Journal of Forensic and Legal Medicine 54 (2018) 53–61

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Journal of Forensic and Legal Medicine

journal homepage: www.elsevier.com/locate/yjflm

Dental age estimation employing CBCT scans enhanced with Mimics T

software: Comparison of two different approaches using pulp/tooth
volumetric analysis
Muhammad Khan Asifa, Phrabhakaran Nambiara,d, Shani Ann Manib,∗, Norliza Binti Ibrahima,
Iqra Muhammad Khanb, Prema Sukumaranc
a
Department of Oral & Maxillofacial Clinical Sciences, Faculty of Dentistry, University of Malaya, 50603, Kuala Lumpur, Malaysia
b
Department of Paediatric Dentistry & Orthodontics, Faculty of Dentistry, University of Malaya, 50603, Kuala Lumpur, Malaysia
c
Department of Restorative Dentistry, Faculty of Dentistry, University of Malaya, 50603, Kuala Lumpur, Malaysia
d
Faculty of Dentistry, MAHSA University, 42610, Saujana Putra, Malaysia

A R T I C L E I N F O A B S T R A C T

Keywords: The methods of dental age estimation and identification of unknown deceased individuals are evolving with the
Dental age estimation introduction of advanced innovative imaging technologies in forensic investigations. However, assessing small
Mimics software structures like root canal volumes can be challenging in spite of using highly advanced technology. The aim of
Malaysian adults the study was to investigate which amongst the two methods of volumetric analysis of maxillary central incisors
CBCT
displayed higher strength of correlation between chronological age and pulp/tooth volume ratio for Malaysian
Volumetric analysis
adults. Volumetric analysis of pulp cavity/tooth ratio was employed in Method 1 and pulp chamber/crown ratio
(up to cemento-enamel junction) was analysed in Method 2. The images were acquired employing CBCT scans
and enhanced by manipulating them with the Mimics software. These scans belonged to 56 males and 54 females
and their ages ranged from 16 to 65 years. Pearson correlation and regression analysis indicated that both
methods used for volumetric measurements had strong correlation between chronological age and pulp/tooth
volume ratio. However, Method 2 gave higher coefficient of determination value (R2 = 0.78) when compared to
Method 1 (R2 = 0.64). Moreover, manipulation in Method 2 was less time consuming and revealed higher inter-
examiner reliability (0.982) as no manual intervention during ‘multiple slice editing phase’ of the software was
required. In conclusion, this study showed that volumetric analysis of pulp cavity/tooth ratio is a valuable
gender independent technique and the Method 2 regression equation should be recommended for dental age
estimation.

1. Introduction
Tooth is the hardest tissue in the human body. Although it can
undergo demineralisation during one's life-time, it has good post-
mortem preservation and it is the last tissue to be destroyed in extreme
conditions.1–5 During the process of human identification, accurate
determination of the age of the deceased becomes very important.
Teeth, which provides the life history of an individual contributes as a
reliable means of determining age from foetal stage (approximately 10
weeks intrauterine) up to old age.6
Dental age estimation in growing children is straightforward due to
the specific pattern of development and eruption of teeth.7–10 This has
proven useful till the last permanent tooth erupts in the oral cavity at
the age of 17–23 years. Thereafter, teeth undergo different physiolo-
gical age-related changes which have been used for dental age esti-
mation.11,12 One of the important physiological age-related change is
secondary dentin deposition which occurs throughout a life of an in-
dividual after root completion. This causes a decrease in the volume of
the pulp cavity, which is the basis for dental age estimation.13–16
The introduction of Cone-Beam Computed (CBCT) technology in the
clinical management of patients is gaining importance due to its rapid
scan time, beam limitation and improved metric accuracy with iso-
tropic voxel resolutions. This scanning technology is advancing rapidly
and is currently more cost effective, and likely to be a routine compo-
nent of a dental operatory. CBCT technology has also proven valuable
in volumetric analysis of pulp/tooth ratio resulting in more reliable

∗
Corresponding author.
E-mail addresses: dr.muhammad.khan@hotmail.com (M.K. Asif), phrabhakaran@mahsa.edu.my (P. Nambiar), shani@um.edu.my (S.A. Mani),
norlizaibrahim@um.edu.my (N.B. Ibrahim), driqramohd@hotmail.com (I.M. Khan), prema@um.edu.my (P. Sukumaran).

