EXAMINATION FOR DETERMINATION OF AGE

In civil cases

• Identification• Employment• Marriage• Majority• Management of property• Competency as witness• Testamentary capacity

In criminal cases

• Rape• Criminal abortion• Infanticide• Abduction• Prostitution• Juvenile offenders• Criminal responsibility• Competency as witness

Proforma for examinationPRELIMINARIES• To,

Name of investigating officerName of police station

• Reference- letter no, date• Name• Age as stated • Sex

• Occupation –Factories act1948 Adult –who had completed their 18 yearsAdolescent – 15-18 yearsChildren -> 14yrs but<15 yrsNote child below 14yrs is not allowed to work in

factory, mines or any hazardous employment

• Address-• Brought by police constable ( name, no, police

station)• Identified by (name of person)• Date and time of examination• Place of examination

Consent• Question (in the language the person giving consent

understands):• Are you willing to be/to have your son / daughter /ward /wife

physically examined by me, and to undergo radiological examination/ to have him /her radiologically examined to estimate your /his/her age for the purpose of ------------ Knowing that you have right to refuse, but that such refusal may go against you?

• Answer given: Yes / No• (If age is apparently less than 12 years, then consent of the

parent / guardian is mandatory)• Signature / thumb impression of person giving consent:• Name & signature of witness to consent:

• If person being examined is female, name & signature of female attendant / Doctor present during examination.

• Identification mark (at least 2 ID marks) (complete description as to shape, colour, nature, dimensions, and location with respect to 2 fixed anatomical landmarks):

• 1] Mole- A black, circular, elevated, non hairy mole of size 0.3 cm in a diameter was present over the right zygomatic region of the face 4 cm above the right angle of mandible.

• 2] Tatoo mark- A green tattoo mark of design “lord hanuman” of size 8 cm x 5 cm, 4 cm below the left elbow joint was present on the flexor aspect of upper part of left arm.

• Date of birth:• Any documentary evidence produced: Yes / No-• If yes, nature:• Documentary evidences are birth certificate,

living certificate, H.S.C. and S.S.C. certificate, passport, voting card, driving licence

• Education

I. General physical examination. II. Development of secondary sexual characters. III. Development and eruption of teeth. IV. Ossification of bones.

General Physical Examination• Height• Weight• Chest girth at nipple level• Abdominal girth at the level of navel • General built and appearance

Age in Years Mean height in cm Average ± 2 SD in cm Mean weight in kg Average ± 2 SD in kg

6 118 107-128 20 15-28

7 120 109-131 22 16-30

8 126 114-138 24 16-36

9 132 119-145 28 20-42

10 138 124-152 37 22-50

11 144 130-158 39 25-56

12 151 137-165 41 27-63

13 159 145-172 46 31 –65

14 160 147-174 50 35-70

15 161 148-175 54 35-72

16 162 149-175 55 39-75

17 163 150-175 56 41 -80

18 163 –164 151-175 57 42-80

Mean Height and Weight in Indian Girls

Age in Years Mean height in cm Average ± 2 SD in cm Mean weight in kg Average ± 2 SD in kg

6 116 106-125 21 16-26

7 121 112-132 23 18-30

8 127 116-138 26 19-35

9 132 120-143 28 21-40

10 138 125-150 31 22-46

11 146 132-161 35 23-49

12 150 135-160 40 27-60

13 157 140-173 45 30-67

14 163 146-180 51 35-75

15 169 152-185 57 40-82

16 174 160-188 62 45-88

17 176 163-189 66 49-95

18 177 164-190 69 51-97

Mean Height and Weight in Indian Boys

Secondary sexual characters females• Development of breast

• Axillary hair- (Absent/Downy /Sparse/Black/Rich/Bushy) • Pubic hair- (Absent/Downy /Sparse/Black/Rich/Bushy)

• Menarche- • If menarche attained yes /no , • Date of last menstrual period• Mestrual cycle- Regular/ irregular/30 days cycle/ blood PV for how

many days• External genitalia- female look for the prominence of the labia and

mons pubis)

Secondary sexual characters males

• Moustache- (Absent/ Downy/rough/ Sparse/dense/Black)

• Beard -(Absent/Downy/rough/Sparse/ dense/Black)• • Axillary hair - (Absent/Downy /Sparse/Black/Rich/Bushy) • Pubic hair - (Absent/Downy/Sparse/Black/Rich/Bushy) • Graying of scalp hairs starts at temporal region around 40yrs followed by hairs

of beard, moustache & chest. Baldness appears around 50yrs.• Graying of pubic hairs starts at 55 yrs. • Voice - (Deep or soft) • Adam's apple- (Prominent/not prominent)

• External genitalia - (In male, look for the development of penis and

pendulousness of scrotum; • History of Ejaculation-

Physical Development of a Female

Years Development Stages

• 8-9 Hormones begin to release, sometimes causing moodiness and skin sensitivity.

