Journal of Forensic and Legal Medicine 65 (2019) 108–112

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Journal of Forensic and Legal Medicine

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

Research Paper

A cut-off value of third molar maturity index for indicating a minimum age T
of criminal responsibility: Older or younger than 16 years?
Sudheer B. Ballaa,∗, Subramanyeswara S. Chinnib, Ivan Galicc, Aditya Mohan Alwalad,
Pramod Machanie, Roberto Camerieref
a
Department of Forensic Odontology, Panineeya Mahavidyalaya Institute of Dental Sciences, Hyderabad, Telangana, India
b
Consultant Forensic Odontologist, Bangalore, Karnataka, India
c
Departments of Research in Biomedicine and Health, University of Split School of Medicine, Spinciceva 2, 21000, Split, Croatia
d
Department of Oral and Maxillofacial Surgery, MNR Dental College, Sangareddy, Telangana, India
e
Nightingales Regional Lead, Bangalore, Karnataka, India
f
Age Estimation Project, Institute of Legal Medicine, University of Macerata, Macerata, Italy

A R T I C LE I N FO A B S T R A C T

Keywords: Providing appropriate legal mechanisms, that evaluate the progression of development from the age of child-
Dental age estimation hood innocence to maturity and full responsibility, considered one of the difficult areas of criminal justice policy.
Minimum age of criminal responsibility The minimum age of criminal responsibility (MACR) in children varies among countries and differs widely
Third molar maturity index owing to history and culture. Due to rising and brutality of criminal offenses, particularly by juveniles, few
Orthopantomograms
countries have lowered the minimum age of criminal responsibility, and many have considered/considering to
16 years
do the same. India is one such country in which is under the proposal of lowering the age of criminal respon-
sibility to 16 years. As there is lack of useful age assessment methods, that can indicate whether if the individual
in question is younger (< 16 years) or older than MACR (≥16 years), the present study was undertaken to
derive a specific cut-off value of the third molar maturity index (I3M) for this purpose. The sample consisted of
1078 orthopantomograms (OPTs) from Andhra Pradesh, India, aged between 11 and 20 years (45.4% males and
54.6% females). The reproducibility of I3M was calculated by intra-class correlation coefficients, which showed
an intra-rater and inter-rater agreement of 0.912 and 0.891, respectively. The sample was divided into training
dataset (819 OPTs), to test I3M and gender as independent variables and MACR as a dependent variable by
logistic regression analysis, and test dataset (259 OPTs). A receiver operating curve (ROC) analysis was per-
formed to evaluate the specific cut-off value of I3M for predicting MACR status. A logistic regression analysis
showed that gender was not statistically significant for predicting MACR status while ROC analysis indicated a
cut-off value of I3M = 0.293 as best for predicting MACR status. The performance of derived cut-off value was
tested in a test data set. The sensitivity of the test was 90.6% and 90%, while specificity was 86% and 87.1% in
males and females, respectively. The proportion of correctly classified individuals was 88.0% and 88.7% in
males and females, respectively. The estimated Bayes post-test probability in males was 87.2% and while in
females it was 88.3%. The results highlight the contribution of the derived cut-off value of I3M for discriminating
individuals around MACR and should be evaluated in other populations.

1. Introduction of criminal justice policy as it is vital to apply appropriate legal me-

Assessing dental age is not just limited to the prediction of growth in
children for diagnosis and treatment planning, but can also be used to
resolve issues related to prosecution in the criminal and civil courts.1 At
times, forensic experts needed to answer question regards juvenile's
attainment of the minimum age of criminal responsibility (MACR) and
age of majority. The former is considered one of the most sensitive areas
chanisms that reflect the transition from the age of childhood innocence
through to maturity and full responsibility under the criminal law.2 In
recent times, Juvenile delinquency has attracted much legislative de-
bate and judicial intervention.3 It refers to the antisocial or the criminal
activity of the child which violates the law and often considered to be a
gateway to adult crime since a large percentage of criminal careers has
their roots in childhood. The legal difference between a criminal and a

∗
Corresponding author.
E-mail address: forensics.Sudheer@gmail.com (S.B. Balla).

