Age estimation using dental radiography in the Brazilian population: a systematic review and meta-analysis

Abstract

Background

Age estimation using dental radiography plays a critical role in forensic and legal contexts. This study aimed to perform a systematic review and meta-analysis to investigate the evidence-based support for various methods of age estimation using dental radiography in Brazilians and to evaluate the precision of these methods.

Main body

The search strategy was performed in 5 electronic databases and in gray literature for articles published until August 3th, 2024. Two independent reviewers performed data extraction and methodological quality using an adapted version of Newcastle − Ottawa Scale. To estimate the precision of different dental methods, the mean absolute error between the age estimated by dental methods and the chronological age was calculated. The mean difference between the two variables was used as the effect measure. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. A total of 28 studies met the eligibility criteria. One study was rated 4 (low quality), 16 studies received scores between 5 and 6 (moderate quality), and 11 studies scored 7 or above (high quality). Fourteen studies were included in the meta-analysis, allowing the evaluation of different dental methods for age estimation in male and female individuals. All methods showed a mean error (expressed in mean difference in chronological age) of less than 2 years. For males, the mean error ranged from 0.2 to 1.75 years. For females, the mean error ranged from 0.01 to 1.27 years.

Conclusions

The methods tended to overestimate the actual chronological age. Significant limitations were found regarding the representativeness of the Brazilian population in the evaluated studies.

Background

Forensic anthropologists often apply their expertise in medico legal investigations, ranging from isolated homicide cases to mass fatality scenarios resulting from violent activities, such as September 11, Bali bombing, war crimes, natural disasters (e.g., tsunami in Southeast Asia) and collapse of an iron-ore tailings dam in Brumadinho, southeastern Brazil (Franklin 2010; Moreira Araújo et al. 2023). Age estimation is a key part of this process, and the choice of method can significantly influence the outcome. Another area where forensic age estimation techniques can be applied is the identification of developmental stages, which aids in determining the optimal timing for dental or medical treatment and diagnosing developmental issues (Flieger et al. 2018; Pereira et al. 2019).

Estimating age from teeth can be accomplished through the radiographic evaluation of crown and root development and mineralization. These techniques are relatively simple and well-documented in the literature (Cameriere et al. 2007, 2004; Demirjian et al. 1973; Demirjian & Goldstein 1976; Willems et al. 2001). The systems are primarily based on populations of European origin, which limits their applicability and may reduce accuracy when used in other populations (Cidade et al. 2023; Davis & Hägg 1994; Liversidge et al. 1999). The Brazilian population reached an estimated 212.6 million people on July 1, 2024, according to the Brazilian Institute of Geography and Statistics (IBGE) (Instituto Brasileiro de Geografia e Estatística/IBGE). Brazil is the seventh most populous country in the world and the second most populous in the Americas, with its population comprising a trihybrid mix of European, African, and Amerindian ancestry (Parra et al. 2003). Consequently, assessing the precision and inherent error margins of age estimation techniques is essential to establish their applicability and reliability for the Brazilian population.

This systematic review and meta-analysis aimed to investigate the evidence-based support for various methods of age estimation using dental radiographs in the Brazilian population and to evaluate the precision of these methods.

Methods

This systematic review was registered and can be accessed in the International Prospective Register of Systematic Reviews (PROSPERO) database, register number CRD42024584168 (http://www.crd.york.ac.uk/). This study was designed in accordance with the recommendations of the Cochrane Handbook for Systematic Reviews (Higgins et al. 2024) and written following the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines (Page et al. 2021).

Eligibility criteria

The eligibility criteria were defined based on the PIRD acronym (Population, Index test, Reference test, Diagnosis), designed to answer the following question: What is the precision of different methods for age estimation using dental radiographs in the Brazilian population?

• Population (P): Brazilian population;

• Index test (I): Radiological methods used for dental age estimation (e.g., periapical and panoramic radiographs);

• Reference test (R): Chronological age;

• Diagnosis (D): Estimation of error between the methods compared to actual age.

Studies were included if the population consisted of individuals of any age undergoing age estimation using radiographic methods. Only observational studies were included.

To ensure consistency and comparability across studies, we included only original studies that applied previously published and validated dental age estimation methods without recalibration or modification. Studies that proposed new methods, formulas, or locally recalibrated versions of existing models — including those specifically adjusted for the Brazilian population — were excluded. This criterion was adopted to prevent bias in error estimates and to maintain the methodological integrity of the meta-analysis.

The exclusion criteria included other imaging exams (i.e., computed tomography), studies with other populations, studies involving populations with systemic diseases, books, book chapters, editorials, letters to the editor, case reports, case series, abstract, reviews, and systematic reviews. Studies proposing new methods or formulas for estimating dental age were also excluded. Only studies evaluating previously tested and published methods or formulas were considered. No restrictions were imposed on the year of publication, language, publication status, or age of the population.

Information sources and search strategy

An electronic search (24 July 2024-3rd August 2024) was performed in five databases to find out primary data: PubMed/Medline, Embase, Latin American and Caribbean Literature in Health Sciences (LILACS), Scopus, and Web of Science. Grey literature was collected from Google Scholar, limiting the analysis to the first 100 articles retrieved from the search. Search strings were built based on Medical Subject Headings (MeSH), Descriptors in Health Sciences (DeCS), Emtree terms, and free terms using associated keywords combined with Boolean operators and truncation strategies. The keywords were associated with dental age estimation using database-specific terms, synonyms, and their variations. Each search strategy and the corresponding number of studies identified are presented in Appendix 1. From the final selection, a manual search of the reference lists of the articles was conducted to supplement the electronic search.

All retrieved references were managed using the EndNote software (EndNote® Web—Thomson Reuters, Philadelphia, PA), and duplicates were removed.

Selection process

The study selection was conducted by two independent reviewers (AA and LAAA), with a third reviewer (EKC) brought in to resolve any discrepancies. The selection process was carried out in two stages. In the first stage, titles and abstracts were reviewed, and those unrelated to the topic of interest were promptly excluded. In cases of uncertainty, the article was retained in the sample and moved to the next stage. In the second stage, a detailed evaluation of the full texts was performed to determine eligibility. Articles deemed eligible proceeded to the data collection process. The entire selection process was conducted using Google Sheets (Google Inc., USA).

Data collection process

Data extraction of the selected studies were conducted independently by two researchers (AA and LAAA). Any uncertainties were resolved through a consensus meeting with a third author (EKC). The data from the included studies were compiled and organized as follows: authors’ names, year and journal of publication, studied population, sample size, age range, radiological method (periapical and/or panoramic radiographic), and method for age estimation. In case of unclear data reported in the eligible studies, emails were sent to the corresponding authors requesting clarification.

Data items

The primary outcome of interest was the comparison between chronological age and dental age estimation. Accordingly, the mean and standard deviation for each of the age estimates were collected when reported. If the studies presented values in months, these were converted to years by dividing the values by 12.

