Diagnostic performance of Demirjian’s third molar maturation stages G, G1, and H for identifying the 18-year age threshold: a sex-specific study

Diagnostic performance of Demirjian’s third molar maturation stages G, G1, and H for identifying the 18-year age threshold: a sex-specific study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Diagnostic performance of Demirjian’s third molar maturation stages G, G1, and H for identifying the 18-year age threshold: a sex-specific study Sudheer Babu Balla, Naga Madhuri Nagarakanti, Subramanyeswara Swamy Chinni, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9318331/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Determining attainment of 18 years is a critical task in forensic age estimation. This study evaluated and compared the sex-specific diagnostic performance of conventional and refined third-molar maturation cut-offs, Demirjian stages G and H, and the refined stage G1 for identifying individuals aged ≥ 18 years in a South Indian population. Panoramic radiographs of 599 individuals aged 14–22 years were retrospectively assessed. Mandibular left third molars were staged using the conventional Demirjian system and the Solari and Abramovitch modification. Diagnostic performance was evaluated separately for males and females using sensitivity, specificity, predictive values, likelihood ratios, accuracy, and post-test probabilities. Intra- and inter-examiner agreement was assessed using kappa statistics. Third-molar maturation effectively discriminated attainment of 18 years in both sexes, with stage-dependent trade-offs between sensitivity and specificity. Stages G and G1 demonstrated high sensitivity and strong exclusion of adulthood when negative, whereas stage H showed higher specificity and greater confirmatory value when present, particularly among females. Diagnostic performance of the refined G1 stage was comparable to that of stage G, with modest improvement in specificity and post-test probability in females. Inter-examiner agreement was excellent for stages G and H but only moderate for G1, indicating reduced reproducibility for the refined stage. In conclusion, conventional Demirjian stages G and H remain reliable and reproducible indicators for assessing attainment of 18 years. Although the refined G1 stage offers increased developmental resolution and supports probabilistic interpretation, its forensic utility is constrained by reduced inter-observer agreement. Dental age estimation Third molar Demirjian method Refined root stages Age of majority Diagnostic accuracy Figures Figure 1 1. Introduction In forensic dental age estimation of living individuals, assessment during late adolescence and early adulthood remains particularly challenging. At this stage, the majority of dental development has already been completed, while age-related regressive changes have not yet commenced, resulting in a narrow biological window with limited age-informative markers [ 1 , 2 ]. Consequently, chronological age estimation in adolescents and young adults is associated with greater uncertainty than in earlier childhood or later adulthood. Within this age range, the third molars are of particular forensic relevance, as they are typically the only teeth still undergoing development, with formation extending into the mid-twenties [ 3 ]. For this reason, third-molar development is widely used in dental age estimation, especially to assess whether an individual has attained the legally significant age threshold of 18 years. The accuracy of such estimations depends not only on the method used to translate dental development into age but also on the precision with which developmental stages are identified and classified [ 4 ]. Against this background, third-molar-based dental age estimation has been extensively investigated. Mincer et al. [ 5 ] evaluated third-molar development in American Caucasians using the staging system proposed by Demirjian et al. [ 6 ], establishing a foundation for subsequent forensic applications. Since then, numerous studies have applied Demirjian’s third-molar developmental stages, particularly the late root stages, to support binary classification of individuals as younger or older than 18 years [ 7 – 10 ]. In addition, probability-based approaches using mandibular third-molar root development have been proposed to quantify the likelihood that an individual has attained 18 years of age, highlighting the practical utility of stage-based inference in forensic casework [ 11 ]. However, a recognised limitation of the original Demirjian A–H system is that developmental transitions occurring near apexification are subsumed within relatively broad stages, potentially limiting discriminatory power precisely at age ranges where legal decisions are most sensitive [ 12 ]. Building on these applications, it has been suggested that staging systems with fewer developmental categories have been regarded as easier to apply because each stage encompasses a broader interval of tooth development. However, such broad stages span wide chronological age ranges and may therefore provide limited discriminatory power at legally relevant thresholds [ 13 ]. In contrast, staging systems that incorporate additional intermediate categories aim to capture finer developmental transitions over shorter time spans, potentially improving alignment with chronological age during late adolescence [ 14 ]. The refined root stages proposed by Solari and Abramovitch were introduced on this basis to enhance age discrimination near apexification [ 15 ]. Despite this rationale, the extent to which these additional stages improve diagnostic performance for determining attainment of 18 years has not been adequately established. Accordingly, the present study aimed to evaluate and compare the sex-specific diagnostic performance of conventional and refined third-molar maturation cut-offs, specifically stages G, G1, and H, for identifying individuals aged 18 years or older. By examining sensitivity, specificity, likelihood ratios, and post-test probabilities, this study sought to determine whether the inclusion of refined root stages improves the evidential reliability of dental age estimation in late adolescence. 2. Materials and Methods 2.1. Study sample Panoramic radiographs (orthopantomograms; OPGs) of 599 individuals with known chronological age and sex were retrospectively obtained from orthodontic clinics. The sample comprised adolescents and young adults of South Indian origin, aged between 14.0 and 21.99 years (Table 1 ). Chronological age was calculated to two decimal places as the difference between the date of birth and the date of radiographic exposure. For analytical purposes, individuals were grouped into one-year age categories (e.g., 14.0–14.99 years, 15.0–15.99 years, and so forth). Radiographs were excluded if they demonstrated severe dental caries affecting the third molars, previous endodontic treatment, pathological lesions involving the jaws, congenitally absent third molars, or insufficient image quality for reliable assessment. In addition, individuals with a reported history of endocrine disorders were excluded due to the potential influence on dental development. Table 1 Age and sex distribution of the total sample n(%). Age group Males Females 14- 14.99 40 (14.3) 42 (13.2) 15- 15.99 40 (14.3) 44 (13.8) 16- 16.99 40 (14.3) 35 (11) 17- 17.99 40 (14.3) 38 (11.9) 18- 18.99 37 (13.2) 40 (12.5) 19- 19.99 36 (12.9) 40 (12.5) 20- 20.99 28 (10) 50 (15.7) 21- 21.99 19 (6.8) 30 (9.4) Total 280 (100) 319 (100) The present study utilised OPGs derived from an existing anonymised dataset previously analysed and reported in earlier research [ 16 , 17 ]. No additional radiographic acquisition or data collection was undertaken. All images were fully anonymised before analysis. For each case, chronological age, sex, and third-molar developmental stage were recorded against a unique identification number (UIN). Examiners were blinded to all personal and demographic information throughout the assessment process to minimise examiner bias. This study utilised OPGs from an existing anonymised database that had been previously analysed and reported in earlier research for which ethical clearance was obtained from the institutional ethics committee (PMVIDS&RC/IEC/OMFP/PR/0261 − 18). No additional data collection was undertaken for the present investigation. This study was conducted in accordance with the ethical standards established by the Declaration of Helsinki (Finland) and its subsequent amendments [ 18 ]. 2.2. Radiographic assessment and Staging procedure The maturation of the mandibular left third molar was initially assessed using the conventional Demirjian eight-stage classification (A–H) [ 6 ]. Following a one-month washout period to minimise recall bias, the same panoramic radiographs were re-evaluated using the Solari and Abramovitch modification of the Demirjian system [ 15 ], which incorporates two additional intermediate root stages (F1 and G1). Stage F1 is characterised by a root length approximately twice the crown length, with apices that remain funnel-shaped. Stage G1 is defined by parallel root walls with incompletely closed apices and a periodontal ligament space at the apex exceeding 1.0 mm (Fig. 1 ). The first author performed all radiographic assessments. Intra-examiner reliability was evaluated by re-scoring a randomly selected 10% subsample of the radiographs (n = 60) after a two-week interval. Inter-examiner reliability was assessed by the second author, who independently evaluated the same subsample. Both examiners applied the conventional Demirjian staging system and the Solari and Abramovitch modification during reliability testing. 2.3. Statistical analysis All statistical analyses were performed using IBM SPSS Statistics (Version 29.0; IBM Corp., Armonk, NY, USA). Statistical significance was set at p < 0.05. Third-molar maturation served as the index test and was evaluated using three sequential cut-off criteria: stage G and above (≥ G), refined stage G1 and above (≥ G1), and stage H (complete apical closure). Each cut-off was treated as a binary diagnostic test, with stages at or beyond the cut-off classified as test-positive and earlier stages as test-negative. All analyses were conducted separately for males and females to account for potential sexual dimorphism in third molar maturation. For each sex and each cut-off stage, 2×2 contingency tables were constructed to cross-classify third-molar stage (test positive vs negative) against chronological age status (≥ 18 vs < 18 years). These tables yielded counts of true positives (TP), false positives (FP), true negatives (TN), and false negatives (FN). The association between third-molar stage and age status was assessed using the Pearson chi-square test. Odds ratios (ORs) were calculated to quantify the strength of association between attainment of the specified third-molar stage and the likelihood of being ≥ 18 years. For each cut-off stage (≥ G, ≥G1, and H), and separately for males and females, the following diagnostic accuracy measures were calculated: sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and likelihood ratios (Table 2 ). Table 2 Summary of diagnostic measures and their interpretation in the context of third-molar maturation for identifying attainment of 18 years Diagnostic measure Description/ Calculation What it represents Interpretation True positive (TP) Individuals aged ≥ 18 years correctly classified as ≥ 18 Correct identification of legally adult individuals Higher TP values indicate a better ability to detect individuals who have attained 18 years. False Positive (FP) Individuals < 18 years incorrectly classified as ≥ 18 Erroneous classification of minors as adults Represents over-aging with significant ethical and legal implications. True Negative (TN) Individuals < 18 years correctly classified as < 18 Correct identification of minors Minimises the risk of assigning adult status to under-18 individuals False Negative (FN) Individuals aged ≥ 18 years incorrectly classified as < 18 Failure to detect legal adulthood Leads to conservative classification, generally considered safer in forensic contexts Sensitivity TP/ (TP + FN) Probability that individuals aged ≥ 18 years are correctly identified High sensitivity reduces the likelihood of misclassifying adults as minors Specificity TN/ (TN + FP) Probability that