Forensic Science International 204 (2011) 209.e1–209.

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Forensic Science International

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Forensic Anthropology Population Data

Age estimation by pulp/tooth area ratio in canines: Cameriere’s method

assessed in an Indian sample using radiovisiography
M.B. Jeevan, Alka D. Kale, Punnya V. Angadi *, Seema Hallikerimath
Department of Oral Pathology and Microbiology, KLEVK Institute of Dental Sciences and Hospital, Belgaum 590010, Karnataka, India

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

Article history: Age estimation of an individual whether living or dead is an intimidating task in forensic investigations.
Received 20 April 2010 Since teeth are more resistant to most peri- and post-mortem changes, they are frequently used for
Received in revised form 13 August 2010 identification and age estimation when skeletal remains are in poor condition. However, most methods
Accepted 25 August 2010
are destructive and warrant extraction of teeth which is not feasible in living individuals. Cameriere’s et
Available online 24 September 2010
al. put forth a radiographic method of age estimation by pulp to tooth area ratio (AR) in canines and
revealed a linear regression between age and the AR. In the present study, we estimated the AR in 456
Keywords:
canines (upper, lower and both) in an Indian sample (114 males and 114 females) using radiovisiography
Pulp/tooth area ratio
Canines
technique. Linear regression equations were derived for upper canine, lower canine and both using the AR
Radiovisiography to estimate chronological age. Additionally, the efficacy of these equations was also evaluated in younger
Indians age group (<45 years). The formulas derived, i.e., age = 96.795  513.561x1 (Eq. (1)) for upper canine,
Age estimation age = 88.308  458.137x2 (Eq. (2)) for lower canine and age = 99.190  283.537x1  306.902x2 +
Regression analysis 400.873x1x2 (Eq. (3)) for both the canines were applied to predict the chronological age. The mean
Forensic anthropology population data value of residuals using these regression equations ranged from 4.28 to 6.39 years with upper canine
equation generally giving a precise result. When these equations were applied for younger ages (<45
years), the regression equation derived from both canines gave a better result (mean residual 2.70 years).
Overall these equations were better able to predict the age in younger ages, i.e., up to 45 years.
ß 2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction the preferred tissue in forensic and archeological investigations

Age estimation of an individual whether living or dead is an
intimidating task in forensic investigations. This helps in both civil
as well as criminal cases like in consent, juvenile offenders,
kidnaps, rape, marriage, attainment of majority, competency as a
witness, senior citizen concession, retirement benefits, etc.
Additionally, it plays an important role in establishing a profile
of a dead person [1–3].
The common indicators used are bone maturation, secondary
sex characteristics, height, weight, etc. Recently, the dental
maturation indicator system has gained impetus as a valuable
index for age estimation [2,4].
Teeth are the hardest structures in the human body resistant to
different external influences, as well as mechanical, chemical and
thermal insults. The specific composition and shape are a source
for many different hereditary and acquired characteristics. Thus,
they can serve as biomarkers of aging. It is also observed that tooth
development is not perceptibly affected by diseases, drugs,
endocrine status as compared to bone, consequently making them
* Corresponding author. Tel.: +91 9880845530; fax: +91 0831 2470640.
E-mail address: punnya_angadi@rediffmail.com (P.V. Angadi).
[5–7].
Dental age estimation is based on morphological, histological,
biochemical and radiological assessment of teeth. However, most
methods are destructive and warrant extraction of teeth which is
unethical and not feasible in living individuals. This makes
utilization of radiographic methods for age estimation a practical
method especially in living individuals as it is a simple,
nondestructive and a reliable method. Moreover, it can also be
used in dead persons as well as in skeletal remains [6].
Radiographic age estimation using teeth rely on developmental
stages of teeth especially in children while in adults; the
continuous deposition of secondary dentin throughout life
depicted by reduction in pulp area can be employed [4–8].
Kvaal et al. [8,10,11] introduced an age estimation method by
indirectly measuring secondary dentine deposition on radiographs
and proposed a number of length and width measurements of
tooth and pulp. Cameriere’s et al. later put forth a similar method
based on radiographic estimation of pulp to tooth area ratio (AR) in
canines. Canines are favored teeth as they are single rooted with
largest pulp area for ease of analysis. In addition, they are
frequently present in older age groups and have less chance for
wear as compared to other anterior teeth. Cameriere’s et al. used
this method on Italians, Portuguese as well as on Skeletal remains

