Forensic Imaging 20 (2020) 200353

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Forensic Imaging
journal homepage: www.sciencedirect.com/journal/forensic-imaging

Third molar development by Demirjian's stages and age estimation among T

Brazilians
Tanise Barbosa Ramaswamia, Gabriela Cauduro da Rosaa,c, , Mário Marques Fernandesa,c,
⁎

Rogerio Nogueira de Oliveirac, Rachel Lima Ribeiro Tinocoa,b

a
Associação Brasileira de Odontologia Legal do Rio Grande do Sul, Brazil
b
Universidade Salgado de Oliveira, Brazil
c
Faculdade de odontologia da Universidade de São Paulo, Brazil

ARTICLE INFO ABSTRACT

Keywords: Objective: To correlate the stages of 3M mineralization with the chronological age of South Brazilians and assess
Third molar the prevalence of complete mineralization in the threshold of 18 years old (age of legal majority). Study Design:
Tooth root The sample consisted of 1,013 panoramic radiographs from South Brazilian subjects aged between 15 and 23
Age determination by teeth years old. Demirjian's Tooth Development Stages (1973) was applied to classify the 3M mineralization into 8
Forensic dentistry
stages (from A to H). Results: Stages D, E, F and G were more associated with subjects aged under 18 years old,
while stage H was associated with subjects older than 18 years old. A smaller part of the sample ageing 18 years
old or above it, was found to be on stages D to G (9.1% and 16.9% for upper and lower 3M, respectively).
Considering exclusively stage H, the probability of someone being above 18 years old is 96.4% for upper 3M for
male and 88,2% for female, and for lower 3M, 95,1% and 78,4%, respectively. Males presented an earlier
development of this dental element, but at stage H, this age difference was significant only for the lower arch
(p=0.018). Conclusion: Demirjian's Tooth Development Stages can be a useful tool to assess 3M mineralization
for age estimation. When analyzing the stage H, the probability of the individuals were above 18 years old is
high, both male and female, in upper 3M or lower 3M. This sample has shown future studies should consider the
influence of ethnic and genetic factors over 3M development.

Introduction
The need for age estimation procedures has increased in the last
decade. This phenomenon occurred due to two main reasons: the
growing number of unidentified bodies and the cases of living persons
without a registered date of birth [1,2]. In the living, age estimation
plays an important part in court procedures for determining the adult
status of asylum seekers [3].
Chronological age does not reflect perfectly the real maturity of an
individual. Each person expresses differently growth and ageing. Age
estimation emerges in this context as a tool for legal purposes.
However, the scientific literature has no consensus on the best tech-
nique for age estimation [4]. Dental development is considered a reli-
able approach because it resists more intrinsic and extrinsic factors, e.g.
nutritional, pathological and hormonal alterations [5].
Teeth have different stages of mineralization. The younger the in-
dividual the more teeth are available for staging. As development
progresses, less information is available. At a certain stage, the only age
information based on dental development is restricted to the third
molars [1,6–9]. Third molars have significant value in Court because
their development covers ages of legal importance in many Law systems
– especially 14 (age of sexual consent) and 18 years old in Brazil(legal
majority) as well as 21 years in other countries [10–12]. On the other
hand, third molar eruption and development vary considerably, being
also the most frequently absent dental element [13–15].
Demirjian's technique [7,16–18] is used for age estimation world-
wide. This technique is founded on the mineralization stages of the
seven mandibular left permanent teeth. Despite broadly used De-
mirjian's technique reports outcomes that vary depending on the po-
pulation under analysis [10,19,20]. More studies are justified to test
and validate this technique in different populations. Investigating the
influence of miscegenation over age outcomes is essential to understand
how accurate Demirjian's technique performs in a Brazilian sample,
considering the limitations of the last stage on age estimation (H), with

Corresponding author at: Faculdade de odontologia da Universidade de São Paulo, Brazil.

