International Journal of Legal Medicine

https://doi.org/10.1007/s00414-020-02377-y

ORIGINAL ARTICLE

Dental age estimation based on pulp chamber/crown volume ratio

measured on CBCT images in a Spanish population
Ana Molina 1 & Manuel Bravo 2 & Gabriel M. Fonseca 3 & Nicholas Márquez-Grant 4 & Stella Martín-de-las-Heras 1

Received: 16 June 2020 / Accepted: 14 July 2020

# Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Dental age estimation in living individuals is one of the most frequent requests undertaken by forensic odontologists. The aim of
this study was to estimate the dental age by pulp/tooth volume ratio, as measured on cone beam computed tomography (CBCT)
images, in a Spanish population. This study included 313 teeth from 107 adult individuals, 56 females and 51 males with a mean
age of 44 ± 14 years. The statistical analysis of the results took account of clustering (multiple teeth in individuals). Linear
regression models were constructed on the relationship between pulp/tooth volume ratio and chronological age for each tooth
type. The highest coefficient of determination (R2) value was provided by the upper incisors (36.6%), and the difference between
chronological and estimated age was less than 5 years in 31.3% of the sample and less than 10 years for 65.7%. CBCT is an
accurate imaging technique to measure dental volume with a relatively low radiation dose, and it can be used to assess dental age
in living adult individuals. Volumetric changes in the pulp cavity with increasing age proved valuable to estimate dental age in
this Spanish population.

Keywords Forensic dentistry . Age estimation . Cone beam CT

Introduction demand for DAE in living individuals (related to migratory

movements, lack of documentation, memory loss, pensions,
Dental age estimation (DAE) is one of the most frequently etc.) and children (related to adoption, underage marriage,
asked questions in forensic odontology. There is a growing legal responsibility, child pornography cases, etc.) [1]. The
advantage of DAE is that teeth are less affected by extrinsic
physical, chemical, or mechanical factors than are other parts
Highlights
of the skeleton. For this reason, DAE results have shown a low
Chronological age was related to pulp chamber/crown volume ratio in a
Spanish population. variability as a function of chronological age [2–5].
Upper incisor ratios revealed the strongest correlation. Forensic dentistry has become an important tool for age esti-
The pulp chamber/crown volume ratio explained 36.6% of the age vari- mation [6]. In cadavers, dental age estimation has allowed the
ability.
reconstruction of biological profiles through biochemical
The difference between chronological and dental age was < 5 years in
31.3% of the sample. methods [7] in order to assist with the identification of the de-
This method of dental age estimation is gender independent. ceased. However, these methods require dental extraction (un-
ethical in living individuals), are time-consuming, and require
* Stella Martín-de-las-Heras sophisticated laboratory equipment [8]. However, simple, inex-
[email protected] pensive, and accurate procedures are available for DAE in living
1
subjects with developing teeth. These methods, based on the
Department of Forensic Medicine, University of Malaga,
29071 Malaga, Spain
tooth formation and development, have been established as the
2
most reliable and accurate means to estimate the age [9].
Department of Preventive and Community Dentistry, University of
Granada, 18071 Granada, Spain
One well-known DAE method is the measurement of pulp/
3
tooth volume ratio [10], based on the progressive decrease in
Centro de Investigación en Odontología Legal y Forense (CIO),
Facultad de Odontología, Universidad de la Frontera, Temuco, Chile
pulp volume caused by the continuous apposition of dentin
4
throughout life [3]. Imaging techniques have been used for
Defence Academy of the United Kingdom, Cranfield Forensic
Institute, Cranfield University, Shrivenham SN6 8LA, UK
this method, but the accuracy of estimations on two-
 Int J Legal Med

