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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 4  |  Page : 238-247

Validation of Kvaal's and Cameriere's methods of age estimation in people of Marathwada origin


1 Department of Conservative Dentistry and Endodontics, Saraswati-Dhanwantari Dental College and Hospital and Post-Graduate Research Institute, Parbhani, Maharashtra, India
2 Department of Oral Medicine and Radiology, Saraswati-Dhanwantari Dental College and Hospital and Post-Graduate Research Institute, Parbhani, Maharashtra, India
3 Department of Conservative Dentistry and Endodontics, Dental College, Rohtak, Haryana, India
4 Department of Oral Pathology and Microbiology, KLR’s Lenora Institute of Dental Sciences, Rajahmundry, Andhra Pradesh, India
5 Department of Oral Medicine and Radiology, KLR’s Lenora Institute of Dental Sciences, Rajahmundry, Andhra Pradesh, India

Date of Web Publication11-Oct-2017

Correspondence Address:
Abhishek Singh Nayyar
44, Behind Singla Nursing Home, New Friends’ Colony, Model Town, Panipat - 132 103, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_22_17

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  Abstract 

Context: Aging, in forensic context, is necessary both for the dead and the living. Kvaal et al. introduced a method of age estimation by indirectly measuring secondary dentin deposition on radiographs. Cameriere et al., later, put forth a method based on radiographic estimation of pulp/tooth area ratio (AR) in specific teeth of the dentition. Aim: The purpose of the present study was to assess the validity of Kvaal's and Cameriere's methods of age estimation in a specific populace of Marathwada origin. Materials and Methods: A total number of 110 patients aged between 15 and 75 years were selected and the variables P = complete pulp length/root length (from enamel-cementum junction [ECJ]-root apex), r = complete pulp length/complete tooth length, a = complete pulp length/root width at ECJ level, b = pulp/root width at midpoint level between ECJ level and mid-root level, and c = pulp/root width at mid-root level; and pulp/tooth AR were recorded as devised in Kvaal's and Cameriere's methods of age estimation, respectively. Statistical Analysis: Statistical analysis was performed with SPSS (version 10.5) package. Mean comparison of morphological variables was carried out using Student's t-test. Intra- and inter-observer reproducibility of measurements was studied using the concordance correlation coefficient. Results: Of all the morphological variables, variables P, r, mean (M), length (L), and pulp/tooth AR of Kvaal's and Cameriere's methods correlated significantly with age with variable P correlating the best among them. Conclusion: Variables associated with width ratios rather than length ratios of Kvaal's and Cameriere's methods correlated best with chronological age in the populace of Marathwada origin.

Keywords: Age estimation, Cameriere's method, Kvaal's method


How to cite this article:
Das M, Nayyar AS, Punhani N, Puri H, Rohilla R, Chalapathi K V, Babu B A. Validation of Kvaal's and Cameriere's methods of age estimation in people of Marathwada origin. CHRISMED J Health Res 2017;4:238-47

How to cite this URL:
Das M, Nayyar AS, Punhani N, Puri H, Rohilla R, Chalapathi K V, Babu B A. Validation of Kvaal's and Cameriere's methods of age estimation in people of Marathwada origin. CHRISMED J Health Res [serial online] 2017 [cited 2017 Oct 17];4:238-47. Available from: http://www.cjhr.org/text.asp?2017/4/4/238/216466


