ORIGINAL ARTICLE
M Celikoglu
A Erdem
A Dane
T Demirci
Authors' affiliations:
M. Celikoglu, Department of Orthodontics,
Faculty of Dentistry, Karadeniz Technical
University, Trabzon, Turkey
A. Erdem, Department of Orthodontics,
Faculty of Dentistry, Ataturk University,
Erzurum, Turkey
A. Dane, Department of Pediatric Dentistry,
Faculty of Dentistry, Ataturk University,
Erzurum, Turkey
T. Demiric, Department of Pediatric
Dentistry, Faculty of Dentistry, Ataturk
University, Erzurum, Turkey
Correspondence to:
Dr Mevlut Celikoglu
Department of Orthodontics
Faculty of Dentistry
Karadeniz Technical University
Trabzon
Turkey
E-mail: mevlutcelikoglu@hotmail.com
DOI: 10.1111/j.1601-6343.2011.01508.x
Dental age assessment in orthodontic
patients with and without skeletal
malocclusions
Structured Abstract
Authors – Celikoglu M, Erdem A, Dane A, Demirci T
Background – The aim of this report was to investigate the dental development in
an orthodontic patient population with and without different sagittal skeletal
malocclusions.
Setting and Sample Population – Department of Orthodontics, Faculty of
Dentistry, Ataturk University, Turkey.
Material and Methods – A retrospective study was performed on a sample of
panoramic radiographs taken from 525 orthodontic patients (Class II: 186, Class III:
177, Class I: 162) aged between 9.00 and 15.00 years. Dental age (DA) from
panoramic radiographs was assessed. Statistical analyses showing the differences
between chronological age (CA) and DA were compared by using the one-way
ANOVA,
paired, and StudentÕs t-tests.
Results – Both genders were advanced in dental maturity when compared with the
reference samples (p = 0.000). The mean difference between CA and DA in
orthodontic patients with different skeletal malocclusions was approximately twice
the difference in the Class I group. However, the difference between CA and DA was
statistically significant for girls in Class III group (p = 0.021).
Conclusion – The results of this study showed that DA of patients with sagittal
skeletal malocclusions was approximately twice more advanced when compared
with patients without sagittal skeletal anomaly patterns.
Key words: DemirjianÕs method; dental age; malocclusions; orthodontics
Introduction
Dates:
Accepted 5 February 2011
To cite this article:
Celikoglu M, Erdem A, Dane A, Demirci T:
Dental age assessment in orthodontic patients
with and without skeletal malocclusions
Orthod Craniofac Res 2011;14:58–62
2011 John Wiley & Sons A ⁄ S
In archeology and forensic odontology, age estimation methods can aid to
the age identification of a deceased child. They have also been proven
valuable when birth data are lacking or doubted in the management of
immigration to help to determine physiologic age (1, 2). Additionally, it is
of particular interest to the pedodontist and orthodontist as information
aids in diagnosis and treatment planning (2, 3).
The dental age (DA) of the children can be determined by dental
eruption and calcification as observed on radiographs. Dental calcification is considered to be more reliable for DA estimation than dental
eruption, because dental eruption is discontinuous and influenced by
Celikoglu et al. Dental age assessment in orthodontic patients
various factors such as malnutrition, crowding,
extractions, ankylosis, ectopic eruption, and persistence of the primary tooth (4, 5). Several methods for
the determination of DA have been described and one
widely used method is that of Demirjian et al. (6), first
described in 1973 and based on a large number of
French-Canadian children. Hägg and Mattson (7) have
found a high precision and accuracy with DemirjianÕs
method when applied to younger age groups rather
than older age groups.
Although reports suggesting accurate techniques for
age estimation have been widely published over the
past two decades, most of these studies have been
performed exclusively in the general population, not
considering the effects of different skeletal malocclusions on dental maturity. Thus, little is known about the
applicability of this method in subjects with different
skeletal malocclusions of the jaws. Only Janson et al. (8)
and Jamroz et al. (9) evaluated the DA in subjects with
short and long faces. The background of the present
study was that different skeletal development of the
jaws might affect the dental development. The aim of
this report was therefore to investigate the dental
development in orthodontic patients with and without
different sagittal skeletal malocclusions of the jaws.
Material and methods
A retrospective study was performed on a sample of 525
orthodontic patients aged between 9.00 and 15.00 years
(Fig. 1). The Local Ethical Board agreed on the study
because it had a retrospective investigation. For all
patients, panoramic X-rays and lateral cephalograms
were available. The lateral cephalograms were traced,
and the anterior–posterior skeletal relationship of the
maxilla and mandible was classified as skeletal Class I,
II, and III using the value for the ANB angle (Class I:
ANB angle between 0 and 4; Class II: ANB > 4; Class
III: ANB < 0). Of them, 186 patients were skeletal Class
II, while 177 patients were skeletal Class III; 162
patients with skeletal Class I were also used as control
group. Skeletal Class II subjects were characterized
with maxillary protrusion and ⁄ or mandibular retrusion
and Class III subjects with mandibular prognathism
and ⁄ or maxillary retrusion. The subjects in the Class I
group were not characterized with any of the sagittal
skeletal anomalies (with minor crowding or spacing).