https://doi.org/10.1016/j.jflm.2019.05.014
Received 23 March 2018; Accepted 19 May 2019
Available online 22 May 2019
1752-928X/ © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
S.B. Balla, et al. Journal of Forensic and Legal Medicine 65 (2019) 108–112

delinquent is a matter of a day on the calendar as if one commits an
illegal act a day before he ceases to be a juvenile is considered a de-
linquent act, otherwise as a criminal offense. Here the unlawful act is
the same, but the perpetrator of the act is a day older, and therefore, a
criminal.4
1.1. MACR and judicial trend in India
Article 40.3 of the Convention on the rights of the child defines
MACR as “the age below which a person is completely immune from any
criminal liability due to lack of maturity and judgment to understand the
consequences of one's actions”.5 In practical terms, a separate justice
system for children that has rehabilitation and reintegration should be
established. In India, the criminal system is governed and regulated by
two major legislations including the Indian Penal Code, 1860 (IPC) and
the Criminal Procedure Code, 1970 (CrPC). The IPC has set the
minimum age of criminal responsibility as 12 years.6 According to Ju-
venile Justice (Care and protection of children) Act, 2000, children
cannot be put into the same category as adults and hence required
special provisions for them. This act has set the age of criminal re-
sponsibility at 18 years that concurs definition of child under the UN
convention on the rights of the child.6,7 Juvenile offenders are accorded
special treatment under this act and are not tried in the same courts as
adult offenders. In extreme cases under Juvenile Justice Act, the of-
fenders will be sent to detention for a maximum period of three years in
reformatory centers.
In India, there has been a sharp rise in crimes committed by juve-
niles or young adults. According to the statistics of National Crime
Records Bureau (NCRB), 27% of the juvenile crimes in 2015 were
perpetrated by the individuals between ages 12–16 years, 1.4% by
those between 7 and 12 years, and 71.6% by those between 16 and 18
years.8 Owing to the rise and brutality of criminal offenses particularly
by juveniles, there was an increasing sense of urgency to create legal
avenues for some deterrence to warn off the under-age perpetrators.9
1.2. Raising concerns
As per NCRB statistics, in 2010, the toll of rape cases by juveniles
stood at 858, it became 1149 in 2011, 1316 in 2012, which further
increased up to 1388 in 2013.9 Moreover, in last ten years, heinous
crimes by juveniles have increased four to five times. One such incident
is frightening gang-rape- cum-murder in Delhi in which one of accused
is a minor who allegedly committed the most brutal act has shifted the
spotlight on juvenile offenders, their age bar, nature of crime and
brutality involved.10 Keeping in mind the rise of offenses by minors,
there is a need for the change of the current MACR (18 years) and to
make special provisions for serious offenses. Following this, there are
serious issues raised by law, regarding amendments to the criminal law
and MACR. This issue has reached the apex court of India, asking for
complete struck off the Act of 2000 and to make changes in various
provisions to enhanced punishment to a juvenile in conflict with the
law.11 Later the government considered a proposal that under 18 years
accused of heinous crimes are tried as adults and passed a bill re-
defining a juvenile's age in these offenses.12,13
12–14 years. Since third molars are the only teeth available growing at
the age of 18 years, their development was considered most suitable
evidence for juvenile/adult discrimination. Mincer et al.19 were the first
to verify the usefulness of Demirjian's stages (DS) and third molars for
the discrimination of juvenile/adult status. Later Cameriere et al.20
have demonstrated the better performance of the specific value of third
molar maturity index (I3M), I3M < 0.08, in discriminating adults or
minors compared to DS system. The applicability of latter in predicting
the age of majority was tested successfully in various popula-
tions.5,21–30
It is vital to adopt accurate age estimation methods prior con-
sidering steps to prevent and treat delinquency. Moreover, recent trends
in India posed a task to forensic experts and pointed out the lack of
useful age estimation methods that can indicate whether if the in-
dividual in question is younger or older than MACR (16 years).
Currently, there are no methods available in practice or in literature to
indicate MACR among Indian individuals. This study was undertaken to
derive a cut-off value of I3M which can be useful for predicting being
younger (< 16 years) or older than MACR (≥16 years).
2. Materials and methods
A final sample of panoramic radiographs (OPTs) of 1078 living
subjects was analyzed retrospectively (Table 1). OPTs used in this study
were initialized for different clinical purposes on patients from the
Panineeya Institute of Dental Sciences, Hyderabad, Telangana and from
private dental clinics, Andhra Pradesh, India. Ethics Committee for
research involving human subjects approved the usage of OPTs in this
study. Each OPT was separately recorded in Excel file. Record com-
prised an identification number, gender, date of birth, date of OPT. Real
age in years was calculated as the difference between dates of OPT and
birth. The inclusion criteria for retrieving the sample for the analysis
were: OPT of the good technical quality, age between 11 and 20 years,
no evidence of hereditary or systematic diseases which can affect the
dental and skeletal development, including hormonal deficiency or
hormonal therapy, gastrointestinal diseases. Exclusion criteria are any
missing or incomplete data on birth, agenesis of any permanent teeth
including all four third molars, extracted second and third molars, ro-
tated or impacted third molars.
All OPTs were recorded in JPG format. Only third molars from the
left side of the mandible were evaluated according to Cameriere's
method. A freeware image-processing program (Adobe® Photoshop®
CS4) was used for all adjustment of a grayscale and brightness and
contrast improvement. Briefly, the measurements of the projections of
open apices, Ai, and height, Li, of the third molars were recorded and
I3M was calculated as the proportion of open apices and heights or
Table 1
Age and Sex distribution of the data (training and test datasets) and the par-
entheses in training dataset represents the number of participants with closed
apices of left second mandibular molar.
Age (years) Malesb Females Total Males Females Total
training training training test test test
dataset dataset dataset dataset dataset dataset