individuals < 18 years are correctly excluded High specificity limits false classification of minors as adults Positive Predictive Value (PPV) TP/ (TP + FP) Probability that an individual classified as ≥ 18 (e.g. ≥G/≥G1/H) is truly ≥ 18 years Provides case-level evidential support for concluding attainment of 18 years Negative Predictive Value (NPV) TN/ (TN + FN) Probability that an individual classified as < 18 (e.g. <G/<G1/<H) is truly < 18 years Indicates the reliability of the method in excluding legal adulthood Accuracy (TP + TN) / Total Overall correct classification rate Summarises the combined discriminative performance Odds Ratio (OR) (TP × TN)/(FP × FN) Strength of association between tooth stage and ≥ 18 status Quantifies the evidential strength of the staging criterion Likelihood Ratio Positive (LR+) Sens / (1- Spec) Degree to which the odds of being ≥ 18 increase following a positive test Values > 10 indicate strong support for adult classification Likelihood Ratio Negative (LR–) (1- Sens)/Spec Degree to which the odds of being ≥ 18 decrease following a negative test Lower values indicate stronger evidence against the attainment of 18 years Post-test Probability (Positive) [Pre-odds × LR+] / [1 + (Pre-odds × LR+)] Probability of being ≥ 18 years given a positive stage (e.g. ≥G/≥G1/H) Reflects the evidential probability of adulthood after observing advanced third-molar maturation Post-test Probability (Negative) [Pre-odds × LR–] / [1 + (Pre-odds × LR–)] Probability of being ≥ 18 years given a negative stage (e.g. <G/<G1/<H) Indicates residual risk of adulthood despite an immature third-molar stage To discriminate between individuals aged < 18 years and those who have attained 18 years, both pre-test and post-test probabilities of being ≥ 18 years were estimated. The pre-test probability (P 0 ) represents the likelihood that an individual in a given population is 18 years or older before application of the diagnostic test, reflecting the underlying age distribution of the sample. In contrast, the post-test probability (PTP) is the probability that an individual is 18 years of age, given the result of the diagnostic test. Sex-specific pre-test probabilities were derived from the observed prevalence of individuals aged ≥ 18 years in the study sample (41.4% for males and 39.0% for females). Post-test probabilities were then calculated using Bayes’ theorem for each third-molar cut-off stage (G, G1, and H), separately for males and females. These estimates quantify the probability that an individual has reached 18 years of age given the observed third-molar maturation stage. 3. Results Intra- and inter-examiner agreement for Demirjian’s stages of third-molar development was assessed using Cohen’s kappa (κ) statistics. Overall, intra-examiner agreement was substantial (κ = 0.912), indicating good consistency in repeated assessments by the same examiner. In contrast, overall inter-examiner agreement was lower, falling within the moderate agreement range (κ = 0.731), suggesting greater variability between observers when applying the staging criteria. Stage-specific analysis revealed marked differences in reproducibility. Inter-examiner agreement was excellent for stages G (κ = 0.946) and H (κ = 0.967), reflecting high consistency in identifying advanced root development and complete apical closure. However, agreement on the modified stage G1 was poor (κ = 0.721), indicating difficulty in consistently distinguishing this transitional stage across examiners. Tables 3 to 5 show the cross-tabulation of third molar maturation stages and chronological age status. They demonstrated a strong association between third-molar maturation stage and chronological age status in both sexes for all evaluated cut-off stages (G, G1, and H). For males, the proportion of individuals classified as ≥ 18 years increased progressively with advancing third-molar development, with the highest number of true positives observed at stage G and the fewest false positives observed at stage H. A similar trend was observed in females, with a higher proportion of advanced stages below 18 years at earlier cut-offs, consistent with earlier maturation patterns. Table 3 Diagnostic cross-tabulation of conventional Demirjian stage G against chronological age status ( ≥ 18 years vs < 18 years) in both sexes ≥ 18years < 18 years Total Males Stage G & above (positive) 116 TP 34 FP 150 Stages A to F (negative) 04 FN 126 TN 130 Total 120 160 280 Females Stage G & above (positive) 146 TP 31 FP 177 Stages A to F (negative) 14 FN 128 TN 142 Total 160 159 319 TP: True positives; FP: False positives; TN: True Negatives; FN: False Negatives Table 4 Diagnostic cross-tabulation of modified Demirjian stage G1 against chronological age status ( ≥ 18 years vs < 18 years) in both sexes ≥ 18years < 18 years Total Males Stage G1 & above (positive) 113 TP 33 FP 146 Stages A to G (negative) 07 FN 127 TN 134 Total 120 160 280 Females Stage G1 & above (positive) 142 TP 26 FP 168 Stages A to G (negative) 18 FN 133 TN 151 Total 160 159 319 TP: True positives; FP: False positives; TN: True Negatives; FN: False Negatives Table 5 Diagnostic cross-tabulation of conventional Demirjian stage H against chronological age status ( ≥ 18 years vs < 18 years) in both sexes ≥ 18years < 18 years Total Males Stage H (positive) 102 TP 24 FP 126 Stages A to G (negative) 18 FN 136 TN 154 Total 120 160 280 Females Stage H (positive) 118 TP 13 FP 131 Stages A to G (negative) 42 FN 146 TN 188 Total 160 159 319 TP: True positives; FP: False positives; TN: True Negatives; FN: False Negatives Sex-specific diagnostic accuracy measures for stages G, G1, and H are summarised in Table 6 . Sex-stratified diagnostic accuracy measures for stages G, G1, and H are summarised in Table X. In males, stage G demonstrated the highest sensitivity (96.7%), indicating excellent ability to identify individuals aged ≥ 18 years, while stage H showed a more balanced sensitivity and specificity (both 85.0%). Stage G1 provided intermediate performance, with a sensitivity of 94.2% and a specificity of 79.4%. Negative predictive values were highest for stage G and G1, reflecting strong exclusion of adulthood when these stages had not been reached. Table 6 Sex-specific diagnostic performance of third-molar maturation cutoffs (G, G1, and H) for identifying individuals aged ≥ 18 years Cut-off (Positive test) Sensitivity % (95% CI) Specificity % (95% CI) PPV (95% CI) NPV (95% CI) Accuracy (95% CI) LR+ (95% CI) LR- (95% CI) Odds Ratio (95% CI) Males (n = 280) Stage G & above 96.7 (92.1–98.6) 78.8 (72.0–84.3) 77.3 (70.0–83.2) 96.9 (92.7–98.7) 86.4 (81.8–90.0) 4.55 (3.37–6.14) 0.04 (0.02–0.11) 107.6 (35.1–329.8) Stage G1 & above 94.2 (88.3–97.2) 79.4 (72.5–85.0) 77.4 (70.1–83.3) 94.8 (90.1–97.3) 86.0 (81.4–89.6) 4.57 (3.32–6.29) 0.07 (0.03–0.16) 62.2 (24.7–156.9) Stage H 85.0 (77.5–90.3) 85.0 (78.4–90.0) 81.0 (72.8–87.2) 88.3 (82.3–92.4) 85.0 (80.5–88.7) 5.67 (3.87–8.32) 0.18 (0.11–0.28) 32.2 (15.8–65.6) Females (n = 319) Stage G & above 91.3 (86.0–94.7) 80.5 (73.6–86.0) 82.5 (76.4–87.2) 90.1 (84.6–93.8) 85.9 (81.5–89.5) 4.68 (3.40–6.44) 0.11 (0.07–0.18) 43.0 (20.0–92.4) Stage G1 & above 88.7 (82.7–92.7) 83.7 (77.0–88.7) 84.6 (78.4–89.2) 88.1 (82.2–92.2) 86.2 (82.1–89.6) 5.45 (3.82–7.78) 0.14 (0.08–0.22) 40.3 (21.0–77.5) Stage H 73.8 (66.3–80.0) 91.8 (86.6–95.2) 90.1 (84.0–94.0) 77.7 (71.1–83.1) 82.1 (77.6–85.9) 9.02 (5.54–14.68) 0.29 (0.21–0.38) 31.4 (15.8–62.2) In females, sensitivity decreased with advancing stage, from 91.3% at stage G to 73.8% at stage H. In contrast, specificity increased from 80.5% at stage G to 91.8% at stage H. Consequently, positive predictive value was highest at stage H in females (90.1%), indicating strong confirmatory value when apical closure was complete. Likelihood ratios supported these patterns: earlier cut-offs (G and G1) yielded moderate LR+ values (approximately 4 to 5), whereas stage H provided strong diagnostic evidence in females (LR + = 9.02). Overall, accuracy remained high across all cut-offs in both sexes (approximately 82–86%). Table 7 shows the sex-specific post-test probabilities, translating diagnostic performance into probabilistic events relevant for forensic interpretation. In males, a positive result at stages G and G1 increased the post-test probability of being ≥ 18 years to approximately 76%, while a positive result at stage H increased this probability to 80%. In contrast, negative test results at stages G and G1 reduced the probability of being ≥ 18 years to below 5% and stage H to 11%, indicating strong exclusion of adulthood when these stages had not been reached. In females, post-test probabilities following a positive test increased from 75% at stage G to 78% at stage G1. They exceeded 85% at stage H, reflecting the higher specificity of advanced maturation in females. Negative test results reduced the probability of being ≥ 18 years to approximately 6–8% for stages G and G1, and to 15.5% for stage H. Table 7 Sex-specific post-test probabilities for ≥ 18 years (≥ conventional Stage G vs conventional Stage H vs ≥ modified Stage G1) Sex Cut-off (Positive test) Pre-test P ( ≥ 18) Post-test P ( ≥ 18/ Positive) Post-test P ( ≥ 18/ Negative) Males Stage G & above 41.4% 76.3% 2.9% Stage G1 & above 41.4% 76.4% 4.9% Stage H 41.4% 80.0% 11.1% Females Stage G & above 39.0% 74.9% 6.5% Stage G1 & above 39.0% 77.6% 7.9% Stage H 39.0% 85.2% 15.5% 4. Discussion A ten-stage scoring system was originally proposed to achieve greater resolution in characterising late root development as teeth approach apex closure [ 15 ]. Although Demirjian et al. did not define intermediate stages such as F1 and G1 within the permanent molar classification [ 6 ], subsequent authors have suggested that these additional stages may be particularly informative for assessing third-molar maturation [ 15 ]. The present study provides a direct forensic evaluation of this proposition by comparing the refined G1 stage with the conventional G and H stages for determining attainment of 18 years. Our findings demonstrate that, while the refined G1 stage offers modest gains in specificity and post-test probability, particularly among females, its overall diagnostic performance was broadly comparable to that of stage G and inferior to that of stage H in confirmatory contexts. In the present study, we found that the conventional Demirjian stages showed the highest kappa scores for both intra- and inter-examiner readings for mandibular third molars. However, the inter-examiner agreement was moderate overall when the refined Demirjian stages were applied, with the greatest variability observed for the G1 stage. This finding is consistent with previous reports highlighting the interpretative challenges associated with intermediate root sub-stages. Dhanjal et al. reported particular difficulty in distinguishing stages F1 and G1 from adjacent conventional stages, noting that observers often found the unmodified Demirjian stages (F, G, and H) easier to apply consistently, with higher reproducibility [ 4 ]. Similar findings were reported by De Salvia et al., who observed that identification of F1 and G1 introduced additional observer-related uncertainty and did not improve diagnostic accuracy, leading the authors to favour the original eight-stage system [ 19 ]. The moderate inter-examiner agreement observed for G1 in the present study likely reflects the subtle morphological criteria that define this transitional stage, namely, parallel root walls with incomplete apical closure and residual periodontal ligament space, which may be variably perceived depending on image quality and observer experience. Importantly, agreement for the conventional late stages G and H remained excellent, reinforcing their robustness and reproducibility in forensic casework. These findings underscore the importance of structured calibration and targeted training in stage assessment to minimise intra- and inter-observer variability, particularly when refined staging systems are applied [ 20 ]. Examiner experience, clarity of stage definitions, and the number of developmental categories employed are all critical determinants of reproducibility and should be carefully considered when implementing modified staging systems in medico-legal age estimation. These observations are further supported by the South African study by Uys et al., which evaluated the modified Demirjian approach incorporating