ORIGINAL ARTICLE

Evaluation of Antegonial Angle and Antegonial Depth to

Estimate Sex in a Prepubertal Turkish Population
Burak Kerem Apaydin, DDS, PhD* and Hilal Ozbey, DDS, PhD†

definitions.10 It has been reported that, after the pelvis, the skull
Abstract: This retrospective study aimed to measure the antegonial angle is the most reliable part of the human skeleton for sex
(AGA) and antegonial depth (AGD) on panoramic radiographs in a Turkish determination.1,11–13 If the complete skeleton is available, sex
subpopulation and to determine how those measurements relate to sex be- can be easily determined by the pelvic bone.1,6 However, when
fore puberty. A total of 600 patients were divided into 3 age groups (5, 6, or skeletal remnants do not present in good condition or do not con-
7 years), and each group consists of 100 boys and 100 girls. For each pa- tain the pelvic bone, the mandible may play a vital role in sex de-
tient, AGA and AGD indices in panoramic radiograph were measured by termination, because of its strength, dimorphism, and its dense
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an oral radiologist and pediatric dentist. To our knowledge, this is the first layer of compact bone.6,11,12 Just like the other bones in the body,
study measuring AGA and AGD parameters on prepubertal subjects and the mandible develops in utero during pregnancy. The mandible
identifying sex differences in these parameters. The data were analyzed consists of 2 parts, which fuse anteriorly and ossify until the end
by independent t test, Mann-Whitney U test, Spearman correlation analy- of the first year of life.14 Growth and development of the mandible
sis, and intraclass correlation coefficient for interobserver compliance continue during the puberty, and several morphological and di-
using the SPSS software program. In all age groups, a statistically signifi- mensional changes occur in the mandible during puberty.15 Be-
cant difference was found between the prepubertal boys and girls in both cause mandibular growth and development differs by sex,
AGA and AGD parameters (P < 0.05). Our findings support the conclusion mandibular ramus size can differ according to sex.13 In addition,
that, in addition to adults, AGA and AGD indices can be used to determine occlusal forces differ from males to females, which affect the form
the sex of prepubertal Turkish children. These parameters can be used to and size of the mandibular ramus and antegonial region.11,16,17
determine the sex in forensic investigations of victims in whose age or pu- The emergence of these discriminative features for males and fe-
bertal condition are not known. males occurs with the onset of puberty.18
Key Words: sex determination, antegonial angle, antegonial depth, Significant differences in growth and development between
prepubertal the sexes do not appear until puberty, which occurs at an average
age of 10 years in girls and at an average age of 11.5 years in
(Am J Forensic Med Pathol 2020;41: 194–198)
boys.18 However, the age at which puberty begins varies widely,
and many factors, such as genetic factors, nutritional status, and
S ex determination is one of the most challenging tasks in med-
icolegal research and forensic dentistry.1 The determination of
sex is of great importance in forensic anthropolgy, paleodemography,
ethnicity, may affect the timing and progression of puberty.19
For instance, precocious puberty occurs when secondary sexual
characteristics appear in girls younger than 8 years and in boys
