ANNALS OF HUMAN BIOLOGY, 1976, VOL. 3, NO.

5, 411--421

New systems for dental maturity based on seven and

four teeth

A. D E M I R J I A N
Centre de Recherche sur la Croissance Humaine, UniversitO de Montreal

and H. G O L D S T E I N
National Children's Bureau, London
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[Received 19 March 1976]

Summary. An updated system for estimating dental maturity is

presented. It extends the original system (Demirjian et al., 1973)
based on radiographs of 7 teeth by including two extra stages, and by
enlarging the standardizing sample to include 2407 boys and 2349
girls. Percentile standards from ages 2.5 to 17-0 years are presented
separately for boys and girls.
Scoring systems and percentile standards are presented for two
different sets of 4 teeth and a comparison of all three systems is
made. It is suggested that these systems may measure somewhat
different aspects of dental maturity.

i. Introduction
In an earlier paper (Demirjian, Goldstein and Tanner, 1973) a new method for
assessing dental maturity was described. It was based on ratings of radiographs of
the seven left side teeth of the mandible, which were shown to be representative of all
the teeth of the mandible. Eight stages of calcification for each tooth were identified
and described and each one was allocated a score. The sum of these scores for an
individual provides an estimate of dental maturity on a scale measuring from 0 to 100.
Scores and percentile standards were given separately for boys and girls for the age
range 3-16 years. The mathematical technique used to calculate the scores for the
stages is the same as has been used for the measurement of skeletal maturity (Tanner,
Whitehouse, Marshall, Healy and Goldstein, 1975), and a detailed description is
given by Healy and Goldstein (1976).
This earlier system had two main shortcomings. First, ratings of all seven teeth
needed to be made. In many older children however, one or more teeth are missing,
nor is it always possible to use the corresponding tooth from the right side of the
mandible. Also, for practical reasons, it is often simpler to take a radiograph of
fewer than seven teeth, so that there is some purpose in studying systems based on
fewer teeth. Naturally some information and precision is lost in the process and such
systems may be measuring slightly different components of dental maturity.
The second limitation of the earlier system was the absence of sufficient numbers
of very young and very old children in the standardizing sample. This meant that the
early stages of some teeth could not be included since they were insufficiently
 412 A, Demirjian and H. Goldstein

represented in the sample, and that percentile standards could not be provided for
the extreme age groups.
The purpose of the present paper is to present new seven-tooth systems which
extend the age range and the number of stages, and also to present two new four-tooth
systems.

2. Materials and methods

A full description of the tooth rating system is given by Demirjian et al. (1973).
Briefly, this consists in identifying eight stages of calcification for each tooth, ranging
from the calcification of the tip of a cusp to the closure of the apex. The stages are
labelled 0 for no calcification and A to H for the 8 calcification stages. Panoramic
radiographs were obtained from a standardizing sample of 1446 boys and 1482 girls
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aged 2-20 years of French-Canadian origin.

Age Boys Girls Total

0.0- 2-5 27 23 50
2-5- 3.5 115 72 187
3.5- 4.5 171 146 317
4.5- 5.5 198 157 355
5.5- 6.5 223 194 417
6.5- 7.5 147 135 282
7.5- 8.5 111 120 231
8.5-9.5 148 167 315
9.5-10.5 223 208 431
10.5-11,5 114 130 244
11.5-12.5 193 170 363
12.5-13.5 234 239 473
13.5-14.5 183 215 398
14-5-15.5 123 157 280
~5.5-16-5 134 166 300
16.5-17-5 57 48 105
17.5-20.0 6 2 8
Total 2407 2349 4756

Table l, Number of children at each age.