G1 and reported that the greatest inter-observer disagreement occurred at the G–G1 transition [ 21 ]. In our data, the refined G1 cut-off provided diagnostic discrimination comparable to stage G (AUC ≈ 0.86–0.89 across sexes), yet reproducibility for G1 remained lower than for stages G and H. Taken together, these findings suggest that while stage G1 provides finer developmental resolution and supports probabilistic inference near the 18-year threshold, its potential benefit is offset by limitations in reproducibility between examiners. In forensic age estimation, minimising misclassification errors at the legal age threshold is critically important, as false positives carry ethical consequences. In contrast, false negatives may affect legal responsibility [ 22 , 23 ]. In the present study, false-positive classifications, in which individuals younger than 18 years were assigned to advanced stages, were predominantly observed at stages G and G1, reflecting the well-recognised overlap between late root development and chronological age in this period. False-negative classifications, in contrast, were more frequently associated with individuals aged ≥ 18 years who had not yet reached apical closure, particularly when earlier cut-offs were applied. Similar findings have been reported in an Indian study. Acharya reported that conventional third-molar staging correctly classified individuals as < 18 or ≥ 18 years in approximately 73.2% of test subjects, with a higher rate of correct juvenile classification (85.7%) than adult classification (60%), indicating a substantial proportion of adults were misclassified as juveniles or vice versa [ 24 ]. These findings collectively underscore that misclassification around the age of majority is an inherent feature of age estimation methods, influenced largely by biological variability rather than methodological error, and that although third-molar development remains a valuable indicator, staging-based classifications near critical legal thresholds must be interpreted with caution in forensic contexts. The key strength of the present study is the direct comparison between conventional Demirjian stages (G and H) and the refined G1 stage, addressing an important evidence gap in the literature. Also, the diagnostic accuracy framework in this study, which goes beyond descriptive age–stage associations, allows direct translation of the findings into probabilistic statements relevant for medico-legal decision-making at the 18-year threshold. Several limitations should be acknowledged. Firstly, the study was retrospective and based on OPGs obtained originally for clinical purposes, which may have introduced variability in image quality and positioning. Second, despite structured scoring protocols, inter-examiner agreement for the refined G1 stage was only moderate, underscoring the inherent difficulty in consistently identifying this transitional stage and limiting its routine forensic applicability without extensive calibration and training. Third, the study relied on mandibular third-molar development alone, and the inclusion of maxillary third molars or multimodal age indicators may have improved overall diagnostic performance. Lastly, while post-test probabilities provide valuable probabilistic insight, they depend on the pre-test probability of adulthood in the study sample, and should therefore be applied cautiously when extrapolating to populations with different age distributions. 5. Conclusion This study evaluated the forensic usefulness of conventional and refined third-molar maturation stages for determining attainment of 18 years in a South Indian population. Third-molar maturation showed a strong ability to distinguish individuals at the 18-year threshold in both sexes, with diagnostic characteristics varying by developmental stage. The conventional Demirjian stages G and H showed high diagnostic performance and excellent reproducibility, supporting their continued use in medico-legal age assessment. The refined G1 stage provided finer developmental resolution and yielded diagnostic performance comparable to stage G, with modest gains in specificity and post-test probability in females; however, these potential benefits were constrained by reduced inter-examiner agreement. Collectively, the findings indicate that while refined staging may enhance probabilistic interpretation of late root development, its routine forensic application should be approached with caution unless supported by rigorous calibration and training. Conventional late-stage Demirjian cut-offs remain the most reliable indicators for assessing attainment of 18 years of age. Declarations ORCID ID 0000-0003-0977-3889 Concise and Informative title Sex-Specific accuracy of Demirjian’s third molar Stages G, G1, and H for 18-year age estimation Compliance with Ethical standards: Yes Conflict of Interest: None Ethics Approval: Obtained Research involving human participants, their data, or biological material Radiographs were collected retrospectively from the archives. Human Ethics and Consent to Participate declarations Not applicable. Methodology Sudheer Babu Balla, Naga Madhuri Nagarakanti Formal Analysis and Investigation Subramanyeswara Swamy Chinni, Waheeda Shanaz, Manasa Bojji Writing- Original draft preparation Naga Madhuri Nagarakanti, Waheeda Shanaz, Manasa Bojji Writing- Review and Editing Subramanyeswara Swamy Chinni, Sudheer Babu Balla Supervision Venkat Baghirath Pacha, Sudheer Babu Balla Funding: None Author Contribution Conceptualisation: Sudheer Babu Balla,Formal Analysis and Investigation: Subramanyeswara Swamy Chinni, Waheeda Shanaz, Manasa BojjiWriting- Original draft preparation: Naga Madhuri Nagarakanti, Waheeda Shanaz, Manasa BojjiWriting- Review and Editing: Subramanyeswara Swamy Chinni, Sudheer Babu BallaSupervision: Venkat Baghirath Pacha, Sudheer Babu Balla References Lee SS, Byun YS, Park MJ, Choi JH, Yoon CL, Shin KJ (2010) The chronology of second and third molar development in Koreans and its application to forensic age estimation. Int J Legal Med 124(6):659–665. 10.1007/s00414-010-0513-x Epub 2010 Sep 10. PMID: 20830590 Oh S, Kumagai A, Kim SY, Lee SS (2022) Accuracy of age estimation and assessment of the 18-year threshold based on second and third molar maturity in Koreans and Japanese. PLoS ONE 17(7):e0271247. 10.1371/journal.pone.0271247 PMID: 35802665; PMCID: PMC9269881 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 – 90. 10.1002/ajpa.21258 . PMID: 20310064 Dhanjal KS, Bhardwaj MK, Liversidge HM (2006) Reproducibility of radiographic stage assessment of third molars. Forensic Sci Int. ;159 Suppl 1:S74-7. 10.1016/j.forsciint.2006.02.020 . Epub 2006 Mar 10. PMID: 16530998 Mincer HH, Harris EF, Berryman HE (1993) The A.B.F.O. study of third molar development and its use as an estimator of chronological age. J Forensic Sci. ;38(2):379 – 90. Erratum in: J Forensic Sci 1993;38(6):1524. PMID: 8454998 Demirjian A, Goldstein H, Tanner JM (1973) A new system of dental age assessment. Hum Biol 45(2):211–227 PMID: 4714564 Caggiano M, Scelza G, Amato A, Orefice R, Belli S, Pagano S, Valenti C, Martina S (2022) Estimating the 18-Year Threshold with Third Molars Radiographs in the Southern Italy Population: Accuracy and Reproducibility of Demirjian Method. Int J Environ Res Public Health 19(16):10454. 10.3390/ijerph191610454 PMID: 36012087; PMCID: PMC9408143 Devi A, Keshena JR, Vidyahayati IL, Skripsa TH, Prabowo YB, Merdietio Boedi R (2025) Third molar assessment for legal age determination in Indonesian juveniles using Demirjian method. Morphologie 109(365):100951. 10.1016/j.morpho.2025.100951 Epub 2025 Jan 18. PMID: 39827766 Acharya AB (2011) Accuracy of predicting 18 years of age from mandibular third molar development in an Indian sample using Demirjian's ten-stage criteria. Int J Legal Med 125(2):227–233. 10.1007/s00414-010-0522-9 Epub 2010 Oct 15. PMID: 20949276 Klingberg G, Benchimol D, Berlin H, Bring J, Gornitzki C, Odeberg J, Tranæus S, Twetman S, Wernersson E, Östlund P, Domeij H (2023) How old are you? A systematic review investigating the relationship between age and mandibular third molar maturity. PLoS ONE 18(5):e0285252. 10.1371/journal.pone.0285252 PMID: 37200251; PMCID: PMC10194975 Liversidge HM, Marsden PH (2010) Estimating age and the likelihood of having attained 18 years of age using mandibular third molars. Br Dent J 209(8):E13. 10.1038/sj.bdj.2010.976 Epub 2010 Oct 15. PMID: 20953166 Lewis JM, Senn DR (2010) Dental age estimation utilizing third molar development: A review of principles, methods, and population studies used in the United States. Forensic Sci Int 201(1–3):79–83 Epub 2010 May 20. PMID: 20493649 AlOtaibi NN, Aldawood FA, AlQahtani SJ (2023) Accuracy of dental age estimations based on individual teeth and staging system comparisons. J Forensic Odontostomatol 41(3):13–25 PMID: 38183969; PMCID: PMC10859074 Thorson J, Hägg U (1991) The accuracy and precision of the third mandibular molar as an indicator of chronological age. Swed Dent J 15(1):15–22 PMID: 2035147 Solari AC, Abramovitch K (2002) The accuracy and precision of third molar development as an indicator of chronological age in Hispanics. J Forensic Sci. ;47(3):531-5. PMID: 12051331 Balla SB, Galic I, Vanin PK, De Luca S, Cameriere S (2017) R. Validation of third molar maturity index (I 3M ) for discrimination of juvenile/adult status in South Indian population. J Forensic Leg Med. ;49:2–7. doi: 10.1016/j.jflm.2017.05.003. Epub 2017 May 3. PMID: 28482246 Pyata JR, Kandukuri BA, Gangavarapu U, Anjum B, Chinnala B, Bojji M, Gurram A, Balla SB (2021) Accuracy of four dental age estimation methods in determining the legal age threshold of 18 years among South Indian adolescents and young. J Forensic Odontostomatol 39(3):2–15 PMID: 34999575; PMCID: PMC9343060 World Medical Association (2025) World Medical Association Declaration of Helsinki: ethical principles for medical research involving human participants. JAMA 333(1):71–74. https://doi.org/10.1001/jama.2024.21972 De Salvia A, Calzetta C, Orrico M, De Leo D (2004) Third mandibular molar radiological development as an indicator of chronological age in a European population. Forensic Sci Int. ;146 Suppl:S9-S12. 10.1016/j.forsciint.2004.09.021 . PMID: 15639599 Kullman L, Tronje G, Teivens A, Lundholm A (1996) Methods of reducing observer variation in age estimation from panoramic radiographs. Dentomaxillofac Radiol. ;25(4):173-8. 10.1259/dmfr.25.4.9084269 . PMID: 9084269 Uys A, Bernitz H, Pretorius S, Steyn M (2018) Estimating age and the probability of being at least 18 years of age using third molars: a comparison between Black and White individuals living in South Africa. Int J Legal Med 132(5):1437–1446. 10.1007/s00414-018-1877-6 Epub 2018 Jun 9. PMID: 29948162 Martin-de las Heras S, García-Fortea P, Ortega A, Zodocovich S, Valenzuela A (2008) Third molar development according to chronological age in populations from Spanish and Magrebian origin. Forensic Sci Int 174(1):47–53. 10.1016/j.forsciint.2007.03.009 Epub 2007 Apr 24. PMID: 17459627 De Luca S, Biagi R, Begnoni G, Farronato G, Cingolani M, Merelli V, Ferrante L, Cameriere R (2014) Accuracy of Cameriere's cut-off value for third molar in assessing 18 years of age. Forensic Sci Int. ;235:102.e1-6. doi: 10.1016/j.forsciint.2013.10.036. Epub 2013 Nov 25. PMID: 24365729 Acharya AB (2011) Accuracy of predicting 18 years of age from mandibular third molar development in an Indian sample using Demirjian's ten-stage criteria. Int J Legal Med 125(2):227–233. 