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ELSEVIER Forensic Science International 175 (2008) 23-26 __ Interoatioval
www.elsevier.com/locate/forscjjnt

Dental age assessment using Demirjian's method on

northern Turkish children
Emine Sen Tunc , Alp Erdin Koyuturk
Department of Pediatric Dentistry, Faculty of Dentistry, University of Ondokuz Mayts, 55139 Samsun, Turkey
Received 9 March 2007; received in revised form 27 April 2007; accepted 27 April 2007
Available online 7 June 2007

Abstract
Tooth formation is widely used to assess maturity and to predict age. 'Within clinical dentistry, such information aids in diagnosis and treatment
planning. Numerous methods exist that allow either the prediction of age or an assessment of maturation. One widely used method was first
described in 1973 by Demitjian et al., as based on a large number of French-Canadian children. The purpose of this study was to evaluate the
applicability of Demirjian's method for dental age estimation and for description of mandibular permanent tooth formation in northern Turkish
children, 4-12 years of age.
Panoramic radiographs of 900 healthy, northern Turkish children, 4-12 years of age were examined with Demiijian's method. Panoramic
radiographs were scored by one examiner. Dental age was compared to chronological age by using a paired t-test. The median age for individual
teeth for each stage was calculated.
The northern Turkish children were generally advanced in dental maturity compared with the children in Deniiijian's sample. The mean
difference between dental and chronologic ages of boys and girls varied from 0.36 to 1.43 years and 0.50-1.44 years, respectively.
The standards of dental age described by Denthjian et al. in 1973 and 1976 may not be suitable for northern Turkish children. Each population
of children may need their own specific standard for an accurate estimation of chronological age.
© 2007 Elsevier Ireland Ltd. All rights reserved.

Keywordc: Age estimation; Dental age calculation; Panoramic radiographs; Demirjian's method

1. Introduction Several methods for the determination of dental develop-

Age estimation plays an important role in forensic medicine,
pediatric endocrinology, archaelogy, and clinical dentistry.
Dental maturity, expressed as a dental age, is one of the age
estimation methods. Dental age is of particular interest to the
pedodontist and orthodontist as such information aids in
diagnosis and treatment planning [1,2].
The dental age of children can be based on dental emergence
or on the stages of tooth formation observed in radiographs. The
second method is superior to the first because tooth emergence
is a short period, which is determined by the time of appearance
of the tooth in the mouth [3] as altered by local factors, such as a
lack of space [4], and systemic factors, such as nutritional status
[5,6].
* Corresponding author. Tel.: +90 3623121919/3008; fax: +90 3624576032.
E-mail address: sentunc@yahoo.com (E.S. Tune).
ment from radiographs have been described [4,7-12]. Most of
these are based on a comparison of the radiographic
development of teeth with standard charts compiled from a
large number of persons, usually in a well-defined geographic
region [2]. One widely used method is that of Demirjian et al.,
first described in 1973 and based on a large number of French-
Canadian children [7]. The method evaluates the development
of seven mandibular teeth from a panoramic radiograph and
calculates dental age. The difference between dental age and
known chronological age is of interest, indicating an
advancement or delay compared to the standard. 3
Demirjian's method has been tested in different populations.
The use of Demirjian's maturity scale has demonstrated
differences between several worldwide groups [1-3,13-18], as
well as between geographical areas or cities within the same
country [19,20]. This method has been tested in a group of 419
northwestern Turkish children and published in a national
journal [17], so that little is known about this method's
applicability in Turkish children. For that reason, the aims of

0379-0738/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.l016/j.forsciint2007.04.228

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24 E.S. Tunc, A.E. Koyuturkl Forensic Science international 175 (2008) 23-26

