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The Assessment and Interpretation of Demirjian, Goldstein and Tanner's Dental

Maturity

Article  in  Annals of Human Biology · October 2012

DOI: 10.3109/03014460.2012.716080 · Source: PubMed

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 Annals of Human Biology, 2012; Early Online: 1–20
Copyright q Informa UK, Ltd.
ISSN 0301-4460 print/ISSN 1464-5033 online
DOI: 10.3109/03014460.2012.716080
REVIEW
The assessment and interpretation of Demirjian, Goldstein and Tanner’s
dental maturity
Helen M. Liversidge
Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Institute of Dentistry, Turner Street,
London E1 2AD, UK
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12
Background: A frequently reported advancement in dental
maturity compared with the 50th percentile of Demirjian,
Goldstein and Tanner (1973, Hum Biol 45:211–27) has been
interpreted as a population difference.
Aim: To review the assessment and interpretation of Demirjian
et al.’s dental maturity.
Subjects and methods: Dental maturity of boys from published
reports was compared as maturity curves and difference to the
50th percentile in terms of chronological age and score. Dental
maturity, as well as maturity of individual teeth, was compared
For personal use only.
in the fastest and slowest maturing groups of boys from the
Chaillet database.
Results: Maturity curves from published reports by age
category were broadly similar and differences occurred at the
steepest part of the curve. These reduced when expressed as
score rather than age. Many studies report a higher than
expected score for chronological age and the database
contained more than expected children with scores . 97th
percentile. Revised scores for chronological age from this
database were calculated (4072 males, 3958 females, aged
2.1 –17.9).
Conclusion: Most published reports were similar to the
database smoothed maturity curve. This method of dental
maturity is designed to assess maturity for a single child and is
unsuitable to compare groups.
Keywords: Demirjian method, tooth formation, population
difference
INTRODUCTION
The aim of this paper is to review the assessment and
interpretation of dental maturity using the method
described by Demirjian et al. (1973). The assessment of
the developing dentition is considered and a short history of
measuring dental maturity, dental age and tooth staging are
described. Demirjian et al.’s method of dental maturity is
Correspondence: Helen M. Liversidge, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Institute of
Dentistry, Turner Street, London E1 2AD, UK. Tel: þ 44 207 882 8619. Fax: þ 44 207 377 7419. E-mail: h.m.liversidge@qmul.ac.uk
(Received 23 July 2012; accepted 24 July 2012)
1
detailed, an example illustrated and the strengths and
limitations discussed. This review seeks to explain the
meaning of significant group differences in dental maturity
and attempts to clarify contradictory findings from the
literature. A number of questions are discussed and
illustrated. An example of a fast and slow maturing
group from the Chaillet database is examined in several ways
showing the influence of sample size, age range and how
dental maturity is expressed (years or score). Dental
maturity curves from published reports for boys are
compared. Differences in dental maturity to the 50th
percentile peak at the steepest part of the maturity curve.
This suggests that significant group differences ( p , 0.01)
in average dental maturity do not reflect population
differences but are due to a number of factors including
sample size, weighted values, slope of the curve and how
differences are expressed. This suggests that Demirjian et al.’s
dental maturity method is (1) universally suitable to assess
dental maturity of a boy or girl, (2) unsuitable to compare
maturity at the group level and (3) remains the best method
to assess the developing dentition of an individual child.
WHY MEASURE DENTAL MATURITY?
Teeth can be used as a measure of developmental age as they
develop from the middle trimester in-utero until late teens
or early 20s. Describing normal variation allows us to
recognize individuals who are advanced or delayed in their
maturation, although in contrast to other measures of
somatic growth and development, we cannot influence the
maturing teeth. Describing and quantifying dental maturity
helps us understand genetic and environmental factors that
influence the timing and rate of growth of teeth and jaws.
This knowledge allows us to predict how the dentition might
develop in children with anomalies of tooth number, size or
shape. Measuring dental maturity allows us to compare the
 2 H. M. LIVERSIDGE
developing dentition or individual teeth in a single child
over several years or to compare an individual child to a
reference group. Having a measure of dental maturity allows
us to compare groups to investigate regional or ethnic
differences. Calculating dental age allows us to infer
chronological age of archaeological skeletal material,
forensic cases, young athletes and children and young
adults with no recorded age. Teeth possess an intrinsic
history of childhood and maturation and scrutiny of fossil
teeth or tooth fragments provide clues about life history.
HOW IS DENTAL MATURITY ASSESSED?
Dental maturation is a complex sequence of events from
initial mineralization of a tooth, crown formation, root
growth, eruption of the tooth into the mouth and root apex
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12
maturation. Normally 20 deciduous and 32 permanent teeth
develop in a sequence that begins before birth and continues
throughout the growth and development of the individual
to early adulthood. Teeth are usually symmetrical in their
development, both within the jaw (left and right sides) and,
for the most part, between the jaws (maxillary and
mandibular teeth). A specific tooth on the left side of the
mandible is usually at the same level of formation as its
counterpart on the right side and, similarly, a maxillary
tooth and its opposite in the mandible are similar in
For personal use only.
formation stage. Assessing one side of one jaw is therefore
sufficient to measure maturity and, as the mandibular teeth
are more easily visualized on a radiograph, these teeth have
been most commonly studied.
Measuring dental maturity in the living can be done
by assessing individual developing teeth or by combining
information from various teeth from a dental radiograph.
The development and growth of a tooth from cusp tip to
root apex can be divided into arbitrary maturity events of
crown and root stages. Many early studies list stages and give
line drawings dividing tooth formation into stages that
number from 3 – 27. One of the first was Gleiser and Hunt
(1955), who divided first molar formation into 15 stages
that include fractions of crown and root formation
illustrated with a line drawing. Many studies have adapted
these stages for other tooth types (Garn et al. 1958; Fanning
1961; Moorrees et al. 1963; Haavikko 1970; Fanning and
Brown 1971, among others). Tooth stages from Nolla (1960)
are ordinal from 1 – 10 for each tooth type, although
fractions between these values are optional. A different
approach scored crown and root maturity of an individual
tooth from 0 – 2, with crown complete being 1 and apex
maturity being 2 (Simpson and Kunos 1998). The interval
between maturity events has also been scored (Kullman et al.
1992). Some studies include a measure of eruption as well as
crown and root formation (Bengston 1935; Garn et al. 1958;
Schopf 1970). Some of the early studies were longitudinal
and assessment of crown or root fractions can be more
reliably estimated retrospectively, if the mature, fully formed
tooth can be seen.
The first study to provide written descriptive criteria
as well as a line drawing and example of a radiograph was
Demirjian et al. (1973), updated in Levesque and Demirjian
(1980). The stages were defined without reference to the
fully mature tooth and avoid the subjective estimation of
fractions by comparing relative measures and shape changes.
Guidelines were provided for the order of tooth assessment
in the jaw, which root of multi-rooted teeth to assess and
what to do if a tooth appears between stages.
Tooth stage assessment requires training and calibration
with an experienced rater to ensure good reliability.
Reliability of tooth stage categories can be calculated using
Cohen’s kappa where maximum agreement is 1 and values
over 0.75 or 0.81 have been interpreted as excellent (Sim and
Wright 2005). Kappa values are influenced by the number of
categories and their probability and ideally a training sample
should include sufficient numbers of each tooth category
and disagreement should be no more than one stage.
Tooth formation can also be assessed quantitatively.
Tooth length of individual permanent teeth, dimensions and
ratio’s of root length and apex width have all been used as a
measure of maturity or to estimate age (Israel and Lewis
1971; Carels et al. 1991; Mörnstad et al. 1994; Liversidge and
Molleson 1999; Cameriere et al. 2006).
HOW IS DENTAL MATURITY MEASURED?
Dental maturity can be quantified by counting the number
of teeth and relating this to chronological age or relating the
timing of tooth stage(s) to age. The number of erupted teeth
in the mouth is one measure of maturity and tooth eruption
into the mouth occurs in phases (between , 6 – 26 months
and 6 –13 years excluding third molars). Several other
eruption stages have been documented with reference to the
alveolar bone level or occlusal level of fully erupted teeth.
Dividing tooth formation into discrete maturity events such
as crown and root stages provides the opportunity to assess
maturity from before birth up to early adulthood. Dental
maturity can be viewed as the whole dentition by looking at
all developing teeth in the jaws, one quadrant (one side of
the jaw) or as several teeth or a single tooth (see reviews by
Demirjian 1986; Smith 1991; Liversidge 2003).
Dental age of an individual is the average chronological
age at which the state of the developing dentition or the
tooth stage is reached. Methods are designed so that dental
and real ages coincide in a child who matures as an average
developer. If dental age is older or younger than
chronological age, a child can be considered advanced or
delayed compared to the average child. This presents a
problem when chronological age is estimated from maturity
because at present we cannot tell if an individual is maturing
at an average rate or if a child is advanced or delayed
compared to the average. Age can be expressed either as
a category or a continuum from birth to late adolescence
or early adulthood, if the third molar is included. Pictorial
references depict tooth formation in age categories showing
tooth formation or key events (Schour and Massler 1941;
Nanda and Chawla 1966; Ubelaker 1978; Kahl and Schwarze
1988; AlQahtani et al. 2010; Blenkin and Taylor 2012).
A more precise dental age can be obtained by assessing
Annals of Human Biology