1.3. Need of the hour and need for the study 11 26 (0) 39 (0) 65 (0) 10 10 20
12 35 (2) 50 (4) 85 (6) 11 10 21
In specific legal requirements, usage of low-invasive methods with 13 45 (15) 47 (14) 92 (29) 10 9 19
14 57 (24) 53 (38) 110 (62) 15 17 32
higher accuracy and precision are required to assign an age to a living
15 54 (43) 62 (55) 116 (98) 17 18 35
child without legal documents.14,15 To further improve the diagnostic 16 31 (30) 42 (40) 73 (70) 13 18 31
accuracy of age estimates, the Study Group on Forensic Age Diagnostics 17 41 (41) 41 (40) 82 (81) 11 15 26
(AGFAD) recommended usage of methods in combination that includes 18 33 (33) 39 (39) 72 (72) 10 17 27
a physical examination with determination of anthropometric mea- 19 31 (31) 51 (51) 82 (82) 11 10 21
20 20 (20) 22 (22) 42 (42) 9 18 27
surements, examination of skeletal development that includes hand-
wrist bones and evaluation of dental status by dental exams.16–18 The Total 373 446 819 117 142 259
mineralization of the second molars completes between the age of

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S.B. Balla, et al. Journal of Forensic and Legal Medicine 65 (2019) 108–112

