Forensic odontology

Prof.Dr. Azza Fouad

Age estimation
Forensic Odontologists assist in the identification process when all other
paths of identification have been exhausted.

When do we use teeth in estimation of age?

In the living: chronological age is needed for civil and social rights when the
individuals have:
• Amnesia
• No acceptable identification documents as:
1.Illegal immigrants,
2.adopted children of unknown age, and
3. Refugees.

In dead persons, when:

1. The identity is unknown; an age estimate may be of importance in the
identification process. Age estimates enable more efficient approach because:
•It can be useful circumstantial information in the identification process.
•Helpful in segregating individuals in cases of multiple, commingled
decedents.
•Narrowing down search within missing persons’ files
2. When only the skeleton of a body remains, age estimation may be even
more important in helping to make a positive identification.
3. Even when the police have some indication of the identity, an estimate of
the age may be used to help confirm the identity if other evidence is weak.
4. In archeological search, estimation of age at death is an aid in
paleodemography.

Why we can use teeth in determination of age?

1. Teeth are considered as a reliable means of determining age from
approximately 10 weeks intrauterine up to old age.
2. Teeth, being the hardest calcified tissue in the body, tend to be intact and
preserved even when other components of the skeleton have disintegrated.
3. The high resistance of teeth to severe insults such as cold, heat, fire and
chemicals make them the favorite tissue in forensic and archeological
investigations.
4. Unlike bones, they can be directly examined in living individuals.

What are Methods of teeth age estimation?

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Forensic odontology
Prof.Dr. Azza Fouad
Age estimation in children and adolescents:
Dentition:
1.Teeth development
2.Sequence of eruption.

Techniques used:
1. Clinical examination
•
2. Radiographic methods
3. Histological incremental line analysis

Age estimation in sub-adults group:

Radiographic methods

1. Development of 3rd molar and calcification.

2. Periodontal recession.

Age estimation in adults:

1. Histological (morphological ) methods:

1. Gustafson’s six variables and

2. Johanson’s modification,
3. Bang & Ramm’s dentine translucency
2. Radiographic method of Kvaal et al.

I.Determination of age in children and adolescents including

fetuses and neonates
• The main criteria for dental age estimation in this age group are the
following indicators of biological development: dentition status and tooth
mineralization.
• Tooth eruption refers to the gingival emergence of the apex of the tooth
crown. It is diagnosed by inspecting the oral cavity of the person concerned and
does not require an X-ray or expensive tools.
• Except for third molars, eruption of permanent teeth is complete around
the age of 12, on average.
• The relative stage of maturity can be compared with developmental charts
such as those developed by Ubelaker who graphically illustrates the state of
development of the dentition from 5 months in utero to 35 years, showing the
deciduous, mixed, and permanent dentitions.

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Forensic odontology
Prof.Dr. Azza Fouad
• This provides an estimate of age for an unknown individual. Conclusions
are usually accurate to approximately ± 5 years.

Ubelaker chart
• Calcification begins during the 4th m of fetal life. By the end of the 6 th m,
all of the deciduous teeth have begun calcification.

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Forensic odontology
Prof.Dr. Azza Fouad

Prenatal Period
Medico-legal importance of age estimation in prenatal period (including
neonates):
1. In cases of putrefaction or skeletonisation:
• Aging of human remains in the prenatal period cannot be separated from
the determination of a human origin for skeletal remains.
• Osteological indicators of maturity and morphological features should be
cross-checked.
• The possibility of commingled remains or twins should be excluded by
checking number and symmetry of teeth.

2. Accurate age estimation is reached if the remains have been wrapped so

we can recover most or all of the developing tooth caps.
3. Decision of being live birth: The presence of neonatal line (birth or
Orban's line) in both dentine and enamel indicates live birth. It is possible that
the time period of survival can be estimated by measuring postnatal deposition
of these hard tissues.

Histological methods:

 Used to assess the stage of tooth development during the pre-

mineralization period.

 Some of the histological methods can detect early mineralization 12

weeks before being detectable in the radiographs.
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Forensic odontology
Prof.Dr. Azza Fouad
The neonatal line:

 It is considered as an indicator of live birth.

