UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2025.e4668
1
Braz Dent Sci 2025 Jan/Mar;28 (1): e4668
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Validation of CBCT panoramic reformatting compared to
conventional panoramic radiography for age determination using
the Demirjian method
Validação da reconstrução panorâmica da TCFC em comparação com a radiografia panorâmica convencional para a
determinação da idade utilizando o método Demirjian
Rosana Mara Adami TUCUNDUVA1 , Cássia Maria Fischer RUBIRA1 , Heitor Marques HONÓRIO2 ,
Camila Lopes CARDOSO1 , Izabel Regina Fischer RUBIRA-BULLEN1
1 - Departamento de Cirurgia, Estomatologia, Patologia e Radiologia, Faculdade de Odontologia de Bauru, Universidade de São Paulo,
Bauru, São Paulo, Brasil.
2 - Departamento de Odontopediatria, Ortodontia e Saúde Coletiva, Faculdade de Odontologia de Bauru, Universidade de São Paulo,
Bauru, São Paulo, Brasil.
How to cite: Tucunduva RMA, Rubira CMF, Honório HM, Cardoso CL, Rubira-Bullen IRF. Validation of CBCT panoramic reformatting
compared to conventional panoramic radiography for age determination using the Demirjian method. Braz Dent Sci. 2025;28(1):e4668.
https://doi.org/10.4322/bds.2025.e4668
ABSTRACT
Objective: Estimating age from dental development is a useful indicator that is considered highly reliable and can be of
great help in determining an individual’s age, although the accuracy of different methods has not been systematically
investigated. The aim of this study was to evaluate images of conventional digital panoramic radiographs (CP) and
panoramic reformats (PR) obtained from cone beam computed tomography (CBCT) in order to conrm the similarity
of the methods. Material and Methods: A sample of 20 patients who had conventional panoramic radiographs
(CP) and also CBCT exams was evaluated. These examinations were performed on the same date, so there was no
variation in the mineralization stage in the different images. The images were analyzed by a dentist, a specialist in
Radiology and Imaging, and, before the beginning of the analysis, an intra-examiner calibration was performed,
resulting in a good Kappa index evaluation (> 0.5). Results: In this study, age estimation based on mineralization
analysis of mandibular third molar teeth was not altered when using PR (CBCT) or CP. The difference in median
values between the two groups is no statistically signicant difference. Conclusion: The methods evaluated were
found to be consistent with one another, thereby conrming the similarity of their efcacy.
KEYWORDS
Age determination by teeth; Cone beam computed tomography; Forensic Dentistry; Panoramic radiography;
Radiography, Dental.
RESUMO
Objetivo: A estimativa da idade a partir do desenvolvimento dentário é um indicador útil, altamente conável
e que pode ser de grande ajuda na determinação da idade de um indivíduo, embora a precisão dos diferentes
métodos não tenha sido sistematicamente investigada. O objetivo deste estudo foi avaliar imagens de radiograas
panorâmicas digitais convencionais (PC) e reformatações panorâmicas (RP) obtidas por tomograa computadorizada
de feixe cônico (TCFC), a m de conrmar a similaridade dos métodos. Material e Métodos: Foi avaliada uma
amostra de 20 pacientes que realizaram radiograas panorâmicas convencionais (CP) e também exames de TCFC.
Esses exames foram realizados na mesma data, de modo que não houve variação no estágio de mineralização
nas diferentes imagens. As imagens foram analisadas por um cirurgião-dentista, especialista em Radiologia e
Imaginologia, e, antes do início da análise, foi realizada uma calibração intra-examinador, resultando em uma
boa avaliação do índice Kappa (> 0,5). Resultados: Neste estudo, a estimativa de idade baseada na análise da
2
Braz Dent Sci 2025 Jan/Mar;28 (1): e4668
Tucunduva, RMA et al.
Validation of CBCT panoramic reformatting compared to conventional panoramic radiography for age determination using the Demirjian method
Tucunduva, RMA et al. Validation of CBCT panoramic reformatting compared to
conventional panoramic radiography for age determination
using the Demirjian method
INTRODUCTION
Estimating age from dental development
is a useful indicator that is considered highly
reliable and can be of great help in determining
an individual’s age, although the accuracy of
different methods has not been systematically
investigated [1,2]. There is a consensus that the
dental development patterns of Demirjian [3] are
among the most accurate systems classications
and one of the most widely accepted by forensic
scientists. They are considered the easiest and
clearest evaluation method [1,4-7].
