comparison between two methods of .... 5...permanent mandibular teeth were eval-uated. the inclusion...

75

Vol. XVII, No. 1, Jan. 2009Mansoura J. Forensic Med. Clin. Toxicol.

El-Bakary et al ...

living humans (Cameriere and Ferrante,2008).

Tooth formation is widely used toassess maturity and to predict age.Within clinical dentistry, such informa-tion aids in diagnosis and treatmentplanning (Tunc and Koyuturk, 2008).The age range from 9 to 14 years re-mains the most critical with regard to esti-mating a child’s dental age and conse-quently, to determine the proper timingfor initiating orthodontic therapy (Al-Emran, 2008).

INTRODUCTlON

Age estimation in children is a funda-mental question in forensic medicine,pediatric endocrinology and in ortho-dontic treatment. The need to evaluateage to consider legal responsibility, orfor application of different laws foryoung people, requires reliable meth-ods. The study of the morphological pa-rameters of teeth and hand / wrist X-raysof children is more reliable than mostother methods for age estimation and ismost commonly used to determine age in

COMPARISON BETWEEN TWO METHODS OF DENTALAGE ESTIMATION AMONG EGYPTIAN CHILDREN

BY

Amal A. El-Bakary , Shaza M. Hammad * and Fatma M. Ibrahim **Departments of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, *Orthodontics,

**Oral-histology, Faculty of Dentistry, Mansoura University,

ABSTRACT

The need to estimate the age of living individuals is becoming increasingly more important in both fo-

rensic science and clinical dentistry. The study of the morphological parameters of teeth on dental X-rays

of adult humans is more reliable than are most other methods for age estimation. Willems and Cameriere

methods are newly presented methods. The aim of this work was to evaluate the applicability of using

these methods for Egyptian children. Digitalized panoramas taken from 286 Egyptian children (134 boys,

152 girls) with age range from 5 to 16 years were analyzed. The seven left permanent mandibular teeth

were valued using the two methods. The results of this research showed that dental age estimated by both

methods was significantly correlated to real age. However, Willems method was slightly more accurate

(98.62 %) compared to Cameriere method (98.02 %). Therefore, both methods can be recommended for

practical application in clinical dentistry and forensic procedures on the Egyptian population.

Key words: Dental age, Cameriere method, Willems method, Children, Forensic odontology.

El-Bakary et al ...76


crown height, apex width and root lengthof the teeth observed in radiographs(Paevlinsky, 2005).

Willems et al. (2001), adapted a methodfor dental age estimation in a Belgian Cau-casian population. It is a modification ofDemirjian method (new tables for boysand girls with age scores directly ex-pressed in years). The adapted methodwas validated and resulted in more accu-rate dental age estimations in this popula-tion.

Cameriere et al. (2006a), took a com-pletely different approach and published amathematical formula for calculating den-tal age on teeth for some Europeancountries. The method is based uponmeasuring the completeness of apical de-velopment via a computer method and allstudies to date show a very strong correla-tion to chronological age.

In the dental literature the existence ofdifferent patterns of dental maturationamong different populations has been re-ported and hence, different standardswere found in several countries (Rai,2008). Since dental age assessment is con-sidered important, the aim of the presentstudy was to evaluate the suitability ofusing Willems method and Camerieremethod standards in a sample of Egyptianchildren through analysis of panoramicX-ray on teeth.

It is commonly accepted that tootheruption as an evaluation method for den-tal age estimation has some limitations,since tooth eruption is heavily influencedby environmental factors such as availablespace in the dental arch, extraction of de-ciduous predecessors, tipping or impac-tion of teeth. Oppositely, the method fordental age estimation using developmen-tal stages of teeth is more useful sincetooth development is less influenced byenvironmental factors (Willems et al.,2001).

Numerous odontological studies havealso been carried out to establish age,assessing mineralization within accepta-ble error limits. The most common meth-od for dental age assessment was firstpublished by Demirjian et al. (1973) andsince then odontology has carried out nu-merous studies in this issue (Willems,2001).

