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Year : 2019  |  Volume : 30  |  Issue : 5  |  Page : 687-691
Comparative assessment of chronological, dental, and skeletal age in children

Department of Paediatric Dentistry, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India

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Date of Submission30-Nov-2017
Date of Decision09-Jul-2018
Date of Acceptance05-Sep-2018
Date of Web Publication18-Dec-2019


Background: Age of a child can be assessed from various parameters such as chronological age, height, weight, secondary sexual characteristics, skeletal age, or dental age. The present study was planned to assess and compare chronological age with dental age (Demirjian's method and Willem's method) and skeletal age (Fishman's method). Materials and Methods: The present study was done on a sample of 100 children in the age group of 9–14 years. The chronological age was computed through the birth certificates and dental age was calculated from their orthopantomograms (OPGs) using Demirjian's and Willem's methods. Hand-wrist radiograph of the left hand was used to compute skeletal age using Fishman's method. Paired t-test and Pearson's correlation coefficients were calculated as a part of statistical analysis at a significance level of P < 0.01. Results: The mean chronological age among the group was 12.37 ± 1.34 years, the mean dental age by Demirjian's method was 12.36 ± 1.72 years, the mean dental age by Willem's method was 12.36 ± 1.51, and the mean skeletal age by Fishman's method was 13.03 ± 1.34 years. Out of the all methods evaluated in the study, Fishman's method of age estimation showed the least value of correlation coefficient (r = 0.728) with the chronological age, whereas Willem's method showed the maximum correlation with the chronological age (r = 0.885). Conclusion: It can be concluded from the present study that the dental age estimation evaluated by the digital OPG by both the methods, that is, Demirjian's method and Willem's method, has shown high accuracy when applied to the children of Faridabad. Skeletal maturation evaluated by Fishman's method using hand-wrist radiographs was found to overestimate the age when compared to chronological age in both the sexes.

Keywords: Age determination by teeth, age determination by skeleton, forensic dentistry, forensic medicine

How to cite this article:
Bhadana S, Indushekar K R, Saraf BG, Sardana D, Sheoran N. Comparative assessment of chronological, dental, and skeletal age in children. Indian J Dent Res 2019;30:687-91

How to cite this URL:
Bhadana S, Indushekar K R, Saraf BG, Sardana D, Sheoran N. Comparative assessment of chronological, dental, and skeletal age in children. Indian J Dent Res [serial online] 2019 [cited 2023 Mar 22];30:687-91. Available from:

   Introduction Top

The development status of a child is usually assessed about physical events that take place during the progress of growth. Although growth events occur in reasonably constant sequences, the age at which they are attained varies considerably among children. Importance of age determination pertains to many fields including treatment planning in pediatric dentistry, orthodontics, forensic sciences, and also in individuals who provide inaccurate details of age as in cases of illegal immigrants and in the corpse of unknown identity.[1],[2] It also plays an important role in forensic medicine not only in the identification of bodies but also in connection with crimes and accidents.[3],[4] Historically, it has even helped in determining nutritional health status in public health programs and for legal purposes.[5] Child's age can be assessed from various parameters such as chronological age, height, weight, secondary sexual characteristics, skeletal age, or dental age. The ideal age estimation technique aims to arrive at an age as close to the chronological age as possible.[6],[7]

Chronological age is important in most societies for school attendance, social benefits, employment, and marriage. In emerging countries, reliable registration of birth details is often not of primary concern. Individuals may not have precise information regarding their date of birth, or they may choose to conceal such information. In such circumstances, age determination technique, that is, estimation of chronological age, may be required.[8]

Lamons and Gray[9] compared the progression of various biological ages as “A company of soldiers who are moving at a constant rate of speed. Now one pair walks together, then they divide and walk with others. Some run ahead, others lag behind and even stop to rest, yet all reach the same goal in the forward advance of events.”To take full advantage of the soldiers' potential, information about their specific roles and degrees of interrelationship is required. There are little published data on different methods of age estimation of children in India as the field of forensic dentistry is relatively untouched. Therefore, an attempt has been made for assessment and comparison of the chronological, dental, and skeletal age in children of Delhi NCR (Faridabad), India. Additionally, the objective of the present investigation was to compare two methods of dental age estimation (Demirjian's method [DM] and Willem's method [WM]) and one method of skeletal age estimation (Fishman's method) and compare it with the chronological age.