The sample has now been increased to 2407 boys and 2349 girls (Table 1). This has
allowed us to include two stages which were excluded in the earlier system, namely
stage A of the first premolar (PMI) and stage C of the first incisor (10. It has also
allowed us to include 3rd and 97th percentile estimates for the maturity standards.
Where panoramic radiographs cannot be used, two periapical radiographs of the
molars and premolars may be taken. We have therefore considered these four teeth
as a separate system (M2, Ml, PM2, PM~) for which scores and standards will be
presented. The development of the lower central incisor being chronologically almost
the same as for the first molar, in older age groups where this latter is often missing
the central incisor has been assessed instead of the molar. This is the reason why we
also present separate scores and standards for this group of four teeth (M2, PM2,
PM1, I1). In this case an additional periapical film of the incisor area is required. In
all three systems we have used equal "biological" weights for each tooth (see Demirjian
et al., 1973).
 New systems for dental maturity 413

. Results

The maturity scores for the three systems are given in tables 2-4.

Boys
Stages

Tooth 0 A B C D E F G H

Mz 0.0 1.7 3.1 5.4 8.6 11.4 12.4 12.8 13.6

Ml 0.0 5.3 7.5 10.3 13.9 16.8
PM2 0.0 1.5 2.7 5.2 8.0 10.8 12.0 12.5 13,2
PM~ 0.0 4.0 6.3 9.4 13.2 14.9 15.5 16.1
C 0.0 4.0 7.8 10.1 11.4 12.0
lz 0.0 2.8 5.4 7.7 10.5 13.2
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1~ 0-0 4-3 6-3 8-2 11"2 15-1

Girls
Stages

Tooth 0 A B C D E F G H

M2 0.0 1.8 3.1 5.4 9.0 11.7 12.8 13.2 13.8

M~ 0.0 3.5 5.6 8.4 12.5 15.4
PM2 0.0 1.7 2.9 5.4 8.6 11.1 12.3 12.8 13.3
PM~ 0.0 3.t 5.2 8.8 12-6 14.3 14.9 15.5
C 0.0 3.7 7.3 10.0 11.8 12.5
12 0.0 2.8 5.3 8.1 11.2 13.8
11 0.0 4.4 6.3 8.5 12.0 15.8

Table 2. Self weighted scores for dental stages. 7 teeth (mandibular left side).

Boys
Stages

Tooth 0 A B C D E F G H

M2 0.0 3.2 6.2 9.9 14.4 18.4 20.7 21,9 23.3

M1 0.0 8.0 12.6 16-9 21.8 27.4
PM2 0'0 3'1 5.6 9-5 13.7 17'4 20'1 21.4 22.5
PM1 0.0 5"9 10'7 15.7 20.7 23"8 25'4 26.8

Girls
Stages

Tooth 0 A B C D E F G H

Mz 0.0 3.6 6.1 9.9 15.3 19.2 21-7 23-0 24.2

Ml 0.0 5.4 9.8 14.3 20.1 25-9
PMz 0.0 3.7 5.8 9.8 14.7 18.1 20.8 22-3 23.3
PM~ 0.0 4,6 9,2 15.1 20.2 23.3 25.1 26.6

Table 3. Self weighted scores for dental stages. 4 teeth M2, Ma, PM2, PMI (mandibular left side).
 414 A. Demirjian and H. Goldstein

Boys
Stages
Tooth 0 A B C D E F G H
M2 0.0 3.3 6.1 9.9 15.0 19.7 21.3 22.1 23.5
PM2 0-0 3.2 5.6 9.6 14.2 18.8 20.9 21.7 22.8
PMt 0.0 7.1 11.6 16-9 22.8 25.8 26-8 27.9
11 0.0 7-4 11.5 14.6 18.9 25.7
Girls
Stages
Tooth 0 A B C D E F G H
M2 0.0 3.4 6.3 10.2 15.7 20.0 21.5 22.3 23.5
PM2 0.0 3.7 6.2 10.3 15.1 19.1 21.0 21.7 22.8
PMI 0.0 5.9 10.2 16.2 21-9 24.6 25.6 26.8
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It 0.0 8.1 12.2 15.6 20.7 27"0

Table 4. Self weighted scores for dental stages. 4 teeth M2, PM2, PM~, 11 (mandibular left side).

