International Journal of Legal Medicine

https://doi.org/10.1007/s00414-019-02112-2

ORIGINAL ARTICLE

Age estimation using pulp/enamel volume ratio of impacted

mandibular third molars measured on CBCT images in a northern
Chinese population
Zhi-yong Zhang 1,2,3 & Chun-xia Yan 1 & Qiao-mei Min 3 & Shao-qing Li 1 & Jing-si Yang 1 & Yu-cheng Guo 2,3 &
Wen-fan Jin 4 & Lan-jiang Li 1 & Pan-Fen Xing 4 & Jun Li 5

Received: 9 December 2018 / Accepted: 19 June 2019

# Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
The present study aims to evaluate the relation between chronological age and the ratio of pulp volume (PV) to enamel volume
(EV) of impacted mandibular third molars (IMTMs) by using cone-beam computed tomography (CBCT) images and an
improved 3D image segmentation technique. A sample of CBCT images of IMTM was collected from 414 northern Chinese
subjects (214 male and 200 female clinical patients) ranging in age from 20 to 65 years. The GrowCut effect image segmentation
(GCEIS) module algorithm was used to calculate the PVand EV from CBCT images. The total sample was divided into a training
group and validation group in a ratio of 7 to 3. The PV/EV ratio (PEr) in the training sample was used to develop a mathematical
formula for age estimation as follows: age = − 5.817–21.726 × Ln PEr (p < 0.0001) (Ln, natural logarithm). The mean absolute
error (MAE) and root mean square error (RMSE) were used to determine the precision and accuracy of the mathematical formula
in the validation group and all samples. The MAEs in the male, female, and pooled gender samples were 9.223, 7.722, and 8.41,
respectively, and the RMSEs in the male, female, and pooled gender samples were 10.76, 9.58, and 9.986, respectively. The
precise and accurate results indicate that the PEr of IMTM in CBCT images is a potential index for dental age estimation and is
possible to be used in forensic medicine.

Keywords Dental age estimation . Cone-beam computed tomography (CBCT) . Impacted mandibular third molar (IMTM) .
Secondary dentin . Pulp volume to enamel volume ratio (PEr)

Introduction
* Chun-xia Yan
yanchunxia@mail.xjtu.edu.cn The assessment of chronological age has gained vital impor-
* Jun Li
tance not only in clinical work but also in civil and criminal
junli@xidian.edu.cn proceedings. In forensic practice, age information concerns
living or deceased individuals and applies to teenage crimi-
1
College of Forensic Medicine, Xi’an Jiaotong University Health nals, child marriage, child adoption, youth sports, immigra-
Science Center, Xi’an 710061, Shaanxi, People’s Republic of China tion, and many other civil procedures. Teeth have the strong
2
Key Laboratory of Shaanxi Province for Craniofacial Precision ability to resist destruction and are useful in the forensic iden-
Medicine Research, College of Stomatology, College of tification of decomposed or skeletal remains [1–3]. Teeth are
Stomatology, Xi’an Jiaotong University, 98 XiWu Road,
Xi’an 710004, Shaanxi, People’s Republic of China
less susceptible to local environmental, nutritional, and hor-
3
monal factors than other tissues for age estimation therefore,
Department of Orthodontics, Stomatological Hospital of Xi’an
Jiaotong University , 98 XiWu Road, Xi’an 710004, Shaanxi,
teeth are among the most important means of age estimation in
People’s Republic of China forensic medicine, orthodontics and anthropology [4, 5].
4
Department of Radiology, Stomatological Hospital of Xi’an Jiaotong
The most common and precise methods of dental age esti-
University, 98 XiWu Road, Xi’an 710004, Shaanxi, People’s mation are based on the development of permanent teeth in
Republic of China children and adolescents [6–8]. However, such methods are
5
School of Life Science and Technology, Xidian University, unsuitable for adults because permanent dentitions have
Xi’an 710071, Shaanxi, People’s Republic of China