Quality assessment

This step was also carried out by two researchers (AA and LAAA). Any uncertainties were addressed in a consensus meeting with a third author (EKC). Personal communication was utilized to resolve cases of missing data or other ambiguities.

The quality assessment was performed using the Newcastle − Ottawa Scale (NOS) (Wells et al. 2024). An adapted version of NOS was used for cross-sectional studies (Modesti et al. 2016). This version presents three dimensions with seven items and it is based on a star system as follows:

1. Selection (maximum 5 stars):

2. Representativeness of the sample (0 or 1): Do the authors discuss the representativeness of the sample in the Methodology or Results section?

3. Sample size (0 or 1): Is the methodology for calculating the sample size described in the Methods or Discussion section?

4. Non-respondents (0 or 1): Is there information about the number of excluded samples in the Methodology or Results section?

5. Ascertainment of the exposure (risk factor) (0 or 2): Was the dental age estimation methodology applied as outlined in the literature?

Comparability (maximum 2 stars):

Confounding factors (0, 1, or 2): Were local and systemic confounding factors considered for exclusion? If both were considered, award 2 points; if only one was considered, award 1 point.

Outcome (maximum 3 stars):

Assessment of the outcome (0, 1, or 2): Was calibration performed, and were the radiograph analyses conducted blindly? If both were yes, award 2 points; if only one was yes, award 1 point.

Statistical test (0 or 1): Is there a statistical test reported, including a p-value?

Then, the studies awarded with 0 to 4, 5 to 6, and > 7 stars were classified as having low, moderate, and high quality, respectively (Wells et al. 2024; Modesti et al. 2016).

Effect measures and synthesis methods

To estimate the precision of different dental methods, the mean absolute error between the age estimated by dental methods and the chronological age was calculated. The mean difference (MD) between the two variables was used as the effect measure. This refers to the absolute mean difference in chronological age, not to a standardized mean difference.

A random-effects meta-analysis was conducted using the R programming language within the RStudio development environment, version 1.2.1335 (RStudio Inc., Boston, USA). Study weights were calculated using the inverse variance method. Heterogeneity was assessed through Higgins’ I² values and Tau², estimated using the DerSimonian and Laird method. Confidence intervals of 95% were calculated for all analyses.

To evaluate data dispersion and assess the extent to which dental age estimates differed from chronological age, a scatter plot stratified by sex was created. This was performed using the Python programming language and the matplotlib library within the Google Colab development environment. The mean values of chronological age were plotted on the X-axis, while the mean values of estimated dental age were represented on the Y-axis. The size of the points was adjusted based on the inverse variance, reflecting the weight of each study in the analysis, and the colors of the points were used to differentiate the evaluated methods. Additionally, a line of identity (45°) was added to the plot to indicate the absence of error between dental age estimates and chronological age.

Due to consistent differences in dental age estimation accuracy between sexes, separate meta-analyses were conducted for males and females. This decision aimed to avoid the introduction of heterogeneity attributable to sex and to ensure analytical consistency. Within each sex-specific analysis, subgroup comparisons were performed based on the dental age estimation methods adopted in the included studies. This approach was considered the most appropriate to preserve methodological rigor and maximize the inclusion of available data.

Assessment of publication bias

The likelihood of publication bias was assessed both graphically, using a funnel plot, and quantitatively, through Egger’s test, with a significance level of 5%.

Grading of recommendations assessment, development and evaluation (GRADE)

Two reviewers (AA and LAAA) independently assessed the certainty of the evidence using the GRADE approach (Ryan & Hill 2016). A third author reviewed the analyses (LSA). The GRADE system assigns rank to the quality or certainty of the evidence. The Summary of Findings (SoF) tables present the results, along with the GRADE rating, for the most important review outcomes. The quality of evidence is evaluated based on five criteria (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and the studies are classified as high, moderate, low, or very low (Ryan & Hill 2016).

Results

Study selection

The flowchart of the research strategy is presented in Fig. 1. From 6 databases (PubMed/Medline, Embase, LILACS, Scopus, Web of Science, and Google Scholar), 2.615 records were identified, 412 duplicates, 2.133 excluded after title reading, 23 excluded after abstract reading, and 22 excluded after manuscript reading. No articles were included from gray literature and 3 were included after hand search. The excluded articles either fell outside the scope of the systematic review or altered the dental age estimation methods established in the existing literature. The final sample included 28 studies (Table 1).

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Fig. 1

Flowchart of the search and selection phases of the systematic review

Table 1. Included studies (n = 28)

