Pulp volume quantification methods in cone-beam computed tomography for age estimation: A critical review and meta-analysis

The secondary dentin deposition that occurs after the tooth formation process results in a decrease in pulp cavity volume in adolescents and adults. The purpose of this critical review was to correlate pulpal and/or dental volume on cone-beam computed tomography (CBCT) with chronological age approximation. A subobjective was to investigate which methodology and CBCT technical parameters would be most appropriate to evaluate this correlation. This critical review followed the PRISMA guidelines, and it was conducted by a search through PubMed, Embase, SciELO, Scopus, Web of Science, Cochrane Library databases, as well as gray literature. Primary studies that used pulp volume, or pulp chamber to tooth volume ratio measured using CBCT were included. Seven hundred and eight indexed and 31 non-indexed records were identified. A qualitative analysis was performed including 25 selected studies with a total of 5100 individuals, age ranging from 8 to 87 years without sex predilection. The most used method was pulp volume/tooth volume. CBCT voxel size ranged between 0.09 and 0.5. Manual segmentation associated with threshold algorithms was used in most of the studies. Correlation between the pulp volume/tooth volume ratio was moderate: −0.66 for the upper central incisors, −0.59 for upper canines and −0.56 for lower canines. High heterogeneity was observed among the studies. It is concluded that pulp volume should be used with caution in age estimation. Evidence supports the preferable use of upper incisors with pulp volume/tooth volume ratio for age estimation. There is not enough evidence that voxel size interferes in age estimation by pulp volume.     

Relationship Between Pulp Tooth Area Ratio and Chronological Age Using Cone‐beam Computed Tomography Images

This study investigated the relationship between chronological age and pulp tooth area ratio (PTR) in maxillary central teeth using cone‐beam computed tomography (CBCT) images in the Turkish population. The sample consisted of CBCT images of 120 male and female subjects between 14 and 75 years old. The PTR of the maxillary central teeth was calculated using inVivo 5 software (Anatomage, San Jose, CA). Data were analyzed with independent t‐test and Pearson's rank correlation test. There was a significant negative correlation between chronological age and PTR (r = ?0.615). The results showed that the PTR of maxillary central teeth is a reliable method for age estimation in the Turkish population.     

Dental age estimation through volume matching of teeth imaged by cone-beam CT

A custom-made voxel counting software for calculating the ratio between pulp canal versus tooth volume based on cone-beam CT tooth images was developed and evaluated. The aim of this study was to attempt establishing a correlation between the chronological age of a certain individual and the pulp/tooth volume ratio of one of the teeth. Twenty-eight single rooted teeth of 19 individuals with well-known chronological age were scanned by the cone-beam CT (3D Accuitomo, J. Morita, Kyoto, Japan). Next the images were analyzed using the custom-made software. Linear regression analysis was performed. The results of the analysis showed a moderate correlation between the pulp/tooth volume ratio and biological age with a coefficient of determination (R2) of 0.29. Although the present work was limited to a pilot study, the developed technique showed promising results for dental age estimation in a non-invasive manner using cone-beam CT images in living individuals.     

Age estimation of adults from dental radiographs

Previous studies have shown that with advancing age the size of the dental pulp cavity is reduced as a result of secondary dentine deposit, so that measurements of this reduction can be used as an indicator of age. The aim of the present study was to find a method which could be used to estimate the chronological age of an adult from measurements of the size of the pulp on full mouth dental radiographs. The material consisted of periapical radiographs from 100 dental patients who had attended the clinics of the Dental Faculty in Oslo. The radiographs of six types of teeth from each jaw were measured: maxillary central and lateral incisors and second premolars, and mandibular lateral incisors, canines and first premolars. To compensate for differences in magnification and angulation on the radiographs, the following ratios were calculated: pulp/root length, pulp/tooth length, tooth/root length and pulp/root width at three different levels. Statistical analyses showed that Pearson's correlation coefficient between age and the different ratios for each type of tooth was significant, except for the ratio between tooth and root length, which was, therefore, excluded from further analysis. Principal component analyses were performed on all ratios, followed by regression analyses with age as dependent variable and the principal components as independent variables. The principal component analyses showed that only the two first of them had significant influence on age, and a good and easily calculated approximation to the first component was found to be the mean of all the ratios. A good approximation to the second principal component was found to be the difference between the mean of two width ratios and the mean of two length ratios, and these approximations of the first and second principal components were chosen as predictors in regression analyses with age as the dependent variable. The coefficient of determination (r²) for the estimation was strongest when the ratios of the six teeth were included (r² = 0.76) and weakest when measurements from the mandibular canines alone were included (r² = 0.56). Measurement on dental radiographs may be a non-invasive technique for estimating the age of adults, both living and dead, in forensic work and in archaeological studies, but the method ought to be tested on an independent sample.     