  Introduction Top


Aging refers to irreversible and inevitable changes that occur with time, which encompass all aspects of human life, namely, anatomic, physiologic, and psychological.[1] Aging, in forensic context, is necessary both for the dead and the living.[2] Although several parts of the body can be used for age estimation, the poor condition of the remains, particularly, in severe crashes or fires in cases of those recently dead or of moisture and burial conditions in cases of historic subjects, make many parts of the body unusable.[3] Despite these problems, in the past few years, the literature has provided several skeletal and dental methods for assessing age. Most of them apply many age indicators related to degenerative changes in the skeleton.[4] Teeth can survive, in most of the conditions, encountered at death and during decomposition, even when the body is exposed to extreme forces and temperatures. Thus, they can serve as reliable biomarkers of aging. It is, also, observed that tooth development is not perceptibly affected by diseases, drugs as well as the endocrine status as compared to the bones, consequently making them the preferred tissue in forensic investigations.[5] In the past few decades, forensic odontology has shown increasing interest in search for age estimation methods in individuals using dental tissues/teeth as evidence. These methods are broadly classified as morphologic and radiologic methods. The former is further subclassified as clinical, histologic, and biochemical methods which include methods analyzing the various forms of tooth modification such as the various age-related regressive alterations of the teeth including attrition, abrasion, erosion, and abfraction, dentin transparency, tooth cementum annulations, racemization of aspartic acid, and apposition of secondary dentin.[3] However, all these methods have one or the other limitation restricting their usage on a mass scale. Furthermore, radiography, being a nondestructive method, plays a vital role in forensic investigations to uncover the hidden facts. Dental examination and comparison between antemortem and postmortem dental records and radiographs produce results with a high degree of reliability and relative simplicity.[6],[7] Radiographic age estimation, using teeth, relies on the developmental stages of teeth, especially, in children, whereas in adults, continuous deposition of secondary dentin, depicted by reduction in pulp area, is used for the estimation of age. A number of methods employed in age estimation using teeth are destructive, thereby limiting their use in the living individuals.[8] Forensic radiography, thus, plays an important role in such cases.[9] Dental pulp is a mesenchymal tissue enclosed in dentin and surrounded by numerous odontoblastic processes which release dentin during life and reduce the size of the pulp area; changes in which are the best morphometric indicators for estimating age in adult participants being a continuous process that takes place throughout the life of an individual. This apposition of secondary dentin can be indirectly measured by the reduction in pulp area on the radiographs. In 1925, Bodecker established this apposition of secondary dentin and reduction in the pulp area on radiographs as reliable indicators in the estimation of age in an individual.[10] Kvaal et al.,[6] later, introduced a method of age estimation by indirectly measuring secondary dentin deposition on the radiographs indicating a number of width and length (W-L) variables of the tooth and pulp while Cameriere et al.[7] put forth a method based on the radiographic estimation of pulp/tooth area ratio (AR) in specific teeth of the dentition. The purpose of the present study was to assess the validity of Kvaal's and Cameriere's methods of age estimation in a specific populace of Marathwada origin.




  Materials and Methods Top


Source of data

A total number of 110 patients, 59 males and 51 females, aged between 15 and 75 years, were selected from the outpatient department and were divided into seven groups (Group I-VII). Group I consisted of 15 patients with age between 15 and 20 years, Group II (age 20–30 years) with 47 patients, Group III (age 30–40 years) with 23 patients, Group IV (age 40–50 years) with 15 patients, Group V (age 50–60 years) with three patients, Group VI (age 60–70 years) with four patients, and Group VII (age 70–75 years) with three patients. The permission to conduct the present study was obtained from the Institutional Ethics Committee. All the patients gave informed consent before being included in the study.

Selection criteria

Inclusion criteria

  1. Patients aged between 15 and 75 years
  2. The selected teeth were the right or left maxillary central incisor, lateral incisor, and second premolar and right or left mandibular lateral incisor, canine, and first premolar which had fully erupted into the oral cavity
  3. The roots of the teeth were fully formed
  4. Individuals were of ethnic origin from Marathwada (history confirmed up to two generations).


Exclusion criteria

  1. Teeth with any pathology such as caries or periodontitis or periapical lesions that would alter the surface area of the tooth
  2. Teeth with any prosthetic rehabilitations and orthodontic appliances
  3. Fractured teeth
  4. Severely attrited teeth secondary to parafunctional habits
  5. Teeth with any developmental anomalies.


After clinical examination, patients who fitted into the inclusion criteria were subjected to digital intraoral periapical radiographs (IOPARs).

