|Year : 2016 | Volume
| Issue : 2 | Page : 89-95
Dental age assessment among a group of children in Tanta city
Abdrhman M Azzawi1, Amina M El Hosary1, Amal M Ezzat2
1 Pedodontics Department, Faculty of Dentistry, Tanta University, Tanta, Egypt
2 Oral Biology Department, Faculty of Dentistry, Tanta University, Tanta, Egypt
|Date of Submission||21-Mar-2016|
|Date of Acceptance||25-Apr-2016|
|Date of Web Publication||23-Aug-2016|
Abdrhman M Azzawi
Pedodontics Department, Faculty of Dentistry, Tanta University, Tanta 31111
Source of Support: None, Conflict of Interest: None
The aim of this study was to assess dental age among a group of children in Tanta city by using the Demirjian method.
Materials and methods
A sample of 400 children aged 5–13 years were selected from the Pedodontic and Orthodontic clinics, Faculty of Dentistry, Tanta University. All patients had to undergo panoramic radiography during their course of treatment. Dental maturity was assessed.
Both boys and girls showed advanced dental age compared with their chronological age, which was found to be statistically significant. Boys were 0.208 years and girls were 0.294 years ahead.
The Demirjian standard is not applicable to Egyptian children and a new adapted dental score for Egyptians must be established for each sex and age separately.
Keywords: age estimation, Demirjian method, dental age calculation, panoramic radiographs
|How to cite this article:|
Azzawi AM, El Hosary AM, Ezzat AM. Dental age assessment among a group of children in Tanta city. Tanta Dent J 2016;13:89-95
| Introduction|| |
Age is usually estimated using skeletal, dental, anthropological, and physiological methods . Dental development is a useful indicator of maturation because of its high reliability, low coefficient of variation, and resistance to environmental effects ,,,.
The development and maturation of teeth in growing children provides two main approaches for assessing their age: evaluation of clinical emergence in the mouth and radiographic evaluation of the mineralization of crowns and roots of primary and permanent dentition . The clinical emergence of both primary and permanent teeth is affected by different local factors, including feeding habits, local trauma, and pathology of primary teeth. In contrast, mineralization and growth of crowns and roots are a continuous process until closure of the apices of the teeth, and these are less affected by local and systemic factors .
Tooth development is a useful measure of maturity, as it represents a series of recognizable events that occur in the same sequence from an initial event to a constant endpoint . Estimating age from teeth is generally reliable, as they are naturally preserved long after the disintegration of tissues and bones . Also, maturational events associated with tooth formation and apical closures are less variable than other developmental events, such as the appearance of bone ossification centers .
Currently, the most common method used for children is Demirjian's method, which is based on French Canadians. This method utilizes orthopantomograms to estimate the extent of mineralized dental tissues and the shape of the chamber of seven left permanent lower teeth. In addition, it is more suitable for determining whether the dental maturity of an individual with a known age is advanced or delayed rather than for predicting an unknown age ,,.
Regarding Demirjian's system, the seven left mandibular teeth (except the third molar) are assessed from panoramic radiographs and are classified by means of an eight-stage system (A to H). The maturity score may be converted directly into dental age (DA), by reading off on the horizontal scale the age at which the 50th percentile attains a given maturity score .
Thus, this study was conducted to estimate the accuracy of Demirjian's method in a group of Egyptian children.
| Materials and Methods|| |
The study was approved by the ethical committee of Faculty of Dentistry, Tanta University, Egypt. The patients had to undergo panoramic radiography during their course of treatment and informed consent was taken from each child's parent.
The children were selected according to the following criteria:
- Native Egyptian ethnicity
- Age between 5 and 13 years
- Healthy status without any systemic disease or growth disorders
- Presence of a complete set of left mandibular permanent teeth (erupted or unerupted).
- Premature birth, presence of congenital anomalies, or suffering from local trauma affecting the primary teeth
- Unclear radiographs or those showing hypodontia or gross pathologic problems.
Dental age assessment
Dental maturity was assessed according to Demirjian et al. :
- The left mandibular permanent teeth were rated in the following order: second molar, first molar, second and first bicuspids, canine, lateral incisor, and central incisor
- All teeth were rated on a scale of A to H if there was calcification. If there was no calcification, the crypt formation was not taken into consideration and a rate of 0 was given ([Figure 1])
- There were no absolute measurements to be taken to compare the relative length (crown/root). In this study, we used the manual method for age estimation. A pair of dividers ([Figure 2]) was sufficient to compare the relative length of the crown/root. We determined apex closure stages with the naked eye and the rating was made according to self-weighted scores of Demirjian (1973)
- Crown height was defined as the maximum distance between the highest tip of the cusps and the cemento-enamel junction. When the buccal and lingual cusps were not at the same level, the midpoint between them was considered the highest point.
|Figure 2: Panoramic radiograph shows stages of seven left mandibular teeth: M2=D, M1=G, PM2=E, PM1=F, C=F, L2=G, L1=H.|
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Stage description according to Demirjian et al. 