⁎

E-mail addresses: tanise.br@hotmail.com (T.B. Ramaswami), gabrielacrosa@usp.br, gabrielacrosa@hotmail.com (G.C.d. Rosa),

mario-mf@live.com (M.M. Fernandes), rogerion@usp.br (R.N.d. Oliveira), rachelrtinoco@gmail.com (R.L.R. Tinoco).

https://doi.org/10.1016/j.fri.2020.200353
Received 19 February 2019; Received in revised form 18 November 2019; Accepted 16 December 2019
Available online 10 January 2020
2666-2256/ © 2020 Elsevier Ltd. All rights reserved.
T.B. Ramaswami, et al.
no upper boundary [11,18]. This investigation is even more important
considering the needs of justice issues involving the legal majority.
The present study aimed to apply Demirjian's dental mineralization
stages for age estimation in third molars and correlate the estimated
and chronological age of South Brazilians. For legal purposes, the
prevalence of complete third molar development can estimate the
probability of a subject being above (or below) 18 years old (age of
legal majority).
Material and methods
The present study consisted of a retrospective cross-sectional and
observational study conducted after the approval of the local
Committee of Ethics in Research under the protocol number 185/2009.
Ethical aspects involved in the declaration of Helsinki were followed.
The sample consisted of 1,013 panoramic radiographs from 369
(36.4%) males and 644 (63.6%) females aged between 15 and 23 (22.9)
years old. All the individuals presented at least one third molars re-
gistered radiographically and had no visible pathology that could in-
fluence dental development. Individuals with nationality other than
Brazilian were not included in the sample, as well individuals that
descended directly from immigrants (1st generation).
The radiographs were obtained with a device for panoramic image
acquisition (Eagle 2D Pan, Dabi Atlante, Ribeirão Preto, Brazil). With a
digital camera (D500, Nikon, Miyagi, Japan) and an ABFO #2
(American Board of Forensic Odontology, USA) the radiographs were
photographed in a light-box (Gnatus – Equipamentos Médico-
Odontológicos Ltda, Ribeirão Preto, Brazil). The radiographs were im-
ported in a personal computer (Inspiron 14 7000, DELL, Eldorado do
Sul, Brazil) with age and sex information registered. The images were
masked to avoid the examiner bias during the analysis. Software
Photoshop, version 3.0 (Adobe Systems; Mountain View, CA) proces-
sing was used to enhance contrast, brightness and gray levels during the
analysis.
Third molar mineralization stages in the maxilla and the mandible
were classified according to Demirjian et al. [6]. This technique clas-
sifies the mineralization stages from A-H, as described in Table 1.
Missing third molars due to extraction or agenesis were coded with “N”,
while third molars superimposed with maxillofacial bones and teeth
were not considered for analysis.
Image analysis was performed by a single examiner. Third molar
stages were associated with the age of the individuals, and
Mann–Whitney test was used to compare the mean ages of the stages
between sexes. The level of statistical significance was set at 5% (0.05).
Intra-examiner reliability was assessed repeating the analysis with 20%
of the sample within a time interval of two weeks from the first analysis.
Kappa coefficient was applied to quantify the intra rater agreement
(IRA). All the statistical tests were performed using SPSS software
package (13.0, Chicago, USA).
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Results
Kappa coefficient revealed a high level of intra-examiner agreement
ranging from 0.945 to 0.958 (p=0.000). In the maxilla, missing third
molars accounted 4.9%, while third molars superimposed with adjacent
structures accounted 0.2%. In the mandible missing and superimposed
third molars reached 5.3% and 0.2%, respectively (Table 2).
Box-and-whisker diagrams were plotted relating development
stages and chronological age, allowing to visually compare both sexes,
for upper (Fig. 1) and lower (Fig. 2) third molars.
In the maxilla, the mean age associated with stage H was 20.2
( ± 1.6) for males and 20.5 ( ± 1.5) for females. In the mandible, stage
H was associated with the mean age of 20.3 ( ± 1.6) for males and 20.7
( ± 1.4) for females. Mann-Whitney test showed statistically significant
2
Forensic Imaging 20 (2020) 200353
Table 1
Description and schematic drawing of stages A to H (Adapted from Demirjian
et al.) [6].
Stage Description Molar draw
A Beginning of calcification at the superior level of the
crypt to form inverted cone or cones; no fusion of
the calcified points
B Fusion of the calcified point forms one or several
cusps which unite give a regularly outlined occlusal
surface
C Complete enamel formation at occlusal surface;
beginning of dentin deposit is seen; the outline of
pulp chamber has a curved shape at the occlusal
border
D Crown formation complete to the CEJ; pulp chamber
has a trapezoidal form; beginning of root formation
is seen in the form of a spicule
E Initial formation of radicular bifurcation is seen in
the form of a calcified point of semi-lunar shape;
root length is still less than the crown height
F Calcified region of the bifurcation has developed
further down to give the roots a more definite and
distinct outline with funnel shaped ending; root
length is equal to or greater than the crown
G The walls of the root canal are parallel; apical end is
still partially open
H The apical end of the root canal is completely
closed; periodontal membrane has a uniform width
around the root and the apex
difference between sexes comparing mean ages of stages E, F, and G for
upper 3M, and stages E, F, G and H for lower 3M. For all mentioned
stages, males presented an earlier development than females (Tables 3
and 4).
Yet in relation to the age of 18 years old, the probability of someone
ageing 18 or more presenting a maxillary third molar in stage H is
96.4% for male and 88,2% for female , while for mandibular third
molar the probability is 95,1% and 78,4%, respectively (Table 5).
Discussion
Considering the different legal regulations for the legal majority
[21], forensic expertises may be requested to provide age intervals in
the Court. As observed in the literature, age estimation techniques are
not accurate enough to provide exactly the age of a person – justifying
the term age “estimation” instead of “determination”. For the reason
forensic reports on age estimation provide age ranges.
In order to establish guidelines for the diagnosis of legal majority,
the Study Group on Forensic Age Diagnostics [22] proposed a evaluation
in three steps: 1. medical examination of sexual development, anthro-
pometric characteristics and developmental disorders; 2. skeletal de-
velopment through the analysis of hand and wrist radiographs; and 3.
T.B. Ramaswami, et al. Forensic Imaging 20 (2020) 200353