   Materials and Methods Top

The study group comprised 100 children, of which 50 were males and 50 females, in the age group 9–14 years who visited the Department of Paediatric and Preventive Dentistry and the Department of Orthodontics, Sudha Rustagi College of Dental Sciences and Research, Faridabad.

Inclusion criteria

  1. No history of any present illness.
  2. No history of medical or surgical disease that could affect the presence and development of mandibular teeth.
  3. Subject who had complete mandibular permanent dentition (clinically or radiographically) except the third molar.
  4. Patient who required orthodontic treatment in which orthopantomogram (OPG) was indicated.
  5. Informed written consent had been obtained from the parents.

Exclusion criteria

  1. Presence of grossly carious tooth/teeth in the lower left quadrant.
  2. Children with long-standing systemic illness and/or on medications for long duration.
  3. Any related dental and skeletal abnormality.
  4. Hypodontia or gross pathology.
  5. Agenesis of teeth.
  6. Systemic disease which might affect eruption of the teeth.

Patient and parents were explained about the study and written informed consent was taken from the parents. General information of the child was taken including child's name, age, gender, and other demographic details. Date of birth of each child was recorded as stated by the parents and was confirmed either from school records or the birth certificate of the child, thereby calculating chronological age. Dental examination was done with a mouth mirror and probe under good illumination, and the state of the eruption of teeth was noted in the proforma. The digital OPG and digital hand-wrist radiograph (HWR) were taken from Kodak 8000c Digital Panoramic and Cephalometric system. OPG was taken a setting of 75 kV, 12 mA, and 13.9 s, whereas HWR was taken at a setting of 66 kV, 15 mA, and 0.400 s. Dental age was calculated from the OPGs of the patients. Skeletal age was calculated from the HWRs of the left hand. Both the digital OPG and digital HWR were given the same code for one child. Eight OPGs were assessed daily to minimize the intra-examiner and inter-examiner fatigue and variability to measure the teeth matching the scores.

Dental age was calculated from digital OPG by the following methods:

  • Demirjian's method[10]: Demirjian (1973) presented a study to derive a method of estimating overall dental maturity or dental age, by a quantity based on the stages observed in each tooth. The digital OPG was also scored according to the criteria given by Demirjian et al. in 1973. The seven left mandibular teeth (central incisor to the second molar) were assessed and scored in the following order: 2nd molar, 1st molar, 2nd bicuspid, 1st bicuspid, canine, lateral incisor, and central incisor. A pair of divider was used to check for the relative length of crown and root (crown/root). No absolute measurements were taken. Determination of the apex closure was done with the naked eye, and when required, magnifying glass was used. Based on the development of the tooth and its root, following carefully the description criteria for each stage given by Demirjian in the original method and after the cross-verification, all teeth were rated on a scale A–H. The ratings were summed up, and the total was checked for assessment of dental age from the conversion table given in the original method.
  • Willem's method[11]: The maturity scores for all the teeth from central incisor to 2nd molar were directly given in the tables for boys and girls in years by Willem. So according to the corresponding developmental stage, ratings were given from A to H, and the maturity scores were assigned directly from the published tables to each tooth. Adding the maturity scores for all the teeth from central incisor to the 2nd molar gave the estimate of the individual's dental age directly.

Skeletal age was calculated from digital hand-wrist radiograph by the following method:

1. Fishman's method[12]: The left-hand-wrist radiograph of the subject was taken to observe the six anatomical sites located on the thumb (adductor sesamoid), third finger (proximal, middle, and distal phalanx), fifth finger (middle phalanx), and the radius. After that, eleven discrete adolescent skeletal maturational indicators (SMIs) covering the entire period of adolescent development were observed on these six anatomical sites. Now, the stages of bone maturation were observed starting with ossification of adductor sesamoid of thumb to note the SMIs. If the ossification had not taken place, then epiphyseal widening on selected phalanges was checked. But if the ossification had taken place, then fusion of distal phalanx of the third finger was checked. If the fusion had not taken place, then capping of selected epiphyses over their diaphysis was checked. But if the fusion had taken place, then further fusion of selected epiphyses and diaphysis and the fusion of radius were continued for assessment. Sequence of four ossification stages are as follows:

  1. Epiphyseal widening on selected phalanges.
  2. Ossification of adductor sesamoid of thumb.
  3. “Capping” of selected epiphyses over their diaphysis.
  4. Fusion of selected epiphyses and diaphysis.