Methodology

Digital intraoral periapical radiographs

Patients were selected according to the decided inclusion criteria. After selection of the patients, their consent was taken for radiographic examination. All the guidelines were followed as per ALARA principle while subjecting the patients to digital IOPARs. The radiographic examination was carried out with the help of X mind X-ray system, 70 kv, 8 mA, 0.425 kVA, 2 mm aluminum filter manufactured by SATELEC (India) Private Limited; DIGORA OPTIME DXR-50 5001, Digital Imaging System with Windows 2.8 Digital Imaging Program. PSP Digital Sensor (DIGORA OPTIME DXR-50 5001, Digital Imaging System) with Size 2 sensor (31 × 41) mm and Film holding instrument: RINN-Greene Stabe Disposable Film Holder were used with Auto-CAD 2007 software (Autodesk Inc., San Rafael, CA, USA) for taking digital IOPARs.

Positioning of the patient

For maxillary teeth, the patient's head was positioned upright with the sagittal plane vertical and the occlusal plane horizontal, while, for mandibular teeth, the patient's head was tilted back slightly to compensate for the change in occlusal plane, when the mouth was opened.

Measurement of Teeth by Kvaal's method [Figure 1]: The following morphological variables were recorded by Kvaal's method:
Figure 1: Measurement of variables by Kvaal's method

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  • P = complete pulp length/root length (from enamel-cementum junction [ECJ]-root apex)
  • r = complete pulp length/complete tooth length
  • a = complete pulp length/root width at ECJ level
  • b = pulp/root width at midpoint level between ECJ level and mid-root level
  • c = pulp/root width at mid-root level.


Measurement of teeth by Cameriere's method [Figure 2]: Pulp/tooth AR was recorded.
Figure 2: Measurement of variable by Cameriere's method

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Measurements were made by a second observer to prevent any interobserver bias. The morphological variables, chronological age, and participant's gender were entered in a Microsoft EXCEL spreadsheet for use as predictive variables for age estimation. Correlation coefficients were evaluated between chronological age and morphological variables. Estimated age was obtained using morphological variables for each tooth.

Statistical analysis

The statistical analysis was carried-out using SPSS (Statistical Package for Social Sciences) version 10.5, SPSS Inc., Chicago, USA. Mean comparison of morphological variables was carried out using Student's t-test. Intra- and inter-observer reproducibility of measurements was studied using the concordance correlation coefficient.


  Results Top


The chronological age of adults was estimated based on the measurements of the different said variables of the various teeth including maxillary central incisor, lateral incisor, and second premolar and mandibular lateral incisor, canine, and first premolar which were numbered 1–6, respectively, on images of digital intraoral radiographs from derived regression equations. The demographic data of the patients are presented in [Table 1] and [Graph 1]. There was no significant difference observed between morphological variables among the males and females indicating gender did not influence the estimation of chronological age [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], In tooth #4 (mandibular lateral incisor), however, morphological variables, b and width (W), showed a weakly positive correlation between gender and chronological age [Table 7]. Comparison of the readings of the two observers did not reveal any statistical significance [Table 8]. Karl Pearson's correlation coefficients between age and morphological variables showed that the variables P, r, mean (M), length (L), and pulp/tooth AR correlated significantly with age with variable P correlating the best among them. The ratios between width measurements (a, b, and c) correlated the least with age and were not found to be statistically significant and therefore were excluded from further statistical analysis. Variable P had the highest P value of −0.920 for central incisor and −0.951 for mandibular first premolar [Table 9]. The scatter plot graph between predicted age and chronological age showed that the resultant values were equally distributed along the line. Comparing between Kvaal's and Cameriere's methods, results of the latter method were found to be more accurate in the estimation of age. The scatter plot graph between predicted versus chronological age showed better distribution in Cameriere's method than Kvaal's method. ([Graph 2],[Graph 3],[Graph 4]; with [Graph 2] showing comparative analysis between Kvaal's and Cameriere's methods; [Graph 3] for Kvaal's method and [Graph 4] for Cameriere's method) Separate regression equations were derived for each tooth for both the methods. The variables mean (M), P, r, a, b, and c and difference between W-L contributed significantly and were utilized in regression equation for Kvaal's method [Table 10]. Variable pulp/tooth AR contributed significantly to derive the regression equation for Cameriere's method [Table 11]. In Kvaal's method, tooth #6 (mandibular first premolar) correlated best with age with an r2 value of 81.90% and a standard error of the estimate (SEE) in years of 5.889 years followed by tooth #1 (maxillary central incisor) with an r2 = 80.30%, tooth #2 (maxillary lateral incisor) with an r2 = 70.70%, tooth #4 (mandibular lateral incisor) with an r2 = 61.90, tooth #5 (mandibular canine) with an r2 = 47.90%, and tooth #3 (maxillary second premolar) with an r2 = 31.50% [Table 10]. In Cameriere's method, tooth #6 (mandibular 1st premolar) correlated best with age with an r2 value of 93.50% and an SEE of 3.564 years, followed by tooth #1 (maxillary central incisor) with an r2 = 87.90%, tooth #4 (mandibular lateral incisor) with an r2 = 86.30%, tooth #2 (maxillary lateral incisor) with an r2 = 85.50%, tooth #5 (mandibular canine) with an r2 = 85.40%, and tooth #3 (maxillary second premolar) with an r2 = 83.30% [Table 11].
Table 1: Distribution of the study sample by age groups and gender

