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Forensic Science International 254 (2015) 13–17

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Evaluation of third molar development in the estimation
of chronological age
Caio Bele´m Rodrigues Barros Soares a,*, Jose´ Natal Figueiroa b,
Renata Moura Xavier Dantas c, Lu´cio Mitsuo Kurita d, Andre´a dos Anjos Pontual e,
Fla´via Maria de Moraes Ramos-Perez e, Danyel Elias da Cruz Perez e,
Maria Luiza dos Anjos Pontual e

Federal University of Pernambuco, Estrada do Arraial 2385, Recife, PE, Brazil
Fernando Figueira Integral Medical Institute, Recife, PE, Brazil
Estate University of Paraı´ba, Joa˜o Pessoa, PB, Brazil
Department of Clinic Dentistry, Federal University of Ceara´, Fortaleza, CE, Brazil
Department of Clinical and Preventive Dentistry, Federal University of Pernambuco, Recife, PE, Brazil



Article history:
Received 9 May 2015
Received in revised form 17 June 2015
Accepted 19 June 2015
Available online 29 June 2015

The purpose of this study was to evaluate the correlation between chronological age and the degree of
third molar mineralization by Demirjian’s developmental stages (Demirjian et al., 1973) using
panoramic radiography. From a total of 11.396 digital panoramic radiographs of patients from three oral
radiology private clinics from the northeast region of Brazil, obtained from January to June 2009, 2097
radiographic images from patients aged between 6 and 22 years were selected. The images were
analyzed individually by two obsevers using a 21-inch computer screen and Windows Picture and Fax
Viewer. Reliability was achieved by intra- and interobserver evaluation, using the Kappa test.
Chronological age, calcification stage, gender and third molar were interrelated using a multiple linear
regression model, considering age as a response variable. There was reliability with Demirjian et al.’s
developmental stage assesment, displaying a significant relationship between mineralization stages and
patients’ age (P < 0.05). There was no significant difference between the average age and the calcification
stage taking gender and localization of the third molar into consideration. It is possible to estimate
chronological age based on Demirjian’s stage of a third molar, regardless of gender and location.
ß 2015 Elsevier Ireland Ltd. All rights reserved.

Age estimation by Teeth
Panoramic radiography
Third molar

1. Introduction
Forensic odontology has reliably been using third molar
mineralization to estimate chronological age as an auxiliary
parameter in the identification of corpses and human remains.
Furthermore, this process can be used as an additional tool to
distinguish between young people and adults for criminal purposes
[1–3]. Radiographic images are frequently used in the age estimation
process as an essential tool in human identification in forensics [4].
Teeth have specific characteristics consistent with the many
phases of human development [5]. Because they go through
different morphological stages, changes in mineralization of dental

* Corresponding author.
E-mail addresses:,
(C.B.R.B. Soares).
0379-0738/ß 2015 Elsevier Ireland Ltd. All rights reserved.

tissues occur gradually and can be less affected by changes in the
endocrine and nutritional systems than other criteria for maturity
estimation [6].
Classification methods for the cycles of dental formation are
based on radiographic analysis and teeth codification according to
the stages defined by Nolla in 1960 [7] or Demirjian et al. in 1973
[8]. Most studies are based on analysis of panoramic radiographs
because of their relative practicality and they provide an overview
of the maxillomandibular complex, alveolar region and adjacent
structures [1–3,6,9–22].
In a retrospective evaluation using MEDLINE and third molar,
radiography and age estimation by teeth as descriptors, 101
articles were found. Of those, 39 based their analysis on
Demirjian’s method of classification or adaptations of it. Few
studies in Brazil were based on this parameter [20,23]; Nolla’s [7]
classification [10,12,16,24,25] and Nicodemo’s [26] classification
[6,27,28] were more commonly studied in Brazil.