Age Estimation Based on Pulp Cavity to Tooth Volume Ratio Using Postmortem Computed Tomography Images

Pulp cavity size is known to decrease with age and can therefore serve as an indicator for age estimation. Here, we evaluated whether reconstructed images of multidetector‐row computed tomography (MDCT) acquired before forensic autopsy are useful for estimating age at death. Images of 136 mandibular first premolars obtained from bodies of known age at death were analyzed, and the volume of the regions corresponding to pulp cavity and that of the whole tooth were determined using a voxel counting function. The pulp cavity was clearly distinguishable from dental hard tissue on the reconstructed images when using a cutoff value of 1400 Hounsfield units. Regression analysis adjusted for sex showed that estimated age correlated significantly with the pulp cavity to tooth volume ratio (r = 0.76). MDCT is gaining more widespread use in forensic medicine, and analyzing dental images to obtain parameters for age prediction is a practical approach for postmortem identification.     

Age calculation using X-ray microfocus computed tomographical scanning of teeth: a pilot study

To correlate dental age with an individual's chronological age based on the calculated volume ratio of pulp versus tooth volume measured, an X-ray microfocus computed tomography unit (microCT) with 25 microm spatial resolution was used to non-destructively scan 43 extracted single root teeth of 25 individuals with well-known chronological age. Custom-made analysis software was used by two examiners to obtain numerical values for pulpal and tooth volume. The ratio of both was calculated and statistically processed. No significant intra- or inter-examiner differences were found. In fact, a very strong concordance correlation coefficient was found. Linear regression analysis showed a coefficient of determination (r) of 0.31 which suggests that there is a rather weak correlation between the volume ratio of pulp versus tooth and biological age. Although rather time consuming, this technique shows promising results for dental age estimation in a non-destructive manner using X-ray microfocus computed tomography.     

上、下尖牙髓腔/牙体表面积比值的年龄判定价值研究

目的通过三维重建测量上、下颌尖牙髓腔/牙体表面积比值(Pulp/Tooth area Ratio,PTR)来推断个体年龄,为临床年龄推断的应用提供科学依据。方法收集口腔门诊患者年龄在16~65岁200例锥形束CT(Cone beam computed tomography,CBCT)影像资料,以4个尖牙为测量对象并进行三维重建,测量各尖牙髓腔和牙体表面积,计算PTR值。应用SPSS17.0软件进行统计学分析,推导实际年龄的推断公式。结果Pearson相关分析显示上、下颌尖牙PTR值与实际年龄呈高度负相关(P<0.001,r值为-0.833~-0.891)。4个尖牙间的PTR值无显著差异(P>0.05)。男女性别间尖牙PTR值无显著差异(P>0.05)。尖牙PTR值(x)推断年龄公式为:年龄=84.42-222.22x,R²=0.739。结论检测尖牙的PTR值,可明显提高临床年龄推断的准确性。     

Three-dimensional modeling of the various volumes of canines to determine age and sex: a preliminary study

Canines are usually used in anthropological and forensic sciences for sex and age determination. The best methods to estimate age are based on secondary dentine apposition, evaluated from periapical X-rays. The aim of this study was to propose a new method of sex and age estimation using 3D models to obtain more precise predictions using tooth volumes. Fifty-eight dental CT scans of patients aged 14-74 with a well-balanced sex ratio composed the sample. One hundred and thirty-three healthy canines were modeled (Mimics 12.0). The sample was divided into a training sample and a validation sample. An age formula was determined using the "pulp volume/tooth volume" ratio. Sex prediction was adjusted with total volumes. Applying the equations to the validation sample, no significant difference was found between the real and predicted ages, and 100% of the sex predictions were correct. This preliminary study gives interesting results, and this method is worth being tested on a larger data sample.     

The applications of MicroCT in studying age-related tooth morphological change and dental age estimation: A scoping review

Conventional dental age estimation relies on destructive methods such as sectioning and staining, which are unpreferable when the tooth is required for evidential or archeological preservation. MicroCT is a non-destructive, high-resolution imaging technique that allows for accurate morphometrical measurement. Although microCT technology has been applied in a variety of dental studies, studies focusing on dental age-related change and dental age estimation based on microCT imaging remain lacking. Based on the question: “How has microCT technology been applied in studying human age-related tooth morphological change and dental age estimation studies?”, the authors conducted a scoping review in accordance with the Arksey and O'Malley (2005) and the PRISMA-ScR guidelines. A literature search using five major scientific databases identified 452 articles, with 11 full-text articles being eligible to be included in the scoping review. Furthermore, 6 out of the 11 studies performed dental age estimation modeling. An overview of the parameters used in the selected articles revealed a variety of tooth characteristics, such as pulp cavity to whole tooth volume ratio, secondary dentin, as well as the diameter of root canal orifice. The findings of this scoping review highlight the extent microCT is used in studying dental age-related changes, as well as the effectiveness of microCT in dental age estimation studies. This review serves as a guide for future forensic odontology age estimation studies.     