erupted and fully developed. Though the third molar (M3) is
the only tooth that continues to develop from adolescents to
adults, its eruption and development arrests usually occur
when an individual reaches skeletal maturity (18 to 25 years
of age) [9–11]. Therefore, the age estimation beyond 25 years
remains a challenge in forensic practice.
As it continues to occur throughout a lifetime, it was found
that secondary dentin deposition could be used as a predict-
able indicator for age estimation in young and old adults.
Secondary dentin deposition leads to the decrease of the pulp
cavity volume which reflects the aging process; it may be
affected by attrition, caries and osmotic pressure changes,
and many other factors [12–16]. Such aging variation can be
measured by two- and three-dimensional radiographic images.
However, these measured data are susceptible to X-ray mag-
nification and tooth location in alveolar bone, such as twisted
or tilted teeth. Therefore, experts resort to line spacing ratios
[17–23] and area ratios [24–29] to estimate age in an attempt
to replace three-dimensional measurements with one- or two-
dimensional measurements. However, one- or two-
dimensional measurements cannot reflect real three-
dimensional morphological changes because secondary den-
tin deposition occurs on all surfaces of the pulp cavities.
As secondary dentin deposition occurs in anywhere of the
pulp cavities surface, three-dimensional measurement can ex-
plore more accurately to the morphological changes of the sec-
ondary dentin deposition in M3. Cone-beam computed tomog-
raphy (CBCT), a three-dimensional tooth display technology, has
been widely utilized in clinical stomatology due to its advantages
of low doses of radiation, fast scanning, and high-quality and
accurate three-dimensional representations of hard tissues [30].
However, research investigating age estimation by CBCT images
has mainly focused on single-rooted teeth due to the complexity
of teeth-root anatomical structure [31–37]. Only a few laborato-
ries perform elementary research on multirooted teeth [38, 39],
and the ratio of pulp cavity volumes to the teeth volumes or
corona volumes is an index used to estimate age. However,
enamel abrasion caused by chewing habits and tooth location
and the difference in secondary dentin deposition caused by
physicochemical irritations in the oral cavity and eating habits
could definitely affect the estimation accuracy. Secondary dentin
deposition in impacted mandibular third molars (IMTMs) is not
affected by physicochemical irritations and chewing habits. The
occurrence of IMTM in Chinese population aged between 16
and 25 years is approximately 52.3% [40] and the occurrence
of IMTM is 2.5 times that of impacted maxillary third molars.
Many experts have conducted research investigating age estima-
tion based on two-dimensional and three-dimensional images of
M3 [41–43] that mainly focus on different mineralization stages
before the age of 25 years. This study aims to evaluate the use-
fulness of pulp volume to enamel volume ratio (PEr) based on
CBCT analysis of IMTM in chronological age estimation in a
northern Chinese population.
Int J Legal Med
Materials and methods
A total of 414 CBCT images of 214 male and 200 female
northern Chinese subjects aged between 20 and 65 years old
were examined. The CBCT images were selected from the
database of the Stomatological Hospital of Xi’an Jiaotong
University Health Science Center, China. The sample
contained 311 IMTM on the left side and 303 IMTM on the
right side. The birth and photo dates of subjects were obtained
from the hospital’s information system. The age of the patients
was calculated by subtracting the photo date from their birth
date and dividing by 365.25 (because of leap years) and
rounding to the nearest hundredth. All the subjects were di-
vided into 5 groups by 10-year age. The subjects’ age and
gender distribution are shown in Table 1. All images were
obtained for diagnosis and therapeutic purposes, and no sub-
jects suffered unnecessary or additional radiation exposure.
The inclusion criteria included subgingival M3, no caries
and pulpal calcification, no artifacts due to metal restorative
materials present in the adjacent teeth, tooth roots developed
completely, and clear CBCT image tooth.
All CBCT images were obtained at 80–90 kVP, 7 mAs, and
field of view (FOV) 16 cm × 10 cm or 20 cm × 19 cm by a
Pax-Zenith 3D digital system (EWOO-VATECH, Gyeonggi-
do, South Korea). The FOV was determined based on diag-
nosis and therapeutic purposes. The images were exported in
the Digital Imaging and Communication in Medicine
(DICOM) format using 3D slicer, an open source 3D image
semiautomatic segmenting and voxel-counting software pro-
gram for 3D image modeling and volume measurement.
The selection of CBCT images in this study was mostly
characterized by a medium or large FOV in which the voxel
size of 407 images was 0.4 × 0.4 × 0.4 mm3, and the voxel size
of 7 images was 0.2 × 0.2 × 0.2 mm3. The voxel size of the
reconstruction images was 0.2 × 0.2 × 0.2 mm3. In previous
studies, the ratio of pulp cavity volumes to the whole tooth
volumes (mostly single-rooted) was commonly used.
However, the modeling setup for whole teeth is time-
consuming and laborious, and distinguishing cementum from
the alveolar bone in CBCT images is also challenging. In the
present study, we use the ratio of pulp volume (PV) to enamel
volume (EV) as observation index as enamel presents sharp
contrast and edges in CBCT image and is easy to distinguish
from dentin. In addition, the pulp cavity can be easily differ-
entiated from the adjacent tissues.
GrowCut effect image segmentation (GCEIS), a powerful
algorithm to segment an image into foreground and back-
ground elements, was used to the reconstructed three-
dimensional structural model of the enamel and pulp cavity.
Lines called draw seed or scribbles can be drawn on the image
to identify specific aspects of interest in the foreground and
background. Then, these input labels can be propagated based
on principles derived from cellular automata to classify all
Int J Legal Med