T h e percentile curves in figures 1-6 enable an assessment o f the percentile position

for the maturity score o f an individual. I f required, a conversion o f a maturity score
to a " d e n t a l a g e " may be obtained by finding the age at which the 50th percentile
value equals the maturity score.

Comparing the systems

A l t h o u g h we have no absolute standard by which to j u d g e the validity o f a dental
m a t u r i t y system, we can require it to have two general properties. First, the change in
m a t u r i t y scores with age should be " s m o o t h " in o r d e r to reflect the c o n t i n u o u s nature
o f biological development. Secondly, the individual variability in m a t u r i t y scores at
each age should be large e n o u g h to reflect the natural variability in the population.

Systems
7 teeth-- 7 teeth-- M2, PM2, PMt, 11
Mz, MI, PM2, PM1 M2, PM2, PML, 11 -M2, M1, PMz, PM~
Age Boys Girls Boys Girls Boys Girls
2.5-3.5 0.8 0.7 1.9 1.5 1.1 0.9
3.5-4.5 2.3 1.9 3.2 3.3 0.9 1.4
4.5-5.5 3.6 2.3 4.8 4.1 1.1 1-7
5.5-6-5 3.2 1.7 4.4 3.7 1-3 2.1
6.5-7.5 1-2 -1-2 3.1 1.6 2.0 2.7
7.5-8.5 -2-0 -3.8 1.5 0.2 3.4 4.0
8.5-9.5 -5.0 -6.0 0~4 -0.6 5.4 5.3
9.5-10.5 -5.7 -5.9 -0.4 -1.2 5.3 4.7
10.5-11.5 -4.6 -4.5 -0.7 -1.3 3.8 3.2
11.5-12.5 -3-0 -2-6 -0.8 -1.3 2.1 1.2
12.5-13-5 -2.0 -1.6 -0.8 -1.1 1-1 0.4
13.5-14.5 -1.3 -0.9 -0.8 -0.7 0.4 0.1
14.5-15.5 -0.8 -0.5 -0.7 -0.4 0.1 0.0
15.5-16.5 -0.3 -0.2 -0.4 -0.2 0.0 0.0
16.5-17.5 -0.1 0.0 -0.3 0.0 0.0 0.0

Table 5. Mean difference between systems at each age.

Smoothed values.
 New systems for dental maturity 415

................ I. . . . . . . i~ • ~

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~....... ~ : 17" i ii:i ii . .... iii~: ~::: ''~:i),.i7 ?lii :::~:::
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

AGE(years]

Figure I. Dental maturity percentiles (7 teeth).

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0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

AGE [years I

Figure 2. Dental maturity percentiles (7 teeth).

 416 A. Demirjian and H. Goldstein

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1 2 3 4 5 6 ? 8 9 10 11 12 13 1 4 15 16 17

AGE (years)

Figure 3. Dental maturity percentiles (4 teeth I) M2, M~, PM2, PM1.

IO0
.-". . . ........
...... ......:i', : 7111
:+!!iil iii!:i

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1o l J / , ~ , i :, I
Z'y r :' ' I
1 2 3 4 5 6 ? 8 9 10 11 12 13 14 15 16 1"7

AGE (years)

Figure 4. Dental maturity percentiles (4 teeth I) M2, Mx, PM2, PMx.

 New systems for dental maturity 417

100 i................. i ; .... ! '

90 ::: i::: :::i::: :::L::: ::::i:::. :::::::::::::::::::::::::::::::::::

::::::::::::::::::::::::::::::::::::::::::+:::::::+,:::::+~::
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50
0
R :/il I ¢]
E i j / / / f
40: 1 1 I /'/
30
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¢:
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/. ¢ /

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"~o/
r
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f/ BOYS
10

0
1 2
/

• qf
3
o/I

4 5 6 7 8 9 10 11 12 13
I
14 15 16 17
=GE (years)

Figure 5. Dental maturity percentiles (4 teeth I1) M2, PM~, PM,, It.