• 9-10 Hips start rounding out.

• 10-11 Breast nipples begin to grow, Breast tissues around and under nipple

begin to appear, Growth spurt may be seen, Downy hair near labia.

Physical development of a Female (Cont'd…)

Years Development Stages

• 12-13 Axially hair, Genital organs growth, Menstruation age (between 9 and14 years),

Pregnancy is possible.

• 13-14 Underpants are wet with clear mucous, more with ovulation and sexual arousal.

• 14-15 Earliest normal pregnancy, Major growth spurt complete.

• 15-16 Acne, Deepening voice.

• 16-17 Full height achieved.

Tanner stage of Pubic hair• Stage 1 Prepubertal no pubic hair, fine brown

villous hair (< 12 years)• Stage 2 Sparse not extending on to mons

pubis, light pigmented (12-13 years) • Stage 3 Darker, coarse extending on to mons

pubis, pigmented, start curling and spread (13-14 years)

• Stage 4 Covering most parts but not going up to thighs (14-15 years)

• Stage 5 Dense hair extending to the inner thighs, Mature pubic hair (> 15 years)

Tanner stage of Breast Development • Stage 1 Prepubertal – Elevated papilla, small

fat areola (not seen before 9-10 years)

• Stage 2 Papilla forms a palpable nodule (Breast bud) (10-11 years)

• Stage 3 Breast development beyond the areola, contour of breast not defined (by 13

years) • Stage 4 Contour of breast well defined, more

breast (by 13 years) development with elevation of the Areola double mound

• Stage 5 Mature breast -more breast development with loss (by 15-16 yrs)

of double mound, papilla project as nipple

Physical Development of a Male

Years Development Stages

• 8-9 Hormones begins to release, sometimes causing moodiness and skin sensitivity.

• 10-11 Testes become larger, Scrotal skin redder in colour and coarse in texture. • 11-12 Prostate gland begins to function,

Penis begins to lengthen.

• 12-13 Pubic hair growth, Growth spurt may begin,

Spontaneous erections.

Physical Development of a Male(Cont'd…)Years Development Stages

• 13-14 Rapid growth of penis, Scrotal skin colour deepens, Pseudo breast.

• 14-15 Axillary hair, Voice changes.

• 15-16 Average age when sperm matures, Can cause pregnancy, Majority of growth spurt complete.

• 16-17 Chest and shoulder will fill out, Acne, Body hair. • 21 Full height achieved.

• Dental status• Any other finding- skin, eyes, other• Advised x-ray – • X-ray plate no.• Date

(III) Development & Eruption of Teeth

Reasonable reliable idea of the age can be made by examining the teeth.

Dental Examination

• The tooth eruption in oral cavity occurs when the root is almost half formed. As the root becomes longer, the crown erupts through the bone and is seen outside of the jaw in an oral cavity.

• Degree of formation of root and crown structures, the stage of eruption and the intermixture of temporary and permanent teeth are helpful in estimating age from birth to 25 years.

Dental Examination (Cont'd….)

• The x-ray of the jaw would show developmental status of unerupted teeth and the degree of root completion in erupted teeth.

• Crown and root development of the second molar, and third molar- helpful for 8 - 21 years.

Temporary Teeth

10 temporary teeth in each jaw —4 incisors,

2 canines & 4molars

(no premolars, no 3rd molar).

Temporary Teeth

Teeth Time of eruption Root calcification completes

Central incisor (Lower) 6 months (6 to 8m) 1/2 Year

Central incisor (Upper) 7 months (7 to 9m) 1/2 Year

Lateral incisor (Upper) 9 months (9 to 10m) 1/2 Year

Lateral incisor (Lower) 10 months (10 to 12m) 1/2 Year

1st Temp. Molar ]2 months (12 to 14m) 2 to21/2 Year

Canines 18 months (17 to 18m) 21/2 to 3Year

2nd Temp. Molars 24 months (20 to 30m) 3 Years

Permanent Teeth

16 permanent teeth in each jaw — 4 incisors, 2 canines,

4 premolars & 6 molars.

Eruption of permanent teeth

Teeth Time of eruption Root calcification completes

1st molar 6-7 years 9-10 years

Central incisor 6-8 years 10 years

Lateral incisor 7-9 years 11 years

1st bicuspid 9-11 years 12-13 years

2nd bicuspid 10-12 years 12-14 years

Canine 11-12 years 12-13 years

2nd molar 12-14 years 14-16 years

3rd molar 17-25 years 22-25 years

Age and number of teeth

Tooth Eruptional Permanent (no of

teeth at different

age)

Temporary (no of

teeth at different

age)

1. First molar

2. Central incisor

3. Literal premolar

4. First premolar

5. Second premolar

6. Canine

7 Second molar

8 Third molar

6yrs

7 yrs

8 yrs

9 yrs

10 yrs

11 yrs

12-14 yrs

17-25 yrs

4

8

12

16

20

24

28

32

20

16

12

8

4

0

0

0

Space for third molar

In the back of jaw-

• In females- 15-16 years. • In males- after 16 years of age.