First author	Year	Journal	State or region	Center (n) and city	Male sample (n)	Female sample (n)	Total sample (n)	Minimum age (years)	Maximum age (years)	Mean age ± SD (years)	Radiological image (panoramic or periapical)	Methods
Nery-Neto et al	2024	Diagnostics	Goiás state	1 (Goiânia)	117	130	247	20	82	Not informed	Panoramic and periapical	Cameriere et al. (2012) Cameriere et al. (2007) Azevedo et al. (2015) Lee et al. (2017) Anastácio et al. (2018)
Cidade et al	2023	Forensic Sci Med Pathol	Goiás state	1 (Goiânia)	600	600	1200	6	15.9	10.9 ± 2.9	Panoramic	Demirjian et al. (1973) Demirjian and Goldstein (1976)
Machado et al	2022	Clin Oral Investig	Rio de Janeiro state	1 (Rio de Janeiro)	995	995	1990	3	15.99	11.0 ± 2.9	Panoramic	Demirjian et al. (1973) Willems et al. (2001)
Rocha et al	2022	Egypt J Forensic Sci	São Paulo state	1 (São José dos Campos)	500	500	1000	6	15.99	Not informed	Panoramic	Willems et al. (2001)
Dezem et al	2021	Acta Stomatol Croat	São Paulo state	1 (Ribeirão Preto)	231	272	503	15	70	Females 29.04 Males 29.97	Panoramic	Olze et al. (2012) Timme et al. (2017)
Gonçalves et al	2021	Forensic Imaging	São Paulo state	1 (Ribeirão Preto)	110	110	220	6	16	Not informed	Panoramic	Demirjian et al. (1973) Willems et al. (2001)
Rocha et al	2021	Forensic Imaging	São Paulo state	1 (Ribeirão Preto)	250	250	500	15	24	19.50 ± 2.88	Panoramic	Olze et al. (2012)
Gobbo et al	2021	RCML	São Paulo state	1 (Ribeirão Preto)	165	165	330	6	16	Not informed	Panoramic	Nicodemo et al. (1974)
Miranda et al	2020	Braz Oral Res	São Paulo state	1 (São Paulo)	160	160	320	20	59	Not informed	Panoramic	Cameriere, Ferrante, Cingolani (2004) Kvaal et al. (1995)
Gonçalves do Nascimento et al	2020	J Forensic Odontostomatol	Paraíba state	1 (João Pessoa)	188	241	429	5	14.99	12.02 ± 2.06	Panoramic	Cameriere, Ferrante, Cingolani (2006)
Rezende Machado et al	2020	J Forensic Odontostomatol	São Paulo state	1 (Ribeirão Preto)	90	90	180	6	14	Not informed	Panoramic	Cameriere, Ferrante, Cingolani (2006) Willems et al. (2001)
Sousa et al	2020	Arch Oral Biol	São Paulo state	1 (Ribeirão Preto)	133	155	288	5	23	Not informed	Panoramic	London Atlas (2010) (AlQahtani et al. (2010)
da Luz et al	2019	Sci Justice	Minas Gerais state Croatia (country)	2 (Campina Verde and Zagreb)	366	564	930	8	14.99	Not informed	Panoramic	Cameriere, Ferrante, Cingolani (2006) Liliequist, Lundberg (1971) with the table of Hagg and Matsson Nolla (1960) 7 teeth Nolla (1960) 8 teeth
Benedicto et al	2018	Forensic Sci Int	Santa Catarina state	1 (Florianópolis)	387	622	1009	8	15.99	Not informed	Panoramic	Liliequist and Lundberg (1971) Haavikko (1974) Mornstad et al. (1994)
Fernandes et al	2018	Rev. Bras. Odontol. Leg	Minas Gerais state	1 (Juiz de Fora)	25	25	50	4	16	Not informed	Panoramic	Cameriere, Ferrante, Cingolani (2006)
Lopes et al	2018	Forensic Sci Int	Not informed	not informed	168	235	403	7	13	Not informed	Panoramic	Demirjian et al. (1973) Nolla (1960) 7 teeth
Machado et al	2018	Arch Oral Biol	Not informed	not informed	108	126	234	5	13.99	11.27 ± 2.27	Panoramic	Cameriere, Ferrante, Cingolani (2006)
Mazzilli et al	2018	J Forensic Leg Med	São Paulo state	1 (São Paulo metropolitan area)	290	322	612	4	16	10.00 ± 3.04	Panoramic	Cameriere, Ferrante, Cingolani (2006)
Lavez et al	2017	J Forensic Leg Med	São Paulo state	1 (Ribeirão Preto)	153	153	306	20	70	Not informed	Panoramic	Olze et al. (2012)
Galo et al	2016	Bioscience Journal	São Paulo state	1 (Ribeirão Preto)	546	654	1200	9	20	Females 9.54 ± 0.858 Males 9.64 ± 0.118	Panoramic	Nicodemo (1969)
Vieira et al	2016	Rev. Bras. Odontol. Leg	Bahia state	1 (Vitória da Conquista)	149	151	300	3	16	11.683 ± 3.2913	Panoramic	Demirjian et al. (1973)
Azevedo et al	2015	Braz Oral Res	São Paulo state	1 (São Paulo)	219	224	443	20	87	47.29 ± 15.99	Periapical	Cameriere, Ferrante, Cingolani (2004)
Franco et al	2013	Forensic Sci Int	Paraná state	1 (Curitiba)	582	775	1357	5	23	Not informed	Panoramic	Willems et al. (2001)
Fernandes et al	2011	J Forensic Sci	RJ, SP, MG states	3 (Niteroi and others not informed)	66	94	160	5	15	Females 10.2 ± 2.7 Males 10.6 ± 2.3	Panoramic	Cameriere, Ferrante, Cingolani (2006)
Oliveira et al	2010	Rev Gaúcha Odontol	Mato Grosso state	1 (Cuiabá)	100	100	200	8	18	Not informed	Panoramic	Nicodemo et al. (1974)
Maia et al	2010	Forensic Sci Int	Ceará state	1 (Fortaleza)	670	821	1491	7	13	Not informed	Panoramic	Demirjian et al. (1973)
Kurita et al	2007	J Appl Oral Sci	Ceará state	1 (Fortaleza)	180	180	360	7	15	Females 11.33 ± 2.57 Males 11.33 ± 2.53	Panoramic	Nolla (1960) Nicodemo et al. (1974
Eid et al	2002	Int J Paediatr Dent	São Paulo state	1 (São Paulo)	321	368	689	6	14.99	9.93 ± 1.98	Panoramic	Demirjian and Goldstein (1976)

Study characteristics

Data extraction and study characterization are described in Table 1. The studies were published between 2002 and 2024 and included samples from 11 of the 27 states (including Federal District) in Brazil: São Paulo (n = 13), Ceará, Goiás, and Minas Gerais (n = 2 each), and Alagoas, Bahia, Mato Grosso, Paraiba, Paraná, Santa Catarina, and Rio de Janeiro (n = 1 each). There were two studies for which the state information was not provided (Lopes et al. 2018; Machado et al. 2018), and one study that included samples from three states (São Paulo, Minas Gerais and Rio de Janeiro) without differentiating in the population analysis (Fernandes et al. 2011). In total, samples were obtained from 14 different cities.

The ages ranged from 3 to 87 years. In the 28 studies, a total of 24 methods for dental age estimation were identified.

Risk of bias

The quality studies assessment is described in Table 2. Study scores ranged from 4 to 9 on a scale of 0 to 10. One study was rated 4 (low quality), 16 studies received scores between 5 and 6 (moderate quality), and 11 studies scored 7 or above (high quality).

Table 2. Quality assessment using an adapted version of Newcastle − Ottawa Scale (NOS). Classification according to star number: low quality (0 to 4) n = 1; moderate quality (5 to 6) n = 16, and high quality (> = 7) n = 11

		Selection: (maximum 5 stars)				Comparability: (maximum 2 stars)	Outcome: (maximum 3 stars)
		1) Representativeness of the sample	2) Sample size	3) Non-respondents	4) Ascertainment of the exposure (risk factor)	1) Confounding factors	1) Assessment of the outcome	2) Statistical test	Total
First author	Year	Do the authors discuss the representativeness of the sample in the Methodology or Results section? (0 or 1)	Is the methodology for calculating the sample size described in the Methods or Discussion section? (0 or 1)	Is there information about the number of excluded samples in the Methodology or Results section? (0 or 1)	Was the dental age estimation methodology applied as outlined in the literature? (0 or 2)	Were local and systemic confounding factors considered for exclusion? If both were considered, award 2 points; if only one was considered, award 1 point	Was calibration performed, and were the radiograph analyses conducted blindly? If both were yes, award 2 points; if only one was yes, award 1 point	Is there a statistical test reported, including a p-value? (0 or 1)
Nery-Neto et al	2024	1	1	0	2	2	1	1	8
Cidade et al	2023	0	0	0	2	1	2	1	6
Machado et al	2022	0	0	0	2	1	2	1	6
Rocha et al	2022	0	0	0	2	2	1	1	6
Dezem et al	2021	0	0	0	2	1	1	1	5
Gonçalves et al	2021	0	0	1	2	1	2	1	7
Rocha et al	2021	0	0	0	2	1	2	1	6
Gobbo et al	2021	0	0	0	2	2	2	1	7
Miranda et al	2020	0	0	0	2	1	1	1	5
Gonçalves do Nascimento et al	2020	1	1	1	2	1	2	1	9
Rezende Machado et al	2020	0	0	0	2	1	2	1	6
Sousa et al	2020	0	0	0	2	2	2	1	7
da Luz et al	2019	0	0	0	2	2	1	1	6
Benedicto et al	2018	0	0	0	2	2	1	1	6
Fernandes et al	2018	0	0	0	2	0	1	1	4
Lopes et al	2018	0	0	0	2	2	2	1	7
Machado et al	2018	0	0	0	2	2	1	1	6
Mazzilli et al	2018	0	0	1	2	1	1	1	6
Lavez et al	2017	0	0	0	2	1	2	1	6
Galo et al	2016	0	0	0	2	2	2	1	7
Vieira et al	2016	0	0	1	2	1	2	1	7
Azevedo et al	2015	0	0	1	2	1	2	1	7
Franco et al	2013	0	0	1	2	1	1	1	6
Fernandes et al	2011	0	0	0	2	2	2	1	7
Maia et al	2010	0	0	1	2	2	2	1	8
Oliveira et al	2010	1	0	0	2	1	1	0	5
Kurita et al	2007	0	0	0	2	2	1	1	6
Eid et al	2002	0	0	0	2	2	0	1	5