Fig. 1. The distribution of the chronological ages among the skeletal
groups.
The radiographs of the children, taken as part of their
routine orthodontic treatment, were randomly selected
from the data of the subjects attending the Department
of Orthodontics, Faculty of Dentistry of the Ataturk
University from January 2003 to January 2009. Data of
23 children (9: Class III, 8: Class II, and 6: Class I) were
excluded from this report because of the following
reasons: agenesis of teeth, systemic diseases affecting
the growth and development of the teeth, poor quality
of panoramic radiographs, or image deformity affecting
mandibular permanent teeth. Finally, this investigation
was performed in 525 orthodontic patients with different skeletal malocclusions described earlier. All
radiographs were performed by an X-ray technician
using a panoramic device (Planmeca Proline CC 2002,
60–80 kVp, 8–10 mA, 12.8 s exposure time, Helsinki,
Finland) with a magnification factor of 1.2.
All assessments were performed by one investigator
in a darkened room with a radiographic illuminator to
ensure contrast enhancement of tooth images. To
avoid observer bias, each panoramic radiograph was
coded with a number and thus the observer was blinded for the gender and skeletal pattern of the child. The
chronological age of the patient was calculated by
subtracting his or her birth date from the date on which
panoramic radiographs were obtained after having
converted both to a decimal age. The stages of dental
maturity of the mandibular left seven permanent teeth
for each subject were evaluated by using the eight
radiographic dental maturity stages demonstrated by
Demirjian et al. (6). Each stage of the seven mandibular
Orthod Craniofac Res 2011;14:58–62
59
Celikoglu et al. Dental age assessment in orthodontic patients
teeth was allocated a biologically weighted score, and
the sum of the scores provided an estimate of the
dental maturity, measured on a scale from 0 to 100. The
overall maturity score was then converted to a DA.
Statistical analysis
To assess the intra-observer reliability, 53 randomly
selected panoramic radiographs were re-evaluated
4 weeks after the first examination by the same investigator. The difference between the two readings was
tested for significance with paired t-test. To determine
the errors associated with digitizing and measurements, 15 radiographs were selected randomly. All
procedures such as landmark identification, tracing,
and measurement were repeated 2 weeks later by the
same author. Intraclass correlation coefficients were
performed to assess the reliability of the measurements
as described by Houston (10). Besides, the mean differences between the DA and chronological age (CA) of
the subjects in each group were tested by means of
paired t-test. On the other hand, the mean differences
between the DA and CA of the subject in different
skeletal malocclusions were calculated. The comparisons between the groups were made by means of the
StudentÕs t-test and one-way ANOVA test. All statistical
analyses were performed using the SPSS software
package program (SPSS for Windows 98, version 10.0,
SPSS Inc, Chicago, Ill).
Results
Repeated evaluating of a subsample of 53 randomly
selected panoramic radiographs indicated no significant intra-observer difference (p > 0.05). The percentage agreement at the second reading of stage
assessments in a total 371 teeth was 89%. Additionally,
the coefficients of reliability of the measurements (ANB
angle) were above 0.90 for all parameters. Table 1
shows the distribution of the girls and the boys into
different skeletal malocclusion groups: 269 (51.2%)
were girls and 256 (48.8%) were boys. Comparison of
the mean chronological ages in patients with different
skeletal malocclusion patterns showed that there were
no statistically significant differences in the distribution of the chronological ages among three skeletal
classes (p > 0.05) (by means of one-way ANOVA).
60
Orthod Craniofac Res 2011;14:58–62
Table 1. The distribution of the subjects with different skeletal
malocclusions
Malocclusion pattern
Girls (%)
Boys (%)
Total (%)
Class I
85 (52.5)
77 (47.5)
162 (30.9)
Class II
91 (48.9)
95 (51.1)
186 (35.4)
Class III
93 (52.5)
84 (47.5)
177 (33.7)
Total (%)
269 (51.2)
256 (48.8)
525 (100)
Both genders were advanced in dental maturity as
compared with the reference samples of FrenchCanadian children. The differences between the CA and
DA were statistically significant for both genders
(p = 0.000). The mean difference between the CA and
DA for orthodontic patients without skeletal malocclusion, the Class I group, was 0.63 years for girls and
0.58 years for boys. The mean difference between CA
and DA in orthodontic patients with different skeletal
malocclusions was approximately twice more than the
mean difference in the Class I group. For girls, the
difference in the Class II and Class III malocclusion
groups was 1.08 and 1.38 years, respectively; for boys, it
was 1.10 and 1.15 years, respectively (Table 2). On the
other hand, when the data of girls and boys with all
skeletal classes were pooled, the difference between CA
and DA for girls was very close to the data found for
boys with no statistical difference (p > 0.05).
Table 3 shows the statistical comparison of the mean
differences in patients with different skeletal malocclusion patterns for both girls and boys. The mean
difference for girls in the Class III group was statistically significant when compared with the Class I group
(p = 0.021).