 Neonatal lines are present in both enamel and dentin of deciduous teeth
and permanent first molars à development during the transitional period
between intrauterine and extra uterine environments.
 So it can be used to assess the amount of pre and post natal enamel
formation.
Stress markers and incremental lines analysis:

 The dentin incremental lines of Von Ebner and contour lines of Owen are
used to estimate age of the neonates or foetus at death.

 Incremental lines of Retzius are caused by variation in the rhythmic

mineralization of enamel prisms which is altered by various external factors
so that the lines may appear closer or the rest periods may be prolonged.

 Incremental line analysis is usually done on ground sections of

longitudinally sectioned dentition which results in the destruction of the
dental structures.

 In 1991, Skinner and Anderson reported a case study involving enamel

histology used for identification based on the presence in the enamel of the
primary and secondary dentition of stress markers, termed striae of Retzius,
which could be correlated with known stressors in the life of the presumed
missing child.

 Gustafson demonstrated in 1955 the similarity in incremental lines

between contralateral pairs of teeth from a single individual.

Other methods:

 Stack has provided a regression line of weight of growing dental tissues

against the age.

 By weighing the teeth specimen, age of unknown can be obtained from 5

months in-utero to postnatal age till 7 months.

The First Few Months of Postnatal Life

• This period still remains the one which least is recorded in the literature.

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Forensic odontology
Prof.Dr. Azza Fouad
• The jaws are enclosing the growing tooth germs of developing teeth.

• This period comes to an end about 6 months after birth when the first
deciduous teeth emerge into the oral cavity.

• Stages of dentition:

o Dental germs

o Deciduous teeth.(6m-3yrs).

o Mixed dentition.(6-12) yrs

o Permanent dentition.

Later Development of the Deciduous Dentition

• The deciduous teeth emerge sequentially and contralateral pairs of teeth
emerge at similar times.
• Once all the deciduous teeth have formed completely it is much less
reliable to estimate age using these features alone.
• Just as the tips of the last deciduous molars are forming at the back of the
mouth, the roots of the incisors, which formed much earlier, are beginning to
resorb.
• Resorption of the deciduous dentition is an internal cell mediated process
whereby the hard tissues of the tooth roots and even some of the enamel of the
crown of the tooth are degraded. The process is phasic with periods of
resorption being interposed with periods of hard-tissue repair.
• Each period of resorption erodes progressively more and more of the
tooth roots until the tooth crown is eventually lost. This provides space in the
jaw for the permanent successor.
• If the successional tooth is absent or displaced, deciduous teeth may be
retained long into adulthood, but this is uncommon and would provide unique
characteristic for individualization.

Mixed Dentition
• At the age of 6 years all the crowns of the 20 teeth of the deciduous
dentition remain in the oral cavity despite resorption of roots occurring within
the jaws.

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Forensic odontology
Prof.Dr. Azza Fouad
• Growth of the facial skeleton makes space for the first permanent molar
to erupt at the back of the dental arch in each quadrant of the mouth, thereby
enlarging the dentition.
• For the ensuing 5 or 6 years there is then a progressive complete
replacement of deciduous teeth by their permanent successors. This process
ends around 12 years of age when the permanent maxillary canines emerge.
• Once the last deciduous tooth has been replaced the period of the mixed
dentition comes to an end.

Techniques:

1. Study of tooth development is divided into an arbitrary number of

identifiable stages, using data obtained from radiographs.

2. Indirect measurement of tooth size from the radiograph is used as the

growth parameter plotted against known age to obtain the necessary regression
equations then used for the aging of unknown remains e.g. A recent study from
the UK examined the use of root length in the determination of age in paediatric
cases.

Differences between Deciduous and permanent teeth

 Deciduous are:
o Fewer and smaller.
o Enamel is thinner and whiter.
o The crowns are rounded.
o Constricted at the neck (cervix).
o Enamel cervical ridges more prominent.
o Deciduous molars are wider mesiodistally than the premolars.
o The roots of d. molars are longer and more slender than the roots of
the permanent molars.
o Deciduous anteriors are narrower mesiodistally than their
permanent successors.
o The roots of deciduous anteriors are longer and narrower.

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Forensic odontology
Prof.Dr. Azza Fouad
Permanent Dentition
• At the age of 12 or 13 years all the teeth present in the mouth are now
permanent. It is around this age that the second permanent molars are added to
the dental arches, bringing the number of teeth present to 28.
• Only the third molars or wisdom teeth remain to erupt between 17 and 25
years of age.

