Forensic Science International 254 (2015) 1317

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Forensic Science International

journal homepage: www.elsevier.com/locate/forsciint

Evaluation of third molar development in the estimation

of chronological age
Caio Belem Rodrigues Barros Soares a,*, Jose Natal Figueiroa b,
Renata Moura Xavier Dantas c, Lucio Mitsuo Kurita d, Andrea dos Anjos Pontual e,
Flavia Maria de Moraes Ramos-Perez e, Danyel Elias da Cruz Perez e,
Maria Luiza dos Anjos Pontual e
a

Federal University of Pernambuco, Estrada do Arraial 2385, Recife, PE, Brazil

Fernando Figueira Integral Medical Institute, Recife, PE, Brazil
c
Estate University of Paraba, Joao Pessoa, PB, Brazil
d
Department of Clinic Dentistry, Federal University of Ceara, Fortaleza, CE, Brazil
e
Department of Clinical and Preventive Dentistry, Federal University of Pernambuco, Recife, PE, Brazil
b

A R T I C L E I N F O

A B S T R A C T

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 Demirjians 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, calcication 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 signicant relationship between mineralization stages and
patients age (P < 0.05). There was no signicant difference between the average age and the calcication
stage taking gender and localization of the third molar into consideration. It is possible to estimate
chronological age based on Demirjians stage of a third molar, regardless of gender and location.
2015 Elsevier Ireland Ltd. All rights reserved.

Keywords:
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 identication 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
[13]. Radiographic images are frequently used in the age estimation
process as an essential tool in human identication in forensics [4].
Teeth have specic 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: caiorodriguesmd@gmail.com, caiorodriguesmd@icloud.com
(C.B.R.B. Soares).
http://dx.doi.org/10.1016/j.forsciint.2015.06.022
0379-0738/ 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].
Classication methods for the cycles of dental formation are
based on radiographic analysis and teeth codication according to
the stages dened 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 [13,6,922].
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
Demirjians method of classication or adaptations of it. Few
studies in Brazil were based on this parameter [20,23]; Nollas [7]
classication [10,12,16,24,25] and Nicodemos [26] classication
[6,27,28] were more commonly studied in Brazil.

14

C.B.R.B. Soares et al. / Forensic Science International 254 (2015) 1317

Therefore, the aim of this study was to evaluate the correlation

between chronological age and mineralization of third molars
using the eight developmental stages (AH) described by
Demirjian et al. [8] in a Brazilian population sample.
2. Materials and methods
The present study was approved by the Ethics Committee of the
Center of Health Science, Federal University of Paraba (UFPB),
under protocol no. 106/09.
A total of 11,396 digital panoramic radiographs of patients who
attended three private dental radiology services in Recife, PE, Joao
Pessoa, PB, and Fortaleza, CE, Brazil, obtained from January to June
2009 were used in this study. The sample comprised 2097 images
from patients aged between 6 and 22 years of any ethnicity and any
gender. Radiographs that displayed a lack of any permanent teeth,
signs of dental development disorders, and lesions of any kind in
the third molar region were excluded.
All panoramic radiographies were obtained using a charged
coupled device direct radiography system at a resolution of 300 DPI
(dots per inch). Age and gender were recorded on an evaluation
sheet for each patient. The panoramic images were exported in
tagged image le format (TIFF) and codied so that the gender and
age could not be identied by the observers during the evaluation.
All observations took place in a quiet, 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, Louwesweg, Amsterdam, the
Netherlands). The images were assessed twice by the observers.
The minimum interval between the evaluations of the same
patient was 30 days. The observers could use the zoom tool up to
three times to determine the calcication stage according to the
mineralization diagrams proposed by Demirjian et al. [8]. Verbal
and written instructions were made available to the observers.
Depending on the grade of development of all third molars, a score
on a scale from A to H was assigned: (A) calcication of certain
occlusal points without fusion; (B) fusion of the occlusal points of
mineralization; (C) end of the formation of enamel and beginning
of the deposition of dentine; (D) formation of the crown-enamel
cement junction; (E) the longitude of the root shorter than the
latitude of the crown; (F) the longitude of the root equal to or
greater than that of the crown; (G) the growth of the root stopped
and the apical orice remains open; (H) closure of the apical orice.
All third molars suitable for evaluation, irrespective of the
direction of eruption, were evaluated in the study. This was