Radiological Assessment of Teeth Development

• Made by viewing X-ray films. • Orthopantogram- provided the facility is available. • Otherwise, X-ray of the oral cavity- Oblique

tangential view with the mouth open. • A tooth erupts in an oral cavity only when there is a

half root formation inside the jaw. • Teeth develop earlier in females in comparison to

males. • The germination centre of the third molar appears

between 7 and 9 years.

Crown and Root Development of the Third Molar

Crown Formation Age(On X-ray)

• Complete Crown Formation 15 years• Crown with 1/3rd Root Formation 16 Years• Crown with 2/3rd Root Formation 17 Years• Crown with

Complete Root Formation 18 years• Apical Closure of Root 21 years (Calcification of the root completed) The eruption and development of teeth in females takes

place 1 year earlier than males.

Some helpful notes on Calcification of teeth

• When molars erupt, the root is about 1/3 of its final length. Or in other words, when roots achieve 1/3 of their final length, the molars erupt.

• At the time of eruption the apical closure has not occurred

Orthopantogram (OPG)

Age from OPGs

• OPG of a child between 8-9 years.

• Both incisors do not have any tooth germ underneath them, indicating they are permanent. Age >8 years.

• Premolar shows a tooth germ beneath it. The germ is of the permanent tooth. This means the premolar is actually a temporary molar. Since permanent premolar has not appeared. Age <9 years.

Charting of teeth-

• Universal system- Teeth are numbered 1to 16 from right to left and 17 to 32 from lower left to lower right

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1632 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17•Palmer notation Right Left 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 88 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

Charting of teeth

• Haderup system-• It is similar to Palmer notation except that it uses a

(+) sign for upper teeth and (-) lower teeth

+8 +7 +6 +5 +4 +3 +2 +1 +1 +2 +3 +4 +5 +6 +7 +8

-8 -7 -6 -5 -4 -3 -2 -1 -1 -2 -3 -4 -5 -6 -7 -8

Charting of teeth

• FDI (Federation Dentaire Inetrnationale)-• FDI system substitutes for permanent teeth

• For temporary teeth 5,6,7and 8 numbers are used

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

2nd temporary molar appeared

Mixed dentition-first molar appeared

2nd Permanent molar appeared

Provisional age certificate

On clinical examination of individual ,age is ---- years. however , the final opinion regarding the age should be collected from this office after submission of radiological report .

Date and place sign. name and designation of doctor

(IV) Ossification of bones

The first step in ossification of the cartilage is

that the cartilage cells, at the point where

ossification is commencing and which is termed

a ossification center. It enlarge and arrange

themselves in rows. There are two types of

ossification centers - primary and secondary.

X-Ray Findings in Bones • In long bones, the appearance and fusion of epiphyses can be

evaluated for the purpose of age estimation. The findings can be described as:- “no fusion” “fusing” “recently fused: “fused”.

• X-ray of the hands, wrists, elbows, shoulders, feet, ankles, knees, the pelvis, and hip joints are very useful.

• The fusion of bones takes place 1 year earlier in females than in males.

X-ray Shoulder joint (AP view)(for the age group 17-18 years)

Age Appearance• 1 year head of humerus • 3 years greater tuberosity • 5 years lesser tuberosity

All these centers unite at 6 years and form conjoint epiphysis. • 11 years tip of coracoid unites at 16 yrs • 15 years tip of acromion appears,

unites with scapula at 18 years. • 19 years secondary center for sternal end

of clavicle appears unites with shaft by 21 years.

X-ray Shoulder (example)

• Head and greater tuberosity are appeared but not fused :

age <18 years.

X-ray Elbow Joint (AP view)(for the age group 5-16 years)

Age Appearance • 1year Capitulum

• 5-7years Medial epicondyle • 10 years Trochlea • 11 years Lateral epicondyle • 14 years of age the 3 centers i.e. Capitulum, Trochlea and Lateral epicondyle unite together and form a conjoint epiphysis. This

conjoint epiphysis unites with the shaft of humerus.

• 16 years of age The last centre to unite at elbow is medial epicondyle, which unites with humerus shaft.

• 5 years Head of radius (upper end), It unites at 16 years.

• 9 years Upper end of ulna, It also unites at 16 years.

X-ray elbow (example)• In the current x-

ray, all four centres (medial epicondyle, capitulum, trochlea and lateral epicondyle) can be seen separately, indicating the age is around 11yeras-14years.