Table 1 provides an estimate of the subject's dental maturity, measured on a scale from 0
Distribution of age and gender in the study population to 100. The overall maturity score is then converted to a dental age by using
available tables and/or percentile curves. Standards are given for each gender
Age (years) Male Female Total
separately [7.8].
4-49 10 10 20
5-5.9 21 18 39 2.3. Assessment of the study sample
6-6.9 42 34 76
7-7.9 72 67 139 All assessments were performed in a darkened room with a radiographic
8-8.9 81 86 167 illuminator to ensure contrast enhancement of tooth images. The stages of seven
9-9.9 78 89 167 permanent teeth, excluding M3, in the mandible were assessed from panoramic
10-10.9 77 56 133 radiographs. After training and calibration, all radiographs were scored by the
11-11.9 51 49 100 second observer without knowing age or gender.
12-12.9 25 34 59 For each gender and age group in the study sample, the mean difference
457 443 900 between the dental age was determined from the French-Canadian standards
Total
[7,8] and the actual chronologic age of the child was calculated. A paired t-test
was used for statistical analysis.
In describing the formation of the mandibular permanent teeth, the same
this study were to evaluate the applicability of Demirjian's data were used. The mean and standard deviation was calculated separately for
method for dental age estimation and also describe the each stage of individual teeth for boys and for girls.
chronology of mandibular permanent tooth mineralization in
northern Turkish children, 4-12 years of age. 2.4. Reproducibility

To assess reproducibility, 50 randomly selected radiographs were re-exam-

2. Materials and methods
2.1. Sample
In this retrospective study, panoramic radiographs of 900 Caucasian Turkish
children of known chronological age and gender were selected; 457 were males
and 443 were females and their ages ranged from 4 to 12 years. The radiographs
of healthy children were randomly selected from patients attending the Depart-
ment of Pediatric Dentistry of the Faculty of Dentistry of the Ondokuz Mayis
University in Samsun, Turkey. Table 1 shows the distribution of panoramic
radiographs by gender and age. The criteria for inclusion in the sample were the
availability in their clinical records of a panoramic radiograph of adequate
quality, and no history of medical or surgical disease that could affect the
presence and development of mandibular permanent teeth. Exclusion criteria
included: image deformity affecting mandibular permanent tooth visualization,
hypodontia, or gross pathology. The chronological age for each subject was
calculated by subtracting the date of the panoramic radiograph from the date of
birth after having converted both to a decimal age.
2.2. Dental age estimation method
The dental age estimation method is based on the development of the seven
left permanent mandibular teeth. Tooth formation is divided into eight stages,
and the criteria for the stages are given for each tooth separately, in detailed
written description and supplementary illustrations. Each stage of the seven
teeth is allocated a biologically weighted score, and the sum of the scores
ined 2 months after the initial examination by the second observer. The
percentage agreement of the two readings was calculated by examining 50
radiographs of 350 teeth. The agreement between duplicate scores of the
mineralization stages of 350 teeth was 87%. The difference between the two
scores did not exceed one stage for any tooth.
3. Results
3.1. Comparisons between dental and chronologic ages
Results showed a strong linear correlation between dental
and chronologic ages for males (r2 = 0.78) and for females
(r2 = 0.77). Both genders were advanced in dental maturity as
compared with the reference samples. Table 2 shows the 71
difference between the dental ages estimated according to
Demirjian's standard (DA) and chronologic age (CA). The
mean difference between the dental and the chronologic ages
ranged from 0.36 to 1.43 years in the boys and from 0.50 to 1.44
years in the girls.
The largest discrepancy between the estimated and
chronologic ages was observed in both genders in the 5-6.9
year age groups, except for the 12-year-old girls.