I3M = [Ai/Li]. I3M is evaluated in a similar way to the ratio Ai to Li,

when i = 6 or 7, as reported for the first and second lower molars, as
described in Cameriere et al.20 Additionally, if the development of the
root of TM completed, then I3M = 0.0 was recorded. Pearson correla-
tion coefficient was performed to test the correlation between I3M and
real age. The first author performed the measures of the sample. The
analyses were performed using a blind approach, and the observer was
not able to detect identification number, gender or age of the subjects.
The first author and one other observer additionally evaluated ran-
domly selected 50 OPTs two weeks after finished the first measure-
ments. The intraclass correlation coefficient (ICC) was calculated to
assess intra-rater and inter-rater agreement of I3M.31 A sample of OPTs
was randomly divided into training dataset (819) and test dataset
(259).
A logistic regression linear model was tested on the training dataset
with dependent variables E = 1 and E = 0 to verify the significance of
the independent variables I3M and gender on the binary answer whether
a subject is ≥ 16 years (E = 1) or < 16 years (E = 0). The dummy
variable gender equals to 1 for boys and 0 for girls. The predictive
accuracy of the specific cut-off value of I3M to test whether a subject
is ≥ 16 years or < 16 years was established by determining the receiver Fig. 1. Scatter-plot of the relationship between age (years) and the third molar
operating characteristic (ROC) analysis. The area under the curve maturity index.
(AUC) and 95% confidence interval (95% CI) was calculated with a
non-parametric method.20,32,33 If the cut-off is closer to the apex of the p < 0.05.
ROC curve to the upper left corner, it is the greater accuracy of the
test.33 The best performance of the discrimination test was established
as the maximum value of Youden's index (J). The greatest Youden's 3. Results
index was used to determine a specific cut-off value of I3M.34
The performance of the established cut-off value of I3M was eval- The final sample consisted of 1078 OPTs. Table 1 demonstrates the
uated by the two-by-two contingency table (CT) on the test dataset of distribution of the training and test datasets according to gender and
OPTs. Precisely, CT in the first row lists the results of those who are age. The number of subjects with closed apices of second molars in each
≥16 years and have I3M less than cut-off value (true positives, TP), age cohort was presented in parenthesis of training dataset of same
following those who are < 16 years and have I3M less than cut-off table. Closed apices were first noticed in both boys and girls at 12 years
value (false positives, FP). In the second row list those who are ≥16 age. None of the apices were open after 16 years of age in both genders.
years and have I3M ≥ than cut-off value (false negatives, FN), and fi- Pearson correlation coefficients for the correlation between I3M and real
nally, those who are < 16 and have I3M ≥ cut-off value (true nega- age were better for females, 0.780 (p < 0.001), than for males, 0.778
tives, TN). The percentage of accurate classification (Ac), sensitivity (p < 0.001), Fig. 1. The intra-class correlation coefficient for the intra-
(Se) or the percentage of the subjects ≥16 years who have I3M < cut- rater agreement was 0.912 while for the inter-rater agreement was
off value, and the specificity (Sp) or the percentage of individuals 0.891. Obtained results of ICC showed excellent results both on the
younger than 16 who have I3M ≥ cut-off value, were calculated. The precision and the repeatability of the variable I3M. The logistic model
positive predictive value (PPV) and the negative predictive value (NPV) showed the significance of variable I3M (p < 0.001) while gender was
or the proportions of positive and negative results that are truly positive not statistically significant (p = 0.053), Table 2. The full model con-
and truly negative results, respectively were calculated.35 Also, the taining I3M as a predictor was statistically significant, χ2 (1,
positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were 819) = 556.3, p < 0.001, indicating that model was able to dis-
also calculated to express how many times more or less likely a test criminate between those who are ≥16 years and < 16 years. The whole
result is to be found in (≥16 years) compared to (< 16 years) parti- model explained between 0.493 (Cox & Snell R Square) and 0.662
cipants.35 (Nagelkerke R Square) of the variance in ≥16 years and < 16 statuses.
The post-test probability p of being 16 years of age or older can help A linear logistic model may be written as:
to discriminate between those individuals who are 16 and over and Logit (p) = 2.086–5.102 × I3M (2)
under 16. According to Bayes theorem, the post-test probability may be
written as: The value for AUC was 0.936 (95% CI, 0.920 to 0.953). A cut-off
value of I3M, to discriminate that individuals are ≥16 years or < 16
Se × p0 years, was established for the highest value of the Youden index.35 The
p=
Se × p0 + (1 − Sp) × (1 − p0 ) (1) highest Youden index was 0.739 for the cut-off value of I3M = 0.293.
The validity and efficiency of a cut-off value of I3M < 0.293 to
where p is post-test probability and p0 is the probability that the subject discriminate individuals between ≥16 years or < 16 years was
in question is ≥ 16 years, given that he or she is aged between 11 and
20 years, which represent the target population. Probability p0 was Table 2
calculated as the proportion of subjects between 16 and 20 years of age Parameter estimates of the third molar maturity index (I3M) and gender (g) as
who live in the Andhra Pradesh according to demographic data from explanatory variables and ≥16 years (E = 1) and < 16 years (E = 0) age as
the 2011 census (http://www.censusindia.gov.in/2011census/C- dichotomous dependent variable on Logistic Regression.
series/C-13.html) and those between 11 and 20 years which was B Std.Error Wald statistics df p
evaluated from data from the same web source. This proportion was
Constant 1.887 0.185 103.618 1 < 0.000
considered to be 51.3% for males and 51.9% for females. Statistical
I3M −5.176 0.340 231.190 1 < 0.000
analysis was performed by IBM SPSS 20.0 software program (IBM® gender 0.424 0.219 3.748 1 0.053
SPSS® Statistics, Armonk, NY). The significant threshold was set at

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Table 3 errors.37,38 To reduce such errors related to subjectivism in the assess-