Wrist Joint and hand (X-ray AP view) (for the age group 16-17 yrs)

Age Appearance • 2 years Lower end of radius• 6 years Lower end of ulna

Both unite with shafts around 19 years.

Carpal bones appearance and ossification• 2 months Capitate• 3 months Hamate • 3 years Triquetral • 4 years Trapezium, Scaphoid, Lunate • 4-5 years Trapezoid • 9-11 years Pisiform • Metacarpals Head of the first metacarpal unites at 16 years while the

heads of other metacarpals unite at 17 years (Thumb first).

X-ray Wrist (example)• Appearance of

carpal bones – (lateral to medial, distal to proximal)

yr yr mth mth4 5 2 3

• T T C H• S L T P

4 4 3 9-12yr yr yr yr

• Age 9-16 yrs.

Sternum • Sternum body has 4 centers since birth, which unite

from below -> upwards direction. 3rd and 4th parts unite at 15 years. 2nd and 3rd unite at 20 years. 1st and 2nd parts unite at 25 years.

• Manubrium unites with body of sternum at 60 years. • Tip of Xyphoid process appears at 3 years and unites

at 40 years with body of sternum.

X-ray Sternum (example 1)• Lateral view of sternum is

taken.• Middle four pieces of

sternum unite from below upwards, between 15-25 years of age and xiphoid procees fuses with at 40 years manubrium fuses with body at 60 years

• In this case, the upper two pieces have not united.

• Age– 15-20 yrs.

X-ray Sternum (example 2) • Showing

sternum and its pieces in a 16 year old male.

• The third and fourth piece have almost united.

• Age- around 15 years.

Upper limbs: summary

In the long bones of the upper limb, the first

to join is the elbow joint followed by the shoulder and wrist joints.

The carpal bones are useful for age in the 1/2 to 12 year age group.

Hip Joint (X –ray AP view)

Age Appearance• 6.5 – 8 year Ischio-pubic ramus unites by 61/2

years • 14 years Iliac crest ossification centre

appears, unites by 20 years.

• 14 years Tip of pubis centre appear • 16 years Tip of ischium appear

Both these centers unite by 20 years. • 13 years Acetabulam cap appears as

triradiate cartilage • 15 years Triradiate gets united and

appears as a cup

X-ray Hip joint (example)

• Iliac crest not appeared:<14 yr

• Triradiate cartilage still visible:<15 years

• Greater trochanter not united:<17 years

X-ray Pelvis & femur (AP view)

• Pelvis is and femur in a 21/2 year old male child.

• Head of femur has appeared- age > 1 year.

• Greater trochanter has not yet appeared- age < 4 years.

X-ray Rt. Hip joint (AP view) • The tri-radiate cartilage

can easily be seen- age > 13 years and < 15 years of age.

• However, a very faint shadow of lesser trochanter can also be seen. Lesser trochanter appears at around 14 years.

• Opinion given was that the child was between 14-15 years.

X-ray Knee jt. (example)• Lower end of

femur, upper end of tibia & fibula not united:<18 years

X-ray Ankle jt. (example)

• Lower end of tibia and fibula not united.

• Age <16 years.

X-ray foot (example)• This is the X-ray

of an 8½ year old child.

• The Secondary center in the calcaneum has appeared (>6 years), but has not united (<14 years).

Lower limbs: summary

In the long bones of the lower limb, the first

to join is the knee joint followed by the hip and ankle joints.

The hip-bones are useful for age in the 13 to 22 age group.

Summary of X-Ray Advised Age Group X-Ray Advised

• 14-16 years Shoulder, Elbow, Wrist, Dentition, Pelvis including

the upper end of femur and iliac crest.

• 16-18 years Wrist, Elbow, Shoulder, Pelvis, Dentition for the 2nd and 3rd molar.

• 18-22 years Pelvis, shoulder, medial end of clavicle, third molar,

wrist, sternum.

Estimation of age as a whole • 2-6 years- tarsal and carpal bones, appearance of epiphyses

of long bones.

• 6-13 years- permanent teeth, epiphyseal centers.

• 13-16 years- Changes at puberty, elbow joint.

• 16-22 years- epiphyses of the most of the long bones with shafts, viz., union at elbow and wrist, followed by head of hummers.

• It is essential the x-rays of wrist, elbow, shoulder, pelvis joints and jaw are taken for determining the age of the trafficked victim.

Opinion Expression by Medical Officer

OPINION OF AGE

• Provisional age certificate immediately• Send for X-rays with id marks on

requisition form• Final report after radiologists opinion(3-

4hrs)• Range should be 6months to 1year and not

more upto 25 years

GIVE OPINION AT THE VERY EARLIEST

JUSTICE DELAYED IS JUSTICE DENIED