J Bagh College Dentistry Vol. 32(1), March 2020 Radiological Age

Radiological age estimation using third molars

mineralization in a sample attending orthodontic clinics

(A retrospective study)

Zainab Mousa Kadhom (1)

ABSTRACT
Background: The evaluation of the chronological age is a practical method in crime investigation field that assists in

identifying individuals to treat them as underage or adult. This study aimed to assess the stages of third molars mineralization

in relation to chronological age of Iraqi individuals, determine the gender differences and arches (maxillary/mandibular)

differences.

Materials and Methods: A total of 300 orthopantomograms of orthodontic patients were collected according to specific

criteria and evaluated visually. The developmental stages of maxillary and mandibular third molars were determined according

to Demirjian method. The chronological age was recorded according to the particular mineralization stages at which it reached

considering genders, sides and jaws. Comparisons were done using paired sample and independent sample t-tests.

Results: Results showed that there was no statistically significant difference (P>0.05) between maxillary and mandibular third

molars. The maxillary third molars reached earlier than mandibular one in stages F and G. There was no significant difference

between the mean ages of males and females at each given developmental stage in the maxillary and mandibular third molars

except for the stage D in the maxilla and stages D and E in the mandible. The development of third molar teeth on the right and

left sides was similar except for the maxillary arch in males when there was a significant difference in stage C and D and stage

E in the mandibular arch.

Conclusion: The Demirjian method is an excellent approach for age assessment using Orthopantomogram. All of the

differences between the current study and other studies could be because of the difference in the populations who were chosen

from different geographical areas.

Keywords: Age estimation, Demirjian method, third molar, Orthopantomogram, chronological age. (Received: 1/7/2019;

Accepted: 29/8/2019)

INTRODUCTION
Over the last period of time, the forensic age

estimation in living people has gained great

importance.(1) Mostly the forensic age can be

legally determined in several countries between 14

and 21 years without recognizing any documents.

It is very important to use dental analysis as an

approach in the medical detection of the crime

because the bone and other tissues have already

been destroyed whilst the most material in the

individual body that can remain and resist to be

analyzed is teeth.(2) However, to determine the age

of the individual, different methods have been

evolved and one of these methods is the

morphology of the cervical vertebrae,(3) added to

that person`s general physical development.(4,5)

An X-ray of the left hand represented an

independent part participated by forensically

experienced experts in age assessment of the

individuals.(6) Moreover, the teeth are regarded as

a means for the chronological age determination in

the populations. What can be seen, the radiological

and the clinical examination of the apparent and

morphological dental variations throughout life

can become a basis in age evaluation.(7)

(1) Assistant Lecturer, Department of Orthodontics,
College of Dentistry, University of Baghdad.

So, generally, in young adults and youths, the

chronological age evaluation can use dental

development as the most acceptable and reliable

method.(8)

In-vivo, the radiological approach in the estimation

of the dental development is a quick, non-invasive

and simple process for investigation.(5,9)

Furthermore, the orthopantomogram (OPG) acts as

a reliable method to assess the age as it is used in

determining the stage of dental mineralization.(5,10)

The third molar is a tooth distinguished by the

variability in the time of its formation and by its

varying presence or absence in the oral cavity,(11)

and the forensic important is a fundamental

property of this tooth since it developed

continuously over a long time.(8,12) At the same

time after about 14 years old, all the permanent

dentitions would have finished their development,

except the third molar; therefore, age assessments

become complicated in this period.(12)

The eight-stage scheme (Figure 1) designed by

Demirjian et al. (5) was very simple, precise, and
did not require more mediation to estimate the

age.(13) Also, by this method, one can compare

between different ethnic groups.(14)

There are different studies(12,13,15) that address age

assessment by third molar mineralization, using

Demirjian et al. (5) approach. No previous study has

assessed chronological age by using the third molar

in Iraq, except one study that assessed the

interrelationships among the chronological age,

J Bagh College Dentistry Vol. 32(1), March 2020 Radiological Age

dental, and skeletal maturation, conducted on all

permanent teeth except third molars.(16)

This study aimed to assess the mineralization

stages of third molars concerning the chronological

age of Iraqi individuals and to determine the gender

and arches (maxillary/mandibular) differences.