Table 1 Tooth position, age, and

gender distribution of the sample Age (year) Sample IMTM Sample with bilateral teeth

Male Female Total Left Right Total Male Female Total

20–30 53 53 106 94 91 185 40 38 78

31–40 48 49 97 68 78 146 25 24 49
41–50 47 41 88 60 60 120 22 14 36
51–60 50 36 86 60 50 110 12 9 21
61–65 16 21 37 29 24 53 8 8 16
Total 214 200 414 311 303 614 107 93 200

pixels [44]. In this experiment, we selected the layer with the
largest axial area in the pulp cavity on CBCT images of IMTM
and drew lines in the pulp cavity and enamel. These lines
served as seeds for the construction of the pulp cavity and
enamel models by highlighting the contrasts of the pulp cavity
and enamel in the selected teeth. Then, we drew circles, i.e.,
the background seeds, around the pulp cavity and enamel in
the three-dimensional direction; i.e., only the pixels in these
circles with the same contrasts as the seeds were used to model
the pulp cavity and enamel. The seeds and the background
seeds of the pulp cavity and enamel are shown in Figs. 1
and 2. Incomplete or excessive pulp cavities and enamel were
repaired by layer-by-layer examination before calculating the
pulp volume (PV), enamel volume (EV), and PV/EV ratio
(PEr). The final segmentation images of the enamel and pulp
cavities of the IMTM are shown in Fig. 3.
Stratified sampling was adopted to set up the mathematical
model; in total, 70% of the individuals in each 10-year age
group in the sample were randomly used to establish the math-
ematical model, and the remaining 30% of individuals were
used to test the model. The PEr values of the validation sample
were entered into the regression equation obtained by the PEr
of the training sample to obtain the estimated ages. The mean
absolute error (MAE) and root mean square error (RMSE)
between the actual age and estimated age in the validation
sample were used to ascertain the accuracy of the mathemat-
ical model. The number and gender distribution of the training
sample and validation sample are shown in Table 2.
The enamel and pulp cavity were modeled by two well-
trained examiners. A random sample of 50 IMTM was exam-
ined by the two examiners, and the PEr was compared to
determine the inter-observer reproducibility. Additionally,

Fig. 1 Seed (green line) and background seeds (yellow line) of the pulp cavity
 Int J Legal Med

Fig. 2 Seed (yellow line) and background seeds (red line) of enamel

the same two examiners re-examined the same 50 IMTM after
an interval of 2 weeks to determine the intra-observer
reproducibility.
Statistical analysis was performed using SPSS version 19.0
(SPSS Inc., Chicago, IL, USA). The intraclass correlation
coefficient (ICC) was calculated to verify the statistical signif-
icance of the intra-observer and the inter-observer reliability.
A logarithmic regression analysis with PEr as the independent
variable was used to establish mathematical equations for den-
tal age estimation in male, female, and pooled gender group.

Fig. 3 Segmented image of the third molar enamel and pulp cavity and their three-dimensional reconstruction
Int J Legal Med

Table 2 Number and gender distributions in the training sample and that the differences in teeth position need not to be considered
validation sample
when using PEr as an independent variable to estimate age.
Age (year) Training sample Validation sample If IMTMs are present on both sides, the mean PEr value of
both sides can be used to obtain the logarithm regression for-
Male Female Total Male Female Total mulas of age estimation; otherwise, the PEr of a single tooth
20–30 37 37 74 16 16 32
can be used.
The logarithmic regression formulas, correlation coeffi-
31–40 34 34 68 14 15 29
cient (r), determination coefficient (R2), and RMSE are shown
41–50 33 29 62 14 12 26
in Table 6.
51–60 34 25 60 16 11 26
According to the R2 valuing, the females exhibited a stron-
61–65 11 15 26 5 6 11
ger correlation between PEr and age than males in both teeth.
Total 149 140 289 65 60 125
The comparison of the Y-intercept (P = 0.3855) and slope (P =
0.4425) of the two sexes by the extra sum-of-squares F test
R2 was calculated to evaluate the relationship between chro- revealed no significant differences between the two logarithm
nological age and the PEr. The MAE and RMSE between the regression equations. Thus, the logarithmic formula from the
chronologic age and estimated age were used to ascertain the PEr of the global group is as follows:
accuracy of the mathematical model.