https://doi.org/10.1016/j.jflm.2017.12.010
Received 19 September 2017; Accepted 29 December 2017
Available online 04 January 2018
1752-928X/ © 2018 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
M.K. Asif et al.
dental age estimation methods amongst adults.17–19 In the nineteen
eighties, age-related changes causing volumetric changes were assessed
with two-dimensional intraoral radiographs (2D). It is certainly evident
now that it is not appropriate to measure the volume of a three-di-
mensional object with 2D radiographs. Thus, with the introduction of
CBCT technology in late nineties, researchers shifted their approach
toward 3-dimensional (3D) volumetric measurement of pulp
cavity.17–28
Studies have investigated volumetric changes in the pulp cavity
with age on different populations around the world and most of them
reported different strength of correlations for their respective popula-
tions.17,20–24,26 It is therefore imperative to investigate this physiolo-
gical age-related change in the Malaysian population to derive an ac-
curate regression equation for dental age estimation based on this
better method.
Many image enhancing softwares are being used for 3-D measure-
ments of pulp cavity.20,21,23,27 Mimics (Materialise Interactive Medical
Image Control System) is one of the better image processing software
which can be used to create 3D surface models, 3D design, 3D mea-
surements and analysis of images from stacks of the scanned data.29
This software is capable of creating 3D models for the pulp cavity and
calcified tooth. However, the software is not able to demarcate small
structural details, particularly in the radicular portion of the tooth. As a
consequence, manual intervention is required in the radicular portion
during ‘multiple slice editing phase’ of the software.
In this study two distinct approaches were used to obtain the pulp/
tooth volume ratio. In one approach, volume of full pulp cavity/tooth
volume ratio was used, while the second method involved volume of
pulp chamber/crown volume ratio, where measurements were done
until the cementoenamel junction. The null hypothesis was that there is
no significant difference in the strength of correlation between chron-
ological age and pulp/tooth ratio using the two different approaches.
These two different approaches for measuring pulp cavity and tooth
volume is conducted in the Malaysian population, namely Malays and
Chinese. Malays and Chinese have a similar origin as they belong to the
Mongoloid race.
2. Materials and methods
Ethical and institutional approval for the study was obtained from
the Medical Ethics Committee University of Malaya (Ref. No: DF
OS1606/002(L)). Sample size was calculated with the help of G*Power
software (version 3.1.9.2) using Z tests for two correlations along with a
power of (1 − β )=0.95 and α=0.05. One hundred and ten scanned CBCT
data of maxillary central incisors (56 males and 54 females) were se-
lected from the Oral and Maxillofacial Imaging Division, Faculty of
Dentistry, University of Malaya for the study. The sample of the study
was divided into 5 age groups with an interval of 10 years for the op-
timal distribution of subjects in each age category ranging from 16 to
65 years [Table 1]. Teeth included in the study were with similar
radiographic acquiring parameters and had no associated pathology or
dental caries. All the selected teeth were analysed for both methods of
Table 1
Sample size distribution. Total of 110 investigated teeth divided into 5 age groups based
on gender-ranging from 16 to 65 years.
Age Groups Maxillary Central Incisors
Male Female
16–25 12 11
26–35 11 10
36–45 12 12
46–55 11 11
56–65 10 10
Total 56 54
Journal of Forensic and Legal Medicine 54 (2018) 53–61
volumetric measurements of pulp/tooth ratio.
CBCT data was acquired using the i-CAT Cone Beam 3D Dental
Imaging System (version 3.1.62 supplied by Imaging Sciences
International, Hatfield, USA). The selected scans had exposure para-
meters of 120 kV, 18 mA. All scans selected had employed a voxel size
of 0.30 mm and scanning time of 20 s. The volumetric analysis was
performed with the help of Mimics software (Materialise NV, Belgium,
version 16.0) after the CBCT data was transferred in DICOM files. The
following two methods were used to obtain the pulp/tooth volume
ratio.
2.1. Method 1
The images in the Mimics software were first oriented in the cor-
onal, sagittal and axial planes. Different threshold values were selected
to create new masks for pulp cavity and calcified tooth structures se-
parately (Fig. 1). As stated earlier, the software was unable to detect
minute structural details in the radicular portion of the tooth, and hence
pulp tissue was not selected in some areas by the software in the ‘new
mask creation phase’. Thus, after cropping the mask in all three planes,
manual intervention was undertaken in the ‘multiple slice editing
phase’ of the software (Fig. 2). Slice by slice, the mask was checked
manually where the software did not detect the radicular pulp tissue or
calcified root structures in the initial ‘new mask creation phase’. Cor-
onal stop at the incisal edge and radicular stop at the apex of the root or
pulp were placed. The areas identified in ‘multiple slice editing phase’
were grown in the ‘region growing phase’ for the three-dimensional
measurement of the pulp cavity and tooth (Fig. 3). The software then
automatically calculated the volume of the pulp cavity and tooth
(Fig. 4). This procedure took at least 3–4 h for each tooth.
2.2. Method 2
After proper orientation of the images in axial, coronal and sagittal
planes, the new masks were created for the pulp cavity and calcified
tooth structures as in Method 1 (Fig. 1). The masks were then cropped
in all 3 planes. In the ‘multiple slice editing phase’ coronal stop was
placed at the incisal edge for calcified tooth and pulp chamber while the
apical stop was positioned at the reference of cementoenamel junction
(Fig. 5). The software automatically detected all structural details cor-
rectly since it did not involve the radicular structures (as in Method 1).
The area between the apical and coronal stops were grown in the ‘re-
gion growing phase’ of the software (Fig. 6). The software then calcu-
lated the volume (without any subjective manipulation) of the pulp
chamber and the crown (Fig. 7). This procedure took an average of half
an hour for each tooth.
The intraclass correlation coefficient (ICC) analysis was carried out
to investigate the interexaminer reliability. Twenty-five samples were
randomly selected from the pool of scans selected, and was investigated
by another trained examiner (dental postgraduate student) for the vo-
lumetric analysis. Squared Pearson correlation coefficient analysis was
performed to find the association between the chronological age and
pulp/tooth volume ratio for each of the investigated methods. Linear
regression analysis was performed using age as dependent variable and
pulp/tooth volume ratios as predictor for each method. Fisher's Z test
was used to investigate significant difference in the strength of corre-
lation values between genders and Steiger's Z-test was used to in-
Total vestigate significant difference in the correlation values for the two
methods.30,31 Independent samples t-test analysis was performed for the
comparison of mean values of pulp/tooth volume ratio between gen-
23 ders. All the data was analysed using SPSS version 23.
21
24 3. Results
22
20
110 The Intraclass correlation value was 0.914 (Method 1) and 0.982
(Method 2) for interexaminer reliability. The results indicated almost
54
M.K. Asif et al. Journal of Forensic and Legal Medicine 54 (2018) 53–61