The major problem detected were representativeness of the sample, sample size calculation, and the number of excluded samples.

Results of individual studies

Of all included studies, 22 different methods for age estimation using dental radiography were found. The most commonly used methods in the studies were Cameriere et al. (2006), Demirjian et al. (1973), and Willems et al. (2001). The way the results were presented range considerably. Some studies separated data by gender, while others separated it by the age group evaluated. Some studies presented the results based on the age group assessed and the average age found, while others evaluated the correlation coefficient. Of the 28 studies, 27 used panoramic radiographs, 1 used periapical radiographs, and 1 used both methods. The majority (54%) of the studies were conducted in the state of São Paulo. Of the 27 Brazilian states, including the Federal District, only 10 were evaluated in the studies. Of the included studies, 19 (68%) evaluated individuals up to 18 years of age, while 9 (32%) studies focused on individuals above this age group (Table 1).

Synthesis of results

Fourteen studies were included in the meta-analysis, allowing the evaluation of different dental methods for age estimation in male and female individuals.

All methods showed a mean error of less than 2 years. For males, the mean error ranged from 0.2 years [95% CI, 0.05 to 0.35; I² = 72%] to 1.75 years [95% CI, − 2.01 to − 1.49] (Fig. 2). For females, the mean error ranged from 0.01 years [95% CI, − 0.18 to 0.20; I² = 81%] to 1.27 years [95% CI, 1.03 to 1.51; I² = 93%] (Fig. 3).

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Fig. 2

Forest plot for age estimation based on the method, compared to chronological age, for males

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Fig. 3

Forest plot for age estimation based on the method, compared to chronological age, for females

Considering all the methods evaluated, the overall mean error was 0.52 years [95% CI, − 0.33 to − 0.71; I² = 95%] for males and 0.38 years [95% CI, 0.13 to 0.62; I² = 97%] for females. The majority of the included studies tended to overestimate the actual chronological age, regardless of the method used (Fig. 4).

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Fig. 4

Scatter plot between age estimation using the method and the chronological age estimation

Reporting biases

No evidence of publication bias was found, as demonstrated by the funnel plot analysis and the Egger test (p > 0.05) (Appendix 2 - male and Appendix 3 - female).

Certainty of evidence

The certainty of evidence of the selected articles in all evaluated outcomes was considered very low. Serious or very serious issues with respect to risk of bias, inconsistency, imprecision were detected in the studies included in this meta-analysis. Explanations of these categorizations are present in the Table 3.

Table 3. Analysis of information quality through GRADE—outcome method of evaluation considering sex

Outcome: Demirjian & Goldstein (1976) methods considering sex (male and female)
Certainty assessment
Nº of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other consideration	Certainty
2	Observational studies	Seriousa	Not serious	Not serious	Not serious	none	⨁◯◯◯
							Very low
2	Observational studies	Seriousa	Very seriousb	Not serious	Seriousd	none	⨁◯◯◯
							Very low
Outcome: Demirjian & Goldstein (1973) methods considering sex (male and female)
Nº of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other consideration	Certainty
4	Observational studies	Seriousa	Very seriousb	Not serious	Not serious	none	⨁◯◯◯
							Very low
4	Observational studies	Seriousa	Very seriousb	Not serious	Not serious	none	⨁◯◯◯
							Very low
Outcome: Nolla (1960) methods (7 teeth) considering sex
Nº of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other consideration	Certainty
2	Observational studies	Seriousa	Seriousc	Not serious	Not serious	none	⨁◯◯◯
							Very low
2	Observational studies	Seriousa	Seriousc	Not serious	Seriousd	none	⨁◯◯◯
							Very low
Outcome: Willems et al. (2001) methods considering sex
Nº of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other consideration	Certainty
2	Observational studies	Seriousa	Very seriousb	Not serious	Seriousd	none	⨁◯◯◯
							Very low
2	Observational studies	Seriousa	Very seriousb	Not serious	Seriousd	none	⨁◯◯◯
							Very low
Outcome: Cameriere, Ferrante, Cingolani (2006) methods considering sex
Nº of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other consideration	Certainty
3	Observational studies	Seriousa*	Very seriousb	Not serious	Seriousd	none	⨁◯◯◯
							Very low
3	Observational studies	Seriousa	Very seriousb	Not serious	Not serious	none	⨁◯◯◯
							Very low

Explanations:^aAbsence of sample size evaluation to determine representative of a target population/exclusion factors were not defined, ^bConsiderable heterogeneity across the studies and there is no overlap of confidence intervals, ^CThere is no overlap of confidence intervals,^dCrosses threshold for a group/wide confidence intervals

Discussion

Age determination is a fundamental process in various fields, playing a pivotal role in forensic science for individual identification, as well as in clinical practice for both medical and dental professionals. Age determination is essential for monitoring growth, planning orthodontic treatments, and diagnosing developmental abnormalities, providing valuable insights into patient care and forensic investigations. Chronological age can be determined through three primary approaches: molecular biology studies guided by laboratory analysis, dental indicators, and bone markers (Wang et al. 2023). Dental age estimation relies on evaluating the development of both primary and permanent teeth and comparing these stages to dental development charts established by different researchers (Wang et al. 2023). The literature suggests that dental methods for age estimation are more reliable than skeletal analysis, as they are considered less influenced by racial and environmental factors (Cunha et al. 2009). Our aim was to investigate the evidence-based support for various methods of age estimation using dental radiographs in the Brazilian population and to evaluate the precision of these methods.