Age ¼ −5:817−21:726  ln PEr P < 0:0001; R2 ¼ 0:419

The scatter diagram shown in Fig. 4 illustrates the relation-

ship between PEr and age for females, males, and all sample
Results of teeth.

The statistical analysis did not reveal significant differences in

the inter-observer (ICC = 0.856, P < 0.001) and intra-observer
(ICC1 = 0.911 and ICC2 = 0.937, P < 0.001, respectively, be-
tween the two examiners) variances. The samples, which were
obtained from 214 males (51.69%) and 200 females (48.31%),
including 614 IMTM are as follows: 311 teeth (50.65%) from
the left side and 303 teeth (49.35%) from the right side. The
mean values and standard deviations of all PVs, EVs, and
PErs were calculated. The descriptive statistics are illustrated
in Table 3.
In total, 200 patients (93 female and 107 male) in this
sample had bilateral IMTM and their PV and EVon both sides
are shown in Table 4.
The results of the paired t tests of PV, EV, and PEr on both
sides are shown in Table 5.
Two-sample t tests of the EV, PV, and PEr on both sides of
all 414 samples were also conducted to test the above results.
The statistical analysis did not reveal significant differences in
the PV (P = 0.327), EV (P = 0.439), and PEr (P = 0.219) of
IMTM between the left and right sides. These results suggest
Discussion
Estimating the chronological age of living individuals or un-
known bodies facilitates civil and criminal lawsuits. Dental
age estimations based on age-related variables observed in
teeth is specifically useful in forensic practice. Converting
the observed status of age-related variable to chronological
age enables age prediction. Radiography is commonly used
in estimating the dental age. The dental age has been success-
fully estimated from two-dimensional dental radiographs
using the ratios between the pulpal size and root size.
However, these radiographic images are created from accu-
mulated two-dimensional images of horizontal or parallel as-
pects of the tooth, and therefore, the ratios calculated by linear
measurements never represent the entire three-dimensional
morphological changes in teeth.
Currently, age estimation by dental CBCT images remains
a focus in the areas of forensic science research. Compared

Table 3 Descriptive statistics of

PV and EV of the IMTM in the Tooth position Number Minimum (mm3) Maximum (mm3) Mean (mm3) SD
pooled gender samples
38 PV 311 4.512 63.34 26.29 10.73
38 EV 311 72.87 375.6 224.84 47.60
48PV 303 5.584 94.46 27.18 11.72
48 EV 303 89.72 366.0 221.8 47.77
All of M3 PV 614 4.512 94.46 26.73 11.23
All of M3 EV 614 72.87 375.6 223.3 47.67