performed using direct comparison of the appearance of each

third molar with Demirjian et al.s diagrams (Fig. 1). In cases
where there was doubt between two stages of mineralization, the
observers determined the least developed stage. Each stage of
mineralization was given a score ranging from 0 (A stage) to 7 (H
stage) for statistical analysis. 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.
2.1. Data analysis
The data collected regarding the Dermijian developmental
stage of each tooth was recorded along with the patients age.
Inter- and intraobserver reliability was assessed by Cohens Kappa
test using the data collected regarding Demirjians stage classication of the third molars. The relationship between age,
calcication stage, and tooth was adjusted using a multiple linear
regression model, where age was a response variable. Repeated
measures analysis of variance (ANOVA) was used for assessment of
average age in relation to calcication stages, gender and dental
elements. The signicance level was 0.05 (or 5%). Stata 9.2 and
Minitab 15 software were used for the statistical analysis.
3. Results
The sample comprised 2097 digital panoramic radiographic
images, of which 1150 (54.8%) belonged to female patients. The age
ranged from 6 to 22 years; the average age  standard deviation
was 15.0  3.4 years.
Table 1 shows the results of the Kappa test for the intra- and
interobserver evaluations. There was agreement ranging from
good to excellent in both evaluations.
Table 2 shows the results of adjustments for age using multiple
linear regression models for age, considering Demirjian stage,
gender and the interaction between gender and Demirjian stage for
each third molar as the predictive variables.
With these adjusted models, 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).
Regression lines with the correlation between different
Demirjian stages and the patients age according to the location
of each third molar are represented in Fig. 2. Fig. 3 shows the
correlation between Dermijian stage and chronological age
according to the patients gender.

Fig. 1. Representation of Demirjians eight stage diagram of mineralization.

C.B.R.B. Soares et al. / Forensic Science International 254 (2015) 1317

15

Table 1
Kappa test conducted for the evaluation of intra- and interobserver agreement.
Teeth

Evaluators

18 (n = 2097)

28 (n = 2.097)

38 (n = 2097)

48 (n = 2097)

Kappa

Kappa

Kappa

Kappa

Intraobserver
1
2

0.75
0.82

67
59

0.70
0.82

71
60

0.80
0.75

61
66

0.77
0.85

64
55

Interobserver

0.73

0.065

0.70

0.071

0.78

0.064

0.83

0.058

Table 2
Results of adjustments using multiple linear regression models.
Arcade

Age (years)

Coefcient

Standard error

P valuea

95% condence interval

Upper (tooth 18)

Stage
Gender
Gender  stage
Constant

1.13
0.24
0.04
9.73

0.04
0.25
0.05
0.18

<0.001
0.335
0.465
<0.001

1.061.20
0.25 to 0.73
0.06 to 0.13
9.3910.08

Upper (tooth 28)

Stage
Gender
Gender  stage
Constant

1.14
0.23
0.046
9.59

0.04
0.26
0.05
0.18

<0.001
0.363
0.378
0.000

1.071.21
0.27 to 0.74
0.06 to 0.15
9.239.56

Lower (tooth 38)

Stage
Gender
Gender  stage
Constant

1.12
0.04
0.10
9.87

0.04
0.25
0.05
0.18

<0.001
0.860
0.057
<0.001

1.051.19
0.44 to 0.53
0.003 to 0.20
9.5210.22

Lower (tooth 48)

Stage
Gender
Gender  stage
Constant

1.12
0.10
0.10
9.87

0.04
0.25
0.05
0.18

<0.001
0.694
0.064
0.000

1.051.19
0.37 to 0.58
0.01 to 0.19
9.5210.22

Student t test.

In this study, the third molars were chosen for evaluation

because they display individual development, matching maxillary
growth [12,29]. Furthermore, 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 [12,29]. The main
reason for choosing Demirjian et al.s [8] developmental stages was
because it is largely used in the English literature, which allows

Table 3
Estimated average age and the respective 95% condence interval according to
gender and Demirjian stage in the upper arcade.

Table 4
Estimated average age and the respective 95% condence interval according to
gender and Demirjian stage in the lower arcade.

4. 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

9.6
10.8
11.9
13.1
14.2
15.4
16.5
17.7

9.49.9
10.611.0
11.712.1
12.913.3
14.114.4
15.215.5
16.416.7
17.517.9

10.1
11.2
12.3
13.5
14.6
15.8
16.9
18.1

9.810.3
11.011.4
12.212.5
13.313.7
14.514.8
15.715.9
16.817.1
17.918.3

Lower right

A
B
C
D
E
F
G
H

9.7
10.8
12.0
13.2
14.3
15.5
16.7
17.8

9.49.9
10.611.1
11.812.2
13.013.3
14.214.5
15.315.7
16.516.8
17.618.0

10.2
11.3
12.5
13.7
14.8
16.0
17.2
18.3

9.910.4
11.111.6
12.312.7
13.513.8
14.715.0
15.916.2
17.017.3
18.218.5

Upper left

A
B
C
D
E
F
G
H

9.5
10.7
11.8
13.0
14.1
15.3
16.5
17.6

9.29.8
10.410.9
11.612.0
12.813.2
14.014.3
15.215.5
16.316.6
17.417.8

9.9
11.1
12.3
13.4
14.6
15.7
16.9
18.1

9.710.2
10.911.3
12.112.4
13.313.6
14.414.7
15.615.9
16.817.1
17.918.3

Lower left

A
B
C
D
E
F
G
H

9.7
10.8
12.0
13.2
14.3
15.5
16.7
17.9

9.49.9
10.611.1
11.812.2
13.013.3
14.214.5
15.415.7
16.516.9
17.618.1

10.1
11.3
12.5
13.6
14.8
16.0
17.2
18.3

9.910.4
11.111.5
12.312.7
13.513.8
14.714.9
15.816.1
17.017.3
18.118.5

*
Minimum-maximum age limit in years with condence interval of 95% for
males.
**
Minimum-maximum age limit in years with condence interval of 95% for
females.