100 !ii.i! I it117 t~I! [ ~I: ~'~_ ~ ' ~

......... :: !i.

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I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
AGE (years)

Figure 6. Dental maturity percentiles (4 teeth 11) M2, PM2, PM~, I~.

A.H.B. 2E
 418 A. Dernirjian and 1t. Goldstein

W h e n c o m p a r i n g two systems, perfect agreement will be indicated by a constant

difference between an individual's score at each age. We may therefore use the
variability of the within-individual difference as a measure of lack of agreement be-
tween systems. The average difference between the systems c a n be used to convert a
m a t u r i t y score on one system into a m a t u r i t y score on the other. (Table 5 gives the
m e a n differences at each age.)
Thus, to convert a m a t u r i t y score based o n M2, Mx, PM2, P M t to one based on
7 teeth for a boy aged 6 . 0 years we add 3 . 2 score points.
As a first step, the new 7-tooth system has been c o m p a r e d to the previous one.
Table 6 shows, at each age, the average difference, the s t a n d a r d deviation of the
difference, the separate s t a n d a r d deviations for each system a n d the average rate of
change of maturity with age. The standard deviation of the difference between the
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Average of Average rate of

Old-New; S.D. of separate S.D.'s change with age
Mean difference* difference* of two systems (Score pts per year)

Age Boys Girls Boys Girls Boys Girls Boys Girls

2.5-3.5 4.3 4.2 1.6 1.6 6.0 6.7 9 9

3.5-4.5 4.0 4.0 1-1 1.2 6.6 8.0 8 8
4.5-5.5 3.6 3.5 0.9 1.0 7.6 9.0 8 9
5.5-6-5 2.8 2-6 1.1 1.2 8.6 9.8 11 15
6.5-7.5 1.6 0.9 1.4 1.7 9-0 9.9 16 20
7.5-8.5 -1.0 -1.7 1.5 1-3 8.4 7.8 15 10
8.5-9.5 -1.7 -1.4 1.0 1.0 6.9 6.1 7 8
9.5-10.5 -0.9 -0.5 0.8 0-8 5.1 4.8 5 5
10-5-11.5 0.0 0.4 0.7 0.6 3.4 3.6 4 3
11.5-12.5 0.8 1.0 0.5 0.5 2.5 2.6 2 2
12-5-13.5 1.0 1.1 0.4 0.4 1.8 1.7 2 1
13.5-14.5 1.0 0.8 0.4 0.4 1.3 1.2 1 1
14.5-15.5 0.8 0.5 0.3 0.4 0.9 0-8 1 1
15.5-16.5 0.4 0.2 0.3 0.3 0.5 0.5 -- --
16.5-17.5 0.0 0.0 0.2 0.2 0.3 0.3 -- --

* Smoothed values.
Table 6. Comparisons of individual scores of new and old 7-tooth systems.

two systems up to the age of 13 is not more t h a n a b o u t three months of the average
change in m a t u r i t y per year. After this age the relative value of the standard deviation
increases, a reflection of the increasing i n d e t e r m i n a n c y associated with assigning a
chronological age to almost fully mature individuals. A similar pattern for both sexes
exists for the standard deviations of the separate systems which are between three
and six times the standard deviations of the difference. There is a decrease in the
standard deviations of the difference to a b o u t age 6 followed by an increase to age 8
a n d thereafter a steady decrease. This is paralleled by the average rate of change of
m a t u r i t y with age where the peak "velocity" occurs at a b o u t age 7.
The similarity of patterns and the relatively small values of the standard deviations
of the differences between the systems implies that only a small change is likely to
occur in m o v i n g from one to the other.
 New systems for dental maturity 419