individual teeth and using methods that combine
information from several teeth. These can be divided into
methods that express dental maturity as a single score from
stages of several teeth (Nolla 1960; Wolanski 1966;
Demirjian et al. 1973; Roberts et al. 2008) or dimensions
and ratios from digital radiographs (Mörnstad et al. 1994;
Cameriere et al. 2006). Other methods are tooth-specific,
where dental age can be calculated from one or more
individual developing teeth, discussed in more detail below.
Differences in the average timing of tooth stages in males
and females are small in childhood, with girls being
advanced compared to boys (Garn et al. 1958; Moorrees et al.
1973; Demirjian and Levesque 1980).
EARLY REPORTS EXPRESSING DENTAL MATURITY AS
A SCORE
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12
One of the first reports to illustrate maturity of the
developing dentition to age was Nolla (1960). She allocated
scores to individual tooth stages and presented results by
tooth type, as well as the sum of scores at specific ages.
Leinonen et al. (1972) also plotted the sum of scores and age,
while Wolanski (1966) illustrates z-scores and the sum of
scores for boys and girls. These studies all used an ordinal
scale that assumed a linear progression of tooth stages
through time. This creates difficulties as neither the time nor
For personal use only.
the proportion of tooth formed between stages is equal
and the score itself indicates only relative maturity; a tooth
with a larger score is more mature than a smaller score.
The second difficulty with numbering categories is the
interpolation between scores with inappropriate calculation
of average ‘score’ for chronological age.
DEMIRJIAN, GOLDSTEIN AND TANNER’S DENTAL
MATURITY
Tanner’s contribution to maturity assessment was colossal.
He developed, among other things, a biologically-based
system of measuring maturity, where selected individual
maturity events were assessed, mathematically weighted and
summed to produce a single maturity score in points that
converted to biological age. This involved longitudinal
assessment of a large number of children over many years.
Maturity score is a percentage of maturity in terms of
chronological age and indicates the position of a child
relative to the beginning and end of the maturation process.
It is a clinical tool to assess the maturity of an individual
child and locate the position of a child on their journey
toward maturity. It also allows comparison with other
children of the same sex and score/age as well as assessing
individual change in maturity over time. In this regard,
Demirjian et al.’s method of dental maturity has not been
improved on.
After assessing the mandibular left seven teeth, the sex-
specific values for each stage are summed and this dental
maturity score expresses maturity as a percentage. The
relationship between maturity score and chronological age
forms a sigmoid curve from 10% to fully mature, excluding
q Informa UK, Ltd.
DENTAL MATURITY 3
the third molar. The 50th percentile dental maturity score
represents the average chronological age of the average
reference boy/girl at that age. Variation in maturity score
and age is illustrated showing 10th, 50th and 90th percentiles
for maturity score and age (Demirjian et al. 1973), with later
addition of 3rd and 97th percentiles (Demirjian and
Goldstein 1976). If the dental maturity score is larger than
the 50th percentile, dental age is said to be advanced
compared to the reference and delayed if less.
HOW IS DENTAL MATURITY CALCULATED?
First, each left mandibular tooth (excluding the third molar)
is assessed. The order of tooth rating is second molar (M2),
first molar (M1), second premolar (P2), first premolar (P1),
canine (C), lateral incisor (I2) and central incisor (I1). Tooth
stages are selected using the descriptive criteria reproduced
in Table I with the help of the radiographic images and a line
drawing of each stage by tooth type (Figure 1). Some tooth
stages have several criteria and a tooth is considered to have
reached the stage if the first of two are met, or the first two of
three are met. If the tooth appears to be between stages, the
earlier stage is chosen. No magnification is required and a
pair of dividers is sufficient to compare relative length of
crown and root. If the molars have reached later root stages,
the distal root is assessed.
Secondly, after identifying seven tooth stages, the
corresponding values from Table II are summed, resulting
in a dental maturity score. This is compared to the reference
by consulting a table of scores for chronological age in 0.1
year intervals from 3 – 16 years or from the percentile curves
(Demirjian et al. 1973). If the tabulated age, given the score,
for a particular child, is identical to the chronological age of
the child, the child is considered average in their dental
development. If the tabulated age is older than the
chronological age of the child, then the child is considered
to have a dental age older than chronological age and
vice versa.
An example of how dental maturity is calculated for a boy
is shown in Figure 2. This shows part of a panoramic dental
radiograph, the seven tooth stages, their weighted values and
how the dental maturity score relates to chronological age.
The variation in age for that score and the variation in score
of the boy’s chronological age are arrowed. This boy has a
lower dental maturity score for age compared to the 50th
percentile. His dental age is 8.75 and he is slightly delayed
compared to the average boy.
STRENGTHS
The strength of Demirjian et al.’s method of dental maturity
is that it quantifies dental maturity and relates this to
chronological age. This provides a clinical tool to assess the
developing dentition of an individual child, comparing
the child to the 50th percentile. Dental maturity score
corresponds to age and comparing this with known
chronological age of the child shows whether he/she is
 4 H. M. LIVERSIDGE

Table I. Tooth stage descriptions.

Stage Descriptions
A In both uniradicular and multiradicular teeth, a beginning of calcification is seen at the superior level of the crypt in the form of an
inverted cone or cones. There is no fusion of these calcified points.
B Fusion of the calcified points forms one or several cusps which unite to give a regularly outlined occlusal surface.
C a. Enamel formation is complete at the occlusal surface. Its extension and convergence towards the cervical region is seen.
b. The beginning of a dentinal deposit is seen.
c. The outline of the pulp chamber has a curved shape at the occlusal border.
D a. The crown formation is complete down to the cemento– enamel junction.
b. The superior border of the pulp chamber in the uniradicular teeth has a definite curved form, being concave towards the cervical
region. The projection of the pulp horns, if present, gives an outline shaped like an umbrella top. In molars the pulp chamber has a
trapezoidal form.
c. Beginning of root formation is seen in the form of a spicule.
E Uniradicular teeth:
a. The walls of the pulp chamber now form straight lines, whose continuity it broken by the presence of the pulp horn, which is larger
than in the previous stage.
b. is less than the crown height.
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12

Molars:
a. Initial formation of the radicular bifurcation is seen in the form of either a calcified point or a semi-lunar shape.
b. is still less than the crown height.
F Uniradicular teeth:
a. The walls of the pulp chamber now form a more or less isosceles triangle. The apex ends in a funnel shape.
b. The root length is equal to or greater than the crown height.
Molars:
a. The calcified region of the bifurcation has developed further down from its semi-lunar stage to give the roots a more definite and
distinct outline with funnel shaped endings.
b. The root length is equal to or greater than the crown height.
G The walls of the root canal are now parallel and its apical end is still partially open (Distal root in molars).
H a. The apical end of the root canal is completely closed (Distal root in molars).
For personal use only.

b. The periodontal membrane has a uniform width around the root and the apex.
Reprinted from Appendix in ‘A New System of Dental Age Assessment’ by Demirjian, A., Goldstein, H., Tanner, J. M. (1973) Human Biology: The
International Journal of Population Genetics and Anthropology, 45 (2). Copyrightq 1973 Wayne State University Press, with the permission of Wayne
State University Press. Stage E point b updated as The root lenght reaches at least 1/3 of crown height for both uniradical teeth and molars (Levesque
and Demirjian 1980).