Contingency table describing discrimination performance of the test (≥16 ment of dental age and for a greater confidence interval, mensuration
years of < 16 years) for cut-off values of third molar maturity index (I3M) in techniques can be adapted to extract dimensional information from
females and males. images.39 In 2008, Cameriere et al.20 introduced such method that re-
Males Total Males Females Total Females quires measurement of apical pulp width and tooth length as visualized
in OPTs and ratio be calculated from them, which means that derived
Age Age index is scale-invariant and can also be applied to non-digital media
≥16 < 16 ≥16 < 16
that lacks information regarding magnification factor.21 Up to the age
of 14, most of the permanent teeth finished their maturation so only
Test third molars, which can maturate up to the early twenties, can be used
I3M < 0.293 48TP 9FN 57 72TP 8FN 80 for discriminating at 16 years threshold.38,40
I3M ≥ 0.293 5FP 55TN 60 8FP 54TN 62
In the present study, the authors analyzed the OPTs of 819 South
Total 53 64 117 80 62 142 Indian subjects aged between 11 and 20 years by logistic regression
analysis to derive a cut-off value using third molar maturity index, to
Abbreviation: TP, true positive; FN, false negative, FP, false positive, TN, true discriminate individuals who are around MACR (16 years of age). Only
negative. I3M statistically significantly contributed to the regression model while
gender did not. ROC analysis showed that cut-off value of I3M < 0.293
Table 4 the best discriminate subjects as 16 years of age and older or under 16.
The quantities from 2-by-2 contingency tables (95% confidence interval) to test For each threshold, there is a combination of sensitivity and specificity
the performance of cut-off value of I3M < 0.293 in males to discriminate obtained for different cut-off values that can be connected in a graph,
subjects as ≥16 years and < 16 years of age.
resulting in ROC curve. The more the ROC curve moves towards the left
Quantities Males Females upper corner, represents the perfect dichotomous test with 100% sen-
sitivity and 100% specificity, the better test it is.41 A measure of per-
Accuracy 88.0% (95% CI, 82.2%–93.9%) 88.7% (95%CI, 83.5%–93.6%)
Sensitivity 90.6% (95%CI, 82.7%–98.4%) 90.0% (95%CI, 83.4%–96.6%)
formance for the test is the area under the ROC curve, and it varies
Specificity 85.9% (95%CI, 77.4%–94.5%) 87.1% (95%CI, 78.8%–95.4%) between 0.5 (totally uninformative test) to 1 (a test that perfectly dis-
PPV 84.2% (95%CI, 74.7%–93.7%) 90.0% (95%CI, 83.4%–96.6%) criminates).42 In this paper, the resulting ROC curve (Fig. 2) has an area
NPV 91.7% (95%CI, 84.7%–98.7%) 87.1% (95%CI,78.8%–95.4%) under the curve (AUC) of 0.936 indicating that this test predicts the
LR + 6.44 (95%CI, 3.49 to 11.87) 6.97 (95%CI, 3.64 to 13.38)
likelihood of age being at least 16 years.35
LR - 0.11 (95%CI, 0.05 to 0.25) 0.11 (95%CI, 0.06 to 0.22)
Bayes PTP 87.2% (95%CI, 78.1%–96.2%) 88.3% (95%CI, 80.1%–96.4%) The results of the analysis of the test sample highlighted the ap-
plicability of derived cut-off value, and similar performance. The cut-off
Abbreviation: LR+, positive likelihood ratio; LR+, negative likelihood ratio; value of I3M < 0.293 showed better sensitivity, 90.6% in males and
Bayes PTP, Bayes post-test probability. 90.0% in females, than specificity, 85.9% in males and 87.1% in fe-
males. Females were slightly better classified (88.7%) than males
evaluated on the test dataset, Table 3. Table 4 shows the values of the (88.0%). Further, the quantities obtained from 2-by-2 contingency table
test for males and females. In males, 103 out of 117 subjects, 88.0% (Table 3) to test the performance of cut-off value for discriminating
(95% CI, 83.9%–91.1%) were correctly classified. The sensitivity, or the subjects around MACR were discussed. What is the probability of an
proportion of subjects being ≥16 years of age whose test was positive, individual at a specific I3M cut-off value being at least 16? This is ex-
was 90.6% (95% CI, 82.7%–98.4%). The specificity, the proportion of pressed as the positive predictive value, and many studies have verified
subjects < 16 years whose test was negative, was 85.9% (95% CI, the forensic usefulness of Positive and Negative predictive values (PPV
77.4%–94.5%). PPV and NPV were 84.2% (95% CI, 74.7%–93.7%) and & NPV) and Likelihood ratios (LRs) to diagnostically analyze the
91.7% (95% CI, 84.7%–98.7%), respectively. Positive likelihood ratio probability of discriminating individuals.24,43 In the present study,
(LR+) and negative likelihood ratio (LR−) were 6.44 (95% CI, 3.49 to predictive values were used, less false positives indicate a higher PPV. A
11.87) and 0.11 (95% CI, 0.05 to 0.25) respectively. The estimated
Bayes post-test probability was 87.2% (95% CI, 78.1–96.2%). In fe-
males, 126 out of 142 participants were correctly classified, 88.7%
(95% CI, 83.5%–93.6%). The sensitivity was 90.0% (95% CI,
83.4%–96.6%) and specificity was 87.1% (95% CI, 78.8%–95.4%). PPV
and NPV were 90.0% (95% CI, 83.4%–96.6%) and 87.1% (95% CI,
78.8%–95.4%), respectively. Positive likelihood ratio (LR+) and ne-
gative likelihood ratio (LR−) were 6.97 (95% CI, 3.64 to 13.38) and
0.11 (95% CI, 0.06 to 0.22), respectively. The estimated Bayes post-test
probability was 88.3% (95% CI, 80.1%–96.4%).