MATERIALS AND METHODS
The study sample of this research was selected

from Iraqi out patients who have attended the

Department of Orthodontics at the College of

Dentistry, University of Baghdad, and two private

orthodontic clinics in Baghdad and Karbal'a cities

between 2015 and 2018.

Out of the 600 OPGs collected and examined, only

300 patients (150 males and 150 females) with

known chronologic age (10-24 years old) were

selected in this study.

Gravely (11) founded that the age of nine years is the

top of the formation period of the third molar, for

that 10 years old was considered the age limit and

an accurate radiological guide of the third molar in

this study. According to Hofmann et al.,(15) the

exclusion criteria of this study were:

• Germectomy, agenesis and extraction of all
four third molars.

• Participant age less than 10 years or more than
24 years.

• Possibility of the local, genetic exogenous or
systemic factors that have effects on dental

development and the facial clefts or any other

craniofacial syndromes and the presence of

dental pathologies like tumors or cysts as seen

in the radiographs.

• OPGs with bad image quality.(17)

The OPGs which were taken as a diagnostic aid for

orthodontic treatment were selected randomly and

evaluated visually.(18)

Patients’ chronological age at the time of OPG

taking, gender, third molars germs locations and

mineralization stage from A to H were recorded

according to Demirjian et al.(5) The full description
of each stage was explained and illustrated in Table

1 and Figure 1. No additional subgrouping of

stages C, D, E, F and H were done.(15)

Table 1: Radiological mineralization stages of permanent teeth as presented by Demirjian et al. (5)

Stage Definition

A The calcification begins firstly at the superior level of the crypt in the form of an inverted cone or cones, in both

uniradicular and multiradicular teeth. There is no fusion of these calcified points.

B Fusion of the calcified points forms one or many cusps, which unite to give an orderly outlined occlusal surface.

C a. Enamel formation is finished at the occlusal surface. An extension and convergence towards the cervical region

are seen.

b. The dentin begins to deposit.

c. At the occlusal border the outline of the pulp chamber has a curved shape.

D a. The crown formation is accomplished down to the cemento-enamel junction.

b. In uniradicular teeth, the superior border of the pulp chamber has a specific curved form, being concave towards

the cervical region. The prominence of the pulp horns is present, creating an outline shaped like an umbrella top.

In molars, the pulp chamber has a trapezoidal form.

c. The root formation starts to begin in a form of spicule.

E a. Uniradicular teeth: The walls of the pulp chamber now form straight lines, whose continuity is broken by the

presence of the pulp horn, which is larger compared to the previous stage.

Molars: Initial formation of the radicular bifurcation is seen in the form of either a calcified point or a semi-

lunar shape.

b. Uniradicular teeth: The crown height is more than the root length.

Molars: The root length is still less than the crown height.

F a. Uniradicular teeth: The walls of the pulp chamber now form a more or less isosceles triangle. The apex ends in

a funnel shape.

Molars: The calcified region of the bifurcation has developed further down to give the roots a more definite and

distinct outline with funnel shaped ends.

b. Uniradicular teeth: The walls of the pulp chamber are equal to or greater than the crown height.

Molars: The crown height is equal to or less than the root length.

G a. 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 closed completely (distal root in molars).

b. The periodontal membrane has a regular width around the root and the apex.

The stages of development determined by OPG

from A to H were corresponded with a particular

point of score of the gender and jaw depended on

Demirjian et al. method.(5) This score point
clarified the chronological age where the

appropriate stages of mineralization reached.

Statistical analyses
The collected data were analyzed with the aid of

SPSS program (version 15, SPSS Inc., USA). For

each stage, the means, standard deviations,

minimum and maximum values were obtained.

J Bagh College Dentistry Vol. 32(1), March 2020 Radiological Age

The gender and arches differences were

determined using independent sample t-test, while

side difference was detected using paired sample t-

test. The probability value was set at 0.05.