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Table 2: Comparison of the morphological variables among males and females

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Table 3: Comparison of the morphological variables among males and females

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Table 4: Comparison of the morphological variables among males and females

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Table 5: Comparison of the morphological variables among males and females

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Table 6: Comparison of the morphological variables among males and females

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Table 7: Comparison of the morphological variables among males and females

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Table 8: Comparison of interobserver observations

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Table 9: Correlation between age and morphological variables

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Table 10: Regression equations for age in years based on dental radiographs from six teeth by Kvaal’s method

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Table 11: Regression equations for age in years based on dental radiographs from six teeth by Cameriere’s method

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  Discussion Top


In 1995, Kvaal et al.[6] presented a method for age estimation which was based on investigation of IOPARs while Paewinsky et al.[11] verified the applicability of this method on orthopantomographs. Later, Cameriere et al., in 2004, conducted a preliminary study to evaluate the variations in pulp/tooth AR as an indicator of age and this method of age estimation to be promising.[7] While the authors obtained high levels of accuracy in age estimation, they advised that future research should investigate the effect of race and culture in model parameters. Indeed, other researchers have also advocated the verification of age estimation methods on independent samples and some have concluded that best results are derived when population-specific regression formulas are used. Babshet et al. found that Cameriere's formula, based on the Italian population, is not as applicable to the Indian population as was the case of naive population.[12] The purpose of the present study was to assess the validity of the various width and length variables used in Kvaal's and Cameriere's methods of age estimation in a specific populace of Marathwada origin using digital IOPARs. The study sample included 110 patients aged between 15 and 75 years, only of Marathwada origin with at least last two generations residing in the location of the study. This was done to ensure ethnic uniformity of the study sample, considering that the development of teeth varies among populations and that it is genetically determined. Digital radiography was selected because of less radiation exposure than the conventional film-based radiography. Since Kvaal et al. did not find significant differences between teeth from the left and the right side of the jaw;[6] teeth from either the left or right side were processed depending on whichever were best suited for measurements. Ratios between the teeth and pulp size were calculated. This procedure helped to reduce the effect of the possible variation in magnification and angulation of the intraoral radiographs. The present study revealed that gender had no significant influence on the morphological variables of teeth, except for morphological variables, b and width (W), which showed a weakly positive correlation between gender and chronological age for mandibular lateral incisor, similar to the findings of the studies conducted by Kvaal et al.[6] and Cameriere et al.[7] Few other studies by Jeevan et al.[13] and Cameriere et al.[14],[15] also showed similar results. In the present study, width ratios (a, b, and c) did not show significant correlation with age. Furthermore, there were no significant differences between inter- and intra-observer measurements in the present study, similar to the studies, conducted by Kvaal et al.,[6] Cameriere et al.,[7],[14],[15] Paewinsky et al.,[11] Jeevan et al.,[13] and Zaheer et al.[16] In the present study, Pearson's correlation coefficients between chronological age and morphological variables showed that the variables P, r, length (L), and pulp/tooth AR correlated well with the chronological age. Using Cameriere's method, it was found that the morphological variable pulp/tooth AR contributed significantly to the chronological age estimation in contrast to the findings of the study conducted by Saxena S.[3] Similarly, contrasting results were found with the studies conducted by Kvaal et al.[6] and Bosman et al.[17] which showed better correlation of chronological age with morphological variables associated with width ratios (a, b, and c) rather than length ratios (P and r). The results of the present study were in slight disagreement with the findings of the studies conducted by Meinl et al.[9] and Kanchan-Talreja et al.[18] with the variations observed explained on the basis of the diversity in the ethnicity of the population under study. In the present study, mandibular first premolar correlated best with age for Kvaal's method with an [2] value of 81.90% and a SEE in years of 5.889 which was in contrast with the study conducted by Kvaal et al.,[6] in which maxillary central incisor correlated best with age with an r2 value of 70.00% and an SEE of 9.5 years. The differences in the findings of the present study as against the other studies might be explained on the basis of the regional, cultural, and ethnic variations seen in the populations studied. This is the reason as to why population-specific regression equations are supposed to be kept in mind while arriving at specific conclusions. Comparing the present study with Cameriere et al.[7] study, the study showed better results for mandibular canine with an r2 = 85.40% as compared to an r2 value of 84.90% in the Cameriere's study. Separate linear regression equations were formulated for all teeth because correlation was stronger with individual tooth rather than the mean value of all teeth together in contrast with the study conducted by Kvaal et al.,[6] in which the r2 value was strongest when the mean values (M, W-L) from all the six teeth were included together (r2 value of 76.00%) and weakest when only one type of tooth was considered. The present study also showed statistical difference between chronological age versus predicted age (SEE between 5.889 years and 11.458 years) to be lesser than in Kvaal et al.'s [6] study (SEE between 8.6 and 11.5 years). Based on these variables, chronological age could be determined with an accuracy of 81.90% with Kvaal's and 93.50% with Cameriere's methods.