4. Discussion

Predicting one's attainment of MACR remains concern both in legal

and forensic aspects. Moreover, through odontology, one can provide a
solution for the application of specific techniques depending on the fact
that tooth mineralization is more controlled by genes and less by en-
vironmental factors.36 Adopting reliable and efficient scientific
methods to determine the status of an individual, i.e., above or below
16 years of age, within a specific population has become increasingly
important to resolve court cases. Although Demirjian's mineralization
stages of tooth mineralization were applied in general, appreciation of
these mineralization stages is often difficult, and the choice of assigning Fig. 2. Receiver operating characteristic curves for ≥16 years or older status of
a stage is quite subjective and commonly associated with prediction the third molar maturity index.

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S.B. Balla, et al.
sensitive test will have a higher NPV in the observed population. Higher
PPV was observed in females, i.e., 90.0% than in males, 84.2% when,
while NPV was greater in males, 91.7%, than in females, 87.1%. A
likelihood ratio is used to interpret the discriminative score as the
strength of evidence and is adapted to convey expert evaluative opi-
nions to the legal system.44 It combines the sensitivity and specificity
into a single value that indicates how much the test result will reduce
the uncertainty of a given diagnosis.45 For males, the LR + ratio was
6.44 and LR-was 0.11 while for females LR+ was 6.97 and LR-was
0.11. When the cut-off value was applied, the percentage of false ne-
gatives in males was 7.7%, in females 5.6% and the proportion of false
positives were 4.3% and 5.6% respectively. From the forensic and legal
point of view, it is important to minimize the percentage of errors. As it
considered being a more serious mistake to charge an individual
younger than 16 years with the charges that apply to the subjects who
are above MACR and it may lead to unfair treatment of these children in
society.46 The error rate is one concept that assesses the performance of
the test,41 and it is referred as a weighted average of errors among false
negatives and false positives. Using the obtained cut-off value of I3M in
the present study, we obtained an error rate of 12% in males and 11.3%
in females.
Guidelines for the age estimation in criminal proceedings suggest a
multidisciplinary approach.47 AGFAD recommended physical ex-
amination with basic anthropometric measurements: height, weight,
pubertal characteristics, discerning signs of sexual maturity or presence
of any developmental disorders, X-ray study of hand-wrist and a dental
examination recording status of dentition and radiographic study.48 In
the study by Cameriere et al.,49 using X-ray images of hand-wrist and
CAD program, evaluated ossification of the carpals which showed good
agreement with chronological age and ossification of epiphyses of ulna
and radius, for which mineralization lasts until 16 or 17 years.49 It
suggests that possible future developments in lines of mineralization of
ulna and radius and determining MACR, can be done and be a possible
addition for better discrimination of these subjects.
5. Conclusion
In conclusion, the choice of third molar maturity index,
I3M < 0.293, can be used as a supplementary method to indicate
MACR age (≥16 years) for forensic and legal purposes. The specific cut-
off value for MACR should be verified in other population.
References
1. Thevissen PW, Fieuws S, Willems G. Third molar development: evaluation of nine tooth
development registration techniques for age estimations. J Forensic Sci. 2013;58:393–397.
2. Urbas G. The age of criminal responsibility (No. 181). Criminology Aio. 2000; 2000:1–6
Canberra: Trends and Issues in Crime and Criminal Justice http://wwwaicgovau/media_
library/publications/tandi_pdf/tandi181pdf.