- Commencement of calcification of cusps.
- Fusion of the calcified cusps, which gives a regular outline on the occlusal surface.
- Completion of enamel formation at the occlusal surface with extensions and convergence toward the cervical region. Beginning of a dentinal deposit is seen.
- (a) Completion of crown formation; the superior border of the pulp is concave to the cervical. (b) Beginning of root formation in the form of a spicule.
- (a) The root length is less than the crown height; the pulp horn is more defined. (b) Initial formation of the radicular bifurcation in the molar seen in the form of either a calcified point or a semilunar shape.
- The root length is equal to or greater than the crown height and pulp apex ends in a funnel shape.
- The walls of the root canal are now parallel and its apical end is still partially open (distal root in molar).
- Closure of the apical foramen; the periodontal membrane has a uniform width around the tooth.
- Each tooth was rated, assessed by the procedure described ([Figure 1] and [Figure 2])
- This rating was converted into a score as shown in [Table 1] for boys and girls as appropriate
- The scores for all seven teeth were added together to give the maturity score
- The maturity score was plotted on the centile charts (boys and girls as appropriate) where the age of the child was known
- The maturity score was converted directly into a DA either by reading off on the horizontal scale the age at which the 50th centile attained that maturity score value, or by using tables ([Table 2] and [Table 3]).
|Table 1: According to Demirjian et al. , self-weighted scores for dental stages of seven teeth (mandibular left side)|
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|Table 2: According to Demirjian et al. , conversion of maturity score to dental age (seven teeth) for boys|
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|Table 3: According to Demirjian et al. , conversion of maturity score to dental age (seven teeth) for girls|
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The chronological age (CA) of an individual was calculated by subtracting his or her birth date from the date on which the radiographs were taken. All data were tabulated and a comparative histogram was made. The difference between DA and CA in the different age groups was tabulated according to sex and age group, and the differences were compared statistically.
Assessments of DA were carried out by one examiner. Intraexaminer consistency was assessed 1 month after the initial assessment by examining 20 randomly selected panoramic radiographs twice to achieve uniform interpretation and application of criteria.
Data analysis was performed using SPSS version 21 (Chicago, Illinois, USA). Statistical analysis of the data with different characteristics was performed with the use of the paired t-test. A P value less than 0.05 was considered statistically significant.
| Results|| |
Examiner reliability was assessed by correlating data obtained in the test and the retest process. The linear Pearson correlation between test and retest gave P values less than 0.001, indicating that the rating was significantly correlated.
All data obtained from panoramic radiographs were tabulated and a comparative histogram was created. The difference between DA and CA in different age groups was tabulated according to sex and age and compared statistically.
Statistically significant differences were found between CA and DA for a male sample at all age groups, as shown in [Table 4]. The least difference between CA and DA was recorded in the age group 5–5.9, whereas the highest difference between CA and DA was recorded in the age group 13–13.9.
|Table 4: Comparison between chronological age and dental age in boys for each age group|
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Statistically significant differences were found between CA and DA for a female sample at all age groups, as shown in [Table 5]. The least difference between CA and DA was recorded for the age group 5–5.9, whereas the highest difference between CA and DA was recorded for the age group 13–13.9.
|Table 5: Comparison between chronological age and dental age in girls for each age group|
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Comparison between male and female DAs revealed a statistically nonsignificant difference (P > 0.05) in all age groups, as shown in [Table 6].
|Table 6: Comparison between male and female dental ages for each age group|
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Comparison between male and female CAs revealed a statistically nonsignificant difference (P > 0.05) in all age groups, as shown in [Table 7].
|Table 7: Comparison between male and female chronological ages in each age group|
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Comparison between male and female groups regarding the differences between CA and DA revealed a statistically significant difference between all age groups (P< 0.05) except for the age groups 5–5.9 and 6–6.9, which showed nonsignificant differences (P > 0.05) as shown in [Table 8].
|Table 8: Comparison between male and female groups regarding the difference between chronological age and dental age for each age group|
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| Discussion|| |
DA estimation has important applications in legal and forensic dentistry and carries a number of legal implications. It will be useful in those cases where no documentation is available to determine the age of a person.