38, the left lower third molars; 48, the right lower third molars

Table 4 Mean values and
standard deviations of EV, PVand LPV (mm3)
PEr in 200 subjects with bilateral
IMTM Mean 28.21
SD 11.17
LEV, left enamel volume; LPV, left pulp cavity volume; REV, right enamel volume; RPV, right pulp cavity volume;
LEPr, left pulp-to-enamel volume ratios; REPr, right pulp-to-enamel volume ratios
with micro-CT, dental CBCT can provide a relatively larger
scanning space, low dose radioactivity and without teeth ex-
traction [45]. The rapid and accurate segmentation of various
tooth structures is essential for this line of research. Due to the
similarities of the gray values between cementum and alveo-
lar, root segmentation is difficult. Segmentation is further
complicated by the contact of the dental crown to the neigh-
boring tooth and opposite teeth, especially the posterior teeth.
IMTMs were selected as the research subject. First,
segmenting images of IMTM enamel is easier and more ac-
curate than other teeth as the enamel of IMTM does not con-
tact the enamel of the neighboring teeth or opposite teeth.
Second, non-IMTMs may suffer pericoronitis and be in the
risk of extraction. IMTMs seldom have any deficiencies.
Third, IMTMs have no abrasions, and their aging process is
free from physiochemical influence, chewing, and dietary
habits. Finally, subsequent research can further compare the
aging variations in IMTM with those of non-impacted third
molars to obtain insight into the effect of abrasion on the pulp
cavity.
Painting segmentation methods and threshold segmenta-
tion methods are the most frequently used techniques for im-
age segmentation. The first technique involves more manpow-
er and time-consuming and has more room for error. The latter
technique has the advantages of faster operating speed, more
effective segmentation of targets, and more settings with a
greater gray difference.
However, for images with less obvious contrast differences
or overlap, this technique is not sufficient. Research investi-
gating teeth modeling tends to focus on accurate, rapid, and
automatic modeling methods with the fewest errors. Thus, this
study selected the ratio of pulp cavities to the enamel volume
as the research object. In addition, their distinguishable parts
with sharp contrast were measured and used to construct the
enamel-pulp model by GCEIS through 3D slice program.
Then, the nonconforming parts were modified by performing
a layer-by-layer comparison of the IMTM images. Generally,
10 min is required for most models to be built; however, if the
Table 5 Results of the paired t
tests of PV, EV, and PEr on both Comparative index
sides in 200 subject with bilateral
IMTM LPV VS RPV
LEV VS REV
LPEr VS RPEr
Int J Legal Med
LEV (mm3) LEPr (%) RPV (mm3) REV (mm3) REPr (%)
227.7 12.55 29.32 230.9 12.83
46.72 4.86 11.83 46.16 4.99
model needs to be modified, this process could require no
longer than 30 min. This approach saves a considerable
amount of time compared with the approaches used in similar
studies [31, 34, 37].
Pulp volume/tooth volume ratios (PTVR) [31, 32, 34, 35,
46, 47] and PVs [38, 39] were the most frequently used inde-
pendent variables in previous studies. Using PV as the inde-
pendent variable could be problematic because it varies from
person to person. Even people of the same age do not always
have the same PV. Using the PTVR as the independent vari-
able could also be problematic because enamel abrasion
resulting from chewing habits, dietary habits, and occluding
habits may cause errors in calculating teeth volumes.
Moreover, the 3D reconstruction of tooth roots involves addi-
tional time because of the approximation between cementum
and alveolar bone. The errors are larger. One advantage of
using the PTVR is that it can reduce the errors caused by tooth
sizes or CBCT image accuracies [48]. Hiroko Agematsu et al.
[36] adapted the volume ratios of the pulp cavity to the whole
tooth after excluding the enamel as the independent variable to
avoid the errors caused by enamel abrasion, while this study
adopted the PEr of IMTM as the independent variable and,
thus, avoided the abovementioned disadvantages.
Regarding the PV of multirooted teeth used in previous
studies, the tooth canal systems simply cut off radicular pulp
[38, 39]. Such a practice may cause systematic errors and,
therefore, cannot accurately reflect PV variations. GCEIS uses
seeds of the pulp cavity to automatically determine the pulp
cavity scope. Due to the voxel size of CBCT images (0.4 ×
0.4 × 0.4 mm3) and the small root canal of IMTM (diameter <
0.4), modeling the root canal is difficult. Manual interventions
to the root canals may exert a negative influence on the pre-
cision of the volume registration. Secondary dentin formation
mostly occurs at the coronal plane of the pulp chamber [49,
50]. According to a study conducted by Solheim et al. [13] and
Aboshi et al. [37], the root neck is more relevant to age than
root apex; therefore, pulp canals are not repaired manually to
reduce artificial error.
Test method P (> 0.05) Statistical result
Paired t test 0.056 No significant difference on both sides
Paired t test 0.293 No significant difference on both sides
Paired t test 0.288 No significant difference on both sides
Int J Legal Med

Table 6 Logarithmic regression

formulas and respective r, R2, Sex Logarithmic formulas r R2 RMSE MAE
RMSE, and MAE in female,
male, and pooled gender group Female group Age = − 9.682 – 23.470 × ln PEr − 0.686 0.470 9.580 7.722
Male group Age = − 3.369 – 20.843 × ln PEr − 0.632 0.400 10.76 9.223
Global sample Age = − 5.817 – 21.726 × ln PEr − 0.647 0.419 9.986 8.410