Figure 1: Third molars' mineralization stages.(5)

RESULTS
About 600 OPGs images have been collected for

this study between 2015 and 2018. Many of these

OPGs contained congenitally missing third molar

germs or all four third molars or these teeth may

have been influenced by many exogenous and

genetic factors during development. Some of the

OPGs were not clear. Too, some of these images

were for the patients with age less or more than the

age range of this study; therefore, about 300 OPGs

had to be excluded and only 300 OPGs were

selected pertinent to 150 males and 150 females

with known chronologic age ranged from 10-24

years.

The landmarks of tooth formation expressed as:

initial calcification (stage A), the completion of the

crown (stage D), and formation of inter-radicular

bifurcation (stage E), root-length completion (stage

G), and close of the apex (stage H).

Descriptive statistics and comparison of age

between the maxilla and mandible were shown in

Table (2). The results statistically showed no

significant difference (P>0.05) between maxillary

and mandibular third molars. The mean age of

stage D was 14.272 years and stage F was 16.794

years in the maxilla and in the mandible was

13.833 years for stage D and 17.128 years for F

stage.

Initial calcification, the first stage of the

developmental level (stage A) according to

Demirjian’s method, was seen at the age between

10 and 16 years. Also, in both arches, minimal age

for appearance of both stages B and C was 10 years

and for stages E and G was 12 years.

Moreover, from the mean ages in both arches, the

maxillary third molars reached earlier than lower

third molars in stages F and G only. The apex of

the maxillary third molars closed (stage H) at the

mean age of 21.127 years and the mandibular third

molars at 21.049 years.

Descriptive statistics and gender difference of the

age in all developmental stages (A to H) for the

maxillary and mandibular third molars were

showed in Tables (3 & 4). Stage B was first

appeared at 12.080 years in the maxillary arch of

females and at 10.857 years in the mandible, while

in males, the appearance of this stage was at 11.800

years in the maxillary arch and 11.400 years in the

mandibular jaw.

The mean ages of males and females were not

significantly different at each given developmental

stage of the maxillary and mandibular third molar

except for stage D in the maxillary arch and stages

D and E in the mandible when males were

significantly earlier to reach these stages than

females.

The side differences in each gender were presented

in Tables (5 & 6). The development of third molar

teeth on the right and left sides was similar in both

genders except for the maxillary arch in males;
there was a significant difference in stage C and D

and stage E in the mandibular arch.

J Bagh College Dentistry Vol. 32(1), March 2020 Radiological Age

Table 2: Descriptive statistics and arch difference of the age (in years) in whole sample.

Stages Maxilla Mandible Comparison

Mean Min Max S.D. Mean S.D. Min Max t-test P-value

A 11.600 10 16 2.503 11.167 1.899 10 16 0.308 0.766

B 11.956 10 16 1.941 11.259 1.631 10 16 0.673 0.516

C 12.976 10 17 1.801 12.921 1.826 10 18 0.101 0.920

D 14.272 10 20 2.201 13.833 2.034 11 20 1.086 0.279

E 15.982 12 23 2.240 15.779 2.002 12 23 0.309 0.758

F 16.794 14 23 1.705 17.128 1.957 13 23 -0.705 0.484

G 19.027 12 24 2.477 19.486 2.263 12 24 -0.684 0.497

H 21.127 17 24 1.777 21.049 1.931 12 24 0.325 0.745

Table 3: Descriptive statistics and gender difference of age (in years) for different developmental stages of maxillary

third molars

Stages Male Female Gender difference

Mean S.D. Min. Max. Mean S.D. Min. Max. t-test P-value

A 10.500 1.225 10 13 13.250 3.202 10 16 -1.948 0.184

B 11.800 1.473 10 14 12.080 2.272 10 16 -0.476 0.620

C 12.806 1.754 10 17 13.476 1.887 10 16 -1.484 0.142

D 13.030 1.858 10 20 15.147 2 12 20 -6.832 0.000

E 16.143 2.265 12 20 15.889 2.252 13 23 0.41 0.684

F 17.152 1.679 14 20 16.400 1.673 14 23 1.777 0.081

G 18.583 2.827 12 23 19.240 2.291 14 24 -1.069 0.289

H 21.058 1.773 17 24 21.244 1.800 18 24 -0.529 0.598

Table 4: Descriptive statistics and gender difference of age (in years) for different developmental stages of mandibular