3. Mahalaxmi T. Doli incapax: Re- accessing the age of criminal responsibility. RHIMRJ.
2015;2:1–4.
4. Burrows AH. The problem of juvenile delinquency. J Educ Sociol. 1946;19:382–390.
5. Balla SB, Galic I, P K, Vanin S, De Luca S, Cameriere R. Validation of third molar maturity
index (I3M) for discrimination of juvenile/adult status in South Indian population. J
Forensic Leg Med. 2017;49:2–7.
6. Bhatia S. The Minimum Age of Criminal Responsibility in India: is it to be blamed for the
increasing youth crime? Rostrum’s Law Review. 2014;2.
7. Bajpai A. Child Rights in India: Law, Policy, and Practice. New Delhi; New York: Oxford
University Press; 2003.
8. Bureau NCRed. Crime in India 2015 Statistics. 2015; 2015. Available from: ncrb.gov.in/
StatPublications/CII/CII2015/FILES/CrimeInIndia2015.pdf.
9. Staff FP. Trying Minors as Adults for Rape: Will Amending Juvenile Justice Act Deter Crime?
Firstpost. Firstpost; 2014.
10. 2012 Delhi gang rape case: a chronology. Available at: http://www.huffingtonpost.in/
2017/05/05/2012-delhi-gang-rape-case-a-chronology_a_22070838/.
11. Mukesh Y, Pooja R. Age of criminal responsibility of juvenile in India vis-a-vis global
scenario: a critical review. J Indian Acad Forensic Med. 2013;35:262–271.
12. India to change age of criminal responsibility for minors accused of rape and murder.
Available at: http://www.telegraph.co.uk/news/worldnews/asia/india/10499798/India-
to-change-age-of-criminal-responsibility-for-minors-accused-of-rape-and-murder.html.
13. 16 to 18: LS passes bill redefining a juvenile's age in serious crimes. Available at: http://
112
Journal of Forensic and Legal Medicine 65 (2019) 108–112
indianexpress.com/article/india/india-others/juvenile-justice-bill-passed-in-lok-sabha/.
14. Gulsahi A, Tirali RE, Cehreli SB, De Luca S, Ferrante L, Cameriere R. The reliability of
Cameriere's method in Turkish children: a preliminary report. Forensic Sci Int.
2015;249:319 e1–5.
15. De Luca S, De Giorgio S, Butti AC, Biagi R, Cingolani M, Cameriere R. Age estimation in
children by measurement of open apices in tooth roots: study of a Mexican sample. Forensic
Sci Int. 2012;221:155 e1–7.
16. 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–S64.
17. Schmeling A, Grundmann C, Fuhrmann A, et al. Criteria for age estimation in living in-
dividuals. Int J Leg Med. 2008;122:457–460.
18. Schmeling A, Geserick G, Reisinger W, Olze A. Age estimation. Forensic Sci Int.
2007;165:178–181.
19. Mincer HH, Harris EF, Berryman HE. The A.B.F.O. study of third molar development and
its use as an estimator of chronological age. J Forensic Sci. 1993;38:379–390.
20. Cameriere R, Ferrante L, De Angelis D, Scarpino F, Galli F. The comparison between
measurement of open apices of third molars and Demirjian stages to test chronological age
of over 18 year olds in living subjects. Int J Leg Med. 2008;122:493–497.
21. Franklin D, Karkhanis S, Flavel A, Collini F, DeLuca S, Cameriere R. Accuracy of a cut-off
value based on the third molar index: validation in an Australian population. Forensic Sci
Int. 2016;266:575 e1–6.
22. Cavrić J, Galić I, Vodanović M, et al. Third molar maturity index (I3M) for assessing age of
majority in a black African population in Botswana. Int J Leg Med. 2016;130:1109–1120.
23. Deitos AR, Costa C, Michel-Crosato E, Galic I, Cameriere R, Biazevic MG. Age estimation
among Brazilians: younger or older than 18? J Forensic Leg Med. 2015;33:111–115.
24. Galic I, Lauc T, Brkic H, et al. Cameriere's third molar maturity index in assessing age of
majority. Forensic Sci Int. 2015;252:191 e1–5.
25. De Luca S, Biagi R, Begnoni G, et al. Accuracy of Cameriere's cut-off value for third molar in
assessing 18 years of age. Forensic Sci Int. 2014;235:102 e1–6.
26. Cameriere R, Pacifici A, Viva S, Carbone D, Pacifici L, Polimeni A. Adult or not? Accuracy
of Cameriere's cut-off value for third molar in assessing 18 years of age for legal purposes.
Minerva Stomatol. 2014;63:283–294.
27. Zelic K, Galic I, Nedeljkovic N, et al. Accuracy of Cameriere's third molar maturity index in