The Effects of Racemization Rate for Age Estimation of Pink Teeth

Pink teeth is thought to result from the seepage of hemoglobin caused by dental pulp decomposition. We investigated whether racemization can be applied for age estimation in cases of pink teeth where the whole tooth is used. The pink teeth used were three cases and the normal teeth for control were five mandibular canines of known age. Age of the pink teeth was calculated on the basis of regression formula obtained from the five control teeth. Only a slight error was noted between the actual and estimated ages of the pink teeth (R² = 0.980, r = 0.990): Cases 1–3 actually aged 23, 53, and 59 years were estimated to be 26, 52, and 60 years. Based on our results of testing pink teeth of known age, we suggest that racemization techniques allow for the age estimation of pink teeth using the same methods for normally colored teeth.     

Age estimation by pulp/tooth ratio in canines by peri-apical X-rays

Estimation of age in individuals has received considerable attention in forensic science, in which it is a widely used method for individual identification, together with paleo-demographic analyses to establish mortality patterns in past populations. The present investigation, which is a continuation of a previously published pilot study, was conducted to examine the possible application of the pulp/tooth area ratio by peri-apical images as an indicator of age at death. A total of 200 peri-apical X-rays of upper and lower canines were assembled from 57 male and 43 female skeletons of Caucasian origin, aged between 20 and 79 years. They belong to the Frassetto osteological collection of Sassari (Sardinia) and are housed in the Museum of Anthropology, Department of Experimental and Evolutionistic Biology, University of Bologna. For each skeleton, dental maturity was evaluated by measuring the pulp/tooth area ratio on upper (x(1)) and lower (x(2)) canines. Very good agreement was found between intraobserver measurements. Statistical analysis was performed in order to obtain multiple regression formulae for dental age calculation, with chronological age as dependent variable, and gender, and upper and lower canines as independent variables. Stepwise regression analysis showed that gender did not contribute significantly to the fit (p=0.881) whereas variables x(1) and x(2) and the first-order interaction between them did. These two variables explained 92.5% of variations in estimated chronological age and the residual standard error was 4.06 years. Lastly, two simple linear regression equations were obtained for age estimation using canines from the maxilla and mandible separately. Both models explained 86% of variations in estimated chronological age and allowed an age-at-death estimate with a residual standard error of about 5.4 years.     

Reliability in age determination by pulp/tooth ratio in upper canines in skeletal remains

Estimation of age of skeletal remains is one of the most complex questions for anthropologists. The most common macroscopic methods are based on dental wear and histological evaluation of bone remodeling. These methods are often qualitative, require great technical expertise, and have proved inexact in the estimation of ages over 50 years. Certain dental methods investigate the apposition of secondary dentine, in the study of tooth cross-sections, and X-rays to study width, height, and pulp area. The primary author previously proposed a method of estimating the age of a living person based on the pulp/tooth ratio (PTR) method in the upper canines. The aim of the present study is to verify whether the PTR method can also be used to estimate the age at death of skeletal remains. This paper investigates the study of historical samples of known age as a means to validate the proposed method.     

Age estimation by pulp/tooth ratio in lower premolars by orthopantomography

Accurate age estimation has always been a problem for forensic scientists, and apposition of secondary dentine is often used as an indicator of age. Since 2004, in order to examine patterns of secondary dentine apposition, Cameriere et al. have been extensively studying the pulp/tooth area ratio of the canines by panoramic and peri-apical X-ray images. The main aim of this paper is to examine the relationship between age and age-related changes in the pulp/tooth area ratio in monoradicular teeth, with the exception of canines, by orthopantomography. A total of 606 orthopantomograms of Spanish white Caucasian patients (289 women and 317 men), aged between 18 and 75 years and coming from Bilbao and Granada (Spain), was analysed. Regression analysis of age of monoradicular teeth indicated that the lower premolars were the most closely correlated with age. An ANCOVA did not show significant differences between men and women. Multiple regression analysis, with age as dependent variable and pulp/tooth area ratio as predictor, yielded several formulae. R(2) ranged from 0.69 to 0.75 for a single lower premolar tooth and from 0.79 to 0.86 for multiple lower premolar teeth. Depending on the available number of premolar teeth, the mean of the absolute values of residual standard error, at 95% confidence interval, ranged between 4.34 and 6.02 years, showing that the pulp/tooth area ratio is a useful variable for assessing age with reasonable accuracy.     