dimensional radiographs [11] is limited by magnification and Table 1 Descriptive

statistics: Subjects (n = Variable n (%)
distortion [12, 13]. The increasing use of three-dimensional
107)a
images in dental practice has led to research exploring the Sex
association between age and pulp/tooth volume ratio in sam- Male 51 (47.7)
ples from Belgium [3, 14], Japan [15–19], India [12, 20], Italy Female 56 (52.3)
[21], China [22], Tunisia [23], and, more recently, Malaysia Age (years)
[8, 24], Brazil [25, 26], Turkey [13, 27], and Iran [28, 29]. The 14–20 8 (7.5)
results have indicated that age can be estimated with reason- 21–30 17 (15.9)
able accuracy using three-dimensional images. 31–40 13 (12.1)
Cone beam computed tomography (CBCT) offers high- 41–50 25 (23.4)
resolution images with relatively low doses of radiation [13] 51–60 34 (31.8)
and offers a simple and conservative approach to the calcula- 69–70 10 (9.3)
tion of dental volume [21]. The aim of this study was to use Mean ± sd 44 ± 14
CBCT images to calculate pulp/tooth volume ratios in teeth Number of teeth
from a Spanish population with the purpose of improving the 1 34 (31.8)
implementation of this imaging technique to estimate dental 2 23 (21.5)
age in living individuals. 3 18 (16.8)
4 10 (9.3)
5 12 (11.2)
Materials and methods ≥6 10 (9.3)
Mean ± sd 2.93 ± 2.14
The study initially included 321 teeth obtained in the School
of Dentistry at the University of Granada (Spain). Only a
These subjects accumulate 313 teeth for
healthy teeth were selected, excluding those that had been the analyses
treated or presented cavities, restorations, or excessive wear
or attrition. Out of the initial sample of 321 healthy teeth,
upper premolars were excluded due to their small number (a separating the coronal pulp by setting a grayscale threshold.
maximum total of 8 teeth). The final study sample therefore The program automatically calculated the volumes of the
comprised 313 teeth (incisors, canines, and lower premolars) crown (CV) and pulp chamber (CPV) from the 3D images
from 107 patients: 56 females and 51 males with a mean age (Fig. 1). The pulp chamber/crown volume ratio was calculated
of 44 ± 14 years (range, 14–70 years) (Table 1). All CBCT for each tooth.
images had been documented for valid clinical reasons by the To determine the reliability of the method, a previous pilot
same radiological technician, using a Cone Beam Computed study was conducted, with two observers measuring the CV
Tomography Planmeca Pro Max (Planmeca Co., Helsinki, and CPV in 33 teeth. Intraclass Correlation Coefficients
Finland). Exposures were taken at 90 kV and 12–14 mA, with (ICCs) were calculated. ICC was 0.83 for CV and 0.63 for
a scanning time of 12 s. The study was conducted in accor- CPV, considered “almost perfect” and “substantial” concor-
dance with the Declaration of Helsinki and was approved by dance, respectively [30].
the Granada University Ethics Committee for Research
Involving Human Subjects.
Since previous studies found virtually no difference in ra- Statistical analysis
diographic adult age determination between teeth from the left
and right side of the dental arch [3, 10, 17, 27], left and right IBM SPSS Statistics v.23.0 (IBM Corp., Armonk, NY, USA)
teeth were pooled in the analyses. was used for the descriptive analysis (percentages, means, and
The CBCT images were analyzed using Planmeca standard deviations) and for the linear regression (true age as
Romexis 2.3.1.R software (Helsinki, Finland). The crown vol- dependent variable and Log10(% pulp) as independent vari-
ume (CV) was calculated by using the “Cube tool” to delin- able) to obtain the estimated (predicted) age for each type of
eate an area from the cementum-enamel junction (CEJ) to the tooth. Use was made of the adjusted predicted value, i.e.,
incisal edge of the tooth in three spatial axes (axial, sagittal, removing each patient from the data set, fitting the regression
and coronal). Segmentation of the crown was automatically model with the remaining data, and then using this model to
performed by setting grayscale thresholds for the enamel, den- make age prediction of the omitted patient, with this algorithm
tin, and pulp. The crown pulp volume (CPV) was calculated being repeated. Hence, the data of a given patient was not used
using the same procedure but delineating the area from the to calculate his/her estimated age, thereby yielding unbiased
CEJ to the roof of the pulp chamber in three spatial axes and age estimates. To estimate the age, upper central and lateral
Int J Legal Med

Fig. 1 Automatic calculation of the crown volume and the entire tooth dental crown (axial section). c Volume of dental hard tissues and pulp
with CBCT images analyzed using Planmeca Romexis 2.3.1.R software. volume of the whole tooth (sagittal section). d Volume of dental hard
a Volume of dental hard tissues and pulp volume of the dental crown tissues and pulp volume of the whole tooth (axial section)
(sagittal section). b Volume of dental hard tissues and pulp volume of the

incisors were pooled together, as were lower central and lat- series method [31]. The statistical methods are also described
eral incisors, and lower first and second premolars in order to in the corresponding table captions.
increase the sample size. SUDAAN 7.0 (Research Triangle
Institute, Research Triangle Park, NC) was used for analytical
purposes to account for clustering, i.e., multiple teeth (n = Results
313) in patients (n = 107). SUDAAN enables to obtain con-
sistent estimates of p values, standard errors, and 95% CIs for Table 2 exhibits the distribution of tooth types and pulp/tooth
cluster-correlated data, after the application of the Taylor volume ratios in this study. The tooth type of each hemiarch