Table 2
Differences between dental age determined by using the standards by Demirjian et al. and chronologic age

Age groups (years) Girls Boys

n DA-CA S.D. Min. Max. p n DA-CA S.D. Min. Max. p

4-4.9 10 0.59 1.29 -0.33 1.51 0.182 10 0.81 0.75 0.26 1.35 0.008
5-5.9 18 1.32 0.81 0.91 1.72 0.000 21 1.43 0.49 1.20 1.66 0.000
6-6.9 34 1.12 0.57 0.92 1.32 0.000 42 1.18 0.35 1.07 1.29 0.000
7-7.9 67 0.88 0.79 0.68 1.07 0.000 72 0.72 0.62 0.58 0.87 0.000
8-8.9 86 0.50 0.82 0.32 0.67 0.000 81 0.50 0.94 0.29 0.71 0.000
9-9.9 89 0.65 1.15 0.41 0.89 0.000 78 0.55 1.05 0.31 0.79 0.000
10-10.9 56 0.75 1.02 0.48 1.03 0.000 77 0.50 1.04 0.27 0.74 0.000
11-11.9 49 0.95 1.46 0.53 1.37 0.000 51 0.64 1.04 0.34 0.93 0.000
12-12.9 34 1.44 1.20 1.02 1.86 0.000 25 0.36 1.50 -0.25 0.98 0.238

DA: dental age; CA: chronologic age.

 E.S. Tunc, A.E. Koyuturk/Forensic Science International 175 (2008) 23-26A 25

Table 3 / (/,lY S
Mean and standard deviation for the mineralization stages of mandibular permanent teeth for boys

Tooth A B C D E F G H

I1 4.46 ± 0.55 5.61 ± 0.85 6.96 ± 0.82 7.95 ± 0.88 10.00+1.31

12 5.03+1.32 6.33+0.97 7.56 ± 0.81 8.81+0.98 10.45±1.18
C 4.00±0.70 5.86 ± 1.11 7.55 ± 1.05 9.72 ± 1.22 11.37 ± 0.66 11.83+0.60
PM! 4.10+0.84 5.11+0.88 6.24+1.08 8.14+1.19 10.22 ± 1.14 11.29+0.69 11.59 ± 0.75
PM2 4.36 ± 0.75 5.15+0.96 5.86 ± 1.46 6.80 ± 1.14 8.47+1.25 10.57+1.12 11.49+0.70
Ml 4.60 ± 0.80 5.15 ± 0.51 6.57+0.76 8.32 ± 1.07 10.43 ± 1.16
M2 4.70 ± 0.80 5.91+1.97 5.90 ± 1.03 7.81 ± 1.16 9.85 ± 0.98 11.06 ± 0.91 11.67 ± 0.60

Table 4 V,- *
Mean and standard deviation for the mineralization stages of mandibular permanent teeth for girls /

Tooth A B C D E F G H

I1 4.65 ± 0.35 5.37 ± 0.79 6.83 ± 0.77 7.84+0.89 9.68 ± 1.40

12 4.74+0.49 6.19 ± 0.88 7.43 ± 0.85 8.58+0.98 10.22 ± 1.25
C 4.60 ± 0.54 5.48 ± 0.79 7.06 ± 0.85 8.95±1.06 10.66+0.94 10.55 ± 0.81
PM1 4.63 ± 0.54 5.97 ± 0.81 7.98+1.04 9.71 ± 1.04 10.94 ± 0.88 11.83 ± 0.63
PM2 4.57 ± 0.33 6.17 ± 1.22 6.68 ± 1.13 8.32 ± 1.14 10.10 ± 1.09 11.55 f 0.73
MI 5.01 ± 0.82 6.14±0.59 8.03 ± 1.01 10.19±1.22
M2 4.97 ± 0.56 4.90 ± 0.84 5.73 ± 0.82 7.84 ± 1.10 9.53 ± 0.95 10.64±0.97 11.44 ± 0.87