10.1007/s00414-010-0522-9 Epub 2010 Oct 15. PMID: 20949276 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9318331","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":626903266,"identity":"791cff98-fafb-4ea6-8323-a13f498ed615","order_by":0,"name":"Sudheer Babu Balla","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYFACHgaGBwUMcnwgNmMDiEwgQkuCAYMxGwMziVoS24jWIt/Ae/BDgoFdehv7+WMfPu6wYeBnzzFg+NmGW4vBAb5kiQSD5Nw2nmTmmTPPpDFI9rwxYOzFp4WBxwCohTm3jSGZmZm37TCDwQ2gLbx4tMg38Bj/SDCoT2fjfwzS8p/BHqiF8S8eLQwHeMyAthxOYJMA23KAwUAix4AZny0Gh/nSLBIMjhu2STw2Zpx5JplH4syzgsMy5/A4rL338I0PFdXy/PyJjxk+7rCT429P3vjwTRkehzGj8XnArsWjYRSMglEwCkYBEQAAOb5HDGQ0Y+UAAAAASUVORK5CYII=","orcid":"","institution":"La Trobe University","correspondingAuthor":true,"prefix":"","firstName":"Sudheer","middleName":"Babu","lastName":"Balla","suffix":""},{"id":626903267,"identity":"43d39cc2-830c-4231-94eb-a8066eeb4ecc","order_by":1,"name":"Naga Madhuri Nagarakanti","email":"","orcid":"","institution":"Government Medical College","correspondingAuthor":false,"prefix":"","firstName":"Naga","middleName":"Madhuri","lastName":"Nagarakanti","suffix":""},{"id":626903268,"identity":"41136070-3458-42a3-8aa7-50e80497c4ef","order_by":2,"name":"Subramanyeswara Swamy Chinni","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Subramanyeswara","middleName":"Swamy","lastName":"Chinni","suffix":""},{"id":626903270,"identity":"60909e60-d696-4c6a-a755-9a9466232444","order_by":3,"name":"Waheeda Shahnaz","email":"","orcid":"","institution":"SVS Institute of Dental Sciences","correspondingAuthor":false,"prefix":"","firstName":"Waheeda","middleName":"","lastName":"Shahnaz","suffix":""},{"id":626903271,"identity":"22491b07-988e-403a-95f5-a09d713c0069","order_by":4,"name":"Manasa Bojji","email":"","orcid":"","institution":"Malla Reddy Dental College for Women","correspondingAuthor":false,"prefix":"","firstName":"Manasa","middleName":"","lastName":"Bojji","suffix":""},{"id":626903272,"identity":"079fe322-286c-4d24-8c2a-ad79700738f0","order_by":5,"name":"Venkat Baghirath Pacha","email":"","orcid":"","institution":"Panineeya Institute of Dental Sciences \u0026 Research Center","correspondingAuthor":false,"prefix":"","firstName":"Venkat","middleName":"Baghirath","lastName":"Pacha","suffix":""}],"badges":[],"createdAt":"2026-04-04 07:08:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9318331/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9318331/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107886819,"identity":"a51ae181-9f2e-49d4-bd99-710a49489cd7","added_by":"auto","created_at":"2026-04-27 09:31:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":456107,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDemirjian third molar development staging F-H as modified by Solari et al [15].\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9318331/v1/ac3908e4450c392fb5366158.png"},{"id":108006228,"identity":"1fe41ca1-d0ee-45cc-94f4-47ad9ab463dc","added_by":"auto","created_at":"2026-04-28 12:54:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":901604,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9318331/v1/394d957d-00cb-4c4f-8e5d-bbb12214bc9f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Diagnostic performance of Demirjian’s third molar maturation stages G, G1, and H for identifying the 18-year age threshold: a sex-specific study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eIn forensic dental age estimation of living individuals, assessment during late adolescence and early adulthood remains particularly challenging. At this stage, the majority of dental development has already been completed, while age-related regressive changes have not yet commenced, resulting in a narrow biological window with limited age-informative markers [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Consequently, chronological age estimation in adolescents and young adults is associated with greater uncertainty than in earlier childhood or later adulthood. Within this age range, the third molars are of particular forensic relevance, as they are typically the only teeth still undergoing development, with formation extending into the mid-twenties [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. For this reason, third-molar development is widely used in dental age estimation, especially to assess whether an individual has attained the legally significant age threshold of 18 years. The accuracy of such estimations depends not only on the method used to translate dental development into age but also on the precision with which developmental stages are identified and classified [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAgainst this background, third-molar-based dental age estimation has been extensively investigated. Mincer et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] evaluated third-molar development in American Caucasians using the staging system proposed by Demirjian et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], establishing a foundation for subsequent forensic applications. Since then, numerous studies have applied Demirjian\u0026rsquo;s third-molar developmental stages, particularly the late root stages, to support binary classification of individuals as younger or older than 18 years [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In addition, probability-based approaches using mandibular third-molar root development have been proposed to quantify the likelihood that an individual has attained 18 years of age, highlighting the practical utility of stage-based inference in forensic casework [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, a recognised limitation of the original Demirjian A\u0026ndash;H system is that developmental transitions occurring near apexification are subsumed within relatively broad stages, potentially limiting discriminatory power precisely at age ranges where legal decisions are most sensitive [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBuilding on these applications, it has been suggested that staging systems with fewer developmental categories have been regarded as easier to apply because each stage encompasses a broader interval of tooth development. However, such broad stages span wide chronological age ranges and may therefore provide limited discriminatory power at legally relevant thresholds [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In contrast, staging systems that incorporate additional intermediate categories aim to capture finer developmental transitions over shorter time spans, potentially improving alignment with chronological age during late adolescence [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The refined root stages proposed by Solari and Abramovitch were introduced on this basis to enhance age discrimination near apexification [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Despite this rationale, the extent to which these additional stages improve diagnostic performance for determining attainment of 18 years has not been adequately established. Accordingly, the present study aimed to evaluate and compare the sex-specific diagnostic performance of conventional and refined third-molar maturation cut-offs, specifically stages G, G1, and H, for identifying individuals aged 18 years or older. By examining sensitivity, specificity, likelihood ratios, and post-test probabilities, this study sought to determine whether the inclusion of refined root stages improves the evidential reliability of dental age estimation in late adolescence.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study sample\u003c/h2\u003e \u003cp\u003ePanoramic radiographs (orthopantomograms; OPGs) of 599 individuals with known chronological age and sex were retrospectively obtained from orthodontic clinics. The sample comprised adolescents and young adults of South Indian origin, aged between 14.0 and 21.99 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Chronological age was calculated to two decimal places as the difference between the date of birth and the date of radiographic exposure. For analytical purposes, individuals were grouped into one-year age categories (e.g., 14.0\u0026ndash;14.99 years, 15.0\u0026ndash;15.99 years, and so forth). Radiographs were excluded if they demonstrated severe dental caries affecting the third molars, previous endodontic treatment, pathological lesions involving the jaws, congenitally absent third molars, or insufficient image quality for reliable assessment. In addition, individuals with a reported history of endocrine disorders were excluded due to the potential influence on dental development.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAge and sex distribution of the total sample n(%).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMales\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemales\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e14- 14.99\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (13.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e15- 15.99\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (13.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e16- 16.99\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e17- 17.99\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (11.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e18- 18.99\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (12.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e19- 19.99\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (12.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (12.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e20- 20.99\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (15.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e21- 21.99\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (9.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e280 (100)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e319 (100)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe present study utilised OPGs derived from an existing anonymised dataset previously analysed and reported in earlier research [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. No additional radiographic acquisition or data collection was undertaken. All images were fully anonymised before analysis. For each case, chronological age, sex, and third-molar developmental stage were recorded against a unique identification number (UIN). Examiners were blinded to all personal and demographic information throughout the assessment process to minimise examiner bias. This study utilised OPGs from an existing anonymised database that had been previously analysed and reported in earlier research for which ethical clearance was obtained from the institutional ethics committee (PMVIDS\u0026amp;RC/IEC/OMFP/PR/0261\u0026thinsp;\u0026minus;\u0026thinsp;18). No additional data collection was undertaken for the present investigation. This study was conducted in accordance with the ethical standards established by the Declaration of Helsinki (Finland) and its subsequent amendments [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Radiographic assessment and Staging procedure\u003c/h2\u003e \u003cp\u003eThe maturation of the mandibular left third molar was initially assessed using the conventional Demirjian eight-stage classification (A\u0026ndash;H) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Following a one-month washout period to minimise recall bias, the same panoramic radiographs were re-evaluated using the Solari and Abramovitch modification of the Demirjian system [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which incorporates two additional intermediate root stages (F1 and G1). Stage F1 is characterised by a root length approximately twice the crown length, with apices that remain funnel-shaped. Stage G1 is defined by parallel root walls with incompletely closed apices and a periodontal ligament space at the apex exceeding 1.0 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe first author performed all radiographic assessments. Intra-examiner reliability was evaluated by re-scoring a randomly selected 10% subsample of the radiographs (n\u0026thinsp;=\u0026thinsp;60) after a two-week interval. Inter-examiner reliability was assessed by the second author, who independently evaluated the same subsample. Both examiners applied the conventional Demirjian staging system and the Solari and Abramovitch modification during reliability testing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Statistical analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed using IBM SPSS Statistics (Version 29.0; IBM Corp., Armonk, NY, USA). Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Third-molar maturation served as the index test and was evaluated using three sequential cut-off criteria: stage G and above (\u0026ge;\u0026thinsp;G), refined stage G1 and above (\u0026ge;\u0026thinsp;G1), and stage H (complete apical closure). Each cut-off was treated as a binary diagnostic test, with stages at or beyond the cut-off classified as test-positive and earlier stages as test-negative. All analyses were conducted separately for males and females to account for potential sexual dimorphism in third molar maturation.