Verbal and written instructions were made available to the observers. (H) closure of the apical orifice. Amsterdam. There was agreement ranging from good to excellent in both evaluations. Materials and methods The present study was approved by the Ethics Committee of the Center of Health Science. The images were assessed twice by the observers. CE. a score on a scale from A to H was assigned: (A) calcification of certain occlusal points without fusion.396 digital panoramic radiographs of patients who attended three private dental radiology services in Recife. Joa˜o Pessoa.05 (or 5%). Depending on the grade of development of all third molars. the Netherlands). 1. PB. A total of 11. Repeated measures analysis of variance (ANOVA) was used for assessment of average age in relation to calcification stages. 3. All third molars suitable for evaluation. (D) formation of the crown-enamel cement junction. [8]. Table 1 shows the results of the Kappa test for the intra. 2. PE. Regression lines with the correlation between different Demirjian stages and the patient’s age according to the location of each third molar are represented in Fig. The relationship between age.and interobserver evaluations. The sample comprised 2097 images from patients aged between 6 and 22 years of any ethnicity and any gender. Table 2 shows the results of adjustments for age using multiple linear regression models for age. (G) the growth of the root stopped and the apical orifice remains open. gender and the interaction between gender and Demirjian stage for each third molar as the predictive variables.2 and Minitab 15 software were used for the statistical analysis.and intraobserver reliability was assessed by Cohen’s Kappa test using the data collected regarding Demirjian’s stage classification of the third molars. the average age  standard deviation was 15. Representation of Demirjian’s eight stage diagram of mineralization. 2. the observers determined the least developed stage. (C) end of the formation of enamel and beginning of the deposition of dentine. Age and gender were recorded on an evaluation sheet for each patient. windowless room with dimmed lighting. Digital images were viewed by the observers on a 21-inch monitor in random order using Windows Picture and Fax Viewer software (Microsoft Word. considering Demirjian stage. This score provided an estimate of age that was converted directly into dental age as per the standard table given or substituted in the regression formula for maturity. under protocol no.’s diagrams (Fig. The observers could use the zoom tool up to three times to determine the calcification stage according to the mineralization diagrams proposed by Demirjian et al. Radiographs that displayed a lack of any permanent teeth. signs of dental development disorders. the aim of this study was to evaluate the correlation between chronological age and mineralization of third molars using the eight developmental stages (A–H) described by Demirjian et al. where age was a response variable. The age ranged from 6 to 22 years. (E) the longitude of the root shorter than the latitude of the crown. and tooth was adjusted using a multiple linear regression model. Stata 9. Fig. 1).R. Data analysis The data collected regarding the Dermijian developmental stage of each tooth was recorded along with the patient’s age. and lesions of any kind in the third molar region were excluded. and Fortaleza. of which 1150 (54.0  3. irrespective of the direction of eruption. Inter. Federal University of Paraı´ba (UFPB). gender and dental elements. Louwesweg. / Forensic Science International 254 (2015) 13–17 Therefore.8%) belonged to female patients.B. calcification stage. [8] in a Brazilian population sample. 3 shows the correlation between Dermijian stage and chronological age according to the patient’s gender. 106/09. In cases where there was doubt between two stages of mineralization. . the average age estimates and the corresponding interval of trust were obtained according to the location of the tooth Demirjian stage and gender (Tables 3 and 4). obtained from January to June 2009 were used in this study.14 C. Each stage of mineralization was given a score ranging from 0 (A stage) to 7 (H stage) for statistical analysis.1. Soares et al. All observations took place in a quiet. This was performed using direct comparison of the appearance of each third molar with Demirjian et al. The minimum interval between the evaluations of the same patient was 30 days. (B) fusion of the occlusal points of mineralization.4 years. (F) the longitude of the root equal to or greater than that of the crown. Results The sample comprised 2097 digital panoramic radiographic images. With these adjusted models. were evaluated in the study. All panoramic radiographies were obtained using a charged coupled device direct radiography system at a resolution of 300 DPI (dots per inch). Brazil.B. The panoramic images were exported in tagged image file format (TIFF) and codified so that the gender and age could not be identified by the observers during the evaluation. 2. Fig. The significance level was 0.