0379-0738/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.forsciint.2010.08.017
209.e2 M.B. Jeevan et al. / Forensic Science International 204 (2011) 209.e1–209.e5

in Italy and state that the actual age can be reliably predicted with Table 1
Age and gender distribution of the study groups.
minimal variance from estimated age in the range of 2.58–5.4
years [12–16]. Group Age (years) No. of males No. of females
They have used intra-oral periapical radiographs and orthopan- Group I 16–30 60 52.6% 50 43.8%
tomographs for this purpose which were later digitalized and used Group II 31–44 35 30.7% 42 36%
for analysis of pulp to tooth area ratio [12–16]. However, use of Group III 45–58 14 12.3% 19 17.6%
advanced radiographic techniques like radiovisiography offer better Group IV 59–72 05 4.4% 03 2.6%
Total 114 100% 114 100%
advantages like reduced radiation exposure, repeatability, precision
and minimal time. When used along with computer aided image
analysis, it can assist in elimination of inter-observer bias to get
improved accuracy, reliability and reproducibility [17,18]. Table 2
Pearson’s correlation between age and predictive morphological variable (AR).
The present study sought to assess the Cameriere’s method in
an Indian sample by evaluating the pulp/tooth ratio in canines Tooth r p
using radiovisiography to establish a population specific formula Upper canine 0.807 <0.000
for age assessment. Lower canine 0.745 <0.000
Both upper and lower canines 0.995 <0.001

2. Materials and methods

The sample consisted of 240 subjects (120 males and 120 females) of Indian
origin in the age range of 16–72 years. They were divided into four groups each with
an interval of 14 years (Table 1).
Canines which were free from caries or any other pathologic changes like
attrition, abrasion, fracture, impaction, not endodontically treated were chosen and
radiovisiography was performed after informed verbal consent. The exposure
factors were kept at 7 mA, 70–74 kVp with a KODAK 5000 Radiovisiography.
The radiovisiographic images of canine (RIC) were processed using a Adobe
Photoshop CS3. Using the magnetic lasso tool (L) provided in this program, the
outline of the canine and its pulp chamber were traced on the radiovisiographic
image. After completion of the tracing, the program displayed the area of the tooth
and its pulp chamber. Later, we derived the morphological variable, i.e., pulp/tooth
area ratio (AR).
3. Statistical analysis
For each individual, pulp/tooth area ratio (AR) was measured on
upper canine (X1), lower canine (X2) and both the canines (X1X2).
The chronological/actual age was noted by subtracting date of birth
from the date of radiograph. All the measurements were carried out
by the same observer. To test intra-observer reproducibility, a
random sample of 20 radiovisiographs were re-examined after an
interval of 1 week. The morphological variables (AR), age and the
subject’s gender were entered in Microsoft 2007 EXCEL spread sheet
and analyzed for use as predictable variables for age estimation. The
correlation coefficients were evaluated between age and predictive
variables. Pearson correlate coefficient was done to demonstrate any
difference in the morphologic variables in relation to sex. A
regression model for age prediction for Indians was developed
and applied to our sample. Statistical analysis was performed with
Statistical Package for the Social Sciences software (SPSS version 16).
4. Results
Out of 240 subjects studied, 12 subjects showed irregular and
double pulp chamber which were excluded from the study. Thus, a
total of 456 teeth from the remaining 228 subjects were analyzed
which included both upper and lower canines.
There were no statistically significant intra-observer differ-
ences noted on the measurements carried out on the re-examined
radiovisiographs (p = 0.49).
Morphological variables for all 114 males and 114 females were
noted. Pulp to tooth area ratio (AR) for males in the upper canine
ranged from 0.064 to 0.171, 0.064–0.194 for lower canine and
overall it ranged from 0.064 to 0.194. AR for females in the upper
canine ranged from 0.072 to 0.192, 0.064–0.165 for lower canines
and overall it ranged from 0.064 to 0.192. To test the difference
between male and female AR of canines, the unpaired ‘t’ test was
done. The upper canine revealed a p value of 0.491 and for lower
canine was 0.095 both of which were statistically not significant
suggesting that gender did not have any effect on the morphologi-
cal variables (AR).
To assess the nature and degree of relation of morphological
variables, i.e., pulp to tooth area ratio (AR) with actual age as given
by subjects, Pearson’s correlation coefficient was done (Table 2). It
was found that all the morphological variables were significantly
correlated with age and have an inverse relation with each other.
A regression model was developed for all the subjects in our
study for AR and age to predict the chronological age (Table 3)
which demonstrated the regression coefficients of all morphologi-
cal variables to be highly significant (p = 0.000).
The regression model utilizing AR from Table 3 yields the
following linear regression formula (Table 4) to predict the
chronological age when only upper canine is used.
age ¼ 96:795  513:561x1 (1)
When only the lower canine is considered, the regression equation
is written as
age ¼ 88:308  458:137x2 (2)
and when both upper and lower canines are used, the formula for
age prediction is
age ¼ 99:190  283:537x1  306:902x2 þ 400:873x1 x2 (3)

