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Age estimation from structural changes of teeth and buccal alveolar bone level

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Age estimation from structural changes of teeth and buccal alveolar

bone level
K.K. Koh a, J.S. Tan a, P. Nambiar b, *, Norliza Ibrahim b, Sunil Mutalik c,
Muhammad Khan Asif b
a
Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
b
Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
c
Faculty of Dentistry, International Medical University, Malaysia

a r t i c l e i n f o a b s t r a c t

Article history: Forensic odontology plays a vital role in the identification and age estimation of unknown deceased
Received 9 June 2016 individuals. The purpose of this study is to estimate the chronological age from Cone-Beam Computed
Received in revised form Tomography (CBCT) images by measuring the buccal alveolar bone level (ABL) to the cemento-enamel
28 January 2017
junction and to investigate the possibility of employing the age-related structural changes of teeth as
Accepted 30 March 2017
Available online 1 April 2017
studied by Gustafson. In addition, this study will determine the forensic reliability of employing CBCT
images as a technique for dental age estimation. A total of 284 CBCT images of Malays and Chinese
patients (150 females and 134 males), aged from 20 years and above were selected, measured and stages
Keywords:
Cone-Beam Computed Tomography (CBCT)
of age-related changes were recorded using the i-CAT Vision software. Lower first premolars of both left
Age estimation and right side of the jaw were chosen and the characteristics described by Gustafson, namely attrition,
Gustafson's criteria secondary dentine formation and periodontal recession were evaluated. Linear regression analysis was
Attrition performed for the buccal bone level and the R values obtained were 0.85 and 0.82 for left and right side
Secondary dentin respectively. Gustafson's characteristics were analysed using multiple regression analysis with chrono-
Periodontal recession logical age as the dependent variable. The results of the analysis showed R values ranged from 0.44 to
Buccal bone level 0.62. Therefore it can be safely concluded that the buccal bone level highly correlated with the chro-
nological age and is consequently the most suitable age-related characteristic for forensic age estimation.
© 2017 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

1. Introduction
Age estimation of living and deceased individuals is imperative
in both forensic and clinical work. As there is global increase in
unidentified corpses and skeletons, it is important to ascertain the
identity of a dead person from ethical, legal and criminal
perspectives.1e4 Besides, cases of age estimation in living in-
dividuals have increased recently due to increased migration from
areas of conflict.5 Due to this demand, several skeletal and dental
methods for assessing age have been developed to ascertain the
biological age of an individual and therefore providing an estimate
of his/her chronological age.
However, age estimation from teeth is of particular importance
because they are highly resistant to mechanical, chemical, or
* Corresponding author. Department of Oro-maxillofacial Surgical and Medical
Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur 50603, Malaysia.
E-mail address: phrabha@um.edu.my (P. Nambiar).
physical impacts and time6e8 and thus, aid greatly in forensic
identification work of decomposed remains. It can also be exam-
ined directly in living individuals.9 In recent years, radiographs or
images have become one of the most important and reliable
methods in dental age determination, especially with the more
advanced imaging techniques.10 This includes Computer Tomog-
raphy and Magnetic Resonance Imaging which provide 3-
dimensional view of a human structure. With the introduction of
Cone-Beam Computed Tomography (CBCT), even general dental
practitioners were recording their patients' dentition in their own
dental clinics.
In 1950, Gustafson became the first to introduce a scientific
method for age estimation using six age-related changes in tooth
structure.11 The six characteristics are regressive changes such as
secondary dentine formation, periodontal recession, attrition, api-
cal translucency, cementum apposition and external root resorp-
tion. Matsikidis et al.12 reported that the characteristics studied by
Gustafson (except apical translucency) in relation to extracted and

http://dx.doi.org/10.1016/j.jflm.2017.03.004
1752-928X/© 2017 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
16 K.K. Koh et al. / Journal of Forensic and Legal Medicine 48 (2017) 15e21

ground teeth can also be determined using dental films. Subse- Table 1
quently, multiple studies have been conducted with different Number of cases per age group.