Table 2. parameters that provide age information at the end of adolescence and
Third molar mineralization stages distributed by sex. beginning of adulthood [12,13,21,26]. For that reason, the present
Sex Total study, chose to study these teeth, which are used as references to age
Male Female estimate of adolescents and young adults [10].
Stages n % n % n % In the study by Mincer et al. [21] as well as Widek et al. [27], when
applying the Demirjian's technique, the authors determine that the
Maxillary
C 3 0.8 2 0.3 5 0.5
higher the number of third molars analyzed, the greater the reliability
D 10 2.7 13 2.0 23 2.3 of the method.
E 25 6.8 47 7.3 72 7.1 Dhanjal et al. [28] assessed the inter-rater agreement of different
F 37 10.0 63 9.8 100 9.9 Tooth Development Stage systems analyzed the third molars for age
G 36 9.8 68 10.6 104 10.3
estimation using different techniques available in the literature. The
H 240 65.0 417 64.8 657 64.9
Missing tooth 17 4.6 33 5.1 50 4.9 authors concluded that Demirjian's stages of mineralization [7] led to
Superimposed 1 0.3 1 0.2 2 0.2 the best outcomes. The scientific literature reveals that Demirjian's
Total 369 100.0 644 100.0 1013 100.0 technique may be used for age estimation mainly because it is founded
Mandibular
on dental mineralization stages well defined. However, population
B 0 0.0 2 0.3 2 0.2
C 4 1.1 6 0.9 10 1.0
variations are evidenced with the application of this technique [4,26].
D 10 2.7 27 4.2 37 3.7 Specifically, Dermirjian's technique reached different age variations
E 42 11.4 73 11.3 115 11.4 when applied in samples of Brazil [5,29], Germany [30], India [13,31],
F 30 8.1 65 10.1 95 9.4 Africa, Japan [30], Turkey [12] and US [21]. Olze et al. [30] confirmed
G 32 8.7 74 11.5 106 10.5
the influence of ancestry in age estimation comparing third molar mi-
H 235 63.7 357 55.4 592 58.4
Missing tooth 15 4.1 39 6.1 54 5.3 neralization stages with Demirjian's technique in Germans, Japanese
Superimposed 1 0.3 1 0.2 2 0.2 and South Africans. It provides evidences to indicate that miscegenation
Total 369 100.0 644 100.0 1013 100.0 potentially affects dental mineralization and consequently dental age
estimation techniques founded on mineralization stages [32].
Based on ethical reasons and also on the feasibility of accessing
Analysis of dental development [4,23]. In parallel, the analysis of third databases for studies in age estimation, most of the literature using
molar mineralization complements the age information retrieved from Demirjian's technique is founded on the analysis of panoramic radio-
skeletal development [24]. In the scientific literature, dental miner- graphs. However, from a practical scope, periapical radiographs would
alization is preferred in face of other parameters, such as dental erup- be enough to assess the mineralization stages of third molars. This as-
tion, justified on the fact that it consists of a continuous process from pect is relevant considering that many medico-legal institutes in de-
birth to the complete root formation [25]. veloping countries do not have devices and facilities for panoramic
Despite the high variation in position, morphology, and timing for radiograph imaging. Oppositely, periapical radiographs are more
development and eruption, the third molars consist of proper markers commonly obtained in these institutes, enabling age estimation with
for age estimation especially because there are few anatomic Demirjian's technique in third molars.