Franco et al. (2021) conducted a systematic review to evaluate the performance of dental age estimation methods in Brazilian children. Their study analyzed publications from 1965 to 2019, focusing on Brazilian populations under 16 years of age. The authors concluded that, although originally designed for other populations, the Willems’ (Willems et al. 2001), Liliequist and Lundberg’s (Liliequist and Lundberg 1971), Nolla’s (Nolla 1960), and Cameriere’s (Cameriere et al. 2006) radiographic methods were applicable to Brazilian children. Our findings suggest that the dental methods assessed for age estimation in both male and female individuals generally show a low mean error, with all methods having a mean error of less than 2 years. For males, the error ranged from 0.2 years to 1.75 years, with a moderate level of heterogeneity among the studies. In females, the error ranged from 0.01 years to 1.27 years, with high heterogeneity. When considering all methods combined, the overall mean error was 0.52 years for males and 0.38 years for females, indicating a slightly higher accuracy for female age estimation. However, a notable trend across most studies was the tendency to overestimate chronological age, regardless of the method applied. This overestimation could be attributed to various factors, including study design or limitations in the methods used.

A significant challenge identified in this systematic review and meta-analysis was the lack of methodological standardization and consistency in result reporting. As a result, many studies could not be included in the meta-analysis. The adoption of standardized methods and uniform result presentation formats is essential to ensure comparability across studies and to enable the inclusion of a larger number of datasets in future analyses. Additionally, this review identified a wide range of techniques — 22 distinct approaches — for dental age estimation, which adds complexity to data synthesis and interpretation. In this context, the decision to conduct separate meta-analyses by sex, rather than using sex as a subgroup factor, was based on both biological and methodological considerations. Combining data from males and females could compromise the assessment of the individual accuracy of each method, making it more difficult to identify relevant variations in their performance. Moreover, the limited number of studies available for each technique would reduce the feasibility and statistical power of performing subgroup analyses by sex within individual methods. Given the substantial differences in accuracy and underlying assumptions across techniques, structuring the analyses by sex — with comparisons between methods within each group — was considered the most appropriate strategy to ensure methodological consistency and clinical relevance.

An important aspect to consider in this review is that Brazil, with a population of over 210 million, exhibits significant regional differences due to its diverse colonization history and, consequently, its population. Therefore, when referring to the “Brazilian population,” it is important to recognize that it is not homogeneous in terms of genetic background, development, and growth characteristics. As such, the results should be interpreted with caution, taking into account these regional variations. More than half of the studies (54%) were conducted in the state of São Paulo, the most populous state in Brazil. Of the 27 Brazilian states, including the Federal District, only 10 had their populations evaluated in the studies. Brazil has a rich history of miscegenation, with European ancestry, particularly of Portuguese, Italian, German, and Spanish origin, playing a predominant role throughout the country (Souza et al. 2019). However, populations in the North of Brazil show more pronounced Native American ancestry, while African ancestry is more prominent in the Northeast region (Souza et al. 2019).

A total of 28 studies met the eligibility criteria for this review. The limited number of studies is attributed to our selection of only those that sampled the Brazilian population and employed radiographic methods for dental age assessment. Despite the limited number of studies and the wide variety of methods, a comprehensive overview of the dental age estimation techniques applicable to the Brazilian population was still possible.

While not within the scope of this systematic review, it is important to note that we are currently in a period of transition regarding dental age estimation methods. Advances in artificial intelligence are enhancing these methods, and the results are promising. Researchers must actively engage with and monitor these developments to refine age estimation techniques and ensure greater accuracy for different populations (Khanagar et al. 2024).

A significant finding of this systematic review is the quality assessment of the included studies. Among the 28 studies evaluated, the majority (16 studies, representing 57%) were classified as having moderate quality. This limitation should be carefully considered when analyzing and interpreting the results. Notably, none of the studies achieved the highest possible quality score. Dimension 1 (Selection) of the quality assessment had the greatest impact on the overall scoring of the studies. This dimension evaluates critical methodological aspects, including sample representativeness, sample size, exclusions, and non-respondents. This finding has the potential to impact the results of the systematic review. Non-representative samples could result in inaccurate conclusions about the applicability of dental age estimation methods, particularly in the Brazilian context, which is characterized by diverse colonial influences and significant regional variations. Moreover, the majority of the eligible studies were conducted in the Southeast region of Brazil (São Paulo state), further limiting the ability to draw comprehensive conclusions regarding the applicability of dental age estimation techniques to the Brazilian population as a whole. It is important to note that the analyses did not differentiate between children, adolescents, and adults. This subdivision was not implemented to maximize the inclusion of studies and provide a broader scope for analysis. On the other hand, this decision may reduce the precision of the analyses and weaken the certainty of the evidence (GRADE). This finding provides valuable insights for future studies, highlighting the importance of considering these aspects in their design and methodology.

Systematic reviews, while regarded as a gold standard for synthesizing evidence, are not without limitations. This systematic review implemented several strategies to control potential risk of bias, including: (i) Pre-registered protocol: A protocol was created and registered in the PROSPERO database before the review was conducted, specifying eligibility criteria aligned with the review question. The criteria were detailed enough to ensure clarity in their application throughout the systematic review; (ii) Peer-reviewed search strategy: The search strategy was peer-reviewed prior to its implementation to ensure robustness and minimize potential bias in the search process; (iii) Comprehensive database coverage: A broad range of databases, additional methods, and gray literature were included, following the Cochrane Handbook guidelines, to minimize publication bias and ensure comprehensive coverage of the relevant literature; (iv) No restrictions on date, language, or publication format: The search strategy imposed no restrictions on publication date, language, or format, ensuring that the widest possible range of eligible studies was included; (v) Independent dual reviewers for screening, inclusion, data collection and quality assessment: During these process two independent reviewers were involved in the process to reduce the risk of subjective error and ensure consistency in study decisions; (vi) Transparency of search strategy: The full search strategy, including all terms and associations used in the database searches, was made available for replication, ensuring transparency and reproducibility of the process.

This assessment revealed limitations regarding the generalizability of the results, as the studies were predominantly region-specific and lacked sample representativeness. Moreover, incomplete data in some studies constrained the meta-analysis, thereby reducing the robustness of the findings. There is a necessity for future research on this topic with improved methodological quality, since currently it is possible to observe several tools that could be used to increase the level of evidence of the systematic review and, therefore, minimize the potential risk of bias, providing greater security and assertiveness for clinicians in decision making.

Furthermore, the lack of methodological standardization across studies represents a significant barrier to evidence synthesis in the field of dental age estimation. Overcoming this challenge requires the development of specific international guidelines that establish minimum standards for study design, implementation, and reporting. Recommended elements include the standardized presentation of descriptive statistics, sex stratification, clear documentation of the methods employed, and the use of uniform validation metrics. Encouraging multicenter collaborations and promoting open data-sharing initiatives may also enhance reproducibility and comparability across different methods. Thus, standardization emerges as a crucial step toward consolidating the clinical and forensic applicability of dental age estimation techniques.