dental radiographic techniques employing the characteristics Age group Number of subjects
studied by Gustafson to aid in age determination. Olze et al.13 has 20e29 108
carried out an investigation to study the reliability of the charac- 30e39 69
teristics employing dental panoramic tomographs. 40e49 55
Kvaal et al.14 introduced the methods of correlations between 50e59 31
60 and above 21
chronological age and ratios of height and width of teeth and the
TOTAL 284
pulp cavities as measured on dental radiographs for age estimation.
In recent years, Kvaal's method of measuring the ratios of pulp
chamber compared to total tooth length have also been conducted
recommendations suggested by Matsikidis et al.12 with additional
with dental panoramic tomographs15 and microfocus X-ray com-
exclusion criteria for bone level measurements obtained from this
puter tomographs.16 However, the studies on microfocus X-ray
pilot study (Table 2). It was determined from this pilot study that
computer tomograph are of questionable reliability due to the
the lower second premolar had a high degree of variability - such as
limited number of samples and the studies were exclusively on
being missing, impacted and rotated. For this reason, lower first
extracted teeth.
premolars of both left and right side of the jaw were selected as the
Interestingly, Micro-CT is the more detailed imaging procedure
subjects of this study.
with more specific information which enabled quantitative evalu-
Although 300 CBCT scans were selected from the database, only
ation of tooth from a three-dimensional view. Vandevoort et al.17
284 images were suitable as they fulfilled the selection criteria. The
described a method that uses the three-dimensional measure-
registration number, gender, race, date of birth and date when the
ments by performing regression analysis for the relationship be-
images were taken were recorded. Measurements were carried out
tween age and the volume ratio of the pulp cavity in different types
by two different observers. Data obtained were recorded and sta-
of single-rooted teeth. In addition, Aboshi et al.18 reported a method
tistically analysed using SPSS 12.0.1 software for Windows.
based on the calculation of ratio of the three-dimensional volume
Gustafson's criteria of attrition, secondary dentine formation
of the pulp chamber compared to the total tooth of lower premolars
and periodontal recession were measured by slicing the images
using microfocus X-ray computed tomography.
sagitally in the centre of the tooth and classified in accordance to
Maret et al.19 have reported the possibility and utilization of
the stages reported by Olze et al.13 Figs. 1e3 show the images for
CBCT machine in age determination. They proved that with the
each stage mentioned below:
help of CBCT images, multiple regression analysis was performed -
including quantitative volumetric measurement of various parts of
Attrition
each tooth were useful significant variables for dental age estima-
Stage 0: No attrition
tion in living subjects. Multiple regression analysis requires a
Stage 1: Beginning attrition with loss of cusp tips
constitution of a large sample sizes and this is possible with CBCT
Stage 2: Attrition reaching into dentine
images.
Stage 3: Attrition reaching into dentine with opening of pulp
This present study investigated the use of CBCT as a modality in
cavity
forensic age determination based on measurement of buccal bone
Secondary dentine formation
level to cemento-enamel junction. Buccal bone level is an impor-
Stage 0: Pulp horn reaches to above crown equator*
tant characteristic for age estimation as it can be measured even in
Stage 1: Pulp horn reaches at maximum to crown equator*
decomposed bodies. Besides that, this study also reassessed
Stage 2: Pulp horn exceeds enamel-cementum boundary and
whether the characteristics described by Gustafson, namely attri-
falls short to crown equator*
tion, secondary dentine formation and periodontal recession can be
Stage 3: Pulp horn reaches at maximum to enamel-cementum
used appropriately for forensic age estimation employing this
boundary
scanning modality images.
*crown equator refers to the mid-point of crown length
measured from cervical line to the highest cusp tip.
2. Materials and methods
Periodontal recession
Stage 0: No periodontal recession
The design of this study was a retrospective cross-sectional
Stage 1: Periodontal recession into cervical root third
study of CBCT images obtained from the Oral and Maxillofacial
Stage 2: Periodontal recession into middle root third
Imaging Division, Faculty of Dentistry, University of Malaya. One
Stage 3: Periodontal recession into apical root third
hundred and fifty female and 134 male images of Malays and
Chinese were selected from the database (recordings) in the i-CAT
Bone level measurements were carried out by slicing the images
imaging system (Imaging Sciences International Inc. Hatfield, PA,
USA). All images were taken following a standardized protocol for
patient positioning, exposure parameter setting (120 kVp, 3e7 mA,
Table 2
20 s) and image acquisition at 0.3 mm voxel size. The scans were
Exclusion criteria according to Matsikidis et al.12 with additional criteria for bone
from the year 2007e2014 and the images obtained were manipu- level.
lated with the i-CAT Vision software. Table 1 shows the number of
CL F C P RF IF R IM AE
cases per age group. The investigation protocol described herein
was approved by the Ethics Committee of Faculty of Dentistry, AT X x x
SE x X x x x x x
University of Malaya (Reference number: DF DP1402/0040(U)).
PE x x x
A pilot study of 20 randomly selected CBCT images were carried BL x x x x x x
out where the lower premolars were assessed with regard to the
C crowned tooth or bridge abutment, F filling, partial crown or inlay, P post and core
position of buccal bone level, characteristics of attrition, secondary restoration, CL carious lesion, RF root filling, IF infected tooth, IM impacted tooth, R
dentine formation and periodontal recession. The exclusion criteria retained root, AE apicocectomy, AT attrition, SE secondary dentine formation, PE
for each characteristic described by Gustafson were drawn from the periodontal recession, BL bone level.
 K.K. Koh et al. / Journal of Forensic and Legal Medicine 48 (2017) 15e21 17