Fig. 1. Developmental stages of the upper third molar plotted against chronological age and sex (notice the line marking 18 years)

3
T.B. Ramaswami, et al. Forensic Imaging 20 (2020) 200353

Fig. 2. Developmental stages of the lower third molar plotted against chronological age and sex (notice the line marking 18 years)

Several studies using Demirjian's Tooth Development Stages for age
estimation through the analysis of third molar mineralization is a
proper approach for estimating the chronological age [11,13,26,29].
Similarly, the present study found positive outcomes but does not ex-
clude the need for assessing sexual maturity and skeletal development
for more accurate age estimation outcomes in the forensic context.
In relation to the influence of sex over age estimation outcomes, the
literature is not unanimous. Darji et al. [13] and Prieto [26] did not
observe differences significant statistically between males and females,
while Attar Al-Taei [33] observed earlier development of third molars
ranging between 6-8 months for the development stages D and E among
Iraqi males. These findings corroborate the outcomes of Sisman et al.
[12] and Kasper et al. [24] in populations from Turkey and US, re-
spectively. Differently, Rai et al. [31] observed earlier dental develop-
ment of 6-21 months in mineralization stages D and G among Indian
females. The earlier dental development in females in the beginning of
dental mineralization was also found by Meinl et al. [23]. With other
techniques, sex also played significant influence over age estimation
outcomes, e.g. Deitos et al. [5] observed earlier development of
mandibular third molars among males using the technique proposed by
Cameriere.
Araújo et al. [29] applied Demirjian's technique for age estimation
using third molars from a Northeastern Brazilian sample from 5.5 to 21
years old. The authors observed a mean age of 19 years for dental de-
velopment stage H. In the present study, the mean age found for
maxillary third molars was 20.2 ( ± 1.6) for males and 20.5 ( ± 1.5) for
females. In mandibular third molars, the mean age was 20.3 ( ± 1.6)
and 20.7 ( ± 1.4), for males and females, respectively. This can be
explained by the age limits of the sample are different, where the
maximum age analyzed is 21 years in Araújo et al. [29], while in this
study it was until 23 years.
Likewise, Márquez-Ruiz et al. [34] when analyzing mineralization
third molars by computed tomography found that on this tooth, males
develop earlier than females, which agrees with the results mentioned
by Karataş et al. [35], who carried out a study using Demirjian´s
method, having Turkish children as sample.
Concerning the probability of estimating the age of majority (18
years old) based on the mineralization stage H, a maxillary third molar