In the current study the Demirjian method  was used because it is the most commonly used method to determine DA as it is a simple, practical, and widely reliable method to estimate DA and dental maturity. This was in agreement with the reports of several authors ,,.
DA may be overestimated, as in the study of Koshy and Tandon  and Leurs et al. , or underestimated, as in the study of Cruz-Landeira et al. . Thus, age estimation studies are needed in medicine and dentistry, being relevant to the timing of treatment procedures in endocrinology, pediatric dentistry, and orthodontics, besides its importance in forensic science.
The physiological age of a person is determined by the degree of maturation of different tissue systems. This physiological age was used to define the progress of a child toward maturity, where DA was used as a biological indicator to access the maturation of the growing child. Thus, it has the least variability between individuals. Tooth formation is a reliable method for assessing dental maturation and is generally used for estimating DA ,,,.
In our study, evaluation of the mineralization of crowns and roots on a radiograph of primary and permanent dentitions was a reliable method for estimating DA as done in several studies ,,,. Thus, panoramic radiography was used in the present study to visualize all teeth in the same film ,,,.
For accuracy and reliability, all measurements were recorded by a single examiner and were reviewed twice with an interval of one month between each measurement.
In our study, the age of all patients ranged from 5 to 13 years, which is similar to that in the study by Nykänen et al. , who studied a Norwegian sample that ranged in age from 5.5 to 12.5 years, and to that of Bagherpour et al. , who studied an Iranian sample aged from 6 to 13 years.
Our results revealed that in the male group the DA exceeded the CA by 0.208 years. This was in accordance with the reports of Nystrom et al.  (0.29 years), Nykänen et al.  (0.20 years), Davidson and Rodd  (0.19 years), McKenna et al.  (0.30 years), and Al-Emran  (0.30 years). However, the DA in the male group was delayed in the study by Qudeimat and Behbehani  (0.71 years), Cruz-Landeira et al.  (0.23 years), and Chen et al.  (0.08 years).
Our study showed that in the female group the DA exceeded the CA by 0.294 years. This result agreed with the reports of Nykänen et al.  (0.30 years). However, the dental maturation in the female group was delayed in the study by Qudeimat and Behbehani  (0.67 years), Cruz-Landeira et al.  (0.10 years), and Chen et al.  (0.15 years).
Our results revealed that dental maturation in the Egyptian female population was more rapid than that in the Egyptian male population by 0.528 years. This came in accordance with the study of Al-Kholy  (0.1 years), Sukhia et al.  (0.211 years), Bagherian and Sadeghi  (0.15 years), and Feijoo et al.  (0.291 years). In contrast, the DA in the male group exceeded that in the female group in the study by Eid et al.  (−0.04 years), Prabhakar et al.  (−0.18 years), Bagherpour et al.  (−0.16 years), and Baghdadi  (−0.73 years).
In our study, the CA in the female group was higher than that in the male group by 0.446 years. Also, the CA in the female group exceeded that in the male group by 0.03 years in the study by Eid et al. , by 0.06 years in Bagherpour et al. , and by 0.03 years in Feijoo et al. , whereas the CA in the male group exceeded that of the female group by −0.01 years in the study by Goya et al. .
In the present study, the difference between CA and DA between male and female groups was 0.086 years. This result nearly agreed with those of Hagg and Matsson  (0.1 years), Nykänen et al.  (0.1 years), Foti et al.  (0.1 years), and Al-Emran  (0.1 years). Our findings are also in agreement with those of other studies in different populations – for example, Finnish and Australian studies: Nystrom et al. and McKenna et al.  found that the difference between male and female DAs was 0.14 years and 0.21 years, respectively.
In contrast, our results disagreed with those of Cruz-Landeira et al. , who studied Venezuelan children and found that the difference between male and female DAs was -0.13 years. Qudeimat and Behbehani , who studied Kuwaiti children, found that the difference between male and female DAs was −0.04 years.
In addition, Andre  found that the mean difference between male and female DAs was −0.3 years, whereas Mani et al.  recorded a greater difference between CA and DA (−0.14 years) in the male population compared with the female population.
Overall, our study showed that Demirjian standards are not applicable to Tanta city children. The differences between the results of our study and that of Demirjian may be related to the time factor, as well as to improvements in social conditions for many populations, including better nutrition and freedom from childhood disease.
| Conclusion|| |
The female Egyptian population is more advanced in their DA development compared with the male Egyptian population. The Demirjian standard is not applicable to Egyptian children and a new adapted dental score for Egyptians must be established for each sex and age separately.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]