Table 7 compares the new 7-tooth system and each 4-tooth system. A somewhat
different pattern is apparent. The standard deviations of the differences do not parallel
the standard deviations and the rates of change for the separate systems (the 4-tooth
systems are similar to the 7-tooth system). For the comparison of the 7-tooth and
4-tooth systems the decrease is slow to about age 9, and more rapid thereafter. The
standard deviations are equivalent to up to 10 months average change in maturity
per year as far as age 13. The comparison between the 4-tooth systems show a rapid
decrease in the standard deviation up to age 6 followed by a slower decrease to about
age 11. It appears therefore that the three systems are not measuring precisely the
same underlying quantity and that relatively large differences can occur in moving
from a 4-tooth to a 7-tooth system.
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7 teeth 7 teeth M2, Ml, PM2, PMI

M2, MI, PM2, PMI - M 2 , PM2, PMI, 11 - M 2 , PM2, PM1, 11
Age Boys Girls Boys Girls Boys Girls

2-5-3-5 3.7 4.0 3.6 4.1 3.8 4.0

3.5-4.5 3.9 4.2 3-7 3.8 3.4 3.6
4.5-5-5 3.6 3.8 3-6 3-5 3-0 3.2
5.5-6.5 3.4 3.6 3.3 3.3 2.9 3.1
6.5-7.5 3.4 3.5 3-3 3.2 2.8 3.0
7.5-8.5 3.3 3.3 2.9 2-9 3.8 3.0
8.5-9.5 3-2 2.9 2.7 2.6 2.7 2-9
9.5-10-5 2.9 2.4 2.4 2-2 2.7 2.8
10.5-11-5 2.4 2.1 2.0 1.6 2.6 2-5
11.5-12-5 1.7 1.6 1.5 1.1 2.4 1.8
12-5-13.5 1.3 1.2 1.0 0.8 1.7 1.3
13.5-14.5 0.9 0.9 0.7 0.6 1.1 0.8
14-5-15.5 0.6 0.6 0.5 0.5 0.4 0.4
15.5-16-5 0.4 0.4 0-4 0.4 0.1 0.1
16.5-17.5 0.2 0.2 0.2 0.2 0.0 0.0

Table 7. Standard deviations of differences between individual scores on new 7-tooth system and
the 4-tooth systems.
Smoothed values.

4. Discussion
The dental maturity system presented earlier by Demirjian et al. (1973) has been
updated. The sample size has been increased, especially at the older and younger ages,
and the new system, based on the same seven teeth, utilizes two additional stages and
covers the age range 2-5 years to 17-0 years. The 3rd and 97th percentiles have also
been estimated and presented in maturity standards. The differences between scores
derived from the original and updated systems are small. Where some individuals
have been scored on the old system and the original ratings are available, they may
readily be assigned the new scores. Alternatively it would be possible to use the
average differences given in the first two columns of Table 6 to provide an approxi-
mate conversion.
It was pointed out in the earlier paper that where a single tooth was missing or
could not be rated for any other reason it was impossible to obtain a valid estimate of
the 7-tooth maturity using just the scores on the remaining six teeth (unless the corres-
ponding tooth from the right side of the mandible was available for substitution).
The best that could be done is to estimate seven separate scoring systems, one for