The authors assert that dental age can be
accurately assessed through direct and indirect
examinations [8]. The direct examination is
made by clinical examination, which denitively
verifies the number and sequence of erupted
teeth as well as the general state of the teeth.
Indirect examination is performed by analyzing
intraoral and extraoral radiographs, which
allow for the definitive evaluation of items
contained in the direct examination, especially
those related to dental mineralization [8]. A
variety of imaging tests are used in radiological
imaging, including periapical, interproximal, and
panoramic radiographs.
Cone beam computed tomography (CBCT)
is a diagnostic tool and an essential part of a
treatment plan [9,10]. It is crucial to emphasize
that these examinations cannot be conducted
solely to ascertain age in certain countries, as
exposure to ionizing radiation without consent
is unlawful in those jurisdictions [11,12]. It is
crucial to validate the various imaging exams
used to assess tooth mineralization and determine
age. This will conrm that age determination
from images produced by various techniques will
not interfere with the age. This allows us to make
this determination from an examination that is
already available, without subjecting the person
to additional ionizing radiation.
So, using lower third molar mineralization
(teeth 38 and/or 48) from conventional panoramic
radiographs (CP) and panoramic reformatting
(PR) obtained from the CBCT, we conducted
a study to ascertain the age of young people.
Analysis was performed using the approach put
forth by Demirjian et al. [3], as modified by
Oliveira in 2012 [5]. The results were compared
to see if there was any variation in the results.
MATERIAL AND METHODS
The study conducted used a reliable
and established method for analyzing tooth
mineralization, which increases the validity and
accuracy of the results obtained. The sample was
obtained from the digital archive of the FOB-USP
Surgery, Stomatology, Pathology, and Radiology
Department, Bauru, São Paulo, Brazil. Therefore,
we confirm that no patient was exposed to
ionizing radiation in the course of this research.
Ethical approval was obtained from Ethics
committee at Bauru School of Dentistry, University
of São Paulo (FOB-USP), ERC Number: 1,959,514
(CAAE: 65053717.4.0000.5417).
A sample of 20 patients who had conventional
panoramic radiographs (CP) and also CBCT
exams was evaluated. These examinations were
performed on the same date, so there was no
variation in the mineralization stage in the
different images. The images were analyzed by
a dentist, a specialist in Radiology and Imaging,
and, before the beginning of the analysis, an intra-
examiner calibration was performed, resulting in
a good Kappa index evaluation (> 0.5). The CP
was performed on the Kodak 8000C® Digital
and Cephalometric System and the CBCT on the
Accuitomo® device and analyzed in a room with
specic equipment for this purpose.
The sample consisted of 9 men and 11 women,
with a mean age of 22.9 years (13–38). The
mineralização dos dentes terceiros molares inferiores não foi alterada quando se utilizou a RP (TCFC) ou a CP.
A diferença nos valores medianos entre os dois grupos não apresentou diferença estatisticamente signicativa.
Conclusão: Os métodos avaliados mostraram-se consistentes entre si, conrmando assim a similaridade de sua
ecácia.
PALAVRAS-CHAVE
Determinação da idade pelos dentes; Tomograa computorizada de feixe cónico; Medicina dentária forense;
Radiograa panorâmica; Radiograa dental.
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Braz Dent Sci 2025 Jan/Mar;28 (1): e4668
Tucunduva, RMA et al.
Validation of CBCT panoramic reformatting compared to conventional panoramic radiography for age determination using the Demirjian method
Tucunduva, RMA et al. Validation of CBCT panoramic reformatting compared to
conventional panoramic radiography for age determination
using the Demirjian method
Chronological Age was calculated by subtracting
the year of birth from the year of the exam, as
found in the medical records. Considering that
the sharpness of the image in CP is related to the
focal layer thickness, for the PR to present similar
characteristics of the CP, they were generated
with a thickness of 12mm, which is, according to
Pinto et al., [10], the CP focal layer thickness of
thepanoramic devices.