assessing legal adulthood on Serbian population. Forensic Sci Int. 2016;259:127–132.
28. Quispe Lizarbe RJ, Solís Adrianzén C, Quezada-Márquez MM, Galić I, Cameriere R.
Demirjian's stages and Cameriere's third molar maturity index to estimate legal adult age in
Peruvian population. Leg Med. 2017;25:59–65.
29. De Luca S, Aguilar L, Rivera M, et al. Accuracy of cut-off value by measurement of third
molar index: study of a Colombian sample. Forensic Sci Int. 2016;261:160 e1–5.
30. Dardouri AA, Cameriere R, De Luca S, Vanin S. Third molar maturity index by measure-
ments of open apices in a Libyan sample of living subjects. Forensic Sci Int. 2016;267:230
e1–e6.
31. Ferrante L, Cameriere R. Statistical methods to assess the reliability of measurements in the
procedures for forensic age estimation. Int J Leg Med. 2009;123:277–283.
32. Martin-de las Heras S, Garcia-Fortea P, Ortega A, Zodocovich S, Valenzuela A. Third molar
development according to chronological age in populations from Spanish and Magrebian
origin. Forensic Sci Int. 2008;174:47–53.
33. Galic I, Mihanovic F, Giuliodori A, Conforti F, Cingolani M, Cameriere R. Accuracy of
scoring of the epiphyses at the knee joint (SKJ) for assessing legal adult age of 18 years. Int
J Leg Med. 2016;130:1129–1142.
34. Schisterman EF, Perkins NJ, Liu A, Bondell H. Optimal cut-point and its corresponding
Youden Index to discriminate individuals using pooled blood samples. Epidemiology.
2005;16:73–81.
35. Fletcher R, Fletcher S. Diagnosis. In: Fletcher R, Fletcher S, eds. Clinical Epidemiology the
Essentials. Baltimore: Wolters, Kluwer, Lippincott. Williams & Wilkins; 2005:35–58.
36. Gleiser I, Hunt Jr EE. The permanent mandibular first molar: its calcification, eruption and
decay. Am J Phys Anthropol. 1955;13:253–283.
37. Foti B, Lalys L, Adalian P, et al. New forensic approach to age determination in children
based on tooth eruption. Forensic Sci Int. 2003;132:49–56.
38. Liversidge HM. Dental age revisted. In: Irish JD, Nelson GC, eds. Technique and Application
in Dental Anthropology. Cambridge: Cambridge University Press; 2008:234–252.
39. SWGDE Guidelines for Forensic Image Analysis. Scientific Working Group on Digital
Evidence. . Available from: https://www.swgde.org/documents/Current%20Documents/
SWGDE%20Guidelines%20for%20Forensic%20Image%20Analysis.
40. Cameriere R, Ferrante L, Cingolani M. Age estimation in children by measurement of open
apices in teeth. Int J Leg Med. 2006;120:49–52.
41. Habbema JDF, Eijkemans R, Krijnen P, Knottnerus JA. Analysis of data on the accuracy of
diagnostic tests. In: Knottnerus J, Buntinx F, eds. The Evidence Base of Clinical Diagnosis.
London: Wiley-Blackwell; 2009:118–145.
42. Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating
characteristic (ROC) curve. Radiology. 1982;143:29–36.
43. Liversidge HM, Marsden PH. Estimating age and the likelihood of having attained 18 years
of age using mandibular third molars. Br Dent J. 2010;209:E13.
44. Martire KA, Kemp RI, Sayle M, Newell BR. On the interpretation of likelihood ratios in
forensic science evidence: presentation formats and the weak evidence effect. Forensic Sci
Int. 2014;240:61–68.
45. Florkowski CM. Sensitivity, specificity, receiver-operating characteristic (ROC) curves and
likelihood ratios: communicating the performance of diagnostic tests. Clin Biochem Rev.
2008;29(Suppl 1):S83–S87.
46. Thevissen PW, Kvaal SI, Willems G. Ethics in age estimation of unaccompanied minors. J
Forensic Odontostomatol. 2012;30(Suppl 1):84–102.
47. Schmeling A, Dettmeyer R, Rudolf E, Vieth V, Geserick G. Forensic age estimation.
Deutsches Arzteblatt international. 2016;113:44–50.
48. Schmeling A, Olze A, Reisinger W, Geserick G. Age estimation of living people undergoing
criminal proceedings. Lancet. 2001;358:89–90.
49. Cameriere R, Ferrante L, Mirtella D, Cingolani M. Carpals and epiphyses of radius and ulna
as age indicators. Int J Leg Med. 2006;120:143–146.