\u003c/p\u003e \u003cp\u003eFor each sex and each cut-off stage, 2\u0026times;2 contingency tables were constructed to cross-classify third-molar stage (test positive vs negative) against chronological age status (\u0026ge;\u0026thinsp;18 vs\u0026thinsp;\u0026lt;\u0026thinsp;18 years). These tables yielded counts of true positives (TP), false positives (FP), true negatives (TN), and false negatives (FN). The association between third-molar stage and age status was assessed using the Pearson chi-square test. Odds ratios (ORs) were calculated to quantify the strength of association between attainment of the specified third-molar stage and the likelihood of being \u0026ge;\u0026thinsp;18 years. For each cut-off stage (\u0026ge;\u0026thinsp;G, \u0026ge;G1, and H), and separately for males and females, the following diagnostic accuracy measures were calculated: sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and likelihood ratios (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of diagnostic measures and their interpretation in the context of third-molar maturation for identifying attainment of 18 years\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnostic measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription/ Calculation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhat it represents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInterpretation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTrue positive (TP)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndividuals aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years correctly classified as \u0026ge;\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorrect identification of legally adult individuals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigher TP values indicate a better ability to detect individuals who have attained 18 years.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFalse Positive (FP)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndividuals\u0026thinsp;\u0026lt;\u0026thinsp;18 years incorrectly classified as \u0026ge;\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eErroneous classification of minors as adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRepresents over-aging with significant ethical and legal implications.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTrue Negative (TN)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndividuals\u0026thinsp;\u0026lt;\u0026thinsp;18 years correctly classified as \u0026lt;\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorrect identification of minors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMinimises the risk of assigning adult status to under-18 individuals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFalse Negative (FN)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndividuals aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years incorrectly classified as \u0026lt;\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFailure to detect legal adulthood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeads to conservative classification, generally considered safer in forensic contexts\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSensitivity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTP/ (TP\u0026thinsp;+\u0026thinsp;FN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProbability that individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years are correctly identified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh sensitivity reduces the likelihood of misclassifying adults as minors\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpecificity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTN/ (TN\u0026thinsp;+\u0026thinsp;FP)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProbability that individuals\u0026thinsp;\u0026lt;\u0026thinsp;18 years are correctly excluded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh specificity limits false classification of minors as adults\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePositive Predictive Value (PPV)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTP/ (TP\u0026thinsp;+\u0026thinsp;FP)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProbability that an individual classified as \u0026ge;\u0026thinsp;18 (e.g. \u0026ge;G/\u0026ge;G1/H) is truly\u0026thinsp;\u0026ge;\u0026thinsp;18 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProvides case-level evidential support for concluding attainment of 18 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNegative Predictive Value (NPV)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTN/ (TN\u0026thinsp;+\u0026thinsp;FN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProbability that an individual classified as \u0026lt;\u0026thinsp;18 (e.g. \u0026lt;G/\u0026lt;G1/\u0026lt;H) is truly\u0026thinsp;\u0026lt;\u0026thinsp;18 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIndicates the reliability of the method in excluding legal adulthood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAccuracy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(TP\u0026thinsp;+\u0026thinsp;TN) / Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOverall correct classification rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSummarises the combined discriminative performance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOdds Ratio (OR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(TP \u0026times; TN)/(FP \u0026times; FN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrength of association between tooth stage and \u0026ge;\u0026thinsp;18 status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQuantifies the evidential strength of the staging criterion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLikelihood Ratio Positive (LR+)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSens / (1- Spec)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDegree to which the odds of being \u0026ge;\u0026thinsp;18 increase following a positive test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eValues\u0026thinsp;\u0026gt;\u0026thinsp;10 indicate strong support for adult classification\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLikelihood Ratio Negative (LR\u0026ndash;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1- Sens)/Spec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDegree to which the odds of being \u0026ge;\u0026thinsp;18 decrease following a negative test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLower values indicate stronger evidence against the attainment of 18 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-test Probability (Positive)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[Pre-odds \u0026times; LR+] / [1 + (Pre-odds \u0026times; LR+)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProbability of being \u0026ge;\u0026thinsp;18 years given a positive stage (e.g. \u0026ge;G/\u0026ge;G1/H)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReflects the evidential probability of adulthood after observing advanced third-molar maturation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-test Probability (Negative)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[Pre-odds \u0026times; LR\u0026ndash;] / [1 + (Pre-odds \u0026times; LR\u0026ndash;)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProbability of being \u0026ge;\u0026thinsp;18 years given a negative stage (e.g. \u0026lt;G/\u0026lt;G1/\u0026lt;H)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIndicates residual risk of adulthood despite an immature third-molar stage\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo discriminate between individuals aged\u0026thinsp;\u0026lt;\u0026thinsp;18 years and those who have attained 18 years, both pre-test and post-test probabilities of being \u0026ge;\u0026thinsp;18 years were estimated. The pre-test probability (P\u003csub\u003e0\u003c/sub\u003e) represents the likelihood that an individual in a given population is 18 years or older before application of the diagnostic test, reflecting the underlying age distribution of the sample. In contrast, the post-test probability (PTP) is the probability that an individual is 18 years of age, given the result of the diagnostic test. Sex-specific pre-test probabilities were derived from the observed prevalence of individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years in the study sample (41.4% for males and 39.0% for females). Post-test probabilities were then calculated using Bayes\u0026rsquo; theorem for each third-molar cut-off stage (G, G1, and H), separately for males and females. These estimates quantify the probability that an individual has reached 18 years of age given the observed third-molar maturation stage.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e Intra- and inter-examiner agreement for Demirjian\u0026rsquo;s stages of third-molar development was assessed using Cohen\u0026rsquo;s kappa (κ) statistics. Overall, intra-examiner agreement was substantial (κ\u0026thinsp;=\u0026thinsp;0.912), indicating good consistency in repeated assessments by the same examiner. In contrast, overall inter-examiner agreement was lower, falling within the moderate agreement range (κ\u0026thinsp;=\u0026thinsp;0.731), suggesting greater variability between observers when applying the staging criteria.\u003c/p\u003e \u003cp\u003eStage-specific analysis revealed marked differences in reproducibility. Inter-examiner agreement was excellent for stages G (κ\u0026thinsp;=\u0026thinsp;0.946) and H (κ\u0026thinsp;=\u0026thinsp;0.967), reflecting high consistency in identifying advanced root development and complete apical closure. However, agreement on the modified stage G1 was poor (κ\u0026thinsp;=\u0026thinsp;0.721), indicating difficulty in consistently distinguishing this transitional stage across examiners.\u003c/p\u003e \u003cp\u003eTables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e to \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e show the cross-tabulation of third molar maturation stages and chronological age status. They demonstrated a strong association between third-molar maturation stage and chronological age status in both sexes for all evaluated cut-off stages (G, G1, and H). For males, the proportion of individuals classified as \u0026ge;\u0026thinsp;18 years increased progressively with advancing third-molar development, with the highest number of true positives observed at stage G and the fewest false positives observed at stage H. A similar trend was observed in females, with a higher proportion of advanced stages below 18 years at earlier cut-offs, consistent with earlier maturation patterns.