and paleopathology.2,3 The determination of human skeletal compo-
younger than 9 years old.20–22 Until puberty occurs, growth and
nents is important in forensic odontology.1 Sex determination is use-
development are relatively similar between the sexes; however,
ful to complete an individuals' biological profile and essential in the
significant differences are observed between boys and girls during
process of the identification of the skeletal remains because it reduces
puberty.18
the number of possible matches by half.4,5 It is the first step of the de-
Anthropologists have often used morphological or metric
termination process and is mainly based on anatomical variations and
methods for skeletal sex determination.3 The morphological
various skeletal morphological characteristics that can be used to dis-
method involves visually observing the sex characteristics in the
tinguish man from women.6 Forensic anthropologists research sexu-
bones. Recognition of these features by an experienced observer
ally dimorphic differences by examining architectural and size
may provide an accurate sex classification.23 The metric method in-
variations through morphological and metric analyses.7 In addition,
volves the metric analysis of the bone measurements by various statis-
skeletal structures differ for different populations; therefore,
tical tests.10 Morphological differences in the mandible have generally
population-specific standards are needed for sex determination.6,8
been evaluated with both morphological and metric methods using ra-
In forensic anthropology, the frequently used bones for sex
diographs. This method is known as radiomorphometric.24,25
determination are the cranium and the bones of the pelvis.3 Sex
Many anatomical indices exist in the mandible, including the
determination becomes more challenging when only cranial skel-
antegonial angle (AGA), antegonial depth (AGD), mandibular
etal remains are available in forensic anthropology.9 Because the
cortical index, gonial angle, condyle angle, and mental foramen
teeth and bone are hard tissues, they are less likely to deteriorate
measurements. The authors evaluated the different anatomical
than soft tissues. They usually serve as a key for forensic
structures of the mandible in various studies.11,26,27 In the litera-
ture, many studies have explored sex determination in adults using
Manuscript received January 23, 2020; accepted May 8, 2020. several mandibular parameters. Although studies have evaluated
From the *Department of Oral and Maxillofacial Radiology, and †Department sex differences in various mandibular parameters in adults,13,17,23,28
of Pedodontics, Faculty of Dentistry, Pamukkale University, Denizli,
Turkey.
to our knowledge, the parameters of mandibula, which are not af-
The authors report no conflict of interest. fected by the pubertal period, have not been identified. In 1 of our
Reprints: Burak Kerem Apaydin, DDS, PhD, Department of Oral and current works, gonial angle, AGA, bicondylar breadth, mental in-
Maxillofacial Radiology, Faculty of Dentistry, Pamukkale University, dex, minimum ramus breadth, bigonial width, and ramus height
Denizli, Turkey. E-mail: drkeremapaydin@gmail.com.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
were measured on panoramic radiographs obtained from Turkish
ISSN: 0195-7910/20/4103–0194 patients. We examined the relationship between those measure-
DOI: 10.1097/PAF.0000000000000579 ments and age and sex in prepubertal and postpubertal periods.