The Demirjian method has beenwidely used ever since and it is ofspecial interest both for the orthodon-tists when planning therapeutical proce-dures of different kinds of malocclu-sions as well as in forensic examinationsfor the dental age determination of liv-ing persons and of human remains (Bagicet al., 2008). To improve this method,several authors developed alternativeapproaches based on the measurement ofsome significant tooth parameters, such as

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El-Bakary et al ...

between 5 and 16 years at the timeof obtaining dental panorama, goodquality radiographs, no agenesis or ex-tractions in the left lower quadrant. Exclu-sion criteria were hypodontia or hyper-dontia.

Dental age methods: 1-Willems method:Each tooth on the left side of the mandi-

ble (except the third molar) is given a let-ter from A to H depending on its develop-mental criteria (Figure 1). Each lettercorresponds to a score. Maturity scoreswere converted into fractions of dental ageusing published conversion tables thenthese were summed to obtain dental age.Different standards are used for boys andgirls (Willems et al., 2001).

SUBJECTS AND METHODS

Study design : It is a study of panoramic radiographs

of patients treated at the Orthodontics De-partment (from Augest 2007 till Augest2008), Faculty of Dentistry, Mansoura Uni-versity.

Samples : Panoramas taken from 286 Egyptian

children (134 boys, 152 girls) aged be-tween 5 and 16 years were analyzed(Cameriere et al., 2006a). Digital panora-mic radiographs were assessed using Im-age Tool program for digitalized images(UTHSCSA, Texas, USA). The seven leftpermanent mandibular teeth were eval-uated. The inclusion criteria were age

Fig. (1) : Assessment of tooth formation stage of left mandibular second molar, first molar,premolars, canine and incisors. The sum of scores fromWillem's table is the dental age.(Willems et al., 2001)



To take into account the effect of possi-ble differences in magnification and angu-lations among X-rays, measurements werenormalized by dividing it by the toothlength (Li, i=1,..,7). Finally, dental maturi-ty was evaluated using the normalizedmeasurements of the seven permanentmandibular teeth (xi=Ai/Li, i=1,…,7), thesum of the normalized open apices (s) andthe number of teeth with complete rootdevelopment (N0) (Figure 2). All measure-ments were carried out by the same ob-server.

2- Cameriere method:The number of teeth with complete root

development, apical ends of the rootscompletely closed (N0), was calculated.Furthermore, the teeth with incompleteroot development and therefore with openapices, were considered. For teeth withone root, the distance (Ai, i=1,...,5) be-tween the inner sides of the open apexwas measured. For teeth with two roots(Ai, i=6, 7), the sum of the distances be-tween the inner sides of the two open api-ces was calculated.

Fig. (2) : An example of tooth measurement. Ai, i=1,...,5 (teeth with one root), is the distance be-tween the inner sides of the open apex; Ai, i=6, 7 (teeth with two roots), is the sum of thedistances between the inner sides of the two open apices; and Li, i=1,...,7, is the length ofthe seven teeth and N0 is a tooth with closed root.

N0N0 N0

A 3

A 5

A 4L 3

L 4

L 5A 7b

A 7a

L 7

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distribution, means and standard devia-tion. Correlation between chronologicalage and dental age was examined by Pear-son correlation coefficient. The percentageof error was calculated by dividing thesubtract from chronological age and den-tal age over the chronological age. Thepercentage of accuracy (100 - percentageof error) was also evaluated.

Acknowledgment: The authors wouldlike to acknowledge Prof. Dr RobertoCameriere, Institute of Legal Medicine,University of Macerata, Italy and SimonaCarmen for his great help.

RESULTS

Cross tabulation of age and sex groupsis demonesterated in table (1). The resultsof this research showed that, age of thecollected sample ranges from 5 years and10 months (5.83 y) to 15 years and 8months (15.75 y), mean is 10.82 + 2.75,while the mean age in girls was 11.04 +2.69 y (range; 6.33 - 15.67) and in boys, itwas 10.56 + 2.79 y (range; 5.83 - 15.75) (Ta-ble 2).

Inter-observer reliability as assessedby reliability Alpha (Cronbach) is 0.985.A significant positive correlation be-tween ages estimated by both methodsand chronological age is found for thetotal sample and in both sexes (Figures3-10).