Table 3
Regression analysis predicting chronological age using canines.

Group Effects Regression coefficient Standard error t value p value

Upper canine Intercept 96.795 1.007 96.076 0.000

x1 513.561 7.899 65.013 0.000
Lower canine Intercept 88.308 0.829 106.538 0.000
x2 458.137 6.575 69.680 0.000
Both upper canine and lower canine Intercept 99.190 3.182 31.168 0.000
x1 306.902 31.722 9.675 0.000
x2 283.537 31.727 8.937 0.000
x1x2 400.873 220.332 1.819 0.071
 [(Fig._3)TD$IG]
M.B. Jeevan et al. / Forensic Science International 204 (2011) 209.e1–209.e5 209.e3

Table 4
Regression model utilizing predictor variables for predicting chrono-
logical age.

Category Prediction of age

Upper canine Eq. (1)

Lower canine Eq. (2)
Both upper and lower canine Eq. (3)

Table 5
The actual and predicted ages with the mean of absolute values of the residual.

Category Upper canine Lower canine Both

Total sample 4.28117 6.39654 4.78809

Groups I and II 3.40582 3.13193 2.70441

The bolds and italics values represent the best predictive variables for age
estimation.

Table 5 depicts the residual standard errors on obtaining the

Fig. 3. Graph of predicted versus actual age with pulp-tooth area ratio of both upper
predicted age using the regression formula for the overall sample.
and lower canine.
Additionally, when the regression was applied to Group I and
Group II together (16–44 years) which formed the majority of the
sample, a superior prediction was obtained as compared to the
overall sample (Table 5). The actual versus predicted age on the data reasonably well with only a few observations outside the
regression plot shows that the regression model fits the trend of boundary (Figs. 1–3).
[(Fig._1)TD$IG]
5. Discussion