Fig. 1. Stage classification to determine degree of attrition.

Fig. 2. Stage classification to determine degree of secondary dentine formation.

Fig. 3. Stage classification to determine degree of periodontal recession.

coronally and measurements were made from cemento-enamel
junction to the highest point of buccal bone. Fig. 4 illustrates how
the measurements were recorded from the images.
2.1. Statistical analyses
The correlation between chronological age and individual
characteristics were studied with the aid of Multiple Regression
Analysis (MRA) and Linear Regression Analysis (LRA). Chronological
age and individual characteristics formed the dependent and in-
dependent variables respectively. Stepwise method was used to
ensure that only influencing variables were included in the model
for MRA.
LRA was used to analyse both Gustafson's characteristics and
bone level. However, MRA was employed only for Gustafson's
characteristics. Pearson correlation was used to determine whether
the value obtained from the left premolar is comparable to the
value obtained from the right premolar. The strength and accuracy
of the data in determining chronological age were studied with
Pearson's correlation coefficient, R and coefficient of determination,
R2. R measures the strength and the direction of a linear relation-
ship between two variables while R2 explain how well the regres-
sion line obtained represents the data.20
Meanwhile, potential multicollinearities between the indepen-
dent variables in MRA were determined by studying the Variance
Inflation Factor (VIF). In MRA, it is important to ensure that one
independent variable is not affecting another independent variable
and for this study, VIF value of more than 4 is considered to be
critical multicollinearity.13
The inter-observer reliability and intra-observer reliability for
18 K.K. Koh et al. / Journal of Forensic and Legal Medicine 48 (2017) 15e21

Fig. 4. Bone level measurement.

the characteristics of attrition, secondary dentine formation and

periodontal recession were studied by k-statistics while bone level
reliability was determined by concordance correlation coefficient.

3. Results

The statistical analyses performed showed that there were no

significant intra-observer and inter-observer differences in the 20
randomly selected images which were re-evaluated. Data obtained
shows high correlation level of 98% among both observers. Pear-
son's Correlation (Table 3) shows that the value obtained from the
right side of jaw is positively correlated with the left side of jaw.
However, left side is more highly correlated to the chronological
age.
Fig. 5 and Fig. 6 show the linear graph of chronological age in
relation to buccal bone level. From the graphs, it is observed that
bone levels measured for the younger age group (from 20 to 40
years of age) showed less dispersion from the linear line compared
to older age group. Interestingly, the buccal bone level measured
increased linearly with advancing age.
The formula obtained for dental age estimation based on the
characteristics of buccal bone level, attrition, secondary dentine
formation and periodontal recession were presented in Table 4 and
Table 5 respectively. R value for attrition alone is higher compared
to the one in MRA. Interestingly, the characteristic of attrition
seems to be a stronger predictor of age when compared to sec-
ondary dentine, periodontal recession and also when all three
characteristics were combined. The value of R obtained for Gus-
tafson's characteristics ranged from 0.44 to 0.62. The R value ob-
tained from buccal bone level was of the highest with value 0.85
and 0.82 for left and right side respectively.

Fig. 5. Linear graph of chronological age versus buccal bone level (left).
4. Discussion

The CBCT images included in this study were taken from pa- was that, all these subjects represent a “normal population”.
tients' database in the Faculty of Dentistry, University of Malaya However, the “lower-socioeconomic group” might be over-
who had agreed to the scanning procedure. The assumption made represented as patients visiting this government-based dental

Table 3
Pearson's correlation of value obtained from buccal bone level (left) and buccal bone level (right).