advanced or delayed compared to the 50th percentile or
average same-sex child.
The reference sample is based on a large number of
radiographs from a wide age range encompassing all teeth,
with the exception of the most variable tooth, the third
molar. Individual tooth reference data are published
separately (Demirjian and Levesque 1980; Levesque et al.
1981). A wide age range is particularly important to describe
the maturation of the developing dentition from as early an
age as is practical to maturity.
Tooth formation is divided into eight stages named A – H,
each defined by several descriptive criteria, in order of
importance that are illustrated with a radiographic image
for each tooth type and stage as well as a line drawing.
Maturity events were carefully selected, probably by virtue of
their reliability. This was a move away from the subjective
estimation of crown or root fractions to an objective
approach with criteria based on shape and relative length.
LIMITATIONS
The relationship between maturity score and dental age was
constructed to follow a sigmoid growth curve (Figure 2).
This is true for individual teeth (Dean 2010) but does not
apply to the sequential development of seven mandibular
teeth and has led to much confusion. The increase in score
with age is uneven over the age range and the slope of the
curve is steepest during the seventh year. The score increases
with age as teeth mature and the change in dental maturity
score at the 50th percentile is plotted against age in Figure 3
(left). Each dot is the change in score at 0.1 year intervals for
boys. It is clear that the increase in dental maturity score is
gradual except around age 7. The shape of the curve is
important when interpreting comparisons in dental
maturity between groups. Figure 3 (right) shows score
gain plotted against score. Comparing these shows the
non-linear relationship between maturity score and
chronological age and suggests that a sigmoid curve is
not ideal.
Dental maturity score ranges from just above 10% at age
2.5 to 98.4 and 100% at 16 (males and females, respectively).
This presents a problem as a proportion of very young
children (3 year olds) have scores below the minimum.
Ideally, maturity should be assessed from 0 – 100%. The
permanent dentition begins around birth and dental
radiographs of very young children are rare for practical
and ethical reasons and the reference sample lacks data from
the first few years of post-natal life. Maturity is attained
when seven teeth reach stage H and this corresponds to an
average ‘age’ of 16 with 3rd and 97th percentiles of 13.5 to
over 17. When an individual has seven teeth in stage H,
he/she has reached dental maturity. The concept of ‘time’
Annals of Human Biology
 DENTAL MATURITY 5

the reference study is a mixed-longitudinal nature, data are

treated as cross-sectional. Mean age entering tooth stages
represent the average for a group and individual duration
of how long a tooth is in a specific stage can only be
determined from longitudinal data. A further complication
is that early stages of tooth development are given low
weighted values and late stages are given high values. This
results in a single unit score change being associated with a
small age change at an early age and a large age change at
later ages. The values of individual tooth stages have no
inherent meaning but were selected to minimize disagree-
ment in maturity between different teeth. It is important to
remember that both the individual tooth stage values and
the dental maturity score are not parameters. Tooth values
are self-weighted quantities and the total dental maturity
score is an expression of maturity. Treating them as
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12

parameters has resulted in inappropriate statistical analyses

and interpretation of group comparisons, discussed in more
detail below.
The 50th age percentile can be read from tables or figures,
however the 3rd and 97th percentiles can only be estimated
from the figures and a discrepancy exists between
the tabulated and illustrated results in Demirjian and
Goldstein (1976) evident in (Figure 2).
For personal use only.

COMPARING MATURITY CURVES

Measuring dental maturity allows comparison to be made
between groups. This can be done by illustrating the
Figure 1. Tooth stages by tooth type—radiograph and line drawing. maturity curve across age categories and comparing it with
Descriptions of these stages are in Table I.
the 50th percentile value from Demirjian et al. (1973). Let us
look at the Chaillet database to explore whether maturity
and maturity is complex (see Cameron 2002, 2004). Dental
curves differ between groups. This collaboration from seven
age and dental years do not have the same meaning as countries combining data from several studies consists of
chronological age and years. The clock ticks at a different 9577 dental radiographs from healthy dental patients aged
pace and the unit of developmental time differs between
individuals. Some children will be dentally mature at the Table II. Sex-specific self-weighted values.
chronological age of 10, while others reach maturity at 17 Stage
(see Liversidge 2010b). Tooth A B C D E F G H
Maturity events are not evenly spread across the age Boys
range, partly because the continuous process of tooth M2 2.1 3.5 5.9 10.1 12.5 13.2 13.6 15.4
formation is divided into discrete tooth stages. Fifteen of M1 8.0 9.6 12.3 17.0 19.3
the 64 tooth stages are not given values as they occur prior to P2 1.7 3.1 5.4 9.7 12.0 12.8 13.2 14.4
age 3. Time between the stages is not uniform and some P1 3.4 7.0 11.0 12.3 12.7 13.5
C 3.5 7.9 10.0 11.0 11.9
stages are close together, while late root stages are widely I2 3.2 5.2 7.8 11.7 13.7
spaced. This is illustrated in Figure 4, where the mean age I1 1.9 4.1 8.2 11.8
entering tooth stages in boys is plotted for each tooth stage Girls
(data from Demirjian and Levesque 1980). Some stages M2 2.7 3.9 6.9 11.1 13.5 14.2 14.5 15.6
M1 4.5 6.2 9.0 14.0 16.2
(lateral incisor I2 stage D and E) are very close in age, others, P2 1.8 3.4 6.5 10.6 12.7 13.5 13.8 14.6
particularly M1 stage G and H, are far apart. This might be P1 3.7 7.5 11.8 13.1 13.4 14.1
influenced by the uneven age distribution of the sample, C 3.8 7.3 10.3 11.6 12.4
with many children having a dental radiograph at or near I2 3.2 5.6 8.0 12.2 14.2
I1 2.4 5.1 9.3 12.9
their birthday and relatively fewer between birthdays (see
Demirjian and Levesque 1980). Reprinted from Appendix in ‘A New System of Dental Age Assessment’
by Demirjian, A., Goldstein, H., Tanner, J. M. (1973) Human Biology:
Mean ages of tooth stage events occur mostly during the The International Journal of Population Genetics and Anthropology,
fourth year in boys and for ages 3 and 4 in girls, followed by 45 (2). Copyrightq 1973 Wayne State University Press, with the
mostly single maturity events per year after age 10. Although permission of Wayne State University Press.

q Informa UK, Ltd.

 6 H. M. LIVERSIDGE
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12
For personal use only.

Figure 2. This example shows how dental maturity is calculated from the left mandibular teeth seen on part of a panoramic radiograph. Tooth stages
are identified, the corresponding individual values and their sum (dental maturity score) are shown. This boy is 81.5% mature. His real age is 9.15 and
he is slightly below the 50th percentile. The average boy with this score would be 8.75 years of age. The 3rd to 97th age percentiles for this score and
age range for score are arrowed.

2 – 25 years (Chaillet and Demirjian 2004; Chaillet et al.
2004a, b, 2005; Liversidge et al. 2006, 2010a, b). With the
exception of a small group of South Koreans, the groups
were of European origin from Canada, Europe and Australia
(Nyström et al. 1986, 1988; Kataja et al. 1989; Liversidge
et al. 1999; Teivens and Mörnstad 2001a, b; Willems et al.
2001; McKenna et al. 2002; Chaillet and Demirjian 2004).
A comparison of maturity between groups showed a
complex pattern, but dental maturity was consistently found
to be fastest in Australians and for some comparisons
slowest in Koreans (Chaillet et al. 2005). The data for these
boys (288 Australian and 170 Korean boys) have been re-
examined for this paper to illustrate difficulties assessing
dental maturity. Figure 5 (left) shows maturity score plotted
Annals of Human Biology
 DENTAL MATURITY 7

Figure 3. Gain in dental maturity score by 0.1 year intervals in boys at the 50th percentile. On the left, score gain is plotted against age in years, on the
right score gain is plotted against score in percentage points.
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12

against age (dots Australia, circles Korea). On the right
(Figure 5) the dental maturity curve is drawn for 1 year
age categories. Looking at the individual scores, several
Australian boys are advanced (score is greater for age) while
a few are delayed (score is less for age). The lines connecting
mean scores differ slightly. At younger ages, Australians are
delayed compared to Koreans; thereafter the lines are similar
except for a crossover for the 9-year olds. Both these age
categories of 5-year-old Australians and 9-year-old Koreans
For personal use only.
COMPARING THE DIFFERENCE IN MATURITY SCORE:
EXPRESSED IN YEARS OR SCORE
Comparing curves and the difference between curves is
difficult. Calculating the score difference of individuals to
the 50th percentile helps us visualize and understand how
children/groups differ in maturity. The score difference of
individuals to the 50th percentile can be calculated and
illustrated in terms of dental age or in terms of dental