Limitations of the study

Although the results of the study are promising, it cannot be generalized to other populations;

Rotated teeth, decayed teeth, or teeth with any prosthesis were excluded from the study. If the individual has any of the mentioned conditions, then this method cannot be employed to estimate the age, as these conditions alter the tooth surface area.

Furthermore, regression equations are not always foolproof. Linear regression is a statistical method for examining the relationship between a dependent variable and one or, more independent variables. It provides a functional relationship between two or more related variables with the help of which the unknown values of one variable can easily be estimated or predicted from the known values of another variable. It also provides a measure of errors of estimates made through the regression line. A little scatter of the observed (actual) values around the relevant regression line indicates good estimates of the values of a variable with less degree of errors involved therein. On the other hand, a great deal of scatter of the observed values around the relevant regression line indicates inaccurate estimates of the values of a variable and high degree of errors involved therein. Linear regression, also, provides a measure of the coefficient of correlation between the two provided variables. Despite the above utilities, though, the technique of regression analysis suffers from numerous serious limitations. Linear regression equations assume that the cause and effect relationship between the variables remains unchanged, though, this assumption might not always hold good, and hence estimation of the values of a variable made on the basis of the regression equation may lead to erroneous and misleading results.


  Conclusion Top


Within the limitations of the present study, it could be concluded that of all the morphological variables of Kvaal's and Cameriere's methods, variables P = complete pulp length/root length (from ECJ-root apex), r = complete pulp length/complete tooth length, mean (M), length (L), and pulp/tooth AR correlated significantly with age with variable P = complete pulp length/root length (from ECJ-root apex) correlating the best among them. Furthermore, variables associated with width ratios (a = complete pulp length/root width at ECJ level, b = pulp/root width at midpoint level between ECJ level and mid-root level, and c = pulp/root width at mid-root level) rather than length ratios (P = complete pulp length/root length (from ECJ-root apex) and r = complete pulp length/complete tooth length) correlated best with the chronological age in the populace of Marathwada origin.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Schmeling A, Geserick G, Reisinger W, Olze A. Age estimation. Forensic Sci Int 2007;165:178-81.  Back to cited text no. 1
    