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Am J Forensic Med Pathol • Volume 41, Number 3, September 2020 Evaluation of AGA and AGD to Estimate Sex

Findings revealed that only AGA values were statistically signifi-

cant between male and female patients in both prepubertal and TABLE 1. Mean, Median, Min-Max, and P Values of the
Subjects
postpubertal periods.29 In light of this study and past studies in
the literature that examined AGA index in adults, we aimed to ex-
Mean ± SD Median Max Min P
amine the AGA index along with the AGD index in a prepubertal
population.17,27,30,31 In cases where child mandibula remnants of 5 y AGA Boys 161.82 ± 4.66 162 171 147 <0.0001* β
unknown age/pubertal condition are found, it is important to have Girls 165.61 ± 4.08 166 174 156
parameters that can be used to distinguish males from females in AGD Boys 1.77 ± 0.55 1.80 3.40 0 <0.0001* β
both prepubertal and postpubertal periods. Therefore, the aim of Girls 1.33 ± 0.47 1.30 2.80 0.30
this study was to evaluate whether AGA and AGD values are asso-
ciated with sex in a prepubertal population and develop a reliable Mean ± SD Median Max Min
method for sex estimation both for prepubertal and postpubertal
population. The null hypothesis of this study was that AGA and 6 y AGA Boys 162.29 ± 162 171 150.80 <0.0001* α
AGD values would not be associated with sex before puberty. 4.59
Girls 166.13 ± 166.45 174.50 158
3.95
MATERIALS AND METHODS
AGD Boys 1.69 ± 0.57 1.60 3.00 0 <0.0001* β
This retrospective study reviewed medical records of patients Girls 1.41 ± 0.48 1.40 2.50 0.40
seen at the Department of Maxillofacial Radiology, Pamukkale
University, Denizli, Turkey. Ethical approval for this study was Mean ± SD Median Max Min
given by the Pamukkale University Ethics Committee (number
7 y AGA Boys 163.76 ± 4.14 164.65 171 150.5 <0.0001* β
60116787-020/83324). A total of 600 subjects, who were given
panoramic x-rays for various purposes, were included in this Girls 166.26 ± 3.64 166.75 174.90 153
study. Subjects were divided into 3 groups based on age: 5 years, AGD Boys 1.56 ± 0.50 1.45 3.40 0.80 0.004* β
6 years, and 7 years. Each age group consisted of 200 subjects Girls 1.35 ± 0.39 1.30 2.60 0.40
(100 boys and 100 girls). *P < 0.05.
The number of subjects needed for this study was calculated α, Independent samples t test; β, Mann-Whitney U test.
using NCSS software (Number Cruncher Statistical Systems),
which determined that at least 78 subjects were required per group to
achieve more than 90% power for a δ value of 1.0 (α = 0.05). Each measurements were made from the images at 100% magnification
patient's orthopantomograph was taken according to the manufacturer's using Java Image Processing Software (ImageJ, a public domain
instructions using Instrumentarium's ORTHOPANTOMOGRAPH program; US National Institutes of Health, Bethesda, MD). In ad-
OP200D (Instrumentarium Dental, Tuusula, Finland) with the head ori- dition, according to the User Manual of Orthopantomograph
ented in the Frankfurt horizontal plane to avoid positioning errors. Sub- OP200D (Instrumentarium Dental, Tuusula, Finland), image mag-
jects with gross facial asymmetry, craniofacial and mandible nification is 14%. Statistical analysis included independent t test,
anomalies, undergoing or had undergone any orthognathic surgery, Mann-Whitney U test, Spearman correlation analysis, and
had any history of facial trauma, and had a presence of distortion or ar- intraclass correlation coefficient for interobserver compliance
tifacts in the radiographs were excluded from the study. using SPSS software (version 25.0, IBM Corp). A P value of
Gonion is defined as the most postero-inferior point at the <0.05 was considered statistically significant.
angle of the mandible.32 Antegonial angle was characterized as
the intersection point of the 2 lines on the deepest point of the RESULTS
mandible's lower border.33 The first line of this angle was drawn Table 1 shows the mean, SD, and median values of the age
from the anterior lower border of the mandible, and the second groups. A statistically significant difference was found in both
line was drawn from the lower border of the mandibular gonion AGA and AGD indexes between boys and girls for all age groups
area. The angle between the 2 lines was determined as the AGA. (P < 0.05) (Table 1). For all age groups, AGD was lower in girls
The vertical distance between the lower border of the mandible than in boys. In boys, although there was a statistically significant
and its deepest point was called the AGD34 (Fig. 1). weak, positive correlation between age and AGA (rboys = 0.187),
An experienced oral radiologist and pediatric dentist mea- there was a statistically significant weak, negative correlation be-
sured the AGA and AGD indices. In this study, AGA and AGD tween age and AGD (rboys = −0.189). No statistically significant
indices were measured on both sides of the mandible on pano- correlation was found between age and either AGA (rgirls = 0.075)
ramic radiographs, and their mean value was used. The or AGD (rgirls = 0.017) in girls (Table 2). The interobserver agree-
ment was excellent, with an AGA ICC of 0.984 (0.938–0.996)
and an AGD ICC of 0.977 (0.906–0.994) indicating good repeat-
ability and reliability.

DISCUSSION
In the current study, we researched whether AGA and AGD
indexes were associated with sex to determine whether these pa-
rameters could be used for sex determination in prepubertal pe-
riod. The null hypothesis of the study was rejected because a
statistically significant difference was found between the sexes
in both AGA and AGD parameters. Bulut et al35 reported that cat-
egorizing the subjects into age groups makes the data more valu-
FIGURE 1. The measurements of AGA and AGD on panoramic able for examining the differences related to sexual dimorphism.
radiographs. The age groups of 5, 6, and 7 years were used in this study because

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Apaydin and Ozbey Am J Forensic Med Pathol • Volume 41, Number 3, September 2020