Discussion
Dental development is an important indicator of disturbances during odontogenesis and factors such as
trauma, systemic diseases, malnutrition, chemotherapy, and radiation therapy can affect the teeth at any
phase prior to their complete formation and calcification (4, 11, 12). Additionally, Garn et al. (11) stated that
genes, hormones, and calories play a role in dental
development.
Janson et al. (8) indicated that subjects with a long
face have in principle a dental maturation advanced by
6 months when compared with the short-face subject.
Celikoglu et al. Dental age assessment in orthodontic patients
Table 2. Descriptive data and statistical analyses showing the
differences among skeletal groups for girls and boys
Chronological Dental Mean
Gender Group
age
age
difference P1
Girls
Class I
13.01
13.64
0.63
0.000 0.285
Class II
12.39
13.47
1.08
0.000
Boys
Total
P2
Class III 11.39
12.77
1.38
0.000
Total
12.30
13.32
1.02
0.000
Class I
12.59
13.17
0.58
0.000 0.887
Class II
12.75
13.85
1.10
0.000
Class III 12.45
13.60
1.15
0.000
Total
12.59
13.57
0.98
0.000
12.51
13.51
1.00
0.000
P1: Results of the paired t-test comparing the difference between
chronological and dental ages.
P2: Results of the one-way ANOVA test comparing the chronological age
among the skeletal groups for girls and boys.
Table 3. Statistical comparison of the mean differences in patients
with different skeletal malocclusion patterns
p value for StudentÕs t-test
Mean differences between groups
Girls
Boys
Total
Class I and Class II Groups
0.154
0.215
0.056
Class I and Class III Groups
0.021
0.155
0.008
However, the sample included in his study was rather
small, and the two extreme groups were overlapping
each other, which might have obscured the results.
Jamroz et al. (9) found this difference between long and
short-face subjects not to be statistically significant.
The reports evaluating the effects of skeletal anomalies
of the jaws are limited in the literature.
Although several methods (2, 13–17) for the determination of DA have been described in the literature,
some of these methods identify a large number of
stages that are difficult to delimit from one another. The
method of Demirjian (6) distinguishes only four stages
of crown development and four stages of root development and uses no numeric identification so as not to
imply that the different stages represent processes of
the same duration. All the stages are defined by changes
of shape. Tunc and Koyuturk (18) also concluded that
this method shows a strong linear correlation between
dental and chronologic ages for males (r2 = 0.78) and
for females (r2 = 0.77). Additionally, Orhan et al. (19)
stated that this method is one of the simplest, practical,
and widely used methods. Therefore, this method of DA
estimation was selected for the present study.
This study revealed that an orthodontic population
showed a more advanced DA compared to the general
populations as presented by many authors who also
obtained overestimation of DA in their populations
when using this method (2, 18, 20, 21). Maber et al. (2)
and Liversidge et al. (20) believed that the overestimation in DA in recent reports using Demirjian method
might be explained by a positive secular trend in
growth and development during the last 25 years.
The results of the present study showed that orthodontic patients with skeletal anomalies of the jaws were
dentally advanced compared to the orthodontic patients without skeletal anomaly. This difference was the
highest for the subjects characterized with mandibular
prognathism for both girls and boys. However, this
difference was statistically significant only for the girls
(p = 0.021). It was also previously stated that sex differences do exist and need to be taken into account.
With most maturational events, the tempo of maturation is faster in girls (13). Additionally, a recent study
(21) investigating the applicability of Demirjian method
in eastern Turkish children showed that eastern Turkish children were dentally advanced when compared to
French-Canadian standards by 1.0 year. The mean
difference found in females was 1.1 year and in males
0.9 year. In this study, the mean difference between the
CA and DA for orthodontic patients without sagittal
skeletal malocclusion, the Class I group, was 0.63 and
0.58 years for girls and boys, respectively. This difference might be because of the sample differences used
in both studies. The authors performed their study on a
sample of 807 healthy eastern Turkish children aged
between 7.00 and 15.00 years. However, we investigated the dental development in 525 orthodontic
patients with and without different sagittal skeletal
malocclusions of the jaws aged between 9.00 and
15.00 years. Additionally, this report showed that
orthodontic patients with sagittal skeletal anomalies
were more advanced in dental maturity when compared with the reference samples than for both FrenchCanadian samples and orthodontic patients without
sagittal skeletal malocclusions in eastern Turkish
population. Because this report was the first in the
literature investigating the relationship of sagittal
Orthod Craniofac Res 2011;14:58–62
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Celikoglu et al. Dental age assessment in orthodontic patients
skeletal anomalies of the jaws and the dental development, future reports are necessary to elucidate precisely the reason for this variation.
Conclusions
Clinical relevance
• This sample of orthodontic patients was more
advanced in dental maturity compared to DemirjianÕs French-Canadian sample.
• When differences between CA and DA were compared, the results of this study showed that orthodontic patients with sagittal skeletal malocclusions
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