Fig. 1. Pulp cavity thresholding during ‘new mask creation phase’ on sagittal, coronal and axial view.

Fig. 2. ‘Multiple slice editing phase’ for slice by slice segmentation and separation of pulp cavity on sagittal, coronal and axial view.

55
M.K. Asif et al.
perfect consistency. The Pearson correlation and regression analysis
showed significant inverse association between pulp/tooth volume
ratio and chronological age for maxillary central incisors in both
methods of volumetric measurements (p < .01) (Figs. 8 and 9). Fur-
thermore, the strength of correlation value for Method 2 (r = 0.880)
was higher than Method 1 (r = 0.799) (Table 2). Regression equations
for dental age estimation for each of the two methods are summarised
in Table 2. Steiger's Z-test results showed significant difference in the
correlation values between both methods of volumetric analysis
(P = .0049).
Based on the gender, Pearson correlation analysis indicated a sig-
nificant inverse association between pulp/tooth volume ratio and
chronological age for both methods of volumetric analysis (p < .01).
The relationship between chronological age and pulp/tooth volume
ratio based on gender was plotted for each of the two methods of vo-
lumetric analysis (Fig. 10 and 11). However, Fisher Z test results
showed no significant difference in the correlation coefficient values
between genders for both methods of volumetric analysis (Z critical
1.96 for p < .05) (Table 3). The equation used to calculate the sig-
nificance of difference in correlation coefficients between male and
female is given below.30
First, correlation coefficient values are converted to z score:
r = 1/2 ln [1 + r / 1 − r ]
(“ln ” is the natural logarithm function)
(“r ” is the correlation coefficient)
56
Journal of Forensic and Legal Medicine 54 (2018) 53–61
Fig. 3. Pulp cavity and tooth ‘Region growing phase’ on
sagittal view.
The Z-test is computed as:
Z (obs ) = Z 1–Z 2 / √ [1 / (n1 − 3) + 1 / (n2 − 3)]
(Z -critical is 1.96 for p < .05).
(Z1 and Z2 correspond to the correlation coefficients (r )).
(n1 and n2 correspond to sample sizes).
Results of the independent t-test also showed no significant differ-
ence in the mean values of pulp/tooth volume ratio between genders
with both methods of volumetric analysis (Table 4).
4. Discussion
CBCT is an effective and noninvasive diagnostic imaging modality
in clinical dentistry due to its limited radiation exposure and the ability
of producing highly accurate life size images. Image enhancing software
like Mimics can utilise data from CBCT for the 3-dimensional re-
construction of the pulp cavity and calcified tooth structures. It's a
known fact that with advancing age, the size of the pulp cavity reduces
due to deposition of secondary dentin. The present study investigated
this phenomena by employing two different methods to find out which
amongst them provided a higher strength of correlation, i.e. between
chronological age and pulp/tooth volume ratio for dental age estima-
tion. Results of the study showed that the strength of correlation was
higher in Method 2 as compared to Method 1 and the difference in the
correlation values between both methods was statistically significant.
Fig. 4. 3D view of the pulp cavity and maxillary right central incisor
tooth.
M.K. Asif et al.
Fig. 5. ‘Multiple slice editing phase’ on sagittal, coronal and axial view to ensure cut off point at cemento-enamel junction (without any slice by slice manual intervention as in Method 1).
Although both methods show high strength of correlation between
chronological age and pulp/tooth volume ratio, the regression equation
derived from Method 2 should be preferred for dental age estimation.
In this research, only one tooth was selected per individual scan to
avoid bias in the results. Selecting two scans per subject can give biased
results because two similar type of teeth belonging to same individual
have a similar developmental origin. Moreover, scans with voxel size of
0.30 mm were selected in the study to prevent the influence of average
volume sampling on the volumetric measurements when different voxel
sizes were used during the CBCT scanning.32
Someda et al.28 and Agematsu et al.17 reported gender specific re-
sults for mandibular central incisors and a higher correlation values for
females than males. Contrary to their findings, the results of the present
study showed no significant difference in strength of correlation values
between genders based on the Fisher Z-test and Independent samples t-