This sample’s exams met the following
inclusion and exclusion rules: 1. CBCT exams
had a field of view (FOV) encompassing the
mandible alone or the maxilla and mandible.
2. In the examination, one or two lower third
molars (teeth 38 and/or 48) should be present,
and, to validate that the evaluated tooth was the
third molar, the presence of the rst and second
molars was a condition “sine qua non “. 3. Tests
with good image quality and no interference in
the area of interest that could compromise the
correct evaluation.
The scores were carefully assigned, following
the criteria described by each dental stage by
Oliveira et al. [5], comparing the images of
the teeth with diagrams provided by Demirjian
and modified by Oliveira et al. [5] (Table I,
Figure 1). If in doubt between two phases, the
least developed stage was assigned to the tooth.
Table I - Stages evaluated description according to the method
proposed by Demirjianetal. [3], modified by Oliveiraetal. [5]
STAGES DESCRIPTION
-1 Radiolucent image with radiopaque halo in the
third molar region related to the dental germ
1 (A)
A start of calcification can be seen at the top of
the crypt in the form of inverted cones. There is
no union between these calcified points.
2 (B) Calcified points form cusps union, which
together form the occlusal surface outline.
3 (C)
Complete enamel formation on the occlusal
surface and convergence to the cervical region.
Beginning of dentinal deposit, with outline of the
pulp chamber in curved shape at the occlusal
edge.
4 (D)
Complete crown formation up to enamel
cementum junction. Beginning of root formation
in spike shape.
5 (E)
Initial formation of root bifurcation in the shape
of a calcified point. The root length is still
shorter than the crown height.
6 (F)
Greater development of the bifurcation calcified
region in the semilunar form. Roots equal to
or greater than crown height, and with more
definite and more distinct funnel-shaped outline
at its end.
7 (G) Root canal walls are parallel, and their apical
regions are still partially open.
8 (H)
Apical end of root canals are completely closed.
The periodontal space has a uniform width
around the root and apex.
Figure 1 - Stages of dental mineralization.
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Braz Dent Sci 2025 Jan/Mar;28 (1): e4668
Tucunduva, RMA et al.
Validation of CBCT panoramic reformatting compared to conventional panoramic radiography for age determination using the Demirjian method
Tucunduva, RMA et al. Validation of CBCT panoramic reformatting compared to
conventional panoramic radiography for age determination
using the Demirjian method
RESULTS
The Chi Square Test was applied to check
if there was a discrepancy between the stages
attributed to teeth 38 and 48 in the PR and
the results obtained in the evaluation of the
PR generated in the CBCT. It was found to
be p = 0.605 for tooth 38 and p = 1.000 for
tooth 48. When applying the Mann-Whitney
Test using age-dependent variables, we found
p = 0.943 for teeth 48 and p = 0.882 for teeth
38. The difference in median values between the
two groups is not large enough to exclude the
possibility that the difference is due to random
sampling variability. There is no statistically
signicant difference.
DISCUSSION
This analysis aimed to verify the similarity
of results between the analyses performed in
CP and the analysis performed in PR obtained
from CBCT. In order to make the panoramic
reformatting image as similar as possible to the
panoramic radiography image, especially with
regard to image overlap, a 12mm thickness was
generated, which is, according to the literature
used, the focal layer thickness of the panoramic
device used for the examinations we evaluated.
In order to compare the results of the
analyses, we evaluated the mineralization stages
of teeth 38 and 48 in the examinations of 20
individuals who had the CP and CBCT exams
performed on the same date. Although our
sample size may seem small compared to similar
studies [13,14], conrmed that a small sample
size is not considered a limitation in forensic
scientic research.
The Demirjian, Goldstein, and Tanne
method [3], which is regarded as a method
with easy reproducibility because it has clearly
defined stages and few intermediate stages,
served as the foundation for the entire study [6].
It is noteworthy that we included stage 1, which
corresponds to the dental crypt, based on the
work of Oliveira [5]. Demirjian et al. [3], who
presented research from a French-Canadian
population and described 8 distinct stages, called
stages A–H, dened by morphological changes,
introduced the method, which is now widely used.
