Textbook of Forensic Odontology

Textbook of
FORENSIC ODONTOLOGY
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FORENSIC ODONTOLOGY
Editor
Nitul Jain MDS
Assistant Professor
Department of Oral and Maxillofacial Pathology
Eklavya Dental College and Hospital
Kotputli, Rajasthan, India
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This book has been published in good faith that the contents provided by the contributors contained herein are original,
and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher
and the editor specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application
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Textbook of Forensic Odontology
First Edition : 2013
ISBN 978-93-5025-722-7
Printed at
Dedicated to
Remembrance of my grandparents
Late Mrs and Mr Parmanand Jain
and
My humble, lovely and ever-supporting family members
My parents, Mrs and Mr Naresh Jain
My wife, Monika
My sisters, Nidhi and Dr Anjali
and
Our one year old little darling, Tim-Tim
Contributors
Abhishek Singhania MDS Shikha Atreja MDS

Department of Conservative Dentistry and Department of Pedodontics
Endodontics, Eklavya Dental College and Hospital MM Mullana Institute of Dental Sciences
Kotputli, Rajasthan, India Mullana, Ambala, Haryana, India
Ajay Telang MDS Sohail Lattoo MDS

Department of Oral Pathology Department of Oral Pathology
Penang International Dental College Government Dental College
Penang, Malaysia Srinagar, Jammu and Kashmir, India
Anil Pandey MDS Soniya Adyanthaya MDS
Department of Oral Pathology Department of Oral Pathology
Maharana Pratap Dental College and Yenepoya Dental College and Hospital
Research Centre, Gwalior Deralakatte, Mangalore, Karnataka, India
Madhya Pradesh, India
Vishal Saxena MDS
Gaurav Atreja MDS Department of Oral Medicine and Radiology
Department of Prosthodontics Eklavya Dental College and Hospital
MM Mullana Institute of Dental Sciences Kotputli, Rajasthan, India
Mullana, Ambala, Haryana, India
Vishwas Bhatia MDS
Hemanth M MDS Department of Prosthodontics
Department of Oral Pathology Eklavya Dental College and Hospital
Malabar Dental College and Research Centre Kotputli, Rajasthan, India
Edappal, Kerala, India
Nitul Jain MDS
Department of Oral and Maxillofacial Pathology
Eklavya Dental College and Hospital
Kotputli, Rajasthan, India
Preface
Generally the dentists are better known for pulling, drilling and filling the teeth. However, largely the
general people and even dentists themselves have limited conceptions regarding the potential of this
32-member strong, hardest natural arsenal of human body, known as human dentition, which render
them to survive various thermal, chemical and physical assaults where all other body tissues may not
survive to enable identification.
Around the globe, since decades, forensic dentists have been credited for solving multiple mysterious
cases involving human identifications or age estimations and facial reconstructions for both high-profile
cases and even in mass fatality disasters.
Forensic Odontology is the study of dental applications in legal proceedings. Human identification
is a mainstay of civilization and the identification of unknown individuals always has been of paramount
importance to the society. Forensic Odontology plays an important role in the retrieval of evidence and
identification, having a high degree of reliability and simplicity.
The science of Forensic Odontology is comparatively new in India and is still struggling to establish
itself as a known specialty amongst its citizens. Lack of subject teaching at undergraduate level and
simultaneously no specialization or postgraduate course in this discipline may be the two main factors
for general lack of interest in this subject, which is having a promising future and bright prospects, both
in India and abroad.
Textbook of Forensic Odontology, in its first edition, has been tailored to make the subject interesting
and easy-to-understand for undergraduates and has also included the requisite details needed for
postgraduate students in the subject of oral pathology, oral medicine and forensic medicine.
Various disciplines like identification, age estimation, bite marks have been presented as separate
chapters, supplemented with concerned historical cases and color photographs.
Importance of dental record keeping and guildelines involving forensic photography has been well
emphasized.
In this very first endeavor of ours, we have utilized our efforts in best possible way to bring out to
students a simple and concise volume of this book, which we promise will be interesting to readers, yet
errors may have been incorporated inadvertently. Readers are always welcome for their suggestions and
constructive criticism to make the title more authentic.
Nitul Jain
Acknowledgments
As popularly said, no dream is too big. To author a book on my name had been a long awaited dream
for me for the last many years. Thanks to Almighty God for listening and fulfilling my dream. This
dream would have remained dream only, if I had not got support from my friends, colleagues and my
family members.
I am immensely thankful to Prof Dr Pushparaja Shetty, Head, Department of Oral Pathology, AB
Shetty Memorial Institute of Dental Sciences, Mangalore, India, for his valuable guidance throughout
my postgraduation. With his vast knowledge, he has always been a constant source of inspiration for
me.
It is with great honor and pride that I convey my honest gratitude to my honorable sir, Prof Dr VS
Sabane, Ex-Principal, Bharati Vidya Peeth Dental College and Hospital, Pune, and Head, Department
of Oral Pathology, Eklavya Dental College and Hospital, Kotputli, for his able guidance and help. I
thank him for the personal concern he has shown throughout preparation of the manuscript.
I especially wish to say thanks to Mr Tarun Duneja, Director-Publishing, Jaypee Brothers Medical
Publishers (P) Ltd, New Delhi, for showing utmost belief in new authors and giving me an opportunity
to fulfill my dream. I also need to say thanks to Mr KK Raman (Production Manager), Ms Samina Khan
(PA to Director-Publishing), Mr Ashutosh Srivastava (Asstt. Editor), Mr Manoj Pahuja (Graphic
Designer), Mr Rakesh Kumar (DTP Operator) and entire staff of Jaypee Brothers Medical Publishers,
for patiently answering all my queries and making this title published.
Contents
1. Forensic Sciences: The Historical Perspective and Branches ............... 1

Nitul Jain
• Identification Parameters 2
• Historical Aspects 3
• Events and Advances 6
• Most Famous Contributors to Forensic Sciences 7
• What is a Forensic Dentist? 8
– Importance 8
2. Forensic Odontology and its Applications ............................................. 10

Hemanth M, Anil Pandey
• Dental Identification 10
– Types of Identification 10
• Bite Marks 11
• Identification 11
– Why a Dentist for Identification? 11
• Comparative Dental Identification 11
• Principles and Phases of Dental Identification 12
– Phases 14
• Reconstructive Postmortem: Dental Profiling 18
– Age 18
– Sex 19
– Role of Skull and Mandible 20
– Classification of Methods 21
– Race 24
• Opinion from Forensic Anthropologists 29
– Other Methods of Dental Identification 30
• Role of DNA Molecule in Identification 31
– The DNA Molecule 33
3. Dental Records and Forensic Photography ............................................ 43

Nitul Jain, Gaurav Atreja
• Introduction 43
– What is a Patient Record? 43
– Creation and Maintenance of a Patient Record 45
– Radiographs Keeping 47
– Retention of Patient Records 48
xiv Textbook of Forensic Odontology
• Long-term Storage of Dental Records 49

– Access to Patient Records 49
– Forensic Uses of Patient Records 50
– Confidentiality of Records 50
– Indian Scenario and Lacunae in the System 51
• Forensic Photography 52
– Need for the Photography 52
– The Technical Considerations 52
– The Basic Optics of Photographic Process 53
– Types and Techniques 54
– Handling of Photographic Evidence 63
4. Oral and Maxillofacial Radiology: An Approach to

Forensic Aspects ...................................................................................... 64
Vishal Saxena
• Radiology and Forensic Sciences 64
– Historical Perspectives 65
– Dental Radiology and Forensic Sciences 65
• Scope