8–17.9 17.9–10.73 0.3 14.7 11.3 15.7 13.80 0.3 14.5 16. Soares et al.8 14.2–12.06 to 0.1–12.7 17.52–10.9 10.9–18. Teeth Evaluators 18 (n = 2097) 28 (n = 2.001 1.22 a Student t test.0 17.18 <0.860 0.1 11.6 12.4 11.7–15.C.4 16.9–18.10 9.8 16.5 13.44 to 0.05–1.5 * Minimum-maximum age limit in years with confidence interval of 95% for males.12 0.75 0.5–14.1 14.18 <0.1 12.01 to 0.001 0.0 11.4–10.8 9.3 12.001 0.85 64 55 Interobserver 0.8–10. * Minimum-maximum age limit in years with confidence interval of 95% for males.14 0.53 0.0–11.0–13.7 13.1 12.6 15.05 0.73 0.7 9. Arcade Age (years) Coefficient Standard error P valuea 95% confidence interval Upper (tooth 18) Stage Gender Gender  stage Constant 1.7 16.23–9.3–15.2 13. Table 4 Estimated average age and the respective 95% confidence interval according to gender and Demirjian stage in the lower arcade.4 11.2 13.10 0.7 10.5–16.378 0.20 9.3 13.3–13.6–15.5 13.9–13.7 14.4 13.0 13.8 12.5 10.8 14.2–9.2–15.2–18.1 15.04 0.06 to 0.8–12.335 0.5 16.70 0.8 11.6 15.097) 38 (n = 2097) 48 (n = 2097) Kappa % Kappa % Kappa % Kappa % Intraobserver 1 2 0.003 to 0.05–1.6–18.3 13.2 11. In this study.694 0.000 1.18 <0.2 17.8–17.6 10.9 11.58 0.78 0.7–15.9 11.75 61 66 0.3 18.29].465 <0.19 0.4 12. / Forensic Science International 254 (2015) 13–17 15 Table 1 Kappa test conducted for the evaluation of intra.20 0.6 14.13 9.2 14. .8–12.15 9.8–13.8 13.1 17.6–11.6–11.8 17.3 Lower right A B C D E F G H 9.3 9.2 10.001 0.2 14.5–17.8 9.1 11.4–9.19 0.05 0.07–1.9 10.4–15.9–16.10 9.2 15.4–14.7 16.2–14.3–12. ** Minimum-maximum age limit in years with confidence interval of 95% for females. 4.5 Upper left A B C D E F G H 9.8 10.73 0.5 16. The main reason for choosing Demirjian et al.3–12.065 0.82 67 59 0.7 17.0 17.56 Lower (tooth 38) Stage Gender Gender  stage Constant 1. the third molars were chosen for evaluation because they display individual development.5 14.9 16.04 0.1 9.39–10.5 13.B.8 12.3 14.7–12.8–16.4 15.24 0.7–10.9 10.9 10.25 0.0 14.071 0.23 0.6–12.1 9.7 15.9 16.046 9.29]. matching maxillary growth [12.6–18. Discussion Quadrant Demirjian stage Gender Quadrant Demirjian stage Female Male Gender Female Male Average 95% CI* Average 95% CI** Average 95% CI * Average 95% CI** Upper right A B C D E F G H 9.R.25 0.4–9.057 <0.363 0.5 15.5–13.1–18.001 0.B.87 0.06–1.0–17.13 0.7 10.1–11.2–14.4 14.3 11.064 0.3 15.27 to 0.3 12.22 Lower (tooth 48) Stage Gender Gender  stage Constant 1.04 0.7 17.7 16.1–11.5–13.26 0.9–11.25 to 0.5 15.0 13.37 to 0.21 0.87 0.52–10.59 0.9 18.2 18.77 0.3 15.7–14.04 0.1 11.5–16.19 9.1–14.25 0.5 16.5 12.7 14.6 14.74 0.0 15.2 18.3–16. ** Minimum-maximum age limit in years with confidence interval of 95% for females.3 16.4–16.9 13.70 0.12 0. which allows Table 3 Estimated average age and the respective 95% confidence interval according to gender and Demirjian stage in the upper arcade.3–13.04 9.058 Table 2 Results of adjustments using multiple linear regression models.6 9.1 17.83 0.5 17.001 1.4–9.1 11.82 71 60 0.0–14.05 0.8 16.9 15.6–11.0–17.2–15.9 9.9–10.0 12.05 0. knowledge about the correlation of development with chronological and skeletal age is of great importance because it can become a target of impaction or initiate pathological processes during its formation [12.0 10.3 9.8 15.6 17.08 Upper (tooth 28) Stage Gender Gender  stage Constant 1.2 14.4–17.’s [8] developmental stages was because it is largely used in the English literature.2 12.1 17.18 <0.1 10. Furthermore.3 12.3 18.and interobserver agreement.000 1.8 16.3 Lower left A B C D E F G H 9.9 18.04 0.5 17.0–13.064 0.