Once all the stages of maturation had been observed in the hand-wrist radiograph and accordingly SMI numbers had been noted, the final SMI number recorded was checked for the assessment of age from the given table by Fishman for boys and girls individually.

Paired t-test was used to analyze the differences between the estimated dental age (DM and WM), chronological age, and skeletal age (Fishman's method) at a significance level of P < 0.01. Age estimation was done in a standardized way by second evaluator on 25 OPGs and kappa value was determined to assess the inter-examiner reliability.

   Results Top

[Table 1] shows the gender-wise distribution of the sample for mean chronological age, mean dental age (by DM and WM), and mean skeletal age (by Fishman's method). The mean chronological age among the group was 12.37 ± 1.34 years, the mean dental age by DM was 12.36 ± 1.72 years, the mean dental age by WM was 12.36 ± 1.51, and the mean skeletal age by Fishman's method was 13.03 ± 1.34 years. The table clearly shows the overestimation of the age by skeletal method (Fishman's method) when compared with the chronological age, Demirjian's method, and WM, the difference being statistically significant (P < 0.001). [Table 2] depicts the correlation coefficients among different methods of age calculation. As can be noted from the table, Fishman's method has the lowest correlation score (r = 0.728) with the chronological age, whereas WM showed the maximum correlation with the chronological age (r = 0.885). The mean difference between different methods of age estimation used in the study is shown in [Table 3] and found to be statistically significant in case of Fishman's method with other methods, wherein Fishman's method overestimated the age. The kappa score for age estimation of 20 subjects was determined to be 0.84 which is a substantial agreement between two evaluators.
Table 1: Intercomparison of mean chronological age, dental age (using Demirjian's method and Willem's method), and skeletal age (using Fishman's method) (in years)

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Table 2: Correlations among the chronological, dental, and skeletal age (Pearson's correlation coefficients)

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Table 3: Mean difference between different pair of ages (paired sample test)

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   Discussion Top

Determination of a child's growth and development are of great value for planning the treatment in orthodontics, pedodontics, pediatric endocrinopathies, and forensic medicine. Chronological age per se is of minimal or no importance and does not constitute a critical factor for estimating the maturation and development of an individual.[13] The goal of methods for age estimation must be to eliminate the methodologic variations as much as possible leaving only the unavoidable individual variability. Although various methods for the age determination do exist, a universal system has not been achieved due to the varying differences in different ethnic population groups.

In the present study, the study group comprised of 100 children in the age group of 9–14 years. The 9-, 10-, and 11-year age groups are of great importance because this period is frequently used as a clinical window when early orthodontic treatment aimed at growth modification is conducted. Even when patients of this age group are not under active treatment, this is a clinically relevant period when orthodontists assess children for beginning treatment; thus, knowledge of skeletal age–chronologic age differences in normally growing children in the 9-, 10-, and 11-year age groups would be of great importance.

Assessment of dental age is of particular interest to the pedodontist and orthodontist in management of different types of malocclusions in relation to maxillofacial growth. Calcification rates of teeth are more dependent on genes than environmental factors; hence, dental age assessment might be considered more reliable than other methods of age estimation. Several methods for estimating dental maturity show variation in degrees of maturation. The most frequently used methods are based on developmental stages of teeth visualized by OPGs. DM, Nolla's, Haavikko's, WM, Kvaal's, and Cameriere method are some of the methods used in the assessment of dental age.[14]

