred to dogs of a normal strain, one would expect to observe some degree of
dominance in the FI generation and independent segregation in F2, as was shown
by Johnson [26]. In contrast with the situation in dogs, the observed human racial
differences in dental structures represent differences in normal variation, which
might be largely dependent on genes with minor effects. Furthermore, the differences detectable are indeed small compared with breed differences in dogs; thus
recombination of these genes in the F2 or subsequent generations, aided by developmental homeostasis, appears to present no significant problem in the risk of
malocclusion in humans.
SUMMARY

Racial variations in occlusion characteristics of 8,189 Hawaii-born children

predominantly of ages 12-18 were studied by the model of diallel cross. In-

494

CHUNG ET AL.

cluded in the study were 248 groups of incrosses and outcrosses. The traits
studied were buccal segment relationship, "good" occlusion, malalignment, overjet,
overbite, crowding, spacing, crossbites, incisor width, congenitally missing incisors,
and three major principal components derived from the above individual measurements.
Compared with Caucasians, Oriental (Chinese, Japanese, and Korean) children
were characterized by higher risks of mesioclusion, crowded teeth, and malalignment, often with missing teeth. Filipinos had buccal segment relationships
comparable to that of Caucasians, but had less overbite and more malalignment; they had more tooth space than other Orientals. Children of Hawaiian
parentage were intermediate between Caucasians and Orientals in buccal segment
relationship but had the least degree of overbite, malalignment, and congenitally
missing teeth, and the most tooth space.
There was some suggestion of maternal effects in malalignment, incisor width,
and lingual crossbite. The racial effects were found to be largely additive, and
there was no significant effect of hybridity of child or recombination. These findings
indicate that human racial crosses present no additional risks for malocclusion.
ACKNOWLEDGMENTS
This study would not have been possible without the able assistance of Mrs. Fay
Nakamoto, Mrs. Helen Morimoto, Mrs. Linda Kumasaka, Mrs. Susan Brown, Mrs.
Christine Yamaoka, Miss Linda Mimura, Mrs. Cheryl Tamashiro, and Mrs. Gay Nagata,
from the School of Public Health; and Mrs. Evelyn Kikuta and Mrs. Catherine Naito,
from the State Health Department. We also wish to thank the students and staffs of the
schools covered and the staff of the State Department of Education for their generous
cooperation. We are also grateful to Mr. George Tokuyama of the State Health Department for giving us access to vital records.
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New Journal of Human Biology

A new Australian journal, Human Biology in Oceania, has recently appeared. It
has arisen out of a great increase of human biologic research in Oceania. The
journal concerns itself with studies of the nature, development, causes, and origins
of variations in the human populations of Oceania and neighboring regions. The
first issue has articles on kuru, fertility and marriage in Fiji, and the population
genetics of the Australian aborigines in the Northern Territory. The articles
illustrate one of the obvious aims of the journal to publish information on populations in their original environment before it is too late.
Human Biology in Oceania is published by the University of Sydney; the annual
subscription rate is $8.50. Communications should be addressed to the Editor,
Prof. R. J. Walsh, Mackie Building, University of Sydney, New South Wales 2006,
Australia.