third molars

Stages

Male Female Gender difference

Mean S.D. Min. Max. Mean S.D. Min. Max. t-test P-value

A 10.889 1.269 10 13 12 3.464 10 16 -0.544 0.637

B 11.400 1.392 10 14 10.857 2.268 10 16 0.751 0.459

C 12.607 1.592 10 17 13.311 2.032 10 18 -1.902 0.061

D 13.140 1.995 11 20 14.460 1.874 12 20 -3.737 0.000

E 15.200 1.883 12 18 16.089 2.012 13 23 -1.997 0.049

F 17.184 1.722 14 20 17.083 2.142 13 23 0.236 0.814

G 18.931 2.389 12 23 19.878 2.112 16 24 -1.75 0.085

H 21.127 2.012 12 24 20.923 1.812 17 24 0.516 0.607

Table 5: Descriptive statistics and side difference of the age (in years) for each developmental stages of maxillary and

mandibular third molar in males

Jaw Stages Descriptive statistics Side difference

Right Left

Mean S.D. Mean S.D. t-test P-value

Maxilla A 10.750 1.500 13.250 3.202 -1.213 0.312

B 11.889 1.453 11.778 1.563 0.164 0.873

C 12.238 1.513 13.476 1.887 -2.540 0.020

D 12.836 1.619 15.491 2.098 -6.480 0.000

E 16.143 2.265 16.095 2.567 0.059 0.953

F 16.967 1.629 16.400 1.673 1.505 0.143

G 18.583 2.827 19.667 2.239 -1.511 0.144

H 20.971 1.834 21.234 1.671 -0.626 0.536

Mandible A 10.333 0.577 12 3.464 -0.762 0.525

B 11.286 1.254 10.857 2.268 0.372 0.723

C 12.615 1.602 13.577 1.922 -1.932 0.065

D 13.000 1.600 12.885 1.904 0.223 0.826

E 15.200 1.883 16.400 2.372 -2.320 0.028

F 17.184 1.722 16.974 2.236 0.428 0.671

G 19.474 1.982 19.842 2.363 -0.538 0.597

H 21.258 1.632 21.000 2.380 0.903 0.374

J Bagh College Dentistry Vol. 32(1), March 2020 Radiological Age

Table 6: Descriptive statistics and side difference of the age (in years) for each developmental stages of maxillary and

mandibular third molar in females

Jaw Stages Descriptive statistics Side difference

Right Left

Mean S.D. Mean S.D. t-test P-value

Maxilla A 10 0 10.500 0.707 -1 0.5

B 12.900 3.479 12.800 3.553 0.061 0.953

C 12.839 1.899 12.774 1.627 0.193 0.848

D 12.818 1.509 13.152 2.123 -1.146 0.260

E 16.400 2.171 15.800 2.530 0.874 0.405

F 17.250 1.807 17.063 1.652 1.379 0.188

G 18.727 3.036 18.273 2.760 0.612 0.554

H 20.939 1.853 21.182 1.740 -0.928 0.360

Mandible A 11 1.414 11 1.414 - -

B 11.333 1.323 11.333 1.323 - -

C 12.654 1.548 12.654 1.548 - -

D 13.222 2.082 13.222 2.082 - -

E 14.923 2.019 14.923 2.019 - -

F 17.278 1.708 17.278 1.708 - -

G 18.571 2.821 18.571 2.821 - -

H 21.3 1.601 21.3 1.601 - -

DISCUSSION
The use of tooth developmental stages is

considered as an accurate method of chronological

age determination adopted over a long time

independent of disease or malnutrition and other

exogenic factors.(9)

The author depended on the third molar formation

to assess the chronological age of the subjects due

to the lack of different processes through the

duration between the teenagers and early 20s.(19) It

is very useful to use third molar mineralization

stages in chronological age evaluation especially

for the legal purposes of unknown victims.(20)

All selected OPGs belong to Iraqi outpatients

attended the Department of Orthodontics at the

College of Dentistry and two private orthodontic

clinics. The age ranged between 10-24 years since

many patients at this age attend orthodontic clinics

seeking orthodontic treatment.

Stage A in the current research is initiated at 10

years old. This is near to that reported in the Thai

population(21) (9.75 years old) and later than Jung

and Cho (22) (7 years of age).