Table 2 Volume of crown (mm3)

and pulp chamber/crown volume Teeth n Crown volume (mm3) % Pulp
ratio (%) (n = 313 teeth, 107 mean ± sd mean ± sd
subjects)
Total 313 469 ± 162 8.8 ± 2.7
11–21 (Upper central incisors) 17 659 ± 127 6.1 ± 1.9
12–22 (Upper lateral incisors) 15 438 ± 112 7.7 ± 2.6
13–23 (Upper canines) 34 636 ± 126 8.5 ± 2.4
31–41 (Lower central incisors) 42 277 ± 50 8.4 ± 2.0
32–42 (Lower lateral incisors) 51 328 ± 67 8.3 ± 2.2
33–43 (Lower canines) 97 539 ± 138 9.5 ± 2.9
34–44 (Lower first premolars) 42 464 ± 94 9.3 ± 2.6
35–45 (Lower second premolars) 15 488 ± 106 9.6 ± 3.9
Global p valuea < 0.001 < 0.001
a
Employing SUDAAN regression procedure to account for clustering (multiple teeth within the subjects)
 Int J Legal Med

(left and right side) was combined and the regression proce- homogeneous on all walls of the pulp cavity [21].
dure to account for clustering (multiple teeth in subjects). The Difficulties have been reported in detecting minute structural
mean CV was 469 ± 162 mm3, and the mean pulp chamber/ demarcations at the root apex (pulp tissue and calcified tooth
crown ratio was 8.8 ± 2.7%. By tooth type, the CV ranged structures), and undertaking this manually for this purpose
from 277 ± 50 for the lower central incisor to 659 ± would be time-consuming [8]. Rai et al. found a significant
127 mm3 for the upper central incisor. Tooth types significant- association between chronological age and pulp/tooth volume
ly differed in CV and ratio: pulp chamber/crown volume. No ratio using CBCT axial planes at the CEJ but not employing
significant differences were found between males and females coronal planes or sagittal planes of CBCT; they attributed this
(results not shown). Linear regression models between pulp/ finding to the clearer demarcation of pulp and tooth outline in
tooth volume ratio and chronological age for each type of the CEJ section compared with more apical sections [20]. In
teeth are shown in Table 3. The highest coefficient of deter- 2018, Asif and colleagues [24] used two approaches to volu-
mination (R2) value was for the upper incisors (36.6%). All metric analysis to examine the relationship between chrono-
associations were statistically significant except for the upper logical age and pulp/tooth volume ratios: pulp cavity/tooth
and lower canines which had the lowest R2 values. ratio and pulp chamber/crown ratio (up to CEJ). Although
Table 4 displays the differences between chronological age both methods obtained a strong correlation with chronological
and estimated age for each tooth type in linear regression age, the coefficient of determination was higher with the pulp
models. Canines were excluded due to previous results. For chamber/crown ratio method (R2 = 0.78), which required less
upper incisors, the difference between chronological and esti- time and achieved greater inter-examiner reliability (0.982),
mated age was < 5 years in 31.3% of the teeth and 5–10 years since no manual intervention is needed for “multiple slice
in 34.4%; thus, the difference was < 10 years in 65.7% of editing phase” of the software [24]. This paper used the pulp
these teeth. For the lower incisors, the difference was < 5 years chamber/crown ratio in the same way in order to strengthen
in 30.1% of samples and < 10 years in 55.9%. The mean the power of the results and save time.
difference between chronological and estimated age was In 2015, Porto et al. [25] reported a weak correlation be-
8.0 years for upper incisors and 9.6 years for lower incisors. tween the pulp cavity/tooth volume ratio in upper central in-
The largest mean difference was for the lower premolars cisors and age (coefficient of determination of 0.21), which
(12.6 years). they attributed to tertiary dentine deposition due to external
stimuli. In our analysis, a post-study evaluation of sample size
indicated that this was sufficient to estimate the absolute age
difference, with a precision of less than 5 years and 95%
Discussion confidence interval for each tooth type (Table 4). Indeed,
36.6% of the age variability was explained by the pulp
The progressive decrease of pulp volume over time has been chamber/crown volume ratio for upper incisors, and the dif-
used to estimate dental age in adult individuals [3, 8, 12–27], ference between chronological and estimated age was <
although the apposition of secondary dentine is not 5 years for 31.3% of these teeth. Similar results have been
published by other authors, indicating that the pulp tooth vol-
ume ratio of incisors offers a reliable DAE method [3, 8, 13,
Table 3 Linear regression models, with pulp/crown volume ratio as
independent variable and age as dependent variable (n = 313 teeth, 107 16, 26–28]. However, results for canines did not prove to be a
subjects), according to tooth typea reliable approach to age estimation in this Spanish population,
unlike findings in Malaysian [8], Tunisian [23], Iranian [28],
Type of tooth Equation: Constant + β × [Log10(Xb)]
Indian [12], and Pakistani [32] populations. Incisors showed a
n R2 Constant β±sec p valuec stronger correlation in the study by Star et al. [3], although
they examined only a small number of canines and premolars.
Upper incisors 32 0.366 69.9 − 42.8 ± 10.3 < 0.001 Gulsahi et al. [13] assessed similar numbers for all tooth types
Upper canines 34 0.028 57.6 − 20.8 ± 24.1 0.390 and found the strongest age correlation on upper central inci-
Lower incisors 93 0.167 83.6 − 45.0 ± 11.6 < 0.001 sors, followed by upper lateral incisors, proposing that the
Lower canines 97 0.010 53.8 − 9.9 ± 11.4 0.389 weaker correlations found for canines may be attributed to
Lower premolars 57 0.152 79.6 − 43.3 ± 12.0 < 0.001 the different qualities of their dentinal deposition in compari-
a
son with other tooth types. Nemsi et al. [23] also analyzed
The interaction type of tooth × Log10% pulp was significant (p < 0.001).
Furthermore, sex did not test significantly (p = 0.564 in a model with canines, but their results cannot be compared with our find-
Log10%pulp, tooth type and sex as independent variables) ings due to differences in the technique employed, given that
b
X = % pulp they used an axial CBCT section of CBCT but excluded the
c
Standard errors (se) and p values calculated with SUDAAN regress enamel. Another study examined canine volumes alone and
procedure, to account for clustering (multiple teeth within the patient) found a stronger relationship with chronological age in lower
Int J Legal Med