Age estimation forms an important aspect in establishing a

profile in forensic investigations. Although several parts of the body
can be used for age estimation, the poor condition of the remains
often prevents their use [19–21]. In particular, crashes and fires in
the case of the recently dead, dampness and burial conditions in the
case of elderly subjects make many parts of the body unusable. Since
teeth are more resistant to most peri- and post-mortem changes,
they are most frequently used for identification and age estimation
when skeletal remains are in poor condition. In addition, teeth can be
examined clinically and radiographs prepared with minimal
radiation exposure in living individuals [22–24]. There are several
methods in age estimation, but most are destructive warranting
extraction of teeth [6,25,26]. Apposition of secondary dentin is an
important parameter as age estimation as it is a continuous process
throughout life [27]. This can be indirectly measured by the
reduction in pulp area in the radiographs.
Fig. 1. Graph of predicted versus actual age in Upper canine.
Cameriere et al. have demonstrated a radiographic method of age
[(Fig._2)TD$IG] estimation which uses the ratio of pulp area in relation to tooth area.
They revealed a linear regression between age and the AR ratio in
canines. Having published four papers on this method studied on
Italian subjects as well as on skeletal remains; they have demon-
strated that the median of absolute value of the residual errors
between actual age and estimated age was usually less than 4 years.
Periapical X-rays and orthopantomographs were used to image the
canines which were then digitalized and used for analysis [12–16].
In the present study, we sought to estimate the AR in canines
(upper, lower and both) in an Indian sample using radiovisio-
graphy. Linear regression equations were derived for upper canine,
lower canine and both using the AR to estimate chronological age.
Additionally, the efficacy of these equations was also evaluated in
different age groups.
The advantages of RVG include first and foremost minimal time
and ease of repeatability as the image is seen immediately on the
computer as compared to traditional radiographs which require
developing X-rays. Additional, advantages include less radiation
exposure, precision, accuracy and reliability. Thus, we endeavored
Fig. 2. Scatter plot of predicted versus actual age using pulp-tooth area ratio of to use this method in our study which overcomes the need for
Lower canine. scanning and digitalization of radiographs [18].
209.e4 M.B. Jeevan et al. / Forensic Science International 204 (2011) 209.e1–209.e5
A total of 228 RVG of upper canines and lower canines were
examined which demonstrated a good intra-observer agreement
(p = 0.49) indicating high reproducibility of the measurements.
This is in accordance with studies by Cameriere et al. [12,14–16]
by digitalizing periapical X-rays in Italian Caucasians as well as on
a Portuguese sample. Similarly, another study using OPG also did
not reveal any statistically significant intra-observer differences
[13].
The present study showed that gender has no significant
influence on the AR ratio of canines. This finding was similar to
studies by Cameriere’s et al. [12–16]. This may be because pulp is
surrounded by dentin all around so external influences like
masticatory stresses, attrition may have minimal influence on the
inner morphology of pulp in both males and females. This appears
to be true regardless of diet as the subjects in our study were from
all over India with varying eating habits.
It has been known that with aging, the pulp cavity gradually
becomes narrower due to secondary dentin deposition [28]. The
amount of secondary dentin deposition is well correlated with
the chronological age and can be measured indirectly on
radiographs [8–10]. The Pearson’s correlation coefficient be-
tween age and AR of upper canine, lower canine and both
canines in the present study too, was significant and correlated
inversely suggesting that AR could be used to determine the
chronological age.
Regression analysis was done and the equations were
obtained to predict the chronological age of the unknown
individuals of Indian origin using the AR ratio of upper canines
(Eq. (1)), lower canine (Eq. (2)) and both (Eq. (3)) similar to the
equations derived by Cameriere et al. [12–16] in their studies. The
variations in the formula in all the studies could be attributed to
the sample size, technique used, and the geographic variation of
the individuals.
In this study, it was found that the regression equation
derived from AR of the maxillary canine correlated with the
subject’s chronological age (4.28 years) as compared to the lower
canines (6.39 years). This was in accordance to a study by
Cameriere’s et al. [16] on Portuguese sample where they
demonstrated maxillary canines (2.37 years) to be more predic-
tive than the lower canines (2.55 years). Additionally, they
developed common regression model for Italian and Portuguese
sample which also demonstrated better results with maxillary
canines (2.68 years) as compared to mandibular canines (2.73
years) [16]. The use of both canines (4.78 years) in our study also
gave a better result as compared to the mandibular canines.
Cameriere’s et al. [12] study on skeletal remains in Italy showed a
better result with use of both the canines in predicting the
chronological age.
In addition, we applied the regression equations derived from
canines on first two groups from 16 to 44 years as they formed the
majority of our sample and derived the chronological age. It was
observed that the regression equations gave better results in
Groups I and II (range 16–44 years) as compared to the overall
sample, suggesting that our formula derived from Indian sample
appears to be more effective in younger age groups, i.e., up to
45 years.
Additionally, it was observed that the regression equation
derived from both canines (Eq. (3)) gave amore precise age
estimate (residuals being 2.70 years) in Groups I and II together as
compared to other two equations (residuals ranging from 3.1 to 3.4
years). While in overall sample, the regression equation derived
from upper canine gave a more accurate result (residuals 4.28
years). Overall however, the regression equation derived using the
AR of upper canines seemed to give a more consistent and precise
results in all the age groups while lower canine showed the
maximum variation in predicting the age.
6. Conclusion
The results of this study confirm the validity of dental
methods for assessing the biologic age to aid the forensic
odontologist to develop a profile of a dead individual as well as
serve in determining age in living subjects. We believe that
population specific formulas are more precise in determining
age in individual subjects, however further research should aim
at involving larger samples which include varying geographic
regions and races to arrive at a common formula. The upper
canines seem to be the ideal candidates for age estimation using
the AR method; however the need to investigate several teeth
like incisors and premolars together to improve age estimation
can also be studied. The present study also demonstrated that
this method gives a more stable age estimate in younger age’s
up to 45 years. This requires corroboration with larger samples
of varying age groups.
Acknowledgements
The first author is thankful to Dr. Deepak Patel for the
suggestion of conduct of this study and Dr. Ashith Acharya, for
providing the articles for this study, Department of Forensic
Odontology, SDM College of Dental Sciences, Dharwad for
providing the articles for this study.
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