All the morphological variables, xi,i=1,...,7, s, N0 and subjects’ gender, wereentered in an EXCEL file for use as predic-tive variables for age estimation in thesubsequent statistical analysis. Chrono-logical age, calculated by subtracting dateof birth from the date of radiograph, wasalso recorded in the EXCEL file. Then thefollowing linear regression formula wasused:

Age = 8.971 + 0.375 x g + 1.631 x 5 +0.674 N0 -1.034 s - 0.176 s x N0

where g is a variable equal to 1 for boysand 0 for girls. Thus the equation pointsout to advanced dental maturity for girlsat all ages (Cameriere et al., 2006a).

Calculating accuracy :Dental age for each method was com-

pared with chronological (real) age foreach subject. The chronological age wassubtracted from the dental age and pos-itive result indicates an overestimationand negative figure an underestimation.Dental age estimation was carried outby two well trained observers. To testintra-observer reproducibility, a randomsample of 50 panoramic radiographswere re-examined after an interval of2 weeks.

Statistical analysis was performed withSPSS version 11.0 statistical program.Chronological age and both estimates ofdental age were described by frequency



man et al., 1992). Hence, considering theregional difference in country region likeEgypt, would be very significant. Theaim of this study was to evaluate theaccuracy of Willems and Camerieremethods in dental aging of a sample ofEgyptian children through panoramicradiographs analysis.

The results obtained in our study onboth boys and girls showed a high correla-tion between the real chronological ageand the age estimated by both Willemsand Cameriere methods.

Age estimation in the studied sampleby Willems method yielded an averageover estimation of age by 0.14 y for girlsand 0.29 y for boys being better in girls.When Willems method was applied onBelgian Caucasian population, an overestimation by median: 0.1 for boys andmedian: 0.2 for girls was demonstrated(Willems et al., 2001). Other authors had asimilar observation on Indian population(Rai and Anand, 2006). However, bothstudies showed better accuracy for boysthan girls. Willems method also yieldedover estimation of dental age in a Malaypopulation (Mani et al., 2008). Although(Cameriere et al., 2007b), confirmed anover estimation of age by Willemsmethod in boys, they observed an underestimation of age in girls. In Bangladeshiand British Caucasian population, Wil-lems method under estimated age by

Willems method showes an averageover estimation of age by 0.15 + 0.62 y forthe total sample, 0.14 + 0.74 y for girls and0.29 + 0.48 y for boys. While that by Came-riere method showes an average underestimation by - 0.29 + 1.04 y for the totalsample, - 0.26 + 1.21 y for girls and - 0.49 +1.03 y for boys (Table 3).

Percentage of accuracy (100- percentageof error) is 98.62% for Willems methodbut Cameriere method is 98.02% accurate(data not shown).

DISCUSSION

Tooth formation has been more widelyused than tooth eruption for assessingdental maturation because it is a continu-ous and progressive process that can befollowed radio-graphically and most teethcan be evaluated at each examination (Rai,2008). Several studies showed that mor-phological measurements can be reliablymade in panoramic radiography, provid-ed that some corrections are made to takeinto account the individual variability oftooth size and the differences in magnifi-cation of radiographs and angulationbetween x-ray beam and film (Cameriereet al., 2006a).

It has been reported that developmentof each individual can be affected bygenetic, racial, nutritional, climate, hor-monal and environmental factors (Kull-

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El-Bakary et al ...

However, it is contradictory to thatof Cameriere et al., (2007b), who foundthat Cameriere method was more accuratethan Willems method in Europianpopulation.

It is important to remember that the dif-ference in chronological age and obtaineddental ages (whatever the method used),can be attributed to numerous factors,such as the accuracy of the method'sexecution, the examiner's subjectivity,sample size, sample structure (age, sex,ethnicity, nationality and social status)and statistic approach to the obtainedresults (Bagic et al., 2008).

Based on the results of this research, itcan be concluded that - both Willems andCameriere methods are suitable for dentalage estimation in Egyptian children, how-ever, Willems method was slightly moreaccurate when applied on this sampleof Egyptian population. Therefore, bothmethods can be recommended forpractical application in clinical dentistryand forensic procedures on the Egyptianpopulation.

an average 0.05 y for boys and 0.2 y forgirls (Maber et al., 2006).