Table 4 Age differences (absolute values) between chronological age and estimated age with linear regression modellinga excluding canines (n = 182
teeth, 79 subjects)b

Age Age differences (years) (absolute values) between chronological and estimated age

Tooth (only crowns) % distribution (years) Mean

n mean ± sd 0–5 > 5–10 > 10–15 > 15–20 > 20–33 mean ± sd 95% CIc

[A] Upper incisors 32 35.4 ± 11.7 31.3 34.4 21.9 9.4 3.1 8.0 ± 5.7 5.6–10.4
[B] Lower incisors 93 42.9 ± 12.6 30.1 25.8 20.4 17.2 6.5 9.6 ± 6.6 7.7–11.5
[C] Lower premolars 57 38.5 ± 15.2 19.3 14.0 29.8 22.8 14.0 12.6 ± 6.8 10.7–14.5
Global p valuea p = 0.005
Paired comparisonsd AB≠C
a
Regression with SPSS, with predictive values estimated as adjusted values (see Methods)
b
After excluding upper (n = 42) and lower canines (n = 97), since their regression models were not statistically significant (see Table 3)
c
Confidence intervals adjusted with SUDAAN Descript procedure, to adjust for multiple teeth within the patient
d
With SUDAAN’s Descript procedure, where “≠” means p < 0.05

rather than upper canines [32] and reported that this relation- sexes. Future studies may focus on standardizing methodolo-
ship was nonlinear and that age estimation was highly influ- gies across several different populations and taking into ac-
enced by sample size and methods employed. count differences according to sex and tooth type.
No statistically significant differences in pulp chamber/
crown volume ratio were found between the sexes in our Funding information This study is partially supported by the Ministry of
Science, Innovation and Universities of Spain (PRX19/00369).
study, as previously reported [8, 21]. Although Star et al. ob-
served a stronger correlation between pulp/tooth volume ratio
and age in women compared to men, the difference was not Compliance with ethical standards
statistically significant [3]. By contrast, statistically significant
High standard of ethics according to the WMA Declaration of Helsinki
differences between the sexes have been found by other au- was applied in all investigations described in the manuscript. The research
thors [15, 22, 28, 32]. In agreement with other studies, there is project was approved by the Granada University Ethics Committee for
a need to consider different tooth types with recognized dif- Research Involving Human Subjects.
ferences in tissue volumes and sexual dimorphism. To our
knowledge, this is the first study to use pulp/tooth volume Conflict of interest The authors declare that they have no conflict of
interest.
ratio for DAE in a Spanish population. Besides the limited
sample size, the different methodology compared with previ-
ous studies limits any comparisons with their results. As noted
by Maret et al. [33], rapid developments in CBCT technology
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