A Reappraisal of Developing Deciduous Tooth Length as an Estimate of Age in Human Immature Skeletal Remains

This study provides an update on a quantitative method for immature age estimation based on postnatal deciduous mandibular tooth length. Two known sex and age skeletal collections from Western Europe were sampled (n = 97). Linear regression models for age estimated were calculated for each individual tooth, each sex, and sex combined sample using classical calibration. Prediction errors, residuals, and percentage of individuals whose real age fell within the 95% prediction interval were calculated. The teeth which develop earlier in life, the incisors and the first molar, showed the greatest precision, while the canine showed the least. This method has greater applicability to archeological skeletons or to children in developing countries than for use in North American or European forensic contexts. The method can be applied to incomplete or poorly preserved remains of unknown sex, particularly when dental radiographs are not an option or when teeth have been removed from the alveolus or crypt.     

Accuracy and reliability of cone beam computed tomography of the jaws for comparative forensic identification: a preliminary study

Conventional computed tomography is an emerging modality in forensic identification but is not sufficiently accurate for use in dental identification primarily because of problems with metallic dental restoration-induced streak artifact. In this study, the accuracy and reliability of recording forensic information from cone beam computed tomography (CBCT) scans of the jaws when compared to conventional panoramic radiographs has been analyzed under experimental conditions. Information could be recorded with near-perfect repeatability and reproducibility. Information could also be recorded accurately, the sensitivity being 96.6% (95% CI, 95.1-98.1) and specificity being 98.4% (95% CI, 96.2-100). The metal dental restoration-induced streak artifact was at a level that permitted, in most cases, accurate observations. This is considered an important step in validating CBCT as a tool in comparative dental identification of bodies. It may have a role in mass fatalities and in chemical, biological, radiological, and nuclear incidents, but further studies are required to assess the feasibility of this.     

Dental hygiene students' matching accuracy when comparing antemortem dental radiographs and oral photographs to simulated postmortem WinID3® odontograms

Matching dental antemortem (AM) and postmortem (PM) data for human identification is especially challenging when the workforce is limited. Dental hygienists have served mass fatality incidents (MFIs) due to dental-related expertise. However, forensics within dental hygiene education and research on transferable skills is limited. This qualitative balance design study assessed senior dental hygiene students' match accuracy of simulated cases varying in dental identifiers based on AM full mouth series (FMS) radiographs and oral photographs to PM WinID3^® odontograms to demonstrate possible disaster victim identification (DVI) transferable skills gained during formal education. A convenience sample of senior dental hygiene students (n = 31) was presented information on WinID3^® interpretation, then presented with 5 mismatched cases and asked to visually interpret each to make 10 total matches; five based on AM FMS with simulated PM WinID3^® odontograms and five based on AM photographs with PM WinID3^® odontograms. Match accuracy scores ranged from 41.9% to 58.1% for cases with 1–10 identifiers, and 77.4% to 93.5% for cases with 11–40 identifiers. Accuracy when matching AM radiographs to PM odontograms versus AM photographs to PM odontograms was compared and revealed no statistical differences in match accuracy depending on image type (p = 0.388 to 1.000). Results of this pilot study suggests transferable match accuracy skills resulted from the participants' dental hygiene formal education. These baseline skills with additional specialized training support the rationale for dental hygienists serving on DVI teams. More research is needed in education and practice when preparing dental hygienists for forensic-based service.     

Gender Determination of Adult Individuals by Three‐Dimensional Modeling of Canines

Gender determination is a fundamental issue in forensic anthropology. Many techniques based on bone and dental remains have been proposed. It is not always possible to implement the techniques using bones, but teeth are often perfectly preserved. It has been demonstrated that the canine has the greatest sexual dimorphism, and the aim of this work was to provide an easy and accurate dental technique for determining the gender in the absence of other skeletal elements. The sample was composed of 210 CT scans with four healthy canines. The 840 canines were modeled using MIMICS^® 10.01 software. The total volume of each tooth was determined. Seven mathematical models were determined by binary logistic regressions and ranked in order of relative performance. The seven proposed predictive models thus performed (0.910 ≤ AUC ≤ 0.938), with overall rates of correct predictions between 82.38 and 85.24%. The 4‐canine model is the most powerful for predicting the gender.     

Variations in pulp/tooth area ratio as an indicator of age: a preliminary study

This paper details a method for age determination of adults from single rooted teeth. The sample consisted of 100 Italian white Caucasian patients (46 men, 54 women) aged between 18 and 72 years. The single rooted maxillary right canine was utilized in this preliminary study. Pulp/root ration, tooth length, pulp/tooth length ratio, pulp/tooth area and pulp/root width ratios at three different levels were computed. Pearson's correlation coefficients between age and these variables showed that the ratio between pulp and tooth area correlated best with age (r2 = 0.85). Stepwise multiple regression models yielded a linear relationship between pulp/root width at mid-root level and chronological age and a linear relationship when pulp/tooth area was compared to age. Statistical analysis indicated that these two variables explain 84.9% of variations in estimated chronological age. The median of the absolute value of residual errors between actual and estimated ages was less than four years.