greater right gonial angle values, whereas Chole et al38 and

TABLE 2. Correlation Table of AGA and AGD Parameters Bhardwaj et al31 found significantly greater left angle values.
According to Boy and Girl Groups
Apart from these studies, in a study of Abdinian et al,45 mandibu-
lar indices were measured on both right and left sides of the man-
AGA AGD
dible, and their average value was used in the study. Because
Boys Age r 0.187* −0.189* different results exist in the literature about the similarity of the
p 0.001 0.001 right and left sides of the mandible, we measured the both sides
Girls Age r 0.075 0.017 and took the average.
p 0.198 0.774 Radiology practice in forensic science was first mentioned in
1896. Dental radiography, which is a simple method used daily in
*Significant difference. dentistry practice, has been used in age and sex estimation
methods since 1982.46 In recent years, several studies that
assessed the reliability of the panoramic radiographs to determi-
Klein et al21 and Chulani and Gordon20 reported that, in some nate morphological dimensions of the mandible have been per-
cases, 8-year-old girls can enter the puberty early because of hor- formed.31,47,48 Panoramic radiographs are also the best choice
monal or genetic factors. Therefore, we were certain that children for the determining the gonial angle.6,38 Despite the unreliability
under the age of 8 years were in the prepubertal period. In the cur- of horizontal measurements, angular measurements might be per-
rent study, we found a statistically significant difference between formed with high reliability in panoramic radiographs. Further-
the sexes in both AGA and AGD values. Therefore, our findings more, even a slight misalignment of the head, which occurs
indicate that both the AGA and AGD parameters can be used frequently in everyday practice, does not significantly affect verti-
for sex determination before puberty. cal measurements in the posterior mandible.30 Therefore, the
In a study performed by Akhlaghi et al,36 it was suggested method of using panoramic radiographs for determining the
that symphysial height and mandibular bigonial breadth could AGA and AGD in this current study could be considered reliable.
be used to determine the sex before 12 years of age. However, they However, cone beam computed tomography (CBCT) does not
did not evaluate the AGA and AGD parameters in their study. In a show any magnification or overlapping of neighboring structures,
study performed by Kaczkowski et al,37 researchers evaluated which are inherent problems in orthopantomograph.49 For these
AGD in 273 adult cadavers and reported that the AGD was higher reasons, angular measurements may be performed with high reli-
in the male cadavers compared with the female cadavers. These ability in CBCT.27
results are in accordance with the current study. Limitations of this study are that it maintains in a single pop-
Chole et al38 reported that gonial angle, AGA, and AGD may ulation and the measurements were made on panoramic radio-
be implicated as a forensic tool for sex determination. Ghosh graphs. However, more studies should be made on other
et al,17 Tozoğlu and Çakur,27 and Dutra et al30 measured AGA populations and on dry skulls to support these findings. Neverthe-
and AGD parameters in panoramic radiographs of the adults. In less, more studies should be done with CBCT. Measurements
these studies, they concluded that women had larger AGA and might be more accurate with a 3-dimensional imaging system. Al-
smaller AGD compared with men. These results were in accor- though there is a statistical difference, the clinical significance of
dance with the current study except that the studies included the study may be limited, as there is a conflict in AGA and AGD
postpubertal subjects.27 values for girls and boys. Therefore, the reliability of sex determi-
In the present study, boys had a lower AGA than girls, and nation by using this method may be limited. More studies are
these results were in accordance with the results of Bhardwaj needed for clear results.
et al,31 Osato et al,39 and Apaydin and Ozbey.6 A possible expla- There are studies examining the relationship between AGD
nation for the results seen is that male (eg, testosterone) and fe- and facial growth50,51 and also many articles about the determina-
male (eg, estrogen) hormonal differences may affect bone tion of sex by the AGA and AGD indices in adults. However, to
metabolism possibly resulting in physical differences between our knowledge, this is the first study measuring AGA and AGD
the sexes.31 However, our study included prepubertal subjects parameters on prepubertal subjects and identifying sex differences
who are less likely to experience hormonal differences that would in these parameters. In our opinion, it is important to find common
affect bone metabolism. parameters for prepubertal period and adulthood period to deter-
Osato et al39 found that the AGA was significantly larger in mine the sex. In the lights of current study and past studies about
women than in men. These findings may be supported by the fact AGA and AGD indices of adults in the literature,27,29,31,38 these
that the antegonial region is sensitive to bone resorption because parameters can be used to determine the sex in forensic investiga-
of the reduced number of muscle fiber insertions.40 It is also tions of victims in whose age or pubertal condition are not known.
thought that these results may also be observed more often in The differences in AGA and AGD measurements between male
women who have metabolic bone loss.27 However, these explana- and female can be used as a forensic tool for sex determination
tions were not convenient with our study, although the results were method when we have only mandibular bone, or as a supportive
convenient. In the present study, all participants were children in sex determination method when analyzing human skeletal re-
their pubertal period, and therefore, none of the participants had mains by using other sex determination methods.
bone loss.
In a study evaluating the mandibular indices on the right and
left side for both male and female groups, Chandra et al41 found
that both sides were almost similar. This is similar to the studies
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Am J Forensic Med Pathol • Volume 41, Number 3, September 2020 Evaluation of AGA and AGD to Estimate Sex

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