Table 4
Table 3. Comparison of mean ages between sexes for each stage of mandibular third
Comparison of mean ages between sexes for each stage of maxillary third molar molar development.
development.
Stage Male Female p
Stage Male Female p n mean SD n mean SD
n mean SD n mean SD
B - - - 2 15,4 0,1 n/a
C 3 15,8 0,2 2 15,5 0,2 n/a C 4 15,5 0,3 6 16,1 0,9 0,352
D 10 16,2 1,2 13 16,2 1,0 0,693 D 10 16,0 1,0 27 17,0 2,1 0,242
E 25 16,0 0,8 47 17,2 1,6 0,001⁎⁎ E 42 16,5 1,3 73 17,8 1,9 0,000⁎⁎
F 37 16,4 0,9 63 17,3 1,7 0,014* F 30 16,6 0,8 65 17,3 1,5 0,020*
G 36 17,0 0,9 68 17,8 1,6 0,019* G 32 17,3 1,1 74 18,4 1,5 0,001⁎⁎
H 240 20,2 1,6 417 20,5 1,5 0,127 H 235 20,3 1,6 357 20,7 1,4 0,018*

n/a: not applicable due to low number of cases; n/a: not applicable due to low number of cases;
⁎⁎
significant statistically p≤0.01; ⁎⁎
significant statistically p≤0.01;
⁎
significant statistically p≤0,05. ⁎
significant statistically p≤0,05.

4
T.B. Ramaswami, et al. Forensic Imaging 20 (2020) 200353

Table 5
Probability rates of estimating the age of legal majority (≥ 18 years old) in male and female in each stage of third molar mineralization.
Male Female
Age Age
< 18 ≥18 < 18 anos ≥18
n % n % n % n %

Mandibular A 0 0,0% 0 0,0% 0 0,0% 0 0,0%

B 0 0,0% 0 0,0% 2 1,2% 0 0,0%
C 4 3,1% 0 0,0% 6 3,7% 0 0,0%
D 10 7,8% 0 0,0% 20 12,2% 7 1,6%
E 38 29,7% 4 1,8% 44 26,8% 29 6,6%
F 28 21,9% 2 0,9% 47 28,7% 18 4,1%
G 27 21,1% 5 2,2% 33 20,1% 41 9,3%
H 21 16,4% 214 95,1% 12 7,3% 345 78,4%
Maxillary A 0 0,0% 0 0,0% 0 0,0% 0 0,0%
B 0 0,0% 0 0,0% 0 0,0% 0 0,0%
C 3 2,3% 0 0,0% 2 1,3% 0 0,0%
D 9 6,9% 1 0,5% 12 7,5% 1 0,2%
E 24 18,3% 1 0,5% 36 22,5% 11 2,4%
F 35 26,7% 2 0,9% 45 28,1% 18 4,0%
G 32 24,4% 4 1,8% 45 28,1% 23 5,1%
H 28 21,4% 212 96,4% 20 12,5% 397 88,2%

in stage H is 96.4% for male and 88,2% for female , while for man-
dibular third molar the probability is 95,1% and 78,4%, respectively.
Meinl et al. [23] observed for the same stage a probability of 99.5% for
males and 99.3% for females; Salvia et al. [36] observed rates of
96.84% (males) and 98.61% (females); Prieto [26] observed rates
>90% apart sex, as Sharma et al. [37].
Comparing the averages of chronological age found in this study,
there is an early development of the upper arch in relation to the lower
one, in agreement with the results of Hofmann et al. [38] who used this
method in a European population. On the other hand, Willershausen
et al. [39] compared the development of third molars between arches
and found that in 68% of the cases there was synchrony and in only
16% the upper arch was one stage ahead.
Ancestry influences potentially over age estimation outcomes.
Consequently, methodological adaptations may be necessary to im-
prove techniques for validation in different populations [34]. In prac-
tice, techniques must be chosen based on their performances in dif-
ferent populations [4]. Concerns remain on the association between
dental and skeletal ages because the current studies vary considerably
regarding the methodology (e.g. sample size and statistics). Ad-
ditionally, skeletal development may be influenced by genetic, en-
vironmental and nutritional factors that highlight deeper investigations
in the Field and further studies in Brazilian samples.
Conclusion
The outcomes obtained in the present study suggest that Demirjian's
technique may be a valuable tool for estimating age through the mi-
neralization of third molars. When analyzing the stage H, the prob-
ability of the individuals were above 18 years old is high, both male and
female, in upper 3M or lower 3M. For more accurate performances,
sexual maturity and skeletal development must remain considered and
more studies are necessary to investigate the influence of genetics and
ancestry over age estimation outcomes.
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