It is possible to determine the chronological age
of Brazilians by using the Demirjian method [3]
to assess the third molar stage of development,
according to Soares et al. [15], who evaluated at
2097 panoramic radiographic images of patients
from northeastern Brazil aged 6 to 22 years.
The method of Demirjian et al. [3] has been
widely used to estimate dental age in numerous
studies across different ethnic groups, analyzing
European, South American, and Asian individuals,
among other populations [14]. It has been
suggested that there may be different patterns of
dental maturation between different populations,
not only between population groups worldwide
but also between individuals from different cities
or regions within the same country [16]. This
motivated us to conduct a new study within the
same parameters of analysis in a portion of the
Brazilian population in order to contribute to an
increase in data and information about the age
estimate in the Brazilian population.
To date, dental age has been primarily
investigated based on dental radiographs, mainly
panoramic radiographs [16,17]. Panoramic
radiography is an important imaging technique
used as a complementary exam for diagnosis
in dental practice because it provides a general
two-dimensional view, allowing the visualization
of oral hard tissues and adjacent structures [18].
However, according to authors, RP is more
advantageous than CP because it allows the
determination of the desired image thickness and
does not present the magnication or distortion
inherent to CP [19].
We measured the degree of mineralization
in teeth 38 and 48, which are third molars. They
are regarded as the most unstable teeth when
compared to other teeth because they exhibit
the greatest variation in morphology, anatomical
position, time of development, and eruption, and
their accuracy in estimating age in chronological
studies is debatable [20]. Age and the completion
of dental maturation, however, cause the amount
of information to diminish until it is only present in
the third molars. According to Thevissen et al. [21],
the development of these teeth is a lengthy process
that may not be completed until the age of twenty-
two. According to authors the third molar is the
last tooth to develop before the human skeleton
starts to grow [21].
CONCLUSION
Our findings show that using CBCT PR
or CP does not interfere with determining age
5
Braz Dent Sci 2025 Jan/Mar;28 (1): e4668
Tucunduva, RMA et al.
Validation of CBCT panoramic reformatting compared to conventional panoramic radiography for age determination using the Demirjian method
Tucunduva, RMA et al. Validation of CBCT panoramic reformatting compared to
conventional panoramic radiography for age determination
using the Demirjian method
from the analysis of lower third molar tooth
mineralization. The methods evaluated were
found to be consistent with one another, thereby
confirming the similarity of their efficacy.
However, we believe that more studies like ours
should be conducted to increase the number
of individuals evaluated, and the findings of
this research should be used wisely, always in
conjunction with other available methods of
estimating age, to avoid incorrect imputations.
Author’s Contributions
RMAT: Conceptualization, Methodology,
Formal Analysis, Validation, Resources, Writing
– Original Draft Preparation, Writing – Review &
Editing. CMFR: Methodology, Writing – Review &
Editing. HMH, CLC: Writing – Review & Editing.
IRFRB: Conceptualization, Methodology, Writing
– Review & Editing, Supervision.
Conict of Interest
The authors declare to have no conict of
interest.
Funding
The authors received nancial support for
the research by CAPES 001.
Regulatory Statement
Ethical approval was obtained from Ethics
committee at Bauru School of Dentistry, University
of São Paulo (FOB-USP), ERC Number: 1,959,514
(CAAE: 65053717.4.0000.5417).
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6
Braz Dent Sci 2025 Jan/Mar;28 (1): e4668
Validation of CBCT panoramic reformatting compared to
conventional panoramic radiography for age determination
using the Demirjian method
Tucunduva, RMA et al.
Validation of CBCT panoramic reformatting compared to conventional panoramic radiography for age determination using the Demirjian method
Tucunduva, RMA et al. Validation of CBCT panoramic reformatting compared to
conventional panoramic radiography for age determination
using the Demirjian method
Date submitted: 2025 Jan 29
Accept submission: 2025 Feb 12
Camila Lopes Cardoso
(Corresponding address)
Departamento de Cirurgia, Estomatologia, Patologia e Radiologia, Faculdade de
Odontologia de Bauru, Universidade de São Paulo, Bauru, São Paulo, Brasil.
Email: cardosolopes@usp.br
21. Thevissen PW, Fieuws S, Willems G. Human third molars
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