2E2
 420 A. Demirjian and H. Goldstein

each combination of six remaining teeth. This is still not completely satisfactory
however, since it appears that each six-tooth system is measuring a slightly different
aspect of maturity. This raises the. whole question of which set of teeth should be
used to define dental maturity. During the developmental period when the assessment
of the maxillary teeth was technically very difficult using X-rays, we confined our
study to the evaluation of the mandibular ones. In the original system, all mandibular
teeth were studied and after taking account of the symmetry of the mandible, the
seven teeth of the left side were chosen as the basis for estimating overall dental
maturity.
Within the overall development of the dentition however, there may be certain
groups of teeth which have a distinctive developmental pattern of their own, contribut-
ing a sub-system of dental maturity. At present we have insufficient knowledge to say
which sub-systems are the important ones requiring their own scoring system. What
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we have done, therefore, is to choose two sub-systems which form convenient groups
of teeth for rating purposes. The results of comparing each system with the 7-tooth
system and with each other raises the possibility that somewhat different aspects of
maturity are being measured. In order to study the question of whether they are
measuring different aspects, we should need to compare children with longitudinal
records using the different systems. Where one of the 4-tooth systems is used, either
because a full panoramic radiograph is Unavailable or because a tooth is missing,
this fact should be recorded in reporting a maturity score.
When using the scoring system and standards presented in this paper, it should
be remembered that the sample is entirely of French-Canadian origin. We do not as
yet know how far the results will generalize to other populations. We would con-
jecture, however, that the scores for the stages will not vary too much between
populations, but that the maturity standards may change appreciably. It would be
possible to study differences in average maturity for different populations using the
present scoring system with relatively small samples.
We plan to extend our results in two directions. First we are accumulating a
longitudinal series of radiographs taken one year apart on the same children in order
to derive longitudinal standards. Secondly we are studying the relationship of dental
maturity to measures of skeletal maturity.

Acknowledgments
We are very grateful to Dr. L. Paraschivescu and Mr. C. Lamarche for rating the
radiographs; to Dr. G. Albert, chief of the dental clinic at Ste-Justine Hospital, for
providing us the radiographs of the younger age group.
This study is supported by grants from the National Health and Welfare, Canada
and the Department of Health and Social Security to the National Children's Bureau,
U.K.

References
Demirjian, A., Goldstein, H., and Tanner, J. M. (1973). A new system of dental age assessment.
Human Biology, 42, 211-227.
Healy, M. J. R., and Goldstein, H. (1976). An approach to the scaling of categorised attributes.
Biometrika, 63, 219-229.
Tanner, J. M., Whitehouse, R. M., Marshall, W. A., Healy, M. J. R., and Goldstein, H. (1975).
Assessment of Skeletal Maturity and Prediction of Adult Height: TW2 Method. London:
Academic Press.
 New systems for dental maturity 421

Address correspondence to: Professor A. Demirjian, Centre de Recherche sur la Croissance

Humaine, Universit6 de Montr6aL Montr6al, Quebec, Canada.

Zusammenfassung. Es wird ein aktualisiertes System zur Sch/itzung der Zahnreife vorgestellt. Es
erweitert das ursprtingliche System (Demirjian u. a., 1973), basierend auf R/Sntgenaufnahmen yon
sieben Z/ihnen, durch EinschluB zweier weiterer Stufen und durch Vergr/51~erung der zugrundelie-
genden Stichprobe auf 2407 Knaben und 2349 M/idchen. Fiir beide Geschlechter werden Perzentil-
normen for 2,5 bis 17,0 Jahre gegeben. Weiterhin werden Punktsysteme und Perzentilnormen for
zwei unterschiedliche S~,tze yon vier Z/ihnen vorgestellt und alle drei Systeme verglichen. Es wird
geschlossen, dab sie wohl etwas unterschiedliche Aspekte der Zahnreife messen.

R6sum6. Un syst6me mis h jour POUr estimer la maturit6 dentaire est pr6sent6. I1 6tend le syst6me
pr6c6dent (Demirjian et al., 1973) bas6 sur des radiographies de 7 dents par l'inclusion de deux stades
suppl6mentaires, et par l'61argissement de l'6chantillon normatif ~ 2407 garqons et 2349 filles. Les
percentiles pour les 5.ges de 2,5/t 17,0 ans sont pr6sent6s s6par6ment pour les gar~;ons et les filles.
Les syst~mes de cotation et les percentiles standard sont pr6sent6s pour deux ensembles diff6rents
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de 4 dents, et une comparaison des trois syst6mes est faite. II est sugg6r6 que ces syst6mes pourraient
mesurer des aspects quelque peu diff6rents de la maturit6 dentaire.