Age Buccal Bone Level (Left) Buccal Bone Level (Right)

Age 1.000 0.816 0.797

Buccal Bone Level (Left) 0.816 1.000 0.936
Buccal Bone Level (Right) 0.797 0.936 1.000
 K.K. Koh et al. / Journal of Forensic and Legal Medicine 48 (2017) 15e21 19

degree of variability such as being congenitally missing, extracted

for orthodontic treatment or simply malpositioned.14 Thus, only the
Age
lower first premolars were assessed as this is the most stable
premolar.
Results obtained from the Gustafson's criteria of attrition, sec-
ondary dentine formation and periodontal recession were not
Observed
90 highly correlated with chronological age as the value of the corre-
Linear
lation coefficient, R ranged from 0.44 to 0.62. This value of R was
lower from the results obtained by Olze et al.13 as they recorded R
80 value of 0.65e0.73 after evaluating dental panoramic tomographs
(DPT). The lower correlation in CBCT may be due to the problem
with “slicing” of the image (0.3 mm voxel size) where there is a
70
possibility of variability in the area of the tooth being sliced.
Meanwhile, images in DPT were 2-dimensional which do not
require “slicing” of images and thus providing “wholesome”
60
morphology of the tooth comprising all the “slices”. Buccal bone
level was highly correlated with chronological age with R value of
50
0.85 for left side and 0.82 for right side. From the data obtained, it
could be concluded that bone level decreases with advancing age.
This may be due to bone resorption that occurs as we grow older.
40 Besides, passive eruption of teeth will also cause the “readings” for
bone level measured to increase due to attrition of teeth. This
method of age estimation is of particular value as it can be applied
30 to living individuals and dead bodies, where bone level can be
measured directly from the skulls of unidentified bodies if imaging
technology is not available.
20 Gustafson's method, which focuses on six regressive changes
has been modified and evaluated in several studies of extracted
1.00 2.00 3.00 4.00 5.00 teeth21 and as well as radiographs.13 In the present study, only three
Buccal Bone Level-Right (mm) regressive changes (attrition, secondary dentine formation and
periodontal recession) were selected as the other three remaining
changes are not clearly seen on CBCT images. In comparison to
study reported by Olze et al.,13 this present study is able to include
Fig. 6. Linear graph of chronological age versus buccal bone level (right).
stage 3 of attrition and stage 3 of secondary dentine which were not
found in the study employing the dental panoramic tomographs. To
faculty are normally from lower-income group due to inexpensive verify the work done by Olze et al.,13 it may be necessary to
charges. A disparity in the number of patients in each age-group manipulate the premolar image using the Maximum Intensity
was evident as at age 50 years and above there were only 52 pa- Projection (MIP) function in the CBCT machine, so as to obtain
tients while 20 to 29-year-old, there were 108 patents. This is direct volume rendering of this tooth, similar to what was offered
probably because a high number of patients in the older age group on the dental panoramic tomographs.22
have been excluded due to the selection criteria described previ- As one of the advanced modalities in dental imaging, CBCT is
ously. In addition, the patients' dental and medical histories were now an important scanning machine for dental diagnosis and
not reviewed which may have affected the growth of their denti- prognostic evaluation as the images formed were in 3-dimen-
tion. For instance, orthodontic treatment may have actually caused sional.19 In this present study, it is evident that CBCT images are
bone resorption and thus affected the height of buccal bone level useful for dental age assessment as bone level measurement was
measured. highly correlated with chronological age. This supported the pre-
At the beginning of the pilot study, lower premolars (either first diction of Maret et al.19 who predicted the usefulness of this ma-
or second) were evaluated with regard to the characteristics of chine for age-estimation. Yang et al.23 have even reported volume
buccal bone level, attrition, secondary dentine formation and matching of teeth imaged by CBCT for dental age estimation.
periodontal recession. The lower premolars were chosen for their Furthermore, unlike in medicine, where the majority of advanced
increased resistance to destruction when compared to incisors and imaging procedures are performed under the supervision of and
their monoradicular morphology compared to molar teeth.18 As interpreted by board-certified medical radiologists, most CBCT
stated earlier the lower second premolars presented with a high scans in dentistry are performed in-office by dental practitioners.24

Table 4
Multiple Regression Analysis and Linear Regression Analysis for left side of jaw.