One of the focuses of this study was whether the pulp
volume and aging changes in teeth in the same position on
both sides were consistent. Previous studies seldom per-
formed such comparison due to tooth type selections, sample
sizes, and experimental designs. Jagannathan et al. [32] and
Tardivo et al. [46]. found no significant differences in either
side after comparing PTVRs of canine teeth. The statistical
analysis performed in this study shows that there are no sig-
nificant differences in EV, PV, and PEr after comparing 200
samples from individuals of different ages with bilateral
IMTM. This result indicates that the age-related changes of
IMTM on both sides can be considered the same.
The deposition of secondary dentin is a nonlinear process
[51]. According to the statistical analysis and comparison, we
found that logarithm regression equations can better reveal the
relationship between age and PEr than linear regression equa-
tions. Since the explanatory variables of previous studies differ
among the studies, determination coefficients are usually used
to reveal the relationship between independent variables and
chronological age. We found that the scope of R2 by CBCT
images for age estimation is 0.21–0.70 [31, 32, 34, 35, 38,
39, 52–55]. After comparing previous determination coeffi-
cients, the trend is obvious, and the value of R2 increases as
the sample size increases, which also explains why the deter-
mination coefficients in this study are comparatively high, with
R2 values at 0.470 (female), 0.400 (male), and 0.419 (combined
gender) and correlation coefficient R values at − 0.686 (female),
− 0.632 (male), and − 0.647 (combined gender). Of the age
variables in this study, 68.6% (female), 63.2% (male), and
64.7% (combined gender) can be explained by the variation
in PEr. By comparing our values with the determination coef-
ficients larger than those found in this study, such as those
reported in a study conducted by Pinchi et al. [55] (R2 =
0.58), we found that these authors used ratios of simplified
coniform PV in simplified tooth hard tissues. The actual mea-
sured volumes differ greatly differ from the simplified volumes.
Their method cannot be applied to multirooted teeth. By com-
paring our results to those reported in Ge’s study [38] (R2 of
maxillary first molars of 0.544 in males, 0.684 in females, and
R2 of mandibular first molars of 0.562 in males, 0.612 in fe-
males), we found that their research sample was rather large
(754 the first molars), and these authors used pulp chamber
volumes, which differ from person to person, as independent
variables to estimate age. Because different gene manifestations
in individuals of the same age may result in different pulp
chamber volumes, personal differences cannot be excluded.
By comparing our results with those reported in Ge’s other
study [39] (which uses multiple types of teeth with R2 of
0.627 in males and 0.701 in females) and Nima Biuki et al.’s
study [47] (which uses the mean of six anterior teeth with an R2
of 0.7225 in males and 0.5476 in females), we found that the
accuracy of age estimation by multiple types of teeth is higher
than that by single teeth. The MAEs were 7.722 in females,
9.223 in males, and 8.41 in the combined gender group in this
study, which are believed to conform to the acceptable ± 10-
year error standard for adult age estimation [56].
This study also found that there were no significant differ-
ences in the age estimation regression equations of the differ-
ent sexes after comparing their logarithm regression equa-
tions, which is consistent with the research results reported
by Star et al. [31], Jagannathan et al. [32], Sakuma et al.
[35], and Tardivo et al. [46] but differs from those reported
by Someda et al. [33], Porto et al. [52], Biuki et al. [47], and
Agematsu et al. [36]. The sample sizes, selected tooth types,
and different independent variable settings all contribute to the
results.

Fig. 4 Scatter diagram showing the relationship between PEr and age for female, male, and pooled gender groups

The following conclusions may be drawn from the results
of the present study:
1. GCEIS can be used to estimate age because it can obtain
EVs and PVs faster and more accurately.
2. There were no significant differences in the PV and EVof
the bilateral IMTM. Thus, the age-related changes in
IMTM are the same on both sides.
3. The PEr of IMTM is a dependable index for estimating
age.
4. The accuracy and precision of modeling technology can
be improved by advances in hardware and software.
Increasing the types of multirooted teeth with complex
root canal systems and changeability will be studied.
The age-related changes in multirooted teeth will be grad-
ually revealed.
The present study focuses on IMTM and cannot be applied
to unimpacted mandibular third molars or conditions of ex-
tracted mandibular third molars. Further research involving
additional tooth types is needed to enhance the accuracy and
applicability of this research.
Acknowledgments The authors would like to thank Dr. Ya-lin Zhao for
her helps in data analysis.
Funding information This work was supported by funding from the
Opening Project of the Key Laboratory of Shaanxi Province for
Craniofacial Precision Medicine Research, College of Stomatology,
Xi’an Jiaotong University (2017LHM-KFKT004) for C.-X. Yan and
the National Natural Science Foundation of China (NSFC No.
81701869) for Y.-C. Guo.
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