contain fewer than 10 boys, showing how age distribution maturity score. Most studies illustrate or report the
can influence results. Dividing a study sample into age difference in terms of dental age and this has not been
categories reduces the number of children in each category helpful in understanding group differences. If we remember
and 10 or 20 boys or girls per year of age has been suggested that dental maturity score is a measure of the proportion
as a minimum to be representative. Despite the finding that mature, it is clear that expressing a difference in dental
Australians were fastest and Koreans slowest in dental maturity score in terms of dental age does not help to clarify
maturity (Chaillet et al. 2005), dental maturity curves for our understanding of variation between children. Figure 7
these groups of boys are similar except around age 5 and this shows the difference in dental maturity score expressed in
can be explained by the fewer younger Australians.
Many studies report data in 1-year age categories, with
the midpoint at year start or year half. A comparison of
maturity curves for boys from these is illustrated in Figure 6,
with the dashed line being the 50th age percentile reference
(Proy et al. 1981; Farah et al. 1999; Hedge and Sood 2002;
Leurs et al. 2005; Al-Emran 2008; Mani et al. 2008; Rozlo-
Kalinwska et al. 2008; Tunc and Koyuturk 2008; Qudeimat
and Behbehani 2009; Bagherpour et al. 2010; Blenkin and
Evans 2010; Chen et al. 2010; Maia et al. 2010; Sukhia et al.
2012; Bagherian and Sadeghi 2011; Celikoglu et al. 2011;
Jayaraman et al. 2011; Kirzioglu and Ceyhan 2011; Nik-
Hussein et al. 2011; Baghdadi and Pani 2012; Nur et al. 2012;
Karatas et al. 2012). The maturity curves are broadly similar
and it is evident that most published studies report a greater
score than the 50th percentile, particularly for younger ages.
Almost all these studies report some or all age categories
having a highly significant ( p , 0.01) average score greater
than the 50th percentile and this has been interpreted as an
advancement in dental maturity. What does a statistically
significant difference in Demirjian’s dental maturity Figure 4. Average age entering individual tooth stages in boys plotted
against age (from Demirjian and Levesque 1980). Tooth stages
indicate? It means that the average dental maturity score are described in Table I and illustrated in Figure 1. I1, central incisor;
for age category differs to the 50th percentile or average I2, lateral incisor; C, canine; P1, first premolar; P2, second premolar;
percentage mature. M1, first molar; M2, second molar.

q Informa UK, Ltd.

 8 H. M. LIVERSIDGE
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12

Figure 5. Comparing dental maturity between groups is not easy to measure or visualize and two groups are compared by plotting raw data and
average score for age. Dental maturity score for 252 dentally immature boys from Australian (filled circles) and 145 from Korean (open circles) is
plotted against age on the left. Maturity curves calculated as average score per year for dentally immature boys from Australia (solid line) and Korea
(dashed line) is shown on the right.

two ways plotted against chronological age for Australian COMPARING AVERAGE DENTAL MATURITY SCORE
and Korean boys from the Chaillet database. Zero difference
Another way to compare dental maturity for a group to the
in both graphs represents the 50th percentile. On the left the
Demirjian reference is to calculate average dental score as a
differences is expressed in terms of score and on the right the
For personal use only.

single value and compare this to average chronological age

same results are reported in years. Looking at the difference
expressed in years, younger boys are relatively advanced for the group. The difference between average dental age
compared to the reference and there is considerable (from the average maturity score) and chronological age for
variation in dental age after the age of 8. Some of the the group is often reported. A single value expressing dental
Korean boys aged 5 – 8 have a greater score than the 50th maturity score for a group hides much information,
percentile, while a few Australian boys aged 8– 10 have a including the age range of the sample and the age
smaller score than the 50th percentile. Variation increases distribution, both factors that influence results. Numerous
with chronological age and there is wide dispersion of studies show highly significant differences for most groups
values, especially from age 11. When differences are
expressed in terms of dental maturity score (Figure 7 left),
a similar pattern is noted for the younger boys where a
number of younger Korean boys have a score greater than
the 50th percentile and a few Australian boys having a
smaller than expected score. This is a reflection of the slope
of the sigmoid maturity curve. The striking difference
between the left and right scatter-plots is the variation from
age 11 –16. A small change in score from age 11 is equivalent
to a large change in age due to the shape of the maturity
curve, the uneven spread of stages over these years and
greater weight of later tooth stages.
Differences in score from some curves illustrated in
Figure 6 are expressed in terms of score in Figure 8. These
are studies that report average score for 1-year age categories
with the mid-point at year start. The difference in scores is
particularly evident between the ages of 5 – 8, where the
curve is steepest and the rate of increase peaks. This is the
age with the highest variation in tooth stage sequence
and therefore scores; when the increase in average score Figure 6. Dental maturity curves for age for boys from published
reports. These curves are constructed from average values for 1-year
points per year is greatest and when the average child enters age categories for studies that report average score for 1-year age
most tooth stages. The majority of studies include this age categories with mid-point at year start and mid-year. The dashed line is
interval. the 50th age percentile reference.

Annals of Human Biology

 DENTAL MATURITY 9

Figure 7. Dental maturity between groups can be assessed by illustrating and measuring the difference in dental maturity score to the 50th percentile.
The difference is appropriately expressed in terms of score, but has frequently been illustrated and quantified in years. The difference in dental
maturity score for 252 Australian (filled circles) and 145 Korean (open circles) boys is plotted against age. On the left the difference is expressed in
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12

score and shows variation in score gain at the ages when the maturity curve is steepest. After age 11 there is little change in score. On the right, the same
data are expressed in years, suggesting that variation is high after age 11. This reflects the score gain for age where the maturity curve is almost flat.

compared to the 50th percentile of the Demirjian reference
and this has been widely interpreted as a population
difference (Proy et al. 1981; Loevy 1983; Proy and Gautier
1985; Nyström et al. 1986, 1988; Koshy and Tandon 1988;
Kataja et al. 1989; Zhao et al. 1990; Davis and Hägg 1994;
Nykanen et al. 1998; Farah et al. 1999; Liversidge et al.
1999; Davidson and Rodd 2001; Teivens and Mornstad
For personal use only.
than the 97th percentile for 1-year age groups is considerable
and greater than expected. These boys are shown as open
circles in Figure 9 (left). These ‘outliers’ occur from ages 6 – 9
and the age groups with mid-points 7, 8 and 9 years have
16%, 10% and 14% of boys with scores greater than the 97th
percentile. Sample size for these age categories is 346, 427
and 467, respectively. All children of this database were

2001a, b; Willems et al. 2001; Eid et al. 2002; Hedge and
Sood 2002; McKenna et al. 2002; Prabhakar et al. 2002; Leurs
et al. 2005; Nyarady et al. 2005; Tao et al. 2007; Al-Emran
2008; Mani et al. 2008; Moananui et al. 2008; Rozlo-
Kalinwska et al. 2008; TeMoananui et al. 2008; Tunc and
Koyuturk 2008; Qudeimat and Behbehani 2009; Bagherpour
et al. 2010; Blenkin and Evans 2010; Chen et al. 2010; Cruz-
Landeira et al. 2010; Galic et al. 2010; Maia et al. 2010; Al-
Tuwirqi et al. 2011; Asab et al. 2011; Bagherian and Sadeghi
2011; Burt et al. 2011; Celikoglu et al. 2011; Flood et al. 2011;
Grover et al. 2011; Kirzioglu and Ceyhan 2011; Lee et al.
2011; Nik-Hussein et al. 2011; Ogodescu et al. 2011; Weddell
and Hartsfield 2011; Baghdadi and Pani 2012; Feijoo et al.
2012; Sukhia et al. 2012).
healthy and it is likely that these boys with very advanced
maturity appeared normal in all respects. The large
proportion of very advanced boys suggests that the
percentiles for mean score for these age groups need
revising. Loevy and Goldberg (1999) illustrate dental
maturity score tracked longitudinally in two boys and
both reach or exceed the 97th percentile score for age for at
least 2 years. The reason why the 50th percentile differs to the
large database and to most published reports is unknown,
but possible reasons include the choice of a sigmoid

WHY DOES DEMIRJIAN, GOLDSTEIN AND TANNER’S

50TH PERCENTILE DIFFER TO PUBLISHED STUDIES?
Let us look at the Chaillet database to explore why published
studies differ so consistently from the 50th percentile from
Demirjian et al. (1973). Figure 9 shows dental maturity score
and age of 4072 dentally immature boys from the Chaillet
database (cleaned data, age 2.11 – 17.88). Two features are
apparent. First, on the left it is clear that there is much
variation in score for chronological age. Secondly, on the
right, the average score for 1-year age groups at the year start
(i.e. average score for boys aged 2.5 – 3.49 is plotted at age 3.0
and so on) is compared to the 50th percentile (dashed line)
from Demirjian et al. (1973). Dental maturity score from the Figure 8. The difference in dental maturity score to the 50th percentile
database is greater than the 50th percentile curve up to 9 years for age from published reports. These data are for boys where results
of age. The proportion of boys with a maturity score greater are reported in 1-year age groups, with age mid-point at year start.

q Informa UK, Ltd.

 10 H. M. LIVERSIDGE

Figure 9. The large sample size of the database shows the high variation in dental maturity score for age, illustrated on the left (4072 dentally immature
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12

boys from the Chaillet database). Open circles indicate boys with score . 97th percentile for age. On the right, the maturity curve of average score for
1-year age groups is plotted against age from the database (solid line labelled Chaillet) and differs to the 50th percentile (dashed line labelled D73).

maturity curve and the manner in which the scores for
chronological age were calculated. Teivens and Mörnstad
(2001a) report personal communications from Demirjian
and Goldstein, commenting that original tables were derived
from regression lines produced as best fit by manual
smoothing and percentile curves were manually fitted.
For personal use only.
difference in dental maturity compared to the 50th
percentile. This report contains several inconsistencies and
deserves further comment. First, it is unclear how dental age
greater than Demirjian’s maximum age was calculated.
Tabulated results show that all children aged 12.1 and over
have a dental age between 16 – 18. Second, the tabulated
results differ considerably to an illustration of average

maturity score for age group. This discrepancy is illustrated

MODIFICATIONS OF MEAN DENTAL MATURITY SCORE in Figure 11, where results for boys from the table and figure
in Koshy and Tandon (1998) are compared to the 50th
Numerous studies have noted statistically significant
percentile curve from Demirjian et al. (1973). The solid line
differences in average scores to the reference and this has
is from the tabulated results and the short dashed line is
resulted in various modifications of tooth stage values
estimated from their graph of average maturity score and is
and/or the relationship of score for age. Modifying the data
not very different to many other studies. Averages are
to fit a maturity curve better is hampered by several factors.
plotted at the year start (rather than mid-point of the year,
Commonly, mature individuals are not excluded. Grouping
the data into age categories results in small samples for each
age group and less than 10 boys or girls per year is
unrepresentative. Most importantly, describing the sigmoid
curve mathematically might improve the coefficient of
determination but it cannot reduce the variation of dental
maturity score with age.
Some studies express the relationship between dental and
chronological age as a straight line (Koshy and Tandon
1998) or by complex formulae that increase the R 2 value but
fail to follow most data points (Cruz-Landeira et al. 2010).
The 50th percentile computed by polynomials (Chaillet et al.
2005) using the Chaillet database also has limitations as it
differs considerably to the average score for age. This is
illustrated in Figure 10 and shows two approaches calculated
from the same data, the average maturity score for 1-year
age groups from the Chaillet database and the 50th percentile
polynomial curve (dotted line). Some authors fail to
understand the nature of a cumulative growth curve and
show variation that exceeds 100% mature and decreases
after full maturity (Koshy and Tandon 1998; Tievens and Figure 10. Complex mathematically approaches describing a maturity
curve can be inappropriate. An example is illustrated of a polynomial
Mörnstad 2001a, b). Others calculate average dental age maturity curve (dotted line calculated from Chaillet et al. 2005) and
greater than the maximum (Koshy and Tandon 1998). average dental maturity score for 1-year age groups and age for boys
Koshy and Tandon (1998) report the largest average from the database (solid line).

Annals of Human Biology

 DENTAL MATURITY 11

from 70 in the most delayed boy to 93.4 in the most

advanced boy. The modal score was found in only eight
boys, but each score can be made up of a different sequence
of seven teeth and 26 boys in this group had a unique
sequence of tooth stages. This indicates how variable tooth
formation is and how few individuals of exactly the same
chronological age are similar in the sequence of tooth
formation. In addition, most studies include the age range
that corresponds to the steepest part of the sigmoid curve. It
is unsurprising that different samples, each made up of a
different age range and structure, differ in their average
dental maturity score.
Explanations for differences in average dental maturity
are often given as a possible secular trend or population
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12

Table III. Dental maturity score for age for boys. These were derived
from linear regression lines for 1-year age categories and manually
Figure 11. Koshy and Tandon (1998) report a large difference in dental smoothed.
maturity score for age, although tabulated and illustrated results are Age Score Age Score Age Score
inconsistent, suggesting a possible error. Dental maturity in 1-year age
2.5 10.8 7.0 60.7 11.5 93.7
groups and age in boys is illustrated from Koshy and Tandon (1998),
2.6 11.3 7.1 62.3 11.6 94.0
with 50th percentile (dashed line labelled D73). The solid line is from
2.7 11.8 7.2 64.0 11.7 94.2
their tabulated results (labelled Koshy_Table), the dotted line is
2.8 12.3 7.3 65.6 11.8 94.5
estimated from their Figure (labelled Koshy_Figure).
2.9 12.8 7.4 67.1 11.9 94.7
3.0 13.2 7.5 68.8 12.0 94.9
3.1 13.8 7.6 70.2 12.1 95.1
which would be more appropriate) and the youngest age
For personal use only.

3.2 14.5 7.7 71.6 12.2 95.3

group is made up of only six boys; in fact, around half the 3.3 15.1 7.8 72.9 12.3 95.5
age categories have fewer than 10 individuals. 3.4 15.9 7.9 74.1 12.4 95.7
Growth and maturity reference samples ideally include 3.5 16.5 8.0 75.2 12.5 95.9
3.6 17.4 8.1 76.4 12.6 96.0
large numbers of individuals for each age category with a 3.7 18.3 8.2 77.5 12.7 96.2
wide age range that encompasses all maturity events to 3.8 19.2 8.3 78.4 12.8 96.4
describe the most advanced and the most delayed children at 3.9 20.2 8.4 79.4 12.9 96.5
all ages (see Smith 1991). Most studies that adapt methods 4.0 21.0 8.5 80.4 13.0 96.6
do not fulfil these criteria. If only a small age range is 4.1 22.1 8.6 81.3 13.1 96.8
4.2 23.1 8.7 82.1 13.2 97.0
studied, a straight line might be appropriate, but more 4.3 24.3 8.8 82.8 13.3 97.1
recently a variety of complicated mathematical expressions 4.4 25.3 8.9 83.6 13.4 97.2
have been suggested. This cannot reduce the variation, 4.5 26.5 9.0 84.4 13.5 97.4
particularly for the ages where the curve is steepest. 4.6 27.5 9.1 85.0 13.6 97.6
Average score for age and age for score for the Chaillet 4.7 28.5 9.2 85.6 13.7 97.7
4.8 29.5 9.3 86.2 13.8 97.8
database are detailed in Liversidge (2010b) and scores for 0.1 4.9 30.6 9.4 86.7 13.9 97.9
year units are to be found in Tables III (boys) and IV (girls) 5.0 32.0 9.5 87.2 14.0 98.0
from the database. These were derived from linear regression 5.1 33.0 9.6 87.7 14.1 98.1
lines for 1-year age categories and manually smoothed. 5.2 34.0 9.7 88.2 14.2 98.2
5.3 35.0 9.8 88.6 14.3 98.3
5.4 36.5 9.9 89.0 14.4 98.4
5.5 37.7 10.0 89.3 14.5 98.5
WHY DO GROUPS DIFFER IN AVERAGE DENTAL 5.6 39.0 10.1 89.7 14.6 98.6
MATURITY SCORE? 5.7 40.5 10.2 90.0 14.7 98.7
5.8 42.0 10.3 90.3 14.8 98.8
Dental maturity score reflects the relative maturity of a 5.9 43.5 10.4 90.6 14.9 98.9
child and the same score can be made up of several tooth 6.0 45.0 10.5 91.0 15.0 99.0
sequences. Each study sample differs in average age, each 6.1 46.4 10.6 91.3 15.1 99.1
group of boys and girls is made up of dentally advanced and 6.2 48.0 10.7 91.6 15.2 99.2
dentally delayed children and most will have a different 6.3 49.5 10.8 91.8 15.3 99.3
6.4 51.0 10.9 92.0 15.4 99.4
sequence of tooth stages. A group of boys of the same 6.5 52.6 11.0 92.2 15.5 99.5
chronological age are likely to differ considerably in their 6.6 54.3 11.1 92.5 15.6 99.6
tooth formation. In fact, boys who have just reached their 6.7 56.0 11.2 92.7 15.7 99.7
9th birthday (age 9.00 –9.09, n ¼ 101) from the Chaillet 6.8 57.5 11.3 93.2 15.8 99.8
database have 46 different dental maturity scores ranging 6.9 59.0 11.4 93.5 15.9 99.9

q Informa UK, Ltd.

 12 H. M. LIVERSIDGE

Table IV. Dental maturity score for age for girls. These were derived detailed. Considerable variation is to be expected with such
from linear regression lines for 1-year age categories and manually small numbers and these differences might reflect sample
smoothed. size rather than a difference in the timing of tooth stages.
Age Score Age Score Age Score This is supported by detailed study of ground sections of
2.5 12.8 7.0 67.1 11.5 95.5 teeth, with molar crown formation time being remarkably
2.6 13.3 7.1 68.8 11.6 95.7 similar between world regions, in contemporary and past
2.7 13.8 7.2 70.2 11.7 95.9
2.8 14.3 7.3 71.6 11.8 96.0
populations (Reid and Dean 2006).
2.9 14.7 7.4 72.9 11.9 96.2 Population differences in dental maturity are poorly
3.0 15.2 7.5 74.1 12.0 96.3 understood. Comparing mean age of individual tooth stages
3.1 15.7 7.6 75.2 12.1 96.4 between groups is hampered by the variation in chrono-
3.2 16.5 7.7 76.4 12.2 96.5 logical age for any tooth stage and requires large samples of
3.3 17.1 7.8 77.4 12.3 96.6
3.4 18.1 7.9 78.8 12.4 96.7
wide age range and is discussed below. Other explanations
3.5 19.1 8.0 80.0 12.5 96.8 include the unsteady non-uniform process of tooth
3.6 20.0 8.1 81.4 12.6 96.9 formation and pubertal fluctuation (Mani et al. 2008).
3.7 20.9 8.2 82.4 12.7 97.0 This seems unlikely as considerable histological evidence
3.8 21.9 8.3 83.3 12.8 97.1 shows that dental hard tissue formation is a highly
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12

3.9 22.8 8.4 84.1 12.9 97.2

4.0 23.9 8.5 84.8 13.0 97.3
regulated, steady and uniform process, although the increase
4.1 24.9 8.6 85.2 13.1 97.4 in tooth length and tooth stage with age is not uniform. The
4.2 25.9 8.7 86.0 13.2 97.5 time interval between mean age entering tooth stages is
4.3 27.0 8.8 86.6 13.3 97.6 uneven and largest for stages G –H of molars (see Figure 4).
4.4 28.0 8.9 87.3 13.4 97.7 In addition, initiation of all permanent teeth occurs before
4.5 29.2 9.0 87.7 13.5 97.8
4.6 30.7 9.1 88.1 13.6 98.0
puberty and, once dentinogenesis begins, the tooth follows
4.7 31.5 9.2 88.5 13.7 98.1 its own growth curve, with crown and root formation
4.8 33.0 9.3 88.9 13.8 98.2 continuing incrementally until the tooth is mature.
4.9 34.1 9.4 89.4 13.9 98.3
5.0 35.4 9.5 89.7 14.0 98.3
5.1 37.0 9.6 90.2 14.1 98.4
For personal use only.

5.2 38.0 9.7 90.6 14.2 98.5

OTHER DIFFICULTIES COMPARING DENTAL MATURITY
5.3 39.2 9.8 91.0 14.3 98.6 Many studies fail to detail the age structure, do not illustrate
5.4 40.5 9.9 91.3 14.4 98.7
5.5 42.0 10.0 91.7 14.5 98.8
raw data in figures or fail to exclude mature individuals
5.6 43.5 10.1 92.0 14.6 98.9 in analyses. Some analyse groups of 2- or 3-year categories,
5.7 45.0 10.2 92.3 14.7 99.0 making comparison difficult (McKenna et al. 2002;
5.8 46.4 10.3 92.6 14.8 99.1 Al-Tuwirqi et al. 2011), especially between ages 6 – 9 when
5.9 48.0 10.4 93.0 14.9 99.1 the slope of the maturity curve is very steep and a small
6.0 49.5 10.5 93.3 15.0 99.2
6.1 51.0 10.6 93.6 15.1 99.3
difference in chronological age corresponds to a large
6.2 52.6 10.7 93.8 15.2 99.4 difference in score. One study converts tooth stages back
6.3 54.3 10.8 94.0 15.3 99.4 to ordinal values, and computes regression equations
6.4 56.0 10.9 94.2 15.4 99.4 inappropriately from the sum of ordinal values and
6.5 57.5 11.0 94.5 15.5 99.6 chronological age (Blenkin and Evans 2010). This report
6.6 60.0 11.1 94.7 15.6 99.6
6.7 62.3 11.2 94.9 15.7 99.7
has several inconsistencies including Demirjian’s dental
6.8 64.0 11.3 95.1 15.8 99.8 maturity scores for children younger than 2.5, the youngest
6.9 65.8 11.4 95.3 15.9 99.9 age category for which 50th percentile scores are available.

differences. A secular trend is difficult to explore, however a
comparison of mean chronological age of individual teeth
from Demirjian and Levesque (1980) and the Chaillet
database is illustrated in Liversidge (2010a) shows that mean
age for many tooth stages are similar in girls. One study
reports a secular trend in root formation over time by
examining 114 individuals from an archaeological collection
of known age-at-death and comparing average age of some
teeth with modern children (Cardoso et al. 2010). Median
age at entry was earlier in the historic compared to the
modern sample for all teeth, however sample size of the
historic sample was very small for all age groups (n ranges
from 2 – 9 per year for ages 6 – 16) and neither sample size for
tooth stage nor confidence interval of median ages are
TOOTH-SPECIFIC METHODS ASSESSING DENTAL
MATURITY
Another way to investigate group differences is to compare
the average chronological age of individual tooth stages
between groups. Mean age can be calculated in two ways.
First, mean age entering a maturity event is calculated
cumulatively by counting the proportion of individuals who
have reached or passed the maturity event per age group,
from zero to all, and estimates the average. Second, mean age
within a maturity event includes all individuals who are in
one stage but have not yet entered the subsequent stage. These
two methods reflect different aspects of a single maturity
event. The first expresses average age entering a stage with no
regard to duration or age overlap of stages. The second is
Annals of Human Biology

highly sensitive to features of the sample age distribution,
especially the age duration and overlap of stages.
Method 1
Average age entering a tooth stage is the age at which half of
individuals have entered/passed the stage. This is not the
median aged child to enter the stage, but an estimate of the
age when half of the children have attained the stage. This
method has long been used to estimate the average age of
individual tooth eruption and is appropriate to calculate
average age of all maturity stages including the most mature
stage H. For example, the average age of tooth eruption can be
calculated by counting the proportion of girls/boys with the
tooth visible per age group. An adequate age range includes
the youngest age group with no child having the specific
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12
tooth erupted up to the age group when all children have the
tooth erupted. A cumulative curve can be drawn, plotting
proportion against the mid-point of each age group, showing
the earliest age category of tooth eruption, the latest age when
the tooth is not yet erupted and when all individuals in an age
category have the tooth erupted. The average age is when half
of the age group has the tooth visible. This is known as the
status quo method and average age can be calculated by
probit (using 1-year age categories) or logistic regression (if
data are transformed to binary). The sample size and age
For personal use only.
structure are important in describing average age entering
individual maturity events. If more than half of the youngest
age group has reached/passed the maturity event, the sample
age is too old to describe the average age entering the event.
Ideally each year of age should be made up of at least 10
individuals for each sex and small samples are likely to have a
large confidence interval of mean age.
Figure 12. A comparison of cumulative (mean age entering) and descriptive (mean age within tooth stage) methods to calculate tooth-specific mean
age. Left: percentage of boys who have reached/passed mandibular second molar (M2) stage D (open bars) and E (shaded bars), calculated from 3297
boys aged 4 – 12. Right: age distribution of 796 boys in M2 stage D (open bars) and 792 boys in M2 stage E (shaded bars).
q Informa UK, Ltd.
DENTAL MATURITY 13
Method 2: Average age within a tooth stage
This includes all individuals who have entered the stage and
who are in the stage. This method is influenced by the
number of individuals in the stage and the age range of the
sample. The age range for any tooth stage can be 4 – 6 years
and more for third molars. This means that a large age range
is necessary to describe mean age and studies with a range of
4 years can only describe unbiased mean age for a few tooth
stages. This method of analysis is unsuitable for the most
mature stage because the duration is long and lifespan is
unknown. Despite this, many studies report average age of
stage H. The difference between method 1 and method 2 for
the second molar (M2) stages D and E in boys of the Chaillet
database is illustrated in Figure 12. The open bars are stage D
and the shaded bars stage E. On the left is the cumulative
method showing that 40% of 6-year-olds and nearly 80% of
7-year-olds have M2 in or past stage D. Mean age entering
M2 stage D in boys is 6.79 (SE ¼ 0.041, SD ¼ 0.52) and for
M2 stage E is exactly 2 years later at 8.79 (SE ¼ 0.036,
SD ¼ 0.55). On the right of Figure 12 is the age distribution
of boys with M2 in stage D and in stage E. Mean age within
M2 stage D is 7.96 (SE ¼ 0.040, SD ¼ 1.10, n ¼ 796) and
for M2 stage E is 9.71 (SE ¼ 0.040, SD ¼ 1.10, n ¼ 792).
This figure shows several important features that relate to
chronological age variation of individual tooth stages. There
is wide age variation of children entering a tooth stage as
well as within a tooth stage and an age range of 6 years.
Consecutive stages overlap and some late boys in stage D,
who have not yet reached M2 stage E, are older than those
early boys who have reached M2 stage E. Mean ages from
methods 1 and 2 are likely to differ because they express
different aspects of chronological age variation of a single
tooth stage.
 14 H. M. LIVERSIDGE
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12
Figure 13. The age distribution of boys with canine stage D, showing the importance of an adequate age range to describe unbiased mean age of
individuals within a tooth stage. On the left all boys from the Chaillet database (n ¼ 511), right Australian n ¼ 12 (above) and Korean boys n ¼ 24
(below). Mean age for this tooth stage in Australian boys is biased as the sample lacks boys aged prior to and of the modal age category from
the database.
INTERPRETING RESULTS FROM TOOTH-SPECIFIC
METHOD 1: AVERAGE AGE ENTERING A TOOTH STAGE
For personal use only.
Let us return to the Australian and Korean boys and
compare maturity of individual tooth stages. Mean age
entering individual stages for these two groups was not
significantly different in 24 of 26 tooth stage comparisons.
The two stages where average age was significantly different
were the most mature root apex stage of the lateral incisor
and the second premolar early root stage E. Mean age for the
lateral incisor was significantly earlier in Australian boys
compared to Koreans, while the opposite was true for the
second premolar stage. Both these tooth stages include
9-year-olds and the small number of nine Koreans compared
to 51 Australians aged 9 might have influenced these results.
The similarities in mean age entering most tooth stages
suggest that overall dental maturity is similar in these two
groups. This suggests that a single value expressing the
difference in dental maturity does not represent advanced
maturity of individual teeth.
Previous reference studies that document mean age
entering individual tooth stages provide only standard
deviation and could not easily compute standard error of
the mean, making comparison difficult with more recent
data (Garn et al. 1958; Fanning 1961; Moorrees et al. 1963;
Haavikko 1970; Fanning and Brown 1971; Demirjian and
Levesque 1980; Nyström et al. 2007). Similarity in average
ages of tooth-specific stages from the Chaillet database and
Demirjian and Levesque (1980) reference is illustrated in
Liversidge (2010a) and shows that average age of most stages
in girls are similar, although the earliest stage for the three
anterior teeth was later than the reference.
Only a few studies compare dental maturity of individual
teeth in populations using average age entering tooth stages
and most find similarities between ethnic and regional
groups (Liversidge 2008, 2011). Almost all tooth stages were
similar in White and Bangladeshi groups in London, UK
(Liversidge 2011). Mean ages entering third molar stages was
significantly earlier in Black South Africans compared to
these London groups and Cape Coloureds in South Africa
(Liversidge 2008). If raw data are tabulated in chronological
age groups, average age can be calculated and the similarity
of mean age entering stage H of the third molar in Koreans,
Hispanics in Texas and the Canadian reference (Levesque
et al. 1981) is illustrated in Liversidge and Marsden (2010).
What is very clear from these studies is that the age variation
within tooth stage is far greater than the variation between
groups. The range from the earliest age entering a tooth
stage to the age when all individuals have entered the stage is
considerable and this applies to all permanent tooth stages
except those in early childhood. Frucht et al. (2000) report
significant retardation of the canine and second pre-molar
formation by looking at the contribution of individual
scores, but results were not detailed. They illustrate
cumulative curves for some canine stages but the age
when half of children enter these stages appears to be similar
to the reference (Demirjian and Levesque 1980), except for
stage G in males.
INTERPRETING RESULTS FROM TOOTH-SPECIFIC
METHOD 2: AVERAGE AGE WITHIN A TOOTH STAGE
Let us compare average chronological age of the Australian
and Korean boys of the Chaillet database. Average ages of
tooth stage were compared if n # 10 per group; 14 of the
23 tooth stage comparisons were not significantly different.
In seven of the nine significant tooth stage comparisons,
average age was advanced in Koreans compared to
Annals of Human Biology

Australians, however the lack of young Australian boys and
small number of 9-year-old Korean boys influence these
findings. Koreans are delayed in tooth formation (stage G
only) of P2 and M2 compared to the Australian boys. These
findings suggest that a single dental maturity value of a
group does not reflect advancement or delay in individual
tooth maturity.
Let us look at canine stage D (crown complete, initial
root visible) in all boys of the Chaillet database shown in
Figure 13. The age distribution of this tooth stage is shown
on the left, across seven age categories with the modal being
5 years of age. Mean age for these boys is 5.79 (SE ¼ 0.044,
SD ¼ 1.00, n ¼ 511). If mean age is calculated from a
sample with only a few age categories or a small number it
will be biased. The age distribution of canine stage D for
Australian and Korean boys is shown on the right of
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12
Figure 13. The Australian boys include few younger boys
with only two 5-year olds, both of whose canines are in stage
C. The age categories in the Koreans include the modal
5-year-old group for this tooth stage and are better
represented across the age range. It is no surprise that mean
age for this tooth stage differs significantly in these two
groups. Mean age of the Australian boys is biased as the
sample lacks boys aged 4 and 5 (the modal age category for
this tooth stage).
These findings suggest that there are more similarities
For personal use only.
than differences in dental maturity between these groups
and that a highly significant difference in Demirjian’s dental
maturity is not reflected by differences in timing of
individual teeth; either average age entering tooth stages or
average age within tooth stages. These findings contradict
the results from a single dental maturity score for each
group that Koreans are most delayed and Australians most
advanced. A significant advancement or delay in dental
maturity is not reflected in an advancement or delay in the
average timing of individual tooth stages. This suggests that
Demirjian’s method is not a helpful way to compare dental
maturity in groups and inappropriate to assess population
differences.
Many studies report mean age of individual tooth stages,
however, few supply sufficient detail (standard error of mean
age, standard deviation, n for each tooth stage) to allow
statistical comparisons. Almost all tooth stages have large
standard deviations and at least three or four year age
categories should be well represented to estimate unbiased
tooth-specific mean age (five for third molars). Qudeimat
and Behbehani (2009) found similarities in mean ages of tooth
stages in Kuwaiti children compared to the Chaillet database.
Earlier dental maturation was reported after comparing
average age of one canine root stage in 150 orthodontic
patients of the same age range from the 1970s and 1990s
(Nadler 1998). The sample was selected randomly from an
orthodontic archive. The average chronological age of
canine stage G differed significantly between these two
groups; however, the average ages of the two samples
differed by almost a year for both girls and boys, so it is
unsurprising that a difference in mean age of this tooth stage
was found. Clearly the average age of patients attending this
q Informa UK, Ltd.
DENTAL MATURITY 15
orthodontic practice changed over these decades and this
was incorrectly interpreted as evidence of earlier dental
maturation.
One study interprets differences as population differences
by comparing permanent tooth formation within immature
individual archaeological remains (Owsley and Jantz 1983).
Permanent teeth were assigned average ages by stage from
Moorrees et al. (1963) and compared using pre-molars as
the reference. They found some tooth types advanced
(maxillary incisors, M2 and M3) and canines and M1
delayed relative to the pre-molars and interpret this as a
population difference. They note that ages assigned to
different teeth of the same individual often vary. Others have
noted that dental maturity is delayed if this reference is used
to assess maturity (Diaz et al. 1993; Phillips and Van Wyk
Kotze 2009). Others report differences in relative tooth
formation between groups (Fanning and Moorrees 1969;
Tompkins 1996) and this approach measuring overlap is
worthy of more investigation.
Dental maturity assessed by tooth-specific stages from
method 1 and 2 is bound to differ, although this has been
interpreted as a population difference (Butti et al. 2009).
Mean ages of tooth stages from these methods differ by about
a year (see Figure 12) and it is unsurprising that mean ages
from reference data that use a cumulative method differ to
mean ages calculated non-cumulatively. Comparing dental
maturity between different methods is beset with difficulties
(see Liversidge et al. 2010). Blenkin and Evans (2010)
compared dental maturity using Demirjian’s method and the
Schour and Massler (1941) atlas. Interpreting results from
incompatible methods is problematic for several reasons.
These methods differ in how they express dental age—
Demirjian expresses age as a continuum from age 2.5 or 3 to
16 in tenths of a year (depending on which reference is used),
while the atlas has 1-year age categories. Reporting average
difference per chronological age category is complicated by
the fact that the atlas lacks age categories 13 and 14 years.
Blenkin and Evans (2010) also treat tooth stages categories as
values and traditional regression using categorical or ordinal
data has no statistically rational justification (Lucy et al.
1996). A number of other studies calculate average tooth
scores for age or compare these between groups (Nanda and
Chawla 1966; Schopf 1970; Liliequist and Lundberg 1971;
Stefanac-Papic et al. 1998; El-Yazeed et al. 2008). Some
studies note a high correlation between dental and
chronological age which is unsurprising and does not
contribute to our understanding of dental maturity (Maki
et al. 1999; Eid et al. 2002; Kurita et al. 2007; Bagic et al. 2008;
Rai 2008; Flores et al. 2010; Grover et al. 2011).
OTHER FACTORS AFFECTING DENTAL MATURITY
The factors that influence dental maturity over which we
have some control include examiner training and experi-
ence, reliability of tooth stage assessment, the quality of the
reference data, features of the age distribution and the
method of analysis of the study sample. Qualitative tooth
stages of maturation have been criticized as being poorly
 16 H. M. LIVERSIDGE
defined and methods prior to Demirjian et al.’s landmark
work include fractions of crown and root growth that are
subjective estimates. Quantitative methods such as tooth
length or ratios of tooth length and apex width attempt
to reduce the variation of tooth stage assessment. Such
methods can accurately assess maturity or estimate age of
skeletal material during the first few post-natal years when
growth is rapid (Liversidge 1994; Cardoso 2007, 2009). In
older children and young adults, the marginal increase in
reliability is over-shadowed by the considerable chronologi-
cal age variation of tooth development. Results comparing
these two approaches differ in their findings. One study
found that a quantitative method estimated age better than
tooth stage assessment (Cameriere et al. 2008), while two
have shown tooth stage assessment was a better measure of
dental maturity (Thevissen et al. 2011; Timmins et al. 2011).
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12
Assessing accuracy and precision as single measures (mean
difference and mean absolute difference between estimated
and chronological age) for a group hides much information
and better approaches are needed. Two studies have divided
Demirjian root stages into more categories in the belief that
it might increase the accuracy of dental maturity (Tompkins
1996; Solari and Abramovitch 2002). Another factor
affecting accuracy is that qualitative and quantitative
approaches differ with regard to the chronological age
when maturity is reached (50th percentile at maturity is 16
For personal use only.
for both sexes in Demirjian’s method, 14.1 and 13.7 for
males and females, respectively, in Cameriere’s method).
This means that an individual aged 17 who is dentally
immature will be relatively more delayed using Cameriere’s
method than Demirjian’s method.
ESTIMATING CHRONOLOGICAL AGE FROM DENTAL
MATURITY
Demirjian et al.’s (1973) study is not designed to estimate
chronological age and neither studies by Demirjian et al.
(1973) nor Demirjian and Goldstein (1976) contain the
words ‘age estimation’. Dental maturity score tells us
whether a child of known age is dentally advanced or
delayed compared to the 50th percentile or average same-sex
child. Chronological age can be inferred from dental age but
we know not whether the child is advanced or delayed in
their developing dentition. The 3rd to 97th percentile age
intervals are large and an interval is more appropriate than a
single point estimate of dental age. The adapted individual
tooth values of Willems et al. (2001) add up to dental age
and have proved to be the best method to calculate dental
age, whilst the new revised scores (Tables III and IV) express
dental maturity score, i.e. proportion mature.
NOLLA’S METHOD OF DENTAL MATURITY
Nolla’s method has also been used to assess dental maturity
and significant differences have also been reported between
dental maturity in one sex and the average score of the
reference (Briffa et al. 2005; Miloglu et al. 2011). Holtgrave
et al. (1997) observed similarities in dental maturity
compared to Nolla’s mean score for chronological age in
girls aged 3 – 18, but a significantly greater mean score for
age in younger boys ( p , 0.05). Holtgrave et al. (1997)
illustrate maturity curves for all teeth and detail
95% confidence interval of score for some age categories
for boys. Ages 5 – 8 were found to be significantly
different ( p , 0.05), interpreted as an acceleration in
dental maturity, however maturity curves of individual
teeth for boys do not appear to be very different to results
from Nolla (1960).
IS DEMIRJIAN, GOLDSTEIN AND TANNER’S METHOD
SUITABLE FOR ALL GROUPS?
The suggestion that dental maturity methods of Demirjian
and Nolla are inappropriate for different population groups
is to misunderstand their use and design. Dental maturity is
calculated when we wish to know how far a particular child
is in his/her journey to maturity. Investigation of the
appropriateness of population-specific dental maturity
reference data has shown that population-specific methods
do not improve the accuracy of dental age assessment (Braga
et al. 2005; Liversidge and Marsden 2010; Thevissen et al.
2010; Baghdadi and Pani 2012). Demirjian’s method has not
been bettered for sample design, age structure and age range.
Maturity curves from most published reports are similar to
the new revised scores for age, although differences occur
when sample size per age category is small as well as for the
youngest age category.
CONCLUSIONS
Demirjian et al.’s method of dental maturity is designed to
assess maturity at the individual level and dental maturity
score is an expression of maturity representing percentage
mature. This method has several limitations and these
become relevant when interpreting dental maturity for a
group of children. The sigmoid curve is not ideal and the
increase in score for age is greatest where the curve is
steepest at ages 6 –9, corresponding to 40 – 80% maturity.
Tooth stages are not evenly spread or evenly weighted
throughout chronological age and the weighted values are
not parameters.
Dental maturity score from most published studies
show higher scores than the 50th percentile, particularly for
younger ages. A large proportion of children from the
Chaillet database aged 6 –9 have scores that exceed the 97th
percentile. This suggests that the 50th percentiles score for
age for younger children need revision.
A single average value of dental maturity, or the
difference from the 50th percentile for a group, is
inappropriate, particularly if expressed in years, and does
not reflect how or which age groups differ.
Comparing dental maturity between groups or with the
50th percentile is best done using maturity curves or as score
difference per age category. If score difference per age
category is expressed in years, variation appears to increase
due to the high weighted values of late tooth stages; if
Annals of Human Biology

expressed in score units, variation is evident when the
sigmoid maturity curve is steepest but is small for other ages.
Complicated statistical equations expressing dental maturity
for age do not reduce the difference between groups or the
variation within the group. Maturity curves from most
published reports are similar to the new maturity curve,
suggesting that populations are similar in dental maturity.
The age variability and overlap of individual tooth stages
complicates how we assess dental maturity for a group and
how we interpret the results. Population differences in the
timing of individual tooth stages are unclear and hampered
by the wide age range for most tooth stages and the age
overlap of consecutive tooth stages. This means that samples
of wide age range are required to describe any one tooth
stage. In addition, methods of analyses differ and average
age entering a tooth stage calculated by cumulative
Ann Hum Biol Downloaded from informahealthcare.com by Dr Helen M. Liversidge on 10/08/12
frequency distribution (such as probit regression) will differ
to average age of individuals within a tooth stage.
Comparing the developing dentition between groups is
complex and remains a challenge, but Demirjian et al.’s
method is the best way to assess dental maturity of an
individual child.
SUMMARY
For personal use only.
. The appropriate use of Demirjian et al.’s method of
dental maturity is to assess maturity of a single child.
. The sigmoid curve of dental maturity score and
chronological age is problematic. The steepest part of
the curve is , 7.5 years of age and, unsurprisingly, this is
the age where maturity curves from most published
studies differ to the 50th percentile.
. Comparing dental maturity for a group as a single
average value has little meaning and groups with
significantly different average score can have similar
maturity curves.
. The difference in dental maturity compared to the 50th
percentile of the reference study to a group of children
expressed in terms of dental age is flawed. This applies to
both analyses by age categories or calculating a single
value for the whole group.
. If the difference in dental maturity is expressed in terms
of score, it becomes apparent that considerable variation
in score occurs where the slope of the sigmoid curve is
steepest but is small for other ages.
. Most published studies differ in score to the 50th
percentile for chronological age, especially for younger
children. More than expected children from the large
Chaillet database have scores . 97th percentile and
revised average scores for age have been calculated.
. Dental maturity curves from different regions are broadly
similar to each other and to the new revised score for
age, suggesting that dental maturity is similar between
populations.
. Demirjian et al.’s method remains the recommended way
to assess dental maturity for an individual child. Revised
scores for age from a large database are provided.
q Informa UK, Ltd.
DENTAL MATURITY 17
Declaration of interest: The author report no conflicts of
interest. The author alone is responsible for the content and
writing of the paper.
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