The results of the present study showed that stage

D (crown completion) reached at age of 14.27

years in the maxilla and 13.83 years in the

mandible. This result was somewhat close to that

reported in Iranian population (23) (13.62 years) and

earlier than Thai population(19) (15.47 years) and

later than Turkish population (24) (12.90 years). This

could be attributed to the difference in ethnic

groups.

In the present study, the root formation (stage H)
was completed at a mean age of 21.12 years in the

maxilla and of 21.04 years in the mandible. These

results were almost close to that of Caucasian

Central Europa,(15) while earlier than the Turkish

subjects reached this stage at 22 years.(24)

Regarding gender differences in this stage, the

mandibular third molars in females began stage H

at 20.9 years which was earlier than males in

contrast to Sujatha et al.(17) who reported that males

reached this stage earlier than females.

Khosronejad et al.(18) and Hassan and Abo Hamilla

(25) supported the findings of the current study

when the Iranian females reached certain third

molar mineralization stages (only the H stage)

sooner than males and in Egyptian females, all

third molars reached H stage earlier than males.

It becomes clear from the mean ages in both arches

that at stages A-F, the subjects were probably

below 18 and at stage G and H, the individuals

were above 18 years; this comes in agreement with

Jung and Cho(22) who reported that Korean

population exhibited stage G at age of 18 years or

older, and Khosronejad et al.(18) who found that
both G and H stages could indicate that the person

might be above 18 years old. Other studies(26,27)

showed that at stage A-D, persons were probably

below 18 years and at stage H and they were above

18 years. This may be due to differences in the third

molars development.(28)

A study by Hofmann et al.(15) showed that girls

seem to achieve the mineralization stage C at a

slightly earlier age than boys. Sujatha et al.(17) also

reported that stage D was early in males and stage

G in females while in the Turkish population, both

D and G stages were earlier in males than

females.(24) In the present study, the development

of third molars in all stages was earlier in males

J Bagh College Dentistry Vol. 32(1), March 2020 Radiological Age

than females except the maxillary third molars in

stages E and F and in stage B, F and H in the

mandibular third molar where females were earlier

than males. This is supported by the findings of

Darji et al. (29) who found that teeth in males were

calcified earlier than in females. This is unrivaled

detection for the third molar as all other permanent

teeth development is earlier in females as

compared to males.

The results in terms of gender differences showed

no significant difference in the developmental

stages of the third molar between males and

females except in stage D in the maxilla and stages

D and E in the mandible since the females reached

these three stages later than males. The highest

difference was seen at stage D in the maxilla when

males were 2.117 years ahead of females.

These results come in agreement with many studies

as in Thai populations(21) where the mandibular

third molar in stage E was significantly higher in

female, also both of Sisman et al.(24) and Rai et
al.(30) reported that the significant differences

regarding D and G stages only occurred between

males and females.

Finally, Simonsson et al. (31) showed that males

significantly reached stages C, D and E earlier than

females. Although each study has no gender

differences, it has certain differences in one or

more developmental stages of the third molar in

both genders as in Khosronejad et al.(18) and

Kaomongkolgit and Tantanapornkul;(21) there were

no statistically significant differences in

mineralization stage of third molars between

maxilla and mandible.

Regarding the left and right side symmetry, there

was no significant side difference at various

developmental stages in both arches like in many

studies (13,18,21,29,31), but males in this study showed

that their right maxillary molars reached stage C

and D significantly earlier than the left one and the

right mandibular third molars reached stage E

earlier than the left one. This is very prevalent for

the third molar to asymmetrically erupted on the

left or right side.(10) This agrees with Satio(32) who

reported that the third molars on the right side of

the mouth calcified and erupted earlier when

compared with those on the left.

The mineralization stages asymmetry of the

antimere tooth was found in many studies, as in

Mincer et al. (26) who found that the symmetry of
the third molar formation of both sides in the

maxilla was more than in the mandible. Also,

Demisch and Wartmann(33) established that the

symmetry in the development of the mandibular

left and right third molars occurred in about 71%
of both sexes, so it is practically a helpful approach

in which the dental age could be obtained from left

and right side when they are both asymmetrical but

scorable.(26)

Sample size, age, the biological variation of

individuals, statistical approach and experience of

the observer in age assessment and other factors are

attributed to the presence of differences between

Iraqi sample and that of other studies.