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiagnostic cross-tabulation of conventional Demirjian stage G against chronological age status (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;18 years vs\u0026thinsp;\u0026lt;\u0026thinsp;18 years) in both sexes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;18years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;18 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eMales\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage G \u0026amp; above\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(positive)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116\u003csup\u003eTP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003csup\u003eFP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStages A to F\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(negative)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e04\u003csup\u003eFN\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e126\u003csup\u003eTN\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e280\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemales\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage G \u0026amp; above\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(positive)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e146\u003csup\u003eTP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003csup\u003eFP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStages A to F\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(negative)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003csup\u003eFN\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e128\u003csup\u003eTN\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e319\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eTP: True positives; FP: False positives; TN: True Negatives; FN: False Negatives\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiagnostic cross-tabulation of modified Demirjian stage G1 against chronological age status (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;18 years vs\u0026thinsp;\u0026lt;\u0026thinsp;18 years) in both sexes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;18years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;18 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eMales\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage G1 \u0026amp; above\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(positive)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113\u003csup\u003eTP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003csup\u003eFP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e146\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStages A to G\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(negative)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e07\u003csup\u003eFN\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e127\u003csup\u003eTN\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e280\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemales\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage G1 \u0026amp; above\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(positive)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142\u003csup\u003eTP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003csup\u003eFP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e168\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStages A to G\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(negative)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003csup\u003eFN\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e133\u003csup\u003eTN\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e319\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eTP: True positives; FP: False positives; TN: True Negatives; FN: False Negatives\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiagnostic cross-tabulation of conventional Demirjian stage H against chronological age status (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;18 years vs\u0026thinsp;\u0026lt;\u0026thinsp;18 years) in both sexes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;18years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;18 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eMales\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage H\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(positive)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102\u003csup\u003eTP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003csup\u003eFP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStages A to G\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(negative)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003csup\u003eFN\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e136\u003csup\u003eTN\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e280\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemales\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage H\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(positive)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118\u003csup\u003eTP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003csup\u003eFP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStages A to G\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(negative)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003csup\u003eFN\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e146\u003csup\u003eTN\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e188\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e319\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eTP: True positives; FP: False positives; TN: True Negatives; FN: False Negatives\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSex-specific diagnostic accuracy measures for stages G, G1, and H are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e. Sex-stratified diagnostic accuracy measures for stages G, G1, and H are summarised in Table X. In males, stage G demonstrated the highest sensitivity (96.7%), indicating excellent ability to identify individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years, while stage H showed a more balanced sensitivity and specificity (both 85.0%). Stage G1 provided intermediate performance, with a sensitivity of 94.2% and a specificity of 79.4%. Negative predictive values were highest for stage G and G1, reflecting strong exclusion of adulthood when these stages had not been reached.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSex-specific diagnostic performance of third-molar maturation cutoffs (G, G1, and H) for identifying individuals aged\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;18 years\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCut-off (Positive test)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSensitivity % (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecificity % (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePPV\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNPV\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAccuracy (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLR+\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLR-\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOdds Ratio (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003eMales (n\u0026thinsp;=\u0026thinsp;280)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage G \u0026amp; above\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96.7\u003c/p\u003e \u003cp\u003e(92.1\u0026ndash;98.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.8\u003c/p\u003e \u003cp\u003e(72.0\u0026ndash;84.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.3\u003c/p\u003e \u003cp\u003e(70.0\u0026ndash;83.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96.9\u003c/p\u003e \u003cp\u003e(92.7\u0026ndash;98.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e86.4\u003c/p\u003e \u003cp\u003e(81.8\u0026ndash;90.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.55\u003c/p\u003e \u003cp\u003e(3.37\u0026ndash;6.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003cp\u003e(0.02\u0026ndash;0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e107.6\u003c/p\u003e \u003cp\u003e(35.1\u0026ndash;329.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage G1 \u0026amp; above\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94.2\u003c/p\u003e \u003cp\u003e(88.3\u0026ndash;97.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.4\u003c/p\u003e \u003cp\u003e(72.5\u0026ndash;85.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.4\u003c/p\u003e \u003cp\u003e(70.1\u0026ndash;83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e94.8\u003c/p\u003e \u003cp\u003e(90.1\u0026ndash;97.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e86.0\u003c/p\u003e \u003cp\u003e(81.4\u0026ndash;89.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.57\u003c/p\u003e \u003cp\u003e(3.32\u0026ndash;6.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003cp\u003e(0.03\u0026ndash;0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e62.2\u003c/p\u003e \u003cp\u003e(24.7\u0026ndash;156.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage H\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003cp\u003e(77.5\u0026ndash;90.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003cp\u003e(78.4\u0026ndash;90.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81.0\u003c/p\u003e \u003cp\u003e(72.8\u0026ndash;87.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88.3\u003c/p\u003e \u003cp\u003e(82.3\u0026ndash;92.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003cp\u003e(80.5\u0026ndash;88.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.67\u003c/p\u003e \u003cp\u003e(3.87\u0026ndash;8.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003cp\u003e(0.11\u0026ndash;0.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e32.2\u003c/p\u003e \u003cp\u003e(15.8\u0026ndash;65.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemales (n\u0026thinsp;=\u0026thinsp;319)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage G \u0026amp; above\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91.3\u003c/p\u003e \u003cp\u003e(86.0\u0026ndash;94.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.5\u003c/p\u003e \u003cp\u003e(73.6\u0026ndash;86.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.5\u003c/p\u003e \u003cp\u003e(76.4\u0026ndash;87.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e90.1\u003c/p\u003e \u003cp\u003e(84.6\u0026ndash;93.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85.9\u003c/p\u003e \u003cp\u003e(81.5\u0026ndash;89.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.68\u003c/p\u003e \u003cp\u003e(3.40\u0026ndash;6.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003cp\u003e(0.07\u0026ndash;0.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e43.0\u003c/p\u003e \u003cp\u003e(20.0\u0026ndash;92.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage G1 \u0026amp; above\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.7\u003c/p\u003e \u003cp\u003e(82.7\u0026ndash;92.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.7\u003c/p\u003e \u003cp\u003e(77.0\u0026ndash;88.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84.6\u003c/p\u003e \u003cp\u003e(78.4\u0026ndash;89.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88.1\u003c/p\u003e \u003cp\u003e(82.2\u0026ndash;92.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e86.2\u003c/p\u003e \u003cp\u003e(82.1\u0026ndash;89.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.45\u003c/p\u003e \u003cp\u003e(3.82\u0026ndash;7.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003cp\u003e(0.08\u0026ndash;0.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e40.3\u003c/p\u003e \u003cp\u003e(21.0\u0026ndash;77.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage H\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73.8\u003c/p\u003e \u003cp\u003e(66.3\u0026ndash;80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.8\u003c/p\u003e \u003cp\u003e(86.6\u0026ndash;95.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.1\u003c/p\u003e \u003cp\u003e(84.0\u0026ndash;94.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77.7\u003c/p\u003e \u003cp\u003e(71.1\u0026ndash;83.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e82.1\u003c/p\u003e \u003cp\u003e(77.6\u0026ndash;85.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.02\u003c/p\u003e \u003cp\u003e(5.54\u0026ndash;14.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003cp\u003e(0.21\u0026ndash;0.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e31.4\u003c/p\u003e \u003cp\u003e(15.8\u0026ndash;62.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn females, sensitivity decreased with advancing stage, from 91.3% at stage G to 73.8% at stage H. In contrast, specificity increased from 80.5% at stage G to 91.8% at stage H. Consequently, positive predictive value was highest at stage H in females (90.1%), indicating strong confirmatory value when apical closure was complete. Likelihood ratios supported these patterns: earlier cut-offs (G and G1) yielded moderate LR+ values (approximately 4 to 5), whereas stage H provided strong diagnostic evidence in females (LR\u0026thinsp;+\u0026thinsp;=\u0026thinsp;9.02). Overall, accuracy remained high across all cut-offs in both sexes (approximately 82\u0026ndash;86%).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e shows the sex-specific post-test probabilities, translating diagnostic performance into probabilistic events relevant for forensic interpretation. In males, a positive result at stages G and G1 increased the post-test probability of being \u0026ge;\u0026thinsp;18 years to approximately 76%, while a positive result at stage H increased this probability to 80%. In contrast, negative test results at stages G and G1 reduced the probability of being \u0026ge;\u0026thinsp;18 years to below 5% and stage H to 11%, indicating strong exclusion of adulthood when these stages had not been reached. In females, post-test probabilities following a positive test increased from 75% at stage G to 78% at stage G1. They exceeded 85% at stage H, reflecting the higher specificity of advanced maturation in females. Negative test results reduced the probability of being \u0026ge;\u0026thinsp;18 years to approximately 6\u0026ndash;8% for stages G and G1, and to 15.5% for stage H.