Dental Age: The method of Demirjian et al. is one of the simplest, most practical, and widely employed methods to predict age and maturation. Although DM uses a modified scoring system for cases with missing teeth based on four teeth, we preferred to adhere to the original method, which is based on seven mandibular teeth. It is to determine the beginning of mineralization up to the end of root formation. The authors looked at eight mineralization stages for premolars and molars (A–H) and six steps (C–H) for incisors and canines. Willems et al. established method by adaptation of scoring system of Demirjian's radiographic stages on 2116 OPGs of Belgian children by weighted ANOVA. Corresponding age scores were expressed directly in years for each of the seven left mandibular teeth in girls and boys separately. WM was subsequently tested on the second sample of 355 OPGs. WM, a modification of the former, is found to be more accurate than the DM. Hence, our choice for the second method of age assessment is the WM.[15],[16] Warhekar, Wanjari, and Phulambrikar[17] estimated the age using DM and found it to be accurate when applied to Central India (Indore and Madhya Pradesh) population which was similar to the results of our study.

Skeletal Age: This has been considered the most reliable method to assess developmental status. The technique for assessing skeletal maturity consists of visual inspection of developing bones, their initial appearance, and their subsequent ossification-related changes in shape and size. Various areas of skeleton have been used such as the foot, ankle, hip, elbow, hand-wrist, and cervical vertebrae. Most common is hand-wrist radiograph for skeletal development assessment.[8] Osseous changes seen in hand and wrist are indicators of more general skeletal changes. Fishman MP3, modified MP3, cervical vertebral maturation, Greulich and Pyle, Eklof and Ringertz, and ER5 and ER3 methods are some of the methods of skeletal age assessment.[13]

Dental age assessments involve the use of radiographs, and different types of radiographs have been used to investigate dental development. Panoramic radiographs have been adopted by most authors due to their accessibility and the possibility to visualize all teeth.[18] It is also easier to take OPG in young or nervous children and use less radiation dose than a full mouth radiographs. Intraoral radiographs are also difficult to obtain without image distortion and hence can lead to inaccuracy of findings in age estimation. Thus, panoramic radiographs were used in this study to determine the dental age by two different methods, that is, DM and WM, which use panoramic radiographic technique. Although there is 3–10% enlargement of left side of mandible on the panoramic radiographs,[19] this is not a serious drawback as the rating of Demirjian system and WM is based on shape criteria and relative values rather than on absolute length. The Fishman's technique offers an organized and relatively simple approach to determine the level of maturation. The system uses only 11 anatomical sites located on the phalanges, the adductor sesamoid, and the radius, all of which exhibit consistency in the time of onset of ossification. It is also an advantage to exclude the carpals from the system since irregularity in the order of onset of ossification occurs more frequently in the carpals than in the metacarpal or phalangeal epiphyses. In addition, it can be utilized without the presence of any  Atlas More Details and thus can be easily used in clinics.[20],[21] In the present study, Fishman's method was the only method which showed significant difference with other pairs of mean age and also the low values of Pearson's correlation. The overestimation of age by Fishman's method in the present study is in contrast to the study done by Mohammed et al.[21] which found it to be quite accurate in Indian children. The limitation of the present study was that the sample size was relatively smaller. It could be recommended that the larger sample size should be used to establish better accuracy in age determination for children of Delhi NCR (Faridabad town). Larger sample size would have reduced the differences in the estimation of the various biological ages. Consideration of the cultural habits, dwelling conditions, maternal influence, environmental factors, and genetic endowment were beyond the scope of the study. The methods used for dental age assessment were based on the foreign population standards. Although various methods of age estimation have been used, the applicability can vary due to the wide ethnic differences between the populations. It is therefore mandatory that maturity standards should be based on the same population for which they are going to be used. Ethnic differences and racial variations suggest that new criteria and new grading scores should be formulated and published exclusively for that particular population.

   Conclusion Top

It can be concluded from the present study that the dental age estimation evaluated by the digital OPG by both the methods, that is, DM and WM, has shown high accuracy when applied to the children of Delhi NCR (Faridabad town). Skeletal maturation evaluated by the digital hand-wrist radiograph by Fishman's method was found to be overestimated when compared to chronological age in both the genders.

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There are no conflicts of interest.

   References Top

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Correspondence Address:
Dr. Divesh Sardana
Faculty of Dentistry, Prince Philip Dental Hospital, The University of Hong Kong S.A.R.

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_698_17

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