The present study was limited by: first, the subjects

in this study were randomly selected from two

areas in Iraq, Baghdad and Karbala; additionally,

those patients were only the patients who referred

to the orthodontic clinics .

Second, ethnicity was not controlled in this study.

Because of successive wares in Iraq, many

populations migrated from western and northern

Iraq to Baghdad and Karbala, so there is a mix of

ethnicity that happened and individuals may be not

all pure Arabs; they maybe Turkman or Kurdish

subjects.

The conclusions that could be drawn from this

study were:

1. Demirjian's method is an excellent approach for
age assessment using OPG.

2. All the differences between the present study
and other studies in many countries could be

due to the difference in the populations chosen

from different geographical areas.

3. In this regard, the third molars of males were
prior to females in attaining most of

Demirjian’s stages in both arches.

4. In the mandibular arch, the third molars reached
all Demirjian's stages earlier than the maxillary

arch except in the stages F and G, and subjects

will probably be below 18 in both arches at

stages A-F while the individuals will be above

18 years at stages G and H.

5. There was no significant gender difference at
each given developmental stage of the

maxillary and mandibular third molar except

stage D in the maxillary arch and stages D and

E in the mandibular arch.

6. The third molars are developed symmetrically
in both sides (right and left) except the

significantly earlier arrival of the maxillary

right third molar in some developmental stages

than the left one in males.

ACKNOWLEDGMENT
The author would like to thank Dr. Mohammad

Nahidh for the invaluable assistance in this study

and Dr. Raoof Rasheed and all colleagues for

kindly providing part of radiographs used in this

study.

J Bagh College Dentistry Vol. 32(1), March 2020 Radiological Age

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الخالصة
الخلفية: تقدير العمر زمنيا هو طريقة عملية في مجال التقصي عن الجريمة اذ يساعد في التعرف عن االشخاص لمعالجتهم سواء كانوا تحت

راد العراقيين وتحديد االختالف بين سن البلوغ او بالغين. تهدف هذه الدراسة الى تقييم مراحل تمعدن سن العقل فيما يتعلق بالعمرالزمني لالف

الجنسين واالختالف بين الفكين العلوي والسفلي.

J Bagh College Dentistry Vol. 32(1), March 2020 Radiological Age

حددت مراحل تطور سن اشعة بانورامية لمرضى تقويم االسنان وفقا لمعايير خاصة وقيمت بصريا. 300 جمعتاالشخاص وطرق العمل:

لمراحل تمعدن معينة والتي تم الوصول اليها وفقا للجنسين الزمني قد سجل وفقا العمر لطريقة ديميرجيان. العقل في الفك العلوي والسفلي وفقا

فحوصات. لالمزدوجة والعينة الغير معتمدة ل نةقات حددت باستخدام العي ,جوانب الفكين والفكين.الفرو

ي تصل اسنان العقل في الفك العلو. العلوي والسفليفروق ذات داللة احصائية بين اسنان العقل في الفكين د ووجالنتائج عدم اظهرت: النتائج

بين فروق ذات داللة احصائية بين اسنان العقل في معدالت االعمار . التوجدGو Fقبل اسنان العقل في الفك السفلي في المرحلتين مبكرا

في Eو D في الفك العلوي وفي مرحلتي Dة اسنان العقل العلوية والسفلية ماعدا في مرحل ناث في كل مرحلة تطور معطاة في الذكور واال

داللة احصائية في اذ هناك فروق ذاتعدا في الفك العلوي للذكور تطور اسنان العقل في الجانبين االيمن وااليسر متشابه ما الفك السفلي.

.في الفك السفلي E وللمرحلة CوD المرحلتين

كل االختالفات بين الدراسة الحالية االشعة البانورامية. ممتازة في تقدير العمرباستخدامديميرجيان هي طريقة ان طريقة :االستنتاجات

. والدراسات االخرى ممكن ان يكون سببها االختالفات في السكان الذين تم اختيارهم من المناطق الجغرافية المختلفة