Characteristic Formula R R2 Standard error of estimate

Attrition þ Secondary dentin formation þ Periodontal recession (MRA) Age ¼ 32.67 þ 17.24  AT þ 4.41  SE þ 5.40  PE 0.44 0.20 12.46
Attrition (LRA) Age ¼ 29.44 þ AT  25.99 0.53 0.28 11.81
Secondary dentin formation (LRA) Age ¼ 31.30 þ SE  9.15 0.44 0.19 12.49
Periodontal recession (LRA) Age ¼ 27.15 þ PE  16.03 0.49 0.24 12.16
Buccal bone level (LRA) Age ¼ 10.64 þ 13.07  BL 0.85 0.72 7.47

AT stages of attrition, SE stages of secondary dentine formation, PE stages of periodontal recession, BL bone level (mm), R correlation coefficient, R2 coefficient of
determination.
20 K.K. Koh et al. / Journal of Forensic and Legal Medicine 48 (2017) 15e21

Table 5
Multiple Regression Analysis and Linear Regression Analysis for right side of jaw.

Characteristic Formula R R2 Standard error of estimate

Attrition þ Secondary dentin formation þ Periodontal recession (MRA) Age ¼ 33.79 þ 15.30  AT þ 15.21  SE þ 7.74  PE 0.48 0.23 12.12
Attrition (LRA) Age ¼ 28.64 þ AT  23.95 0.62 0.39 10.92
Secondary dentin formation (LRA) Age ¼ 30.06 þ SE  21.29 0.48 0.23 12.19
Periodontal recession (LRA) Age ¼ 27.24 þ PE  19.96 0.57 0.32 11.46
Buccal bone level (LRA) Age ¼ 10.05 þ 13.42  BL 0.82 0.68 7.16

AT stages of attrition, SE stages of secondary dentine formation, PE stages of periodontal recession, BL bone level (mm), R correlation coefficient, R2coefficient of determi-
nation.
Multicollinearities were not present as all VIF values fell below the critical value of 4 (Table 6).

Table 6 staff of the Oral and Maxillofacial Imaging Division, Faculty of

Values of Variance Inflation Factor (VIF). Dentistry, University of Malaya for providing CBCT scans and
VIF assistance in the use of i-CATVision software. The authors are also
AT SE PE
grateful to the biostatistician, Assoc Prof. Dr. Noor Lide Abu Kassim
for her help in performing various statistical analyses. We also are
Left side of jaw 1.042 1.023 1.037
grateful to the Ministry of Education, Malaysia for providing the
Right side of jaw 1.050 1.011 1.057
High Impact Research Grant No: UM.C/HIR/MOHE/Dent/19 to un-
AT stages of attrition, SE stages of secondary dentine formation, PE stages of peri-
dertake this research.
odontal recession.

CBCT technology will therefore, most likely, become a distributed
diagnostic technology with a high degree of penetrance in clinical
dental practice whereby ready availability of the images will be
possible for identification and also further beneficial researches.25
5. Conclusion
From the results of this study, it may be concluded that mea-
surement of buccal bone level from CBCT correlated best with
chronological age. Therefore, buccal bone level is suitable for
forensic age estimation if at least the selection criteria are respec-
ted. Moreover, if imaging technology is not available, forensic age
estimation can be done by direct measurement of bone level on
skulls of unidentified bodies.
6. Limitation
Samples obtained for the older age group were not sufficient
compared to the younger age group. Thus, the results may have to
be used cautiously as an age indicator in the older age group.
Moreover, the quality and geometrical accuracy of CBCT images
must be excellent in order for us to accept the CBCT images for any
further research.
7. Recommendation
Future research with focus on Gustafson's criteria should be
conducted employing Maximum Intensity Projection (MIP) func-
tion of the CBCT for more accurate measurement. We will be
looking into this possibility in order to validate the work done by
Olze et al. (13) to confirm whether “whole tooth” image provides
better correlation to Gustafson's criteria in comparison to sliced
images (measuring at a voxel size of only 0.3 mm) in the centre of
the tooth.
Conflict of interest
The authors have no relevant conflicts of interest to declare.
Acknowledgements
The authors would like to express their sincere thanks to the
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