In the present study, age estimation byCameriere method resulted in an averageunder estimation of age by 0.26 y for girlsand 0.49 y for boys. Similar resultswere observed in European population(Cameriere et al., 2006b; Cameriere etal., 2007a; Cameriere et al., 2007b). InIndian population, Cameriere methodyielded a mean over estimation by 0.05 yfor boys and 0.04 y for girls (Rai, 2008).This controversy can be explained bydifference in genetic factor, environmen-tal factors, nutritional factors and geo-graphical factors (Rai and Anand, 2008).

Comparing the percentage of accuracyof both methods, Willems method wasmore accurate than Cameriere method.This confirms previous studies on Indianpopulation (Rai and Anand, 2006). OnRomanian children, Carmen (2008), com-pared the two methods. She concludedthat both methods can be applied butCameriere method was less accurate inolder age group (11- 15 y) and in boys.



Table (1) : Cross tabulation of age and sex groups.

SexAge groupsFemales Males

Total

5-6 y 0 (0%) 6 (4.5%) 6 (2.1%)

6-7 y 9 (5.9 %) 16 (11.9%) 25 (8.7%)

7-8 y 7 (4.6%) 13 (9.7%) 20 (7%)

8-9 y 29 (19.1%) 8 (6%) 37 (12.9%)

9-10 y 16 (10.5%) 4 (3%) 20 (7%)

10-11 y 26 (17.1%) 24 (17.9%) 50 (17.5%)

11- 12 y 8 (5.3%) 6 (4.5%) 14 (4.9%)

12-13 y 3 (2%) 24 (17.9%) 27 (9.4%)

13-14 y 23 (15.1%) 25 (18.7%) 48 (16.8%)

14-15 y 17 (11.2%) 0 (0%) 17 (5.8%)

15-16 y 14 (9.2%) 8 (6%) 22 (7.7%)

Total 152 (100%) 134 (100%) 286 (100%)

Table (2): Mean and standard deviation of chronological age and ages estimated byboth methods (in years).

Total(boys and girls)

Girls Boys

ChronologicalAge

RangeMean ± SD

5.83 - 15.7510.82 ± 2.75

6.33 - 15.6711.04 ± 2.69

5.83 -15.7510.56 ± 2.79

Dental age(Willems method)

Rangemean ± SD

6.41 - 16.0310.97 ± 2.65

6.94 - 15.7911.1 ± 2.56

6.41- 16.0310.83 ± 2.75

Dental age(Cameriere method)

Rangemean ± SD

6.64 -14.0610.39 ± 2.14

6.68 -14.0610. 39 ± 2.05

6.64 -14.0610.39 ± 2.24

Table (3): The estimated error (in years) by both methods

Total

(boys and girls)Girls Boys

Willems method (mean ± SD) 0.15 ± 0.62 0.14 ± 0.74 0.29 ± 0.48

Cameriere method (mean ± SD) -0.29 ± 1.04 -0.26 ± 1.21 -0.49 ± 1.03

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Fig. (3) : An example of panorama of a male.His chronological age was 10.75 y.Age estimation by Willems methodwas 10.88 y and that by Camerieremethod was 10.61 y.

Fig. (5) : Showing correlation between agesestimated by Cameriere method andchronological age in total sample(p=0.000).

Fig. (4) : An example of panorama of a fe-male. Her chronological age was 8y. Age estimation by Willems meth-od was 7.92 y and that by Came-riere method was 7.97 y.

Fig. (6) : Showing correlation between agesestimated by Willems method andchronological age in total sample(p=0.000).

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Fig. (7) : Showing correlation between agesestimated by Cameriere method andchronological age in girls(p=0.000).

Fig. (9) : Showing correlation between agesestimated by Cameriere method andchronological age in boys(p=0.000).

Fig. (8) : Showing correlation between agesestimated by Willems method andchronological age in girls(p=0.000).