in a study conducted by Rai et al. equivalent to 2 and so forth up to stage H. Bhardwaj. .36. as happened in Belgium [13]. [35]. there was no intra. there was in average difference of 5 months in age between genders for each calcification stage. according to the quadrant where the third molar is located. African [15].18–20. indiscriminate use of idealized tables of calcification for every population is not appropriate.B. In this study. corroborating previous studies [2. However. Reproducibility of radiographic stage assessment of third molars. de Arau´jo et al.53 years). [18]. [34] verified earlier apical closure in males.31].3. Dhanjal. For stage H. 5. Japanese [42]. Int. England [1]. The following regression equation was found: 9. [19].and interobserver assessments. The reliability of the method is evaluated from two perspectives: the proximity of dental age to the patient’s chronological age and the reproducibility of intra. males tend to develop earlier compared with females.23. the average age higher than among a Spanish sample (6. The research conducted by Olze et al. for German. There are a few studies that used a sample similar to the one used in this study [3.32. On the other hand. As verified in the results in relation to the average age at several calcification stages.8. Olze et al. African [15]. H. [13]. therefore it is possible to determine chronological age by the development stage of just one third molar. There is no difference between the average age and the calcification stage of third molars from different locations and in both genders. in the study conducted by Teivens et al.34]. [23]. but each gender has its own regression formula [4]. Gunst et al. Each stage was codified by a number so they could be inserted into the formula.16 years) [32] and a Korean sample (9.S. 159 (2009) S74–S77. Conclusion There is reliability in Demirjian et al. de Oliveira et al. Therefore. females were found to display earlier dental development than males [9.37]. References [1] K. [32] and de Oliveira et al.C.K. Korean [31] and Colombian/Mexican [34] people.39]. there is great variability in the literature. Meinl et al. China [30] and Colombia/Mexico [34]. [23]. the average age for stage A was 9. Dental mineralization is a highly valuable tool for the estimation of age.23. Correlation between Demirjian stage (x axis) and chronological age (y axis). 3. Soares et al. In this study. there was a significant difference in third molar development in relation to gender for Demirjian stages D and G.07 years) [41]. Thus. Regarding the average age for the calcification stages. In this study. which also assessed a Brazilian population (18. In contrast. However. The lines displayed in Figs. [32]. For correct use of this method in the Brazilian population. Jung and Cho [31] and Costa et al. M. However. de Arau´jo et al. in the present study. which means that the same regression equation can be used to determine the patient’s age regardless of the third molar that is going to be evaluated and the patient’s gender. [9] in Sweden. there may be cross-population variations in the progress or delay of the mineralization process and the Brazilian population has not been evaluated with a sample as large as presented in this study. there was no difference between third molars in agreement with other research on a Brazilian [20. Turkish [41]. because there are different characteristics among the world’s populations [10]. 2.86 years) [31]. Forensic Sci. Turkish [2] and Korean sample [31].14.B. However. the third molar teeth were found at an average age >21 years. other studies did not verify this correlation [6. Orhan et al.16].32]. in this study the age average was 17. there was a correlation between the dental development of third molars and chronological age. Children of the same age could display up to four stages and children from 5 to 12 years of age could display the same dental development stage in the evaluation of mandibular teeth. These differences in dental development between genders are only visible after the age of 5 years.9 years in concordance with de Arau´jo et al. In addition.2  stage). the study of age estimation by teeth mineralization in different population groups is important. According to the formula generated Fig.M. Male precocity was also found in this study. 3. such as those presented in this study (regression equation).12. Brazil [23. must be applied.30. comparisons between the dental development of the studied population with the populations from other countries. there is no difference between the average age for calcification stages in relation to gender. 25 20 15 10 5 A B C D E F G H Demirjian stage Male Female Fig. Heras et al. This also occurred in previous studies [2. / Forensic Science International 254 (2015) 13–17 16 25 Age (years) 20 15 10 5 A B C D E Demirjian stage Quadrant 1 Quadrant 3 F G H Quadrant 2 Quadrant 4 Fig.and interobserver reliability using this method. According to the studies by Nolla [7]. [14] was the only one to compare samples of different populations (from Japan and Germany). Turkey [33]. [20]. 2 and 3 are practically coincidental. [2].R. stage C.35]. Liversidge. equivalent to 1. it is an easy method to apply. correction factors.8 years.12. [8] developmental stages for the Brazilian population. Stage A was equivalent to zero. [14]. In previous studies. Correlation between the Demirjian stage (x axis) and chronological age (y axis) according to the patient’s gender.’s study [32]. stage B.31.8 + (1. the reliability of Dermijian’s method was tested and presented agreement ranging from good to excellent for both evaluations. Araujo et al. Brazilian (9. which was lower than among a Turkish sample (12 years) [40]. Estimation of patients’ age according to the mineralization stages of third molars is possible.

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