Conclusions

In conclusion, this systematic review and meta-analysis demonstrated that all evaluated methods for dental age estimation presented a mean error of less than 2 years, indicating acceptable levels of accuracy. However, most methods tended to slightly overestimate chronological age. Among the techniques applied to the Brazilian population, the methods proposed by Cameriere and Willems consistently showed better performance in both male and female samples, with lower mean differences between estimated and actual ages. Nonetheless, important limitations were identified, particularly regarding the representativeness of the population samples and methodological inconsistencies across studies. This study provides evidence-based guidance for the selection of age estimation methods and supports their use in forensic and clinical contexts involving Brazilian individuals.

Acknowledgements

Research and Innovation Support Foundation of Santa Catarina State (Fundação de Amparo à Pesquisa e Inovação do Estado de Santa Catarina – FAPESC) (doctoral funding) (AA). Conselho Nacional do Desenvolvimento Cientifico e Tecnológico – CNPq (postdoctoral funding) (LAAA).

Authors’ contributions

Conceptualization: AA; LAAA. Methodology: LAAA; CMA. Formal analysis: AA; CMA; LSA; LAAA; ECK. Validation: PVPMN; KRC; LSA; PHCF. Investigation: LSA; PVPMN; KRC. Data Curation: LAAA; PPHCF. Supervision: ECK, FBF. Writing - original draft: AA; ECK; FBF. Writing - review and editing: All authors read and approved the final manuscript.

Funding

No funding was received for conducting this study.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Declaration of generative AI and AI‐assisted technologies in the writing process

No tool used.

Competing interests 

The authors declare no competing interests.

Abbreviations

IBGE

Brazilian Institute of Geography and Statistics

PROSPERO

International Prospective Register of Systematic Reviews

PRISMA

Preferred Reporting Items for Systematic Reviews guidelines

LILACS

Latin American and Caribbean Literature in Health Sciences

MeSH

Medical Subject Headings

DeCS

Descriptors in Health Sciences

MD

Mean Difference

GRADE

Grading of Recommendations Assessment, Development and Evaluation

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

AlQahtani SJ, Hector MP, Liversidge HM (2010) Brief communication: The London atlas of human tooth development and eruption. Am J Phys Anthropol 142(3):481–490. https://doi.org/10.1002/ajpa.v142:3, https://doi.org/10.1002/ajpa.21258

Azevedo A de C, Alves NZ, Michel-Crosato E, Rocha M, Cameriere R, Biazevic MG (2015) Dental age estimation in a Brazilian adult population using Cameriere’s method. Braz Oral Res 29:S1806–83242015000100215. https://doi.org/10.1590/1807-3107BOR-2015.vol29.0016.

Benedicto, EN; Azevedo, ACS; Michel-Crosato, E; Biazevic, MGH. Validity and accuracy of three radiographic dental age estimation methods in Brazilians. Forensic Sci Int; 2018; 283, pp. 128-135. [DOI: https://dx.doi.org/10.1016/j.forsciint.2017.12.014]

Cameriere, R; De Luca, S; Alemán, I; Ferrante, L; Cingolani, M. Age estimation by pulp/tooth ratio in lower premolars by orthopantomography. Forensic Sci Int; 2012; 214, 1–3 pp. 105-112. [DOI: https://dx.doi.org/10.1016/j.forsciint.2011.07.028]

Cameriere, R; Ferrante, L; Belcastro, MG; Bonfiglioli, B; Rastelli, E; Cingolani, M. Age estimation by pulp/tooth ratio in canines by peri-apical X-rays. J Forensic Sci; 2007; 52, pp. 166-170. [DOI: https://dx.doi.org/10.1111/j.1556-4029.2006.00336.x]

Cameriere R, Ferrante L, Cingolani M (2004) Precision and reliability of pulp/tooth area ratio (RA) of second molar as indicator of adult age. J Forensic Sci 49:1319–23. Erratum in: J Forensic Sci. 2005;50(2):486

Cameriere, R; Ferrante, L; Cingolani, M. Age estimation in children by measurement of open apices in teeth. Int J Legal Med; 2006; 120, 1 pp. 49-52. [DOI: https://dx.doi.org/10.1007/s00414-005-0047-9]

Cidade, R; Dos Santos, M; Alves, TC; Bueno, JM; Soares, M; Arakelyan, M et al. Radiographic dental age estimation applying and comparing Demirjian’s seven (1973) and four (1976) teeth methods. Forensic Sci Med Pathol; 2023; 19, pp. 175-183. [DOI: https://dx.doi.org/10.1007/s12024-022-00563-5]

Cunha, E; Baccino, E; Martrille, L; Ramsthaler, F; Prieto, J; Schuliar, Y et al. The problem of aging human remains and living individuals: a review. Forensic Sci Int; 2009; 193, pp. 1-13.1:STN:280:DC%2BD1MjnsVWhtw%3D%3D [DOI: https://dx.doi.org/10.1016/j.forsciint.2009.09.008]

da Luz, LCP; Anzulović, D; Benedicto, EN; Galić, I; Brkić, H; Biazevic, MGH. Accuracy of four dental age estimation methodologies in Brazilian and Croatian children. Sci Justice; 2019; 59, pp. 442-447. [DOI: https://dx.doi.org/10.1016/j.scijus.2019.02.005]

Davis, PJ; Hägg, U. The accuracy and precision of the “Demirjian system” when used for age determination in Chinese children. Swed Dent J; 1994; 18, pp. 113-116.1:STN:280:DyaK2czmslCnsg%3D%3D

Demirjian, A; Goldstein, H. New systems for dental maturity based on seven and four teeth. Ann Hum Biol; 1976; 3, pp. 411-421.1:STN:280:DyaE2s%2Fktlahug%3D%3D [DOI: https://dx.doi.org/10.1080/03014467600001671]

Demirjian, A; Goldstein, H; Tanner, JM. A new system of dental age assessment. Hum Biol; 1973; 45, pp. 211-227.1:STN:280:DyaE3s3gslWqug%3D%3D

Dezem, TU; Franco, A; Machado Palhares, CE; Deitos, AR; Alves da Silva, RH; Santiago, BM et al. Testing the olze and timme methods for dental age estimation in radiographs of Brazilian subadults and adults. Acta Stomatol Croat; 2021; 55, pp. 390-396. [DOI: https://dx.doi.org/10.15644/asc55/4/6]

Eid, RM; Simi, R; Friggi, MN; Fisberg, M. Assessment of dental maturity of Brazilian children aged 6 to 14 years using Demirjian’s method. Int J Paediatr Dent; 2002; 12, pp. 423-428.1:STN:280:DC%2BD38npt1yisA%3D%3D [DOI: https://dx.doi.org/10.1046/j.1365-263x.2002.00403.x]

Fernandes, MM; Tinoco, RL; de Braganca, DP; de Lima, SH; Francesquini Junior, L; Daruge Junior, E. Age estimation by measurements of developing teeth: accuracy of Cameriere’s method on a Brazilian sample. J Forensic Sci; 2011; 56, pp. 1616-1619. [DOI: https://dx.doi.org/10.1111/j.1556-4029.2011.01860.x]

Fernandes, PO; Reis, LG; Devito, KL; Leite, ICG; Paula, MVQ. Application and adjustment of Cameriere’s formula for a Brazilian sample: a pilot study. Rev Bras Odontol Leg RBOL; 2018; 5, pp. 20-27.