Fig. (10) : Showing correlation between agesestimated by Willems method andchronological age in boys(p=0.000).

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Cameriere, R., Ferrante, L.; Scarpino,F.; Ermenc, B. and Zeqiri, B. (2006b) :“Dental age estimation of growing chil-dren: comparison among various Europe-an countries”. Acta Stomatol. Croat., 40(2):256-262.

Carmen, S. (2008) : The applicapilityof two dental age estimation techniquesto Romanian children. Procceding fromthe 3rd Egyptian International Conferenceof Medical and Forensic Sciences (Absr-tact).

Demirjian, A.; Goldstein, H. andTanner, J. M. (1973) : “A new system ofdental age assessment”. Hum. Biol., 45:221-227.

Kullman, L.; Johanson, G. and Akes-son, L. (1992) : “Root development of thelower third molar and its relation tochronological age”. Swed. Dent. J., 16: 161-167.

Maber, M.; Liversidge, H. M. andHector, M. P. (2006) : “Accuracy of age es-timation of radiographic methods usingdeveloping teeth”. Forensic Sci. Int., 15(159): 68-73.

Mani, S. A.; Naing, L.; John, J. andAmsudin, A. R. (2008) : “Comparison oftwo methods of dental age estimation in7-15-year-old Malays”. Int. J. PaediatricDentistry, 18 (5) : 380-388.

REFERENCES

Al-Emran, S. (2008): “Dental age assess-ment of 8.5 to 17 year-old Saudi childrenusing demirjian’s method”. ContemporaryDental Practice, (9)3: 64-71.

Bagic, I. C.; Sever, N.; Brkic, H. andKern, J. (2008) : “Dental age estimation inchildren using orthopantomograms”. ActaStomatol. Croat., 42(1):11-18.

Cameriere, R.; Angelis, D. D.; Ferrante,L.; Scarpino, F. and Cingolani, M. (2007a):“Age estimation in children by measure-ment of open apices in teeth: a Europeanformula”. Int. J. Legal Med., 121 (6) : 449-453.

Cameriere, R. and Ferrante, L. (2008) :“Age estimation in children by meas-urement of carpals and epiphyses of ra-dius and ulna and open apices in teeth: apilot study”. Forensic Sci. Int., (174) 1: 59-62.

Cameriere, R.; Ferrante, L. and Cingo-lani, M. (2006a) : “Age estimation in chil-dren by measurement of open apices inteeth”. Int. J. Legal Med., 120: 49-52.

Cameriere, R.; Ferrante, L.; Liversidge,H. M.; Prieto, J. L. and Brkic, H. (2007b) :“Accuracy of age estimation in childrenusing radiograph of developing teeth”. Fo-rensic Sci. Int., 176(2-3):173-177.



The Internet Journal of BiologicalAnthropology, (1) 2 : [serial on the inter-net]. Available from: http://www. IS-PUB.com.

Tunc, E. S. and Koyuturk, A. E. (2008):“Dental age assessment using Demirjian'smethod on northern Turkish children”.Forensic Sci. Int., 25;175(1):23-26.

Willems, G. (2001) : “A review of themost commonly used dental age estima-tion techniques”. J. Forensic Odontostom-atol., 19: 9-17.

Willems, G.; Van Olmen, A.; Spies-sens, B. and Carels, C. (2001) : “Dental ageestimation in Belgian children: Demirjian’stechnique revisited”. J. Forensic Sci., 46(4):893-895.

Paevlinsky, E.; Pfeiffer, H. and Brink-mann, B. (2005) : “Quantification of secon-dary dentine formation from orthopanto-mograms- a contribution to forensic ageestimation methods in adults”. Int. J. LegalMed., 119:27-30.

Rai, B. (2008) : “An accuracy of fourmethods of age estimation from panoram-ic radiographs”. Inter. J. Dental Anthro-pol., 13: 7-10.

Rai, B. and Anand, S. C. (2006) : “Toothdevelopments: an accuracy of age esti-mation of radiographic methods”. WorldMedical Sciences, 1 (2) : 130-132.

Rai, B. and Anand, S. C. (2008) :“Age estimation in children from den-tal radiograph : a regression equation”.

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