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSex-specific post-test probabilities for \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;18 years (\u0026ge;\u0026thinsp;conventional Stage G vs conventional Stage H vs\u0026thinsp;\u0026ge;\u0026thinsp;modified Stage G1)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCut-off\u003c/p\u003e \u003cp\u003e(Positive test)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-test P (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;18)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost-test P (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;18/ Positive)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePost-test P (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;18/ Negative)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eMales\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage G \u0026amp; above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e76.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage G1 \u0026amp; above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e76.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage H\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e80.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eFemales\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage G \u0026amp; above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e74.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage G1 \u0026amp; above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e77.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage H\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e85.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eA ten-stage scoring system was originally proposed to achieve greater resolution in characterising late root development as teeth approach apex closure [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Although Demirjian et al. did not define intermediate stages such as F1 and G1 within the permanent molar classification [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], subsequent authors have suggested that these additional stages may be particularly informative for assessing third-molar maturation [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The present study provides a direct forensic evaluation of this proposition by comparing the refined G1 stage with the conventional G and H stages for determining attainment of 18 years. Our findings demonstrate that, while the refined G1 stage offers modest gains in specificity and post-test probability, particularly among females, its overall diagnostic performance was broadly comparable to that of stage G and inferior to that of stage H in confirmatory contexts.\u003c/p\u003e \u003cp\u003eIn the present study, we found that the conventional Demirjian stages showed the highest kappa scores for both intra- and inter-examiner readings for mandibular third molars. However, the inter-examiner agreement was moderate overall when the refined Demirjian stages were applied, with the greatest variability observed for the G1 stage. This finding is consistent with previous reports highlighting the interpretative challenges associated with intermediate root sub-stages. Dhanjal et al. reported particular difficulty in distinguishing stages F1 and G1 from adjacent conventional stages, noting that observers often found the unmodified Demirjian stages (F, G, and H) easier to apply consistently, with higher reproducibility [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Similar findings were reported by De Salvia et al., who observed that identification of F1 and G1 introduced additional observer-related uncertainty and did not improve diagnostic accuracy, leading the authors to favour the original eight-stage system [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The moderate inter-examiner agreement observed for G1 in the present study likely reflects the subtle morphological criteria that define this transitional stage, namely, parallel root walls with incomplete apical closure and residual periodontal ligament space, which may be variably perceived depending on image quality and observer experience. Importantly, agreement for the conventional late stages G and H remained excellent, reinforcing their robustness and reproducibility in forensic casework. These findings underscore the importance of structured calibration and targeted training in stage assessment to minimise intra- and inter-observer variability, particularly when refined staging systems are applied [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Examiner experience, clarity of stage definitions, and the number of developmental categories employed are all critical determinants of reproducibility and should be carefully considered when implementing modified staging systems in medico-legal age estimation.\u003c/p\u003e \u003cp\u003eThese observations are further supported by the South African study by Uys et al., which evaluated the modified Demirjian approach incorporating G1 and reported that the greatest inter-observer disagreement occurred at the G\u0026ndash;G1 transition [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In our data, the refined G1 cut-off provided diagnostic discrimination comparable to stage G (AUC\u0026thinsp;\u0026asymp;\u0026thinsp;0.86\u0026ndash;0.89 across sexes), yet reproducibility for G1 remained lower than for stages G and H. Taken together, these findings suggest that while stage G1 provides finer developmental resolution and supports probabilistic inference near the 18-year threshold, its potential benefit is offset by limitations in reproducibility between examiners.\u003c/p\u003e \u003cp\u003eIn forensic age estimation, minimising misclassification errors at the legal age threshold is critically important, as false positives carry ethical consequences. In contrast, false negatives may affect legal responsibility [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In the present study, false-positive classifications, in which individuals younger than 18 years were assigned to advanced stages, were predominantly observed at stages G and G1, reflecting the well-recognised overlap between late root development and chronological age in this period. False-negative classifications, in contrast, were more frequently associated with individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years who had not yet reached apical closure, particularly when earlier cut-offs were applied. Similar findings have been reported in an Indian study. Acharya reported that conventional third-molar staging correctly classified individuals as \u0026lt;\u0026thinsp;18 or \u0026ge;\u0026thinsp;18 years in approximately 73.2% of test subjects, with a higher rate of correct juvenile classification (85.7%) than adult classification (60%), indicating a substantial proportion of adults were misclassified as juveniles or vice versa [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. These findings collectively underscore that misclassification around the age of majority is an inherent feature of age estimation methods, influenced largely by biological variability rather than methodological error, and that although third-molar development remains a valuable indicator, staging-based classifications near critical legal thresholds must be interpreted with caution in forensic contexts.\u003c/p\u003e \u003cp\u003eThe key strength of the present study is the direct comparison between conventional Demirjian stages (G and H) and the refined G1 stage, addressing an important evidence gap in the literature. Also, the diagnostic accuracy framework in this study, which goes beyond descriptive age\u0026ndash;stage associations, allows direct translation of the findings into probabilistic statements relevant for medico-legal decision-making at the 18-year threshold. Several limitations should be acknowledged. Firstly, the study was retrospective and based on OPGs obtained originally for clinical purposes, which may have introduced variability in image quality and positioning. Second, despite structured scoring protocols, inter-examiner agreement for the refined G1 stage was only moderate, underscoring the inherent difficulty in consistently identifying this transitional stage and limiting its routine forensic applicability without extensive calibration and training. Third, the study relied on mandibular third-molar development alone, and the inclusion of maxillary third molars or multimodal age indicators may have improved overall diagnostic performance. Lastly, while post-test probabilities provide valuable probabilistic insight, they depend on the pre-test probability of adulthood in the study sample, and should therefore be applied cautiously when extrapolating to populations with different age distributions.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study evaluated the forensic usefulness of conventional and refined third-molar maturation stages for determining attainment of 18 years in a South Indian population. Third-molar maturation showed a strong ability to distinguish individuals at the 18-year threshold in both sexes, with diagnostic characteristics varying by developmental stage. The conventional Demirjian stages G and H showed high diagnostic performance and excellent reproducibility, supporting their continued use in medico-legal age assessment. The refined G1 stage provided finer developmental resolution and yielded diagnostic performance comparable to stage G, with modest gains in specificity and post-test probability in females; however, these potential benefits were constrained by reduced inter-examiner agreement. Collectively, the findings indicate that while refined staging may enhance probabilistic interpretation of late root development, its routine forensic application should be approached with caution unless supported by rigorous calibration and training. Conventional late-stage Demirjian cut-offs remain the most reliable indicators for assessing attainment of 18 years of age.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eORCID ID\u003c/h2\u003e\n\u003cp\u003e0000-0003-0977-3889\u003c/p\u003e\n\u003ch2\u003eConcise and Informative title\u003c/h2\u003e\n\u003cp\u003eSex-Specific accuracy of Demirjian\u0026rsquo;s third molar Stages G, G1, and H for 18-year age estimation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with Ethical standards:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003ch2\u003eConflict of Interest:\u003c/h2\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eObtained\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch involving human participants, their data, or biological material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRadiographs were collected retrospectively from the archives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eMethodology\u003c/h2\u003e\n\u003cp\u003eSudheer Babu Balla, Naga Madhuri Nagarakanti\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFormal Analysis and Investigation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSubramanyeswara Swamy Chinni, Waheeda Shanaz, Manasa Bojji\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWriting- Original draft preparation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNaga Madhuri Nagarakanti, Waheeda Shanaz, Manasa Bojji\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWriting- Review and Editing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSubramanyeswara Swamy Chinni, Sudheer Babu Balla\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupervision\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVenkat Baghirath Pacha, Sudheer Babu Balla\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eConceptualisation: Sudheer Babu Balla,Formal Analysis and Investigation: Subramanyeswara Swamy Chinni, Waheeda Shanaz, Manasa BojjiWriting- Original draft preparation: Naga Madhuri Nagarakanti, Waheeda Shanaz, Manasa BojjiWriting- Review and Editing: Subramanyeswara Swamy Chinni, Sudheer Babu BallaSupervision: Venkat Baghirath Pacha, Sudheer Babu Balla\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLee SS, Byun YS, Park MJ, Choi JH, Yoon CL, Shin KJ (2010) The chronology of second and third molar development in Koreans and its application to forensic age estimation. Int J Legal Med 124(6):659\u0026ndash;665. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00414-010-0513-x\u003c/span\u003e\u003cspan address=\"10.1007/s00414-010-0513-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2010 Sep 10. PMID: 20830590\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOh S, Kumagai A, Kim SY, Lee SS (2022) Accuracy of age estimation and assessment of the 18-year threshold based on second and third molar maturity in Koreans and Japanese. PLoS ONE 17(7):e0271247. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0271247\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0271247\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 35802665; PMCID: PMC9269881\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlQahtani SJ, Hector MP, Liversidge HM (2010) Brief communication: The London atlas of human tooth development and eruption. Am J Phys Anthropol. ;142(3):481\u0026thinsp;\u0026ndash;\u0026thinsp;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ajpa.21258\u003c/span\u003e\u003cspan address=\"10.1002/ajpa.21258\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 20310064\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDhanjal KS, Bhardwaj MK, Liversidge HM (2006) Reproducibility of radiographic stage assessment of third molars. Forensic Sci Int. ;159 Suppl 1:S74-7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.forsciint.2006.02.020\u003c/span\u003e\u003cspan address=\"10.1016/j.forsciint.2006.02.020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2006 Mar 10. PMID: 16530998\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMincer HH, Harris EF, Berryman HE (1993) The A.B.F.O. study of third molar development and its use as an estimator of chronological age. J Forensic Sci. ;38(2):379\u0026thinsp;\u0026ndash;\u0026thinsp;90. Erratum in: J Forensic Sci 1993;38(6):1524. PMID: 8454998\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemirjian A, Goldstein H, Tanner JM (1973) A new system of dental age assessment. Hum Biol 45(2):211\u0026ndash;227 PMID: 4714564\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaggiano M, Scelza G, Amato A, Orefice R, Belli S, Pagano S, Valenti C, Martina S (2022) Estimating the 18-Year Threshold with Third Molars Radiographs in the Southern Italy Population: Accuracy and Reproducibility of Demirjian Method. Int J Environ Res Public Health 19(16):10454. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijerph191610454\u003c/span\u003e\u003cspan address=\"10.3390/ijerph191610454\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 36012087; PMCID: PMC9408143\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDevi A, Keshena JR, Vidyahayati IL, Skripsa TH, Prabowo YB, Merdietio Boedi R (2025) Third molar assessment for legal age determination in Indonesian juveniles using Demirjian method. Morphologie 109(365):100951. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.morpho.2025.100951\u003c/span\u003e\u003cspan address=\"10.1016/j.morpho.2025.100951\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2025 Jan 18. PMID: 39827766\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAcharya AB (2011) Accuracy of predicting 18 years of age from mandibular third molar development in an Indian sample using Demirjian's ten-stage criteria. Int J Legal Med 125(2):227\u0026ndash;233. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00414-010-0522-9\u003c/span\u003e\u003cspan address=\"10.1007/s00414-010-0522-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2010 Oct 15. PMID: 20949276\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlingberg G, Benchimol D, Berlin H, Bring J, Gornitzki C, Odeberg J, Tran\u0026aelig;us S, Twetman S, Wernersson E, \u0026Ouml;stlund P, Domeij H (2023) How old are you? A systematic review investigating the relationship between age and mandibular third molar maturity. PLoS ONE 18(5):e0285252. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0285252\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0285252\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 37200251; PMCID: PMC10194975\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiversidge HM, Marsden PH (2010) Estimating age and the likelihood of having attained 18 years of age using mandibular third molars. Br Dent J 209(8):E13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/sj.bdj.2010.976\u003c/span\u003e\u003cspan address=\"10.1038/sj.bdj.2010.976\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2010 Oct 15. PMID: 20953166\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis JM, Senn DR (2010) Dental age estimation utilizing third molar development: A review of principles, methods, and population studies used in the United States. Forensic Sci Int 201(1\u0026ndash;3):79\u0026ndash;83 Epub 2010 May 20. PMID: 20493649\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlOtaibi NN, Aldawood FA, AlQahtani SJ (2023) Accuracy of dental age estimations based on individual teeth and staging system comparisons. J Forensic Odontostomatol 41(3):13\u0026ndash;25 PMID: 38183969; PMCID: PMC10859074\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThorson J, H\u0026auml;gg U (1991) The accuracy and precision of the third mandibular molar as an indicator of chronological age. Swed Dent J 15(1):15\u0026ndash;22 PMID: 2035147\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSolari AC, Abramovitch K (2002) The accuracy and precision of third molar development as an indicator of chronological age in Hispanics. J Forensic Sci. ;47(3):531-5. PMID: 12051331\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalla SB, Galic I, Vanin PK, De Luca S, Cameriere S (2017) R. Validation of third molar maturity index (I\u003csub\u003e3M\u003c/sub\u003e) for discrimination of juvenile/adult status in South Indian population. J Forensic Leg Med. ;49:2\u0026ndash;7. doi: 10.1016/j.jflm.2017.05.003. Epub 2017 May 3. PMID: 28482246\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePyata JR, Kandukuri BA, Gangavarapu U, Anjum B, Chinnala B, Bojji M, Gurram A, Balla SB (2021) Accuracy of four dental age estimation methods in determining the legal age threshold of 18 years among South Indian adolescents and young. J Forensic Odontostomatol 39(3):2\u0026ndash;15 PMID: 34999575; PMCID: PMC9343060\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Medical Association (2025) World Medical Association Declaration of Helsinki: ethical principles for medical research involving human participants. JAMA 333(1):71\u0026ndash;74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jama.2024.21972\u003c/span\u003e\u003cspan address=\"10.1001/jama.2024.21972\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Salvia A, Calzetta C, Orrico M, De Leo D (2004) Third mandibular molar radiological development as an indicator of chronological age in a European population. Forensic Sci Int. ;146 Suppl:S9-S12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.forsciint.2004.09.021\u003c/span\u003e\u003cspan address=\"10.1016/j.forsciint.2004.09.021\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 15639599\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKullman L, Tronje G, Teivens A, Lundholm A (1996) Methods of reducing observer variation in age estimation from panoramic radiographs. Dentomaxillofac Radiol. ;25(4):173-8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1259/dmfr.25.4.9084269\u003c/span\u003e\u003cspan address=\"10.1259/dmfr.25.4.9084269\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 9084269\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUys A, Bernitz H, Pretorius S, Steyn M (2018) Estimating age and the probability of being at least 18 years of age using third molars: a comparison between Black and White individuals living in South Africa. Int J Legal Med 132(5):1437\u0026ndash;1446. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00414-018-1877-6\u003c/span\u003e\u003cspan address=\"10.1007/s00414-018-1877-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2018 Jun 9. PMID: 29948162\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin-de las Heras S, Garc\u0026iacute;a-Fortea P, Ortega A, Zodocovich S, Valenzuela A (2008) Third molar development according to chronological age in populations from Spanish and Magrebian origin. Forensic Sci Int 174(1):47\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.forsciint.2007.03.009\u003c/span\u003e\u003cspan address=\"10.1016/j.forsciint.2007.03.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2007 Apr 24. PMID: 17459627\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Luca S, Biagi R, Begnoni G, Farronato G, Cingolani M, Merelli V, Ferrante L, Cameriere R (2014) Accuracy of Cameriere's cut-off value for third molar in assessing 18 years of age. Forensic Sci Int. ;235:102.e1-6. doi: 10.1016/j.forsciint.2013.10.036. Epub 2013 Nov 25. PMID: 24365729\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAcharya AB (2011) Accuracy of predicting 18 years of age from mandibular third molar development in an Indian sample using Demirjian's ten-stage criteria. Int J Legal Med 125(2):227\u0026ndash;233. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00414-010-0522-9\u003c/span\u003e\u003cspan address=\"10.1007/s00414-010-0522-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2010 Oct 15. PMID: 20949276\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Dental age estimation, Third molar, Demirjian method, Refined root stages, Age of majority, Diagnostic accuracy","lastPublishedDoi":"10.21203/rs.3.rs-9318331/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9318331/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDetermining attainment of 18 years is a critical task in forensic age estimation. This study evaluated and compared the sex-specific diagnostic performance of conventional and refined third-molar maturation cut-offs, Demirjian stages G and H, and the refined stage G1 for identifying individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years in a South Indian population. Panoramic radiographs of 599 individuals aged 14\u0026ndash;22 years were retrospectively assessed. Mandibular left third molars were staged using the conventional Demirjian system and the Solari and Abramovitch modification. Diagnostic performance was evaluated separately for males and females using sensitivity, specificity, predictive values, likelihood ratios, accuracy, and post-test probabilities. Intra- and inter-examiner agreement was assessed using kappa statistics. Third-molar maturation effectively discriminated attainment of 18 years in both sexes, with stage-dependent trade-offs between sensitivity and specificity. Stages G and G1 demonstrated high sensitivity and strong exclusion of adulthood when negative, whereas stage H showed higher specificity and greater confirmatory value when present, particularly among females. Diagnostic performance of the refined G1 stage was comparable to that of stage G, with modest improvement in specificity and post-test probability in females. Inter-examiner agreement was excellent for stages G and H but only moderate for G1, indicating reduced reproducibility for the refined stage. In conclusion, conventional Demirjian stages G and H remain reliable and reproducible indicators for assessing attainment of 18 years. Although the refined G1 stage offers increased developmental resolution and supports probabilistic interpretation, its forensic utility is constrained by reduced inter-observer agreement.\u003c/p\u003e","manuscriptTitle":"Diagnostic performance of Demirjian’s third molar maturation stages G, G1, and H for identifying the 18-year age threshold: a sex-specific study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-27 09:31:45","doi":"10.21203/rs.3.rs-9318331/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"640a874e-ab6f-4332-81c0-54569a16b84f","owner":[],"postedDate":"April 27th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-08T10:04:06+00:00","index":8,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T09:31:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-27 09:31:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9318331","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9318331","identity":"rs-9318331","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}