test. However, the strength of correlation values was slightly higher for
males as compared to females in both methods of volumetric analysis.
57
Journal of Forensic and Legal Medicine 54 (2018) 53–61
With regards to Method 1, some manual intervention was required
in ‘multiple slice editing phase’ of the software at the apical portion of
the root, both for the pulp cavity and apical calcified structures. In
order to nullify any human error the study investigated another method
(Method 2) measured the pulp chamber and tooth volumes (up to ce-
mentoenamel junction). This was without any manual intervention and
wholly dependent on the software. The results of the present study
indicated higher coefficient of determination values for volumetric
analysis of pulp chamber/crown (R2 = 0.78) as compared to the pulp
cavity/tooth (R2 = 0.64). However, in contrast to our study, Someda
et al.28 reported higher coefficient of determination values for the vo-
lumetric analysis of pulp cavity to the whole tooth (Male, R2 = 0.65;
Female, R2 = 0.77) as compared to the crown region alone (Male,
R2 = 0.57; Female, R2 = 0.69). Similarly, Aboshi et al.21 also reported
higher correlation values for coronal one third of the root when com-
pared to volumetric analysis in the crown region alone in mandibular
first and second premolars.
Fig. 6. ‘Region growing phase’ of maxillary central incisor's
pulp chamber and crown up to cementoenamel junction on
axial and sagittal view.
M.K. Asif et al.
Different strength of correlation between chronological age and
pulp/tooth volume ratio have been reported on single rooted teeth in
Belgium,20,27 France26 and Italy.25 Similarly, results in the present
study showed different strength of correlation values as compared to
studies carried on other populations.17–20,33 Thus, the strength of cor-
relation may vary among populations due to different geographical and
racial origins. Therefore, it is mandatory that each population must
have their own regression equation for dental age estimation of their
adult persons.
The results of the present study showed higher strength of correla-
tion between chronological age and pulp chamber/crown ratio for
Method 2 of volumetric analysis. Unlike this study where pulp cavity/
tooth ratios were employed, Zhipu et al.33 just measured pulp cavity
volumes among single rooted teeth and pulp chamber volumes of multi-
rooted teeth. Their study reported lower coefficient of determination
value for maxillary central incisors (R2 = 0.323). Furthermore,
amongst the 13 different types of teeth investigated, the maxillary
second molar (R2 = 0.498) showed the highest strength of correlation
in their study. Their study also reported gender specific results for
dental age estimation. In another study, Zhipu et al.,22 measured the
pulp chamber volumes of first molars alone and reported a coefficient of
determination value of 0.564, which was less than the results in the
58
Journal of Forensic and Legal Medicine 54 (2018) 53–61
Fig. 7. 3D view of the pulp chamber and crown of maxillary
right central incisor.
Fig. 8. Relationship between chronological age
and pulp/tooth volume ratio in maxillary central
incisors for Method 1.
present study (Method 1, R2 = 0.64; Method 2, R2 = 0.78). Their
lower correlation coefficient values may be due to the lack of con-
sideration for the variability in the sizes of teeth studied, which may
have caused disparity in the sizes of the pulp cavities. Findings of this
research indicated that pulp/tooth volume ratio is the valuable pre-
dictor of dental age. Furthermore, Method 2 provided a higher corre-
lation with chronological age and should also be investigated for other
different types of teeth, thereby having more regression equations for
age estimation.
Lastly, during identification of victims in a disaster it is critical to
get the age of the deceased speedily to help in the identification process.
The present study showed that Method 2 was less time consuming (only
30 min) for volumetric analysis when compared to Method 1, which
took 3–4 h due to the demanding manual intervention in the Mimics
software. However, with further improvements in the CBCT technology
and image enhancing software, this method of dental age estimation
can become more precise and accurate as small pulpal structures,
especially in the apical portion of the root might be digitally detectable
and measurable in the future.
M.K. Asif et al. Journal of Forensic and Legal Medicine 54 (2018) 53–61