2.
Cunha E, Baccino E, Martrille L, Ramsthaler F, Prieto J, Schuliar Y, et al. The problem of aging human remains and living individuals: A review. Forensic Sci Int 2009;193:1-13.  Back to cited text no. 2
    
3.
Saxena S. Age estimation of Indian adults from orthopantomographs. Braz Oral Res 2011;25:225-9.  Back to cited text no. 3
    
4.
Cameriere R, De Luca S, Alemán I, Ferrante L, Cingolani M. Age estimation by pulp/tooth ratio in lower premolars by orthopantomography. Forensic Sci Int 2012;214:105-12.  Back to cited text no. 4
    
5.
Eckert WG. Introduction to Forensic Science. 2nd ed. Dunfermline, United Kingdom: Better World Books Ltd., CRC Press Inc.; 1997.  Back to cited text no. 5
    
6.
Kvaal SI, Kolltveit KM, Thomsen IO, Solheim T. Age estimation of adults from dental radiographs. Forensic Sci Int 1995;74:175-85.  Back to cited text no. 6
    
7.
Cameriere R, Ferrante L, Cingolani M. Variations in pulp/tooth area ratio as an indicator of age: A preliminary study. J Forensic Sci 2004;49:317-9.  Back to cited text no. 7
    
8.
Schmeling A, Reisinger W, Geserick G, Olze A. Age estimation of unaccompanied minors. Part I. General considerations. Forensic Sci Int 2006;159 Suppl 1:S61-4.  Back to cited text no. 8
    
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Meinl A, Huber CD, Tangl S, Gruber GM, Teschler-Nicola M, Watzek G. Comparison of the validity of three dental methods for the estimation of age at death. Forensic Sci Int 2008;178:96-105.  Back to cited text no. 9
    
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Drusini AG. The coronal pulp cavity index: A forensic tool for age determination in human adults. Cuad Med Forense 2008;14:235-49.  Back to cited text no. 10
    
11.
Paewinsky E, Pfeiffer H, Brinkmann B. Quantification of secondary dentine formation from orthopantomograms – A contribution to forensic age estimation methods in adults. Int J Legal Med 2005;119:27-30.  Back to cited text no. 11
    
12.
Babshet M, Acharya AB, Naikmasur VG. Age estimation in Indians from pulp/tooth area ratio of mandibular canines. Forensic Sci Int 2010;197:125.e1-4.  Back to cited text no. 12
    
13.
Jeevan MB, Kale AD, Angadi PV, Hallikerimath S. Age estimation by pulp/tooth area ratio in canines: Cameriere's method assessed in an Indian sample using radiovisiography. Forensic Sci Int 2011;204:209.e1-5.  Back to cited text no. 13
    
14.
Cameriere R, Cunha E, Sassaroli E, Nuzzolese E, Ferrante L. Age estimation by pulp/tooth area ratio in canines: Study of a Portuguese sample to test Cameriere's method. Forensic Sci Int 2009;193:128.e1-6.  Back to cited text no. 14
    
15.
Cameriere R, Ferrante L. Canine pulp ratios in estimating pensionable age in subjects with questionable documents of identification. Forensic Sci Int 2011;206:132-5.  Back to cited text no. 15
    
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Jaklin ZF, Atef I, Reffat S. Age estimation from pulp/tooth area ratio in maxillary incisors among Egyptians using dental radiographic images. Forensic Sci Int 2001;18:62-5.  Back to cited text no. 16
    
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Bosmans N, Ann P, Aly M, Willems G. The application of Kvaal's dental age calculation technique on panoramic dental radiographs. Forensic Sci Int 2005;153:208-12.  Back to cited text no. 17
    
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Kanchan-Talreja P, Acharya AB, Naikmasur VG. An assessment of the versatility of Kvaal's method of adult dental age estimation in Indians. Arch Oral Biol 2012;57:277-84.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]



 

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