3.2. The an es of formation of mandibular
permanent teeth 9 common finding of Demirjian's method overestimated age
Descriptive statistics (me and standard deviation) for
individual stages of each tooth are shown in Tables 3 and 4.
Nearly all the mean ages of attainment of tooth developmental
stages were earlier in girls as compared to boys.
4. Discussion
The methods for determination of a child's growth and
development are of great value from both medical and
odontologic points of view [2]. Tooth formation is widely
used to calibrate growth and maturity. Numerous methods exist
that allow either the prediction of age or an assessment of
maturation [4,7-12]. Demirjian's method is one of the simplest,
ti(►„4 1 most practical, and widely employed methods to predict age
and maturation [21,22], as it is comprised of clearly defined
)l >V'~
changes in shape that do not require speculative estimation
[23]. Also, Demirjian's standard charts are an attempt to
provide an international means of evaluating the dental
maturity for children [17]. Various investigators have applied
and modified this method to their own populations. The
investigations using Demirjian's method on several ethnic and
geographical groups showed some changes in dental formation
[1-3,13-20]. For that reason, the aim of this study was to
appraise the suitability of Demirjian's method for assessing
dental maturation in northern Turkish children. This informa-
tion aids us in comparing the status of dental maturity of our
population with those of other populations, which were
previously tested.
Comparison of results between northern Turkish children
and the French-Canadian reference sample in the present study
showed that the northern Turkish children were generally
somewhat advanced in dental maturity. As in our study, a
[1-3,13-18,24]. Liversidge et al. [15] believe that the over-
estimation in dental age in recent findings using Demirjian's
method in different populations may be partly explained by a
positive secular trend in growth and development during the last
25 years.
In our study, the mean difference between the dental age and
the chronologic age ranged from 0.36 to 1.43 years in the boys
and from 0.50 to 1.44 years in the girls. This finding is in
accordance with a previous Turkish study [17]. The mean
difference observed in this study sample were, however,
generally higher than that of the reported in the other Turkish
study. The greatest mean difference was 1.44 years, compared
with 0.73 years reported in the study of Mentes et al. [ 17]. This
difference has been attributed to both regional differences
within the same country and the sample size.
Although Hagg and Mattson [24] suggested that Demirjian's
method affords a high degree of reliability and precision,
particularly in younger children, the largest discrepancy
between dental and chronologic ages was observed in both
genders in the 5-6.9 year age group in our study. This result was
in accordance with another Turkish study [ 17] and two of
different population-based studies [15,18]. This situation was
explained due to growth prediction uncertainties in younger age
group children [18].
The discrepancy between dental and chronologic ages in 12-
year-old girls was higher than the other age groups of both
genders in our study. This higher overestimation of the dental
age observed in the older girls in this study was probably due to
the pre-pubertal or pubertal growth changes pertinent during
this age period.
One must remember that any difference found between the
standard population and the sample population can be attributed

26 E.S. Tunc, . . Koyururk/Forensic Science International 175 (2008) 23-26
to many variables, including precision of the method, age
structure of the sample, sample size, statistical approach, and
biological variation of individual children [1]. The interpreta-
tion of results from differing dental growth standards is
hindered by these factors. This is overcome by direct
comparison [19] or by calculating age-of attainment data for
each group [25,26]. For this reason, the other aim of this study
was to describe the chronology of mandibular permanent teeth
mineralization in northern Turkish children.
Demirjian's classification system has been widely used to
determine the chronology of third molar mineralization
[22,23,27-30]. Similar to our study, Liversidge and Speechly
[26] described the chronology of mandibular seven permanent
teeth. The mean age results for the mandibular seven permanent
teeth for each stage showed that in nearly all stages of
evaluations, the girls were ahead of the boys, as in Liversidge
et al. [26]. However, northern Turkish children were generally
more advanced than Liversidge's British children sample.
Tooth development is a continuous process, but determining
the end point of tooth development is very difficult. Thus, the
)2 calculation of a mean age for each stage is difficult. On this
J note, further research is needed to determine the apex closure
stage of teeth.
5. Conclusions
Northern Turkish children are significantly more advanced
in dental maturity compared to Demirjian's French-Canadian
sample. The standards of dental maturation described by
Demirjian et al. in 1973 and 1976 may not be suitable for
northern Turkish children. This data supports the need for
population-specific standards.
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