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Forensic odontology
Prof.Dr. Azza Fouad
• Some researchers prefer tooth formation to tooth eruption (i.e. actual
emergence of the tooth in the oral cavity) for assessment of age due to:
1. The eruption dates of teeth are highly variable because eruption can be
influenced by exogenous factors such as:
• Infection,
• Injury at the area, earlier extraction of deciduous teeth etc.
• Obstruction and overcrowding.
2. Teeth formation is a continuous process until the tooth is completely
calcified. The actual developmental stages of the teeth are more accurate
because the dental development is tightly controlled and protected against
disturbances so not markedly affected by diseases, drug intake and dietary
changes. (A process known as canalization).
3. The incremental pattern of mineralization is subject to periodic
disturbances that affect the developing teeth in a unique way like: Birth,
diseases, drug intake, dietary deficiencies and changes, and the uptake of certain
chemical elements.

II. Sub adult age groups

The third molar development the most important choice for age assessment
from the late teens to the early twenties up to about the age of 23 years when the
apices of the roots of the third molars are complete because:

1.All permanent teeth except the third molars have finished their development
after the median ages of 15 or 16 yr.
i. Third molars usually erupt after age 17 (at least in Caucasian
populations).
ii. After another two to four years, the occlusal plane is reached.
iii. If the third molar crowns are less than half complete, it is virtually
certain that the subject is less than 14 yr old.
iv. Late in adolescence, the third molars have completed their crown
developments, and the roots are the only dental structure that can be
used for age estimation up to a median age of about 19–20 yr, when
apex closure has taken place.
v. In younger adults, the calcification stages of the third molars are
the most reliable dental indicators, but in living individuals, they can be
examined only by X-rays.

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Forensic odontology
Prof.Dr. Azza Fouad
2. The use of other biological indicators such as epiphyseal fusion, changes of
the pubic symphysis, wrist bones and fusion of cranial sutures are not credible
during these years.
3.Those who advocate third molar use claim an accuracy of 4 years.

Disadvantages of using 3rd molar eruptionas an indicator of age:

• The third molar is very variable in position, anatomy and timing of
development.
• Sometimes it does not exist at all. These teeth are frequently congenitally
absent or restrained from entering the dental arches due to lack of available
space when they become jammed (impacted) against other teeth.
• It may even be larger than the 1st.and 2nd molar with the roots fused and
delineated by vertical grooves. The maxillary molar generally consists of 3
cusps, whereas some exhibit 4 cusps. In the mandible, the variability is between
4 or 5 cusps.
• The third molar formation and eruption occur earlier in males than in
females and maxillary was slightly advanced over mandibular third molars, and
root formation occurred earlier in males than females. This is opposite to the
development of the other teeth.

Demirjian’s system
• It is the worldwide reference method of age determination in living
individuals.
• It classifies 8 stages of crown and root formation and mineraization and is
used to score the third molar development: It defines four stages of crown
mineralization (A–D) and four stages of root mineralization (E–H).
• The degree of mineralization of second molars allows estimates of age
approximately until the age of 16 years.
• Tooth mineralization is evaluated using an orthopantomogram.

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Forensic odontology
Prof.Dr. Azza Fouad

Schematic drawing of the eight stages of crown - root formation of the molars
as proposed by Demirjian et al.
• Tooth mineralization begins with the development of the crown at the
occlusal surface and progresses over the neck of the tooth down to the root.
• If the third molar root apices are completely closed, and the periodontal
ligament has attained a uniform width (stage H of Demirjian’s system), there is
a high probability that an individual is at least 18.

Limitations of the Demirjian’s system

1. It is based on observations derived from radiographs,

2. The choice of the tooth developmental stage is quite subjective,
3. Age cannot be precisely evaluated after 16 yr specifically around 18 yr
and the analysis of the wisdom teeth do not yield precise conclusions as even
before the age of 18, some or all third molars might have reached complete root
development.
4. The third molar is a non ideal developmental marker because it is the
most variable tooth in the dentition with regard to size, time of formation, and
time of eruption, and it can be congenitally absent, malformed, impacted, or
extracted.
5. In impacted teeth, completion of root formation may be delayed 3 years.