Flieger, R; Matys, J; Dominiak, M. The best time for orthodontic treatment for Polish children based on skeletal age analysis in accordance to refund policy of the Polish National Health Fund (NFZ). Adv Clin Exp Med; 2018; 27, pp. 1377-1382. [DOI: https://dx.doi.org/10.17219/acem/69976]

Franco, A; de Oliveira, MN; Campos Vidigal, MT; Blumenberg, C; Pinheiro, AA; Paranhos, LR. Assessment of dental age estimation methods applied to Brazilian children: a systematic review and meta-analysis. Dentomaxillofac Radiol; 2021; 50, 20200128. [DOI: https://dx.doi.org/10.1259/dmfr.20200128]

Franco, A; Thevissen, P; Fieuws, S; Souza, PH; Willems, G. Applicability of Willems model for dental age estimations in Brazilian children. Forensic Sci Int; 2013; 231, pp. 401.e1-4. [DOI: https://dx.doi.org/10.1016/j.forsciint.2013.05.030]

Franklin, D. Forensic age estimation in human skeletal remains: current concepts and future directions. Leg Med (Tokyo); 2010; 12, pp. 1-7. [DOI: https://dx.doi.org/10.1016/j.legalmed.2009.09.001]

Galo, R; Leite, NP; L de Tonin, O; Lass, N; Silva, RHA et al. Age estimation based on the stage of mineralization of third molars on orthopantomograms. Biosci J; 2016; 32, pp. 805-12.

Gobbo, SFR; Alonso, MBCC; Kawamoto, KKM; Teixeira, DB; da Silva, RHA; Comar, LP. Revista Criminalística e Medicina Legal; 2021; 6, pp. 10-18.

Gonçalves do Nascimento L, Ribeiro Tinoco RL, Lacerda Protasio AP, Arrais Ribeiro IL, Marques Santiago B, Cameriere R (2020) Age estimation in north east Brazilians by measurement of open apices. J Forensic Odontostomatol 38:2–11.

Gonçalves, LS; Machado, ALR; Gaêta-Araujo, H; Recalde, TSF; Oliveira-Santos, C; da Silva, RHA. A comparison of Demirjian and Willems age estimation methods in a sample of Brazilian non-adult individuals. Forensic Imaging; 2021; 25, 200456. [DOI: https://dx.doi.org/10.1016/j.fri.2021.200456]

Haavikko K (1974) Tooth formation age estimated on a few selected teeth. A simple method for clinical use. Proc Finn Dent Soc 70(1):15–19.

Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors) (2024) Cochrane Handbook for Systematic Reviews of Interventions version 6.5 (updated August 2024). Cochrane. Available from www.training.cochrane.org/handbook.

Khanagar, SB; Albalawi, F; Alshehri, A; Awawdeh, M; Iyer, K; Alsomaie, B et al. Performance of artificial intelligence models designed for automated estimation of age using dento-maxillofacial radiographs-a systematic review. Diagnostics (Basel); 2024; 14, 1079. [DOI: https://dx.doi.org/10.3390/diagnostics14111079]

Kurita, LM; Menezes, AV; Casanova, MS; Haiter-Neto, F. Dental maturity as an indicator of chronological age: radiographic assessment of dental age in a Brazilian population. J Appl Oral Sci; 2007; 15, pp. 99-104. [DOI: https://dx.doi.org/10.1590/s1678-77572007000200005]

Kvaal, SI; Kolltveit, KM; Thomsen, IO; Solheim, T. Age estimation of adults from dental radiographs. Forensic Sci Int; 1995; 74, pp. 175-185.1:STN:280:DyaK28%2FgsVKluw%3D%3D [DOI: https://dx.doi.org/10.1016/0379-0738(95)01760-g]

Lavez, GP; Terada, ASSD; Dezem, TU; Galo, R; da Silva, RHA. Age estimation using Olze’s method in an adult Brazilian population. J Forensic Leg Med; 2017; 52, pp. 241-244. [DOI: https://dx.doi.org/10.1016/j.jflm.2017.10.003]

Lee, Jeong-Hee; Lee, Chena; Battulga, Bulgan; Na, Ji Yeon; Hwang, Jae Joon; Kim, Young Hyun; Han, Sang-Sun. Morphological analysis of the lower second premolar for age estimation of Korean adults. Forensic Sci Int; 2017; 281, pp. 186.e1-186.e6. [DOI: https://dx.doi.org/10.1016/j.forsciint.2017.10.005]

Liliequist, B; Lundberg, M. Skeletal and tooth development. A Methodologic Investigation Acta Radiol Diagn (Stockh); 1971; 11, pp. 97-112.1:STN:280:DyaE3M3js1ShtA%3D%3D [DOI: https://dx.doi.org/10.1177/028418517101100201]

Liversidge, HM; Speechly, T; Hector, MP. Dental maturation in British children: are Demirjian’s standards applicable?. Int J Paediatr Dent; 1999; 9, pp. 263-269.1:STN:280:DC%2BD3c3nsVOhug%3D%3D [DOI: https://dx.doi.org/10.1111/j.1365-263x.1999.00144.x]

Lopes, LJ; Nascimento, HAR; Lima, GP; Santos, LAND; Queluz, DP; Freitas, DQ. Dental age assessment: which is the most applicable method?. Forensic Sci Int; 2018; 284, pp. 97-100. [DOI: https://dx.doi.org/10.1016/j.forsciint.2017.12.044]

Machado, MA; Daruge Júnior, E; Fernandes, MM; Lima, IFP; Cericato, GO; Franco, A et al. Effectiveness of three age estimation methods based on dental and skeletal development in a sample of young Brazilians. Arch Oral Biol; 2018; 85, pp. 166-171. [DOI: https://dx.doi.org/10.1016/j.archoralbio.2017.10.014]

Machado, MVF; Soares, MQS; Baz, AMSA; Junqueira, JLC; Franco, A. A large sample-sized study on dental development of children treated at the Central Dental Clinic (OCEx) of the Brazilian Army. Clin Oral Investig; 2022; 26, pp. 5439-5447. [DOI: https://dx.doi.org/10.1007/s00784-022-04511-z]

Maia MC, Martins M da G, Germano FA, Brandão Neto J, da Silva CA (2010) Demirjian’s system for estimating the dental age of northeastern Brazilian children. Forensic Sci Int 200(1–3):177.e1–4. https://doi.org/10.1016/j.forsciint.2010.03.030.