Fig. 9. Relationship between chronological age

and pulp/tooth volume ratio in maxillary central
incisors for Method 2.

Table 2
Coefficient of correlation (r), coefficient of determination (R2), standard error of the estimate values and regression equations for maxillary central incisors in both methods of volumetric
analysis. (PTV ratio = Pulp/Tooth volume ratio).

Methods of volumetric analysis Coefficient of Correlation (r) Coefficient of Determination (R2) Std. Error of the estimate Regression equation for dental age estimation
‘y’

Method 1 0.799 0.639 8.646 Y = 69.229-(953.04x PTV ratio)

Method 2 0.880 0.775 6.825 Y = 66.180-(884.04x PTV ratio)

Fig. 10. The relationship between chronological

age and pulp/tooth volume ratio for maxillary
central incisors (based on gender) employing
Method 1 for volumetric analysis.

59
M.K. Asif et al. Journal of Forensic and Legal Medicine 54 (2018) 53–61

Fig. 11. The relationship between chronological

age and pulp/tooth volume ratio for maxillary
central incisors (based on gender) employing
Method 2 for volumetric analysis.

Table 3 during the research. We are also thankful to the Ministry of Higher
Pearson correlation, Fishers Z test for both methods based on gender. (p < .01), (Z cri- Education, Malaysia for providing the High Impact Research Grant No:
tical 1.96 for p < .05).
UM.C/625/1/HIR/MOHE/DENT/19 to undertake this research.
Method of volumetric analysis Pearson correlation (r) Fishers Z test
Conflicts of interest
Male Female Z-value P-value
The authors have no conflict of interest to declare.
Method 1 0.851 0.776 1.14 .254
Method 2 0.912 0.885 0.72 .4715
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Table 4
Comparison in the mean values of pulp/tooth volume ratio between genders in both
methods using independent t-test. (P < .05).
Method of volumetric analysis Mean (SD)
Male Female
Method 1 0.029 (0.011) 0.033 (0.012)
Method 2 0.027 (0.015) 0.032 (0.013)
5. Conclusion
This study investigated the relationship between chronological age
and pulp/tooth volume ratio by two different methods of volumetric
analysis for dental age estimation among Malaysian adults. The results
indicated a strong relationship between chronological age and pulp/
tooth volume ratio for both methods. However, volumetric analysis in
Method 2 (pulp chamber/crown volume ratio) gave higher strength of
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