*
Minimum-maximum age limit in years with condence interval of 95% for
males.
**
Minimum-maximum age limit in years with condence interval of 95% for
females.

C.B.R.B. Soares et al. / Forensic Science International 254 (2015) 1317

16

25

Age (years)

20

15

10

5
A

D
E
Demirjian stage
Quadrant 1
Quadrant 3

Quadrant 2
Quadrant 4

Fig. 2. Correlation between Demirjian stage (x axis) and chronological age (y axis),
according to the quadrant where the third molar is located.

25

20

15

10

5
A

Demirjian stage
Male

Female

Fig. 3. Correlation between the Demirjian stage (x axis) and chronological age (y
axis) according to the patients gender.

comparisons between the dental development of the studied

population with the populations from other countries. In addition,
it is an easy method to apply.
Dental mineralization is a highly valuable tool for the
estimation of age. However, 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 are a few studies that used
a sample similar to the one used in this study [3,14,30,31]. The
research conducted by Olze et al. [14] was the only one to compare
samples of different populations (from Japan and Germany).
The reliability of the method is evaluated from two perspectives: the proximity of dental age to the patients chronological age
and the reproducibility of intra- and interobserver assessments. In
this study, the reliability of Dermijians method was tested and
presented agreement ranging from good to excellent for both
evaluations, as happened in Belgium [13], England [1], Brazil
[23,32], Turkey [33], China [30] and Colombia/Mexico [34].
However, in the study conducted by Teivens et al. [9] in Sweden,
there was no intra- and interobserver reliability using this method.
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.
In this study, there was a correlation between the dental
development of third molars and chronological age, corroborating
previous studies [2,3,1820,23,31,32,34]. On the other hand, other
studies did not verify this correlation [6,12,16].

The lines displayed in Figs. 2 and 3 are practically coincidental,

which means that the same regression equation can be used to
determine the patients age regardless of the third molar that is
going to be evaluated and the patients gender. Each stage was
codied by a number so they could be inserted into the formula.
Stage A was equivalent to zero; stage B, equivalent to 1; stage C,
equivalent to 2 and so forth up to stage H. The following regression
equation was found: 9.8 + (1.2  stage).
In previous studies, females were found to display earlier dental
development than males [9,12,35]. However, Gunst et al. [13],
Meinl et al. [18], Heras et al. [19], Olze et al. [14], de Araujo et al.
[32], de Oliveira et al. [23], Jung and Cho [31] and Costa et al. [34]
veried earlier apical closure in males. Male precocity was also
found in this study; there was in average difference of 5 months in
age between genders for each calcication stage. According to the
formula generated Fig. 3, males tend to develop earlier compared
with females. These differences in dental development between
genders are only visible after the age of 5 years, but each gender
has its own regression formula [4]. This also occurred in previous
studies [2,8,36,37]. According to the studies by Nolla [7], Orhan
et al. [2], Araujo et al. [20], de Araujo et al. [32] and de Oliveira et al.
[23], there is no difference between the average age for
calcication stages in relation to gender. However, in a study
conducted by Rai et al. [35], there was a signicant difference in
third molar development in relation to gender for Demirjian stages
D and G.
In this study, there was no difference between third molars in
agreement with other research on a Brazilian [20,23,39], African
[15], Turkish [2] and Korean sample [31]. Regarding the average
age for the calcication stages, in the present study, the average
age for stage A was 9.8 years, which was lower than among a
Turkish sample (12 years) [40]. In contrast, the average age higher
than among a Spanish sample (6.07 years) [41], Brazilian (9.16
years) [32] and a Korean sample (9.86 years) [31]. For stage H, in
this study the age average was 17.9 years in concordance with de
Araujo et al.s study [32], which also assessed a Brazilian
population (18.53 years); for German, Japanese [42], African
[15], Turkish [41], Korean [31] and Colombian/Mexican [34]
people, the third molar teeth were found at an average age >21
years.
As veried in the results in relation to the average age at several
calcication stages, there is great variability in the literature.
Therefore, indiscriminate use of idealized tables of calcication for
every population is not appropriate, because there are different
characteristics among the worlds populations [10]. Thus, the study
of age estimation by teeth mineralization in different population
groups is important.

5. Conclusion
There is reliability in Demirjian et al. [8] developmental stages
for the Brazilian population. Estimation of patients age according
to the mineralization stages of third molars is possible. There is no
difference between the average age and the calcication stage of
third molars from different locations and in both genders,
therefore it is possible to determine chronological age by the
development stage of just one third molar. For correct use of this
method in the Brazilian population, correction factors, such as
those presented in this study (regression equation), must be
applied.

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