Mazzilli, LEN; Melani, RFH; Lascala, CA; Palacio, LAV; Cameriere, R. Age estimation: Cameriere’s open apices methodology accuracy on a southeast Brazilian sample. J Forensic Leg Med; 2018; 58, pp. 164-168. [DOI: https://dx.doi.org/10.1016/j.jflm.2018.06.006]

Miranda, JC; Azevedo, ACS; Rocha, M; Michel-Crosato, E; Biazevic, MGH. Age estimation in Brazilian adults by Kvaal’s and Cameriere’s methods. Braz Oral Res; 2020; 34, e051. [DOI: https://dx.doi.org/10.1590/1807-3107bor-2020.vol34.0051]

Modesti, PA; Reboldi, G; Cappuccio, FP; Agyemang, C; Remuzzi, G; Rapi, S et al. ESH working group on CV risk in low resource settings. panethnic differences in blood pressure in Europe: a systematic review and meta-analysis. PLoS One; 2016; 11, e0147601.

Moreira Araújo R, Vieira Lemos Y, Dias do Nascimento E, Silva Paraizo AH, Wainstein AJA, Drummond-Lage AP (2023) Identification of victims of the collapse of a mine tailing dam in Brumadinho. Forensic Sci Res 7:580–589. https://doi.org/10.1080/20961790.2022.2113623.

Mörnstad H, Staaf V, Welander U (1994) Age estimation with the aid of tooth development: a new method based on objective measurements. Eur J Oral Sci 102(3):137–143. https://doi.org/10.1111/eos.1994.102.issue-3, https://doi.org/10.1111/j.1600-0722.1994.tb01169.x

Nery-Neto, I; Guedes, OA; Estrela, LRA; Cintra, LTA; Estrela, CRA; Estrela, C. Age estimation in Brazilian adults using the pulp/tooth ratio of the maxillary canine and mandibular second premolar. Diagnostics (Basel); 2024; 14, 7 749. [DOI: https://dx.doi.org/10.3390/diagnostics14070749]

Nicodemo, RA. Study of the chronology of mineralization of 3d molars using the radiographic method, in white Brazilians of the Paraiba Valley, State of São Paulo. Rev Fac Odontol Sao Paulo; 1969; 7, 2 pp. 419-44.1:STN:280:DyaE3c3ht1Olug%3D%3D

Nicodemo, RA; Moraes, LC; Médici Filho, E. Table of the chronological mineralization of permanent teeth among Brazilians. Rev Fac Odontol Sao Jose dos Campos; 1974; 3, 1 pp. 55-6.1:STN:280:DyaE1c%2FpsFOrsA%3D%3D

Nolla, CM. The development of the permanent teeth. J Dent Child; 1960; 27, pp. 254-266.

Oliveira OF, Fernandes MM, Daruge Junir E, Melani RFH, Paranhos LR (2010) Rev Gaúcha Odontol–RGO 58(2):203–206.

Olze, A; Hertel, J; Schulz, R; Wierer, T; Schmeling, A. Radiographic evaluation of Gustafson’s criteria for the purpose of forensic age diagnostics. Int J Leg Med; 2012; 126, 4 pp. 615-621. [DOI: https://dx.doi.org/10.1007/s00414-012-0701-y]

Page, MJ; McKenzie, JE; Bossuyt, PM; Boutron, I; Hoffmann, TC; Mulrow, CD et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ; 2021; 372, n71. [DOI: https://dx.doi.org/10.1136/bmj.n71]

Parra, FC; Amado, RC; Lambertucci, JR; Rocha, J; Antunes, CM; Pena, SD. Color and genomic ancestry in Brazilians. Proc Natl Acad Sci USA; 2003; 100, 1 pp. 177-182.1:CAS:528:DC%2BD3sXktlOgtg%3D%3D [DOI: https://dx.doi.org/10.1073/pnas.0126614100]

Pereira, CP; Russell, LM; de Pádua, FM; Alves da Silva, RH; de Sousa Santos, RFV. Dental age estimation based on development dental atlas assessment in a child/adolescent population with systemic diseases. Acta Stomatol Croat; 2019; 53, pp. 307-317. [DOI: https://dx.doi.org/10.15644/asc53/4/1]

Rezende Machado, AL; Borges, BS; Cameriere, R; Palhares Machado, CE; Alves da Silva, RE. Evaluation of Cameriere and Willems age estimation methods in panoramic radiographs of Brazilian children. J Forensic Odontostomatol; 2020; 38, 3 pp. 8-15.1:STN:280:DC%2BB3srmtlKmsA%3D%3D

Rocha, LT; Ingold, MS; Panzarella, FK et al. Applicability of Willems method for age estimation in Brazilian children: performance of multiple linear regression and artificial neural network. Egypt J Forensic Sci; 2022; 12, 9 pp. 1-9. [DOI: https://dx.doi.org/10.1186/s41935-022-00271-9]

Rocha, MFN; Matteussi, GT; Pereira, JGD; da Silva, RHA. Age estimation by teeth and legal majority through the Olze method in Brazilian population. Forensic Imaging; 2021; 27, 200480. [DOI: https://dx.doi.org/10.1016/j.fri.2021.200480]

Ryan R, Hill S (2016) How to GRADE the quality of the evidence. Cochrane Consumers and Communication Group, available at http://cccrg.cochrane.org/author-resources. Version 3.0 December 2016.

Sousa, AMDS; Jacometti, V; AlQahtani, S; Silva, RHAD. Age estimation of Brazilian individuals using the London Atlas. Arch Oral Biol; 2020; 113, 104705. [DOI: https://dx.doi.org/10.1016/j.archoralbio.2020.104705]

Souza, AM; Resende, SS; Sousa, TN; Brito, CFA. A systematic scoping review of the genetic ancestry of the Brazilian population. Genet Mol Biol; 2019; 42, pp. 495-508. [DOI: https://dx.doi.org/10.1590/1678-4685-GMB-2018-0076]

Timme, M; Timme, WH; Olze, A; Ottow, C; Ribbecke, S; Pfeiffer, H et al. Dental age estimation in the living after completion of third molar mineralization: new data for Gustafson’s criteria. Int J Legal Med; 2017; 131, 2 pp. 569-577.1:STN:280:DC%2BC2sjis12isw%3D%3D [DOI: https://dx.doi.org/10.1007/s00414-016-1492-3]

Vieira MCA, Lima TBS, Costa RL, Nery IFNO, Corrêa GTB, Andrade RCDV (2016) Revista Brasileira de Odontoogia Legal–BOL 3(1):32–40

Wang, J; Dou, J; Han, J; Li, G; Tao, J. A population-based study to assess two convolutional neural networks for dental age estimation. BMC Oral Health; 2023; 23, 109. [DOI: https://dx.doi.org/10.1186/s12903-023-02817-2]

Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al (2024) The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 26 Oct 2024

Willems, G; Van Olmen, A; Spiessens, B; Carels, C. Dental age estimation in Belgian children: Demirjian’s technique revisited. J Forensic Sci; 2001; 46, pp. 893-895.1:STN:280:DC%2BD3MzpvFagsw%3D%3D