Periodontal recession
Olze et al. study the periodontal recession as an indication of whether a person
has attained the age of 21 years.
An increasing periodontal recession correlated well with an increasing age of
the subjects.

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Forensic odontology
Prof.Dr. Azza Fouad
periodontal recession Individuals 21 years old

stage 1 Incipient 50%

stage 2 Advanced 75%

stage 3 Severe 100%

Stage 3 was hardly found in the examined age group.

It was concluded that the periodontal recession seems to be suitable as an
additional criterion for the forensic age diagnostics of young adults.

III. Older people

For individuals who have attained full dental maturity, dental
development is useless as an age estimator. When the teeth are relatively stable
in the mouth, certain changes occur within the tooth, which enable an age
estimation of the older unknown body to be made. Accuracy using these highly-
variable markers is in the range of 10–12 years.

Destructive methods:

• Gustafson's method (1950)

• Johanson's modifications (1971)
• Bang and Ramm (1970)
• Incremental lines of cementum

Gustafson's method for age determination from teeth

Gustafson's method (1950) is based on the evaluation of ground sections of

teeth to detect structural changes on fully erupted teeth.
His method use combined scores from measurements of 6 parameters of
histological changes:
•Attrition of incisal or occlusal surface,
•Periodontitis (level of attachment of the periodontal tissues),
•Secondary dentine deposited around the pulp chamber,
•Cementum apposition,
•Root resorption and

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Forensic odontology
Prof.Dr. Azza Fouad
•Root dentine translucency (The extent of sclerotic or translucent dentine
spreading from the apex of the tooth).

Technique:
• One or more teeth are extracted from the body, and Ground longitudinal
sections are prepared.
• The age-associated 6 parameters are evaluated in the ground section:
Two of these changes, transparency of radicular dentin and secondary dentin,
have the highest correlation with age.
• Gustafson used 4 scores (0, 1, 2, and 3) to indicate the various changes.
• The point values of each age change are added according to formula:
An+Pn+Sn+Cn+Rn+Tn = points
• The increase in points corresponds to increase age.
• The points are entered in the regression curve of age versus the age-
associated changes in sections taken from teeth of known age.
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Prof.Dr. Azza Fouad
Limitations:

1.It can't be used in living person, only in dead when extraction of teeth is
allowed.
2.Point values are subjective evaluation of the changes.
3.Time consuming method.
4.Periodontitis is impossible to determine due to decomposition of soft tissues.
5.Regression line is given for all teeth ignoring eruption time and morphological
differences of various teeth.
6.The method assumes that all 6 parameters of equal importance and ignore the
interrelationship between parameters.

Gustafson has become the basis for all other techniques which aim at the
increase of precision of measurement.

Johanson's modifications:

Johanson (1971) tested Gustafson’s method on a larger sample and he added

two major refinements Intermediate grades for scoring each variable to reach 7
stages and multiple regressions.

Maples (1978)
 Transparency of root dentin and secondary dentin, have the highest
correlation with age.
 Translucency of the root apex increases with age.
 Elimination of root resorption, attrition increase accuracy.
 This means that teeth with broken crown still give accurate age estimate

Bang and Ramm (1970): Transparency of radicular (apex) dentin

• This feature is the most useful method of estimating age because it occur
independent of any pathological process affecting the tooth and the least
influenced by environmental effects and is likely to be the most physiologically
regulated.
• Translucency of the root apex increases with age, and so a determination
of its extent can provide information as to the age of the owner of the tooth.
• Traditionally, the translucent dentine can be measured under a light
microscope and plotted against known age.

Advantages:

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Prof.Dr. Azza Fouad
1. Simple and rapid
2. Objective method: not based on point system but on measurements.
3. Applied without extensive training or expensive equipment.
4. No difference between dead and living.

Disadvantages:
1. underestimation of age in older age groups due to slowing down of
dentin sclerosis

2. Irregular junction at translucent and non translucent zones will

make difficulties in measuring the length.

Additional methods to overcome that include:

1. The use of SEM-EDXA, a method used to examine root dentine

translucency in relation to age determination also detect teeth restorations.

2. High-resolution micro-focused computed tomography scanning is now

becoming more available and is capable of quantifying mineral density in three
dimensions throughout the entire domain of the dentine of the tooth.

Kashyap and Koteswara Rao's method (1990)

It is based on the quantitative evaluation of four markers:
 the attrition ,
 the secondary dentine,
 the secondary cementum and
 the transparency of root.
They omitted periodontosis and root resorption from Gustafson’s method
They calculated the index values of various parameters undergoing regressive
changes.

The index values are plotted against the known ages and statistically analysed to
derive regression equation.

The index value of attrition

 It is calculated by measuring the width of attrited area in relation to
the width of the teeth
 How to apply the equation?

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Forensic odontology
Prof.Dr. Azza Fouad
a
Index value of attrition = ---- x 100
A
‘a’ is width in mm of attrited teeth
’A’ is the width in mm of the teeth at the cervical margin.
The incremental lines of cementum
 The incremental lines of cementum will help to determine the age
of adults.
 The disadvantages:
1. The necessity to extract or section the tooth.
2. It is not practical among living individuals.
Non destructive methods:
Examination of the teeth can provide information on the possible age of the
deceased by:

I.Examining the amount of tooth wear,

II.Color of the teeth:
o Principle: teeth tend to darken with age
o Changes in the color of tooth roots with age have been studied and
this color change may be related to the same changes in the optical
properties of the dental tissues, which also give rise to translucency.
o The colour changes in the cementum and dentin are caused by
infusion of decomposition products from erythrocytes.
o Measurement of intensity of fluorescence in dentin and cementum,
which shows strong correlation between age, deepening of colour of the
tooth and increase in intensity of fluorescence.
o Age estimation techniques based on color change alone have never
found widespread application.
III.Size of the pulp chamber (as seen radio graphically); pulp chambers become
smaller with age.
IV.Presence or absence of periodontal diseases and amount of alveolar bone
loss may also help in determining a possible age.
Periodontal disease progression, excessive wear, multiple restorations,
extractions, bone pathosis and complex restorative work may indicate an older
individual.

Radiological method:

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Forensic odontology
Prof.Dr. Azza Fouad
Indications of using radiological method:
1. Living persons
2. Fragile tissues: burnt bodies.
3. Skeletal remains from archeological excavations to avoid
destruction

kvaal and Solheim (1994) and Bosmans et al.,2005

They estimate age from the size of pulp cavity without tooth extraction. The
size of the pulp cavity is reduced by secondary dentine deposition so
measurements correlate with age.
Using radiographs the measure pulp length and width as well as root length and
width. Then different ratios between root and pulp were measured.

Yang et al., (2006)

Use cone beam CT scanning for generating the 3D images of teeth in living
individuals and calculating the ratio of pulp/tooth volume.

How to estimate the age?

1. Visual assessment

2. Radiographs

3. Extraction and preparation of teeth if dead or living with indiction

to extract teeth e.g. malocclusion

Accuracy of using teeth in assessment of age

• Actually, the 100% confidence in dental age assessment has been never
reached, and no one can make an exact judgment or a certain prediction of age.
• Therefore, it is impossible to give a precise age; the only appropriate way
is to give an age interval for a specific confidence.
• Assessment of age reflects greater accuracy when derived from multiple
indicators.
• The accuracy of any method of age assessment using teeth is much better
in children than adults where any estimate may be very inaccurate (Solheim and
Kvaal 2000).
• This is because in children:
a. Many teeth are undergoing development and calcification
simultaneously.

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 Forensic odontology
Prof.Dr. Azza Fouad
b. The intervals between morphological stages are shorter, and therefore,
more precise. However, the older a person becomes, the more inaccurate will be
age determination from teeth (Whittaker and MacDonald 1989).
• While in adults, it becomes much harder to estimate age because the
features which have to be used are much more susceptible to modification due
to:
o Environmental factors, some of which cannot be known or inferred when
postmortem remains are being examined
o The ethnic, cultural influences that may affect the rate of change of
structure in the teeth and jaws.

References:
1. Encyclopedia of Forensic and Legal Medicine, Forensic Odontology,
Elsevier (USA), 2004; 391-5.
2. Paul G. Stimson, Curtis A. Mertz, Forensic Dentistry, CRC Press
(London), 1997; 20-21.
3. C. Michael Bowers, Forensic Dental Evidence: An Investigator’s
Handbook, First Edition, Elsevier (USA), 2004; 82.
4. http://pafmat.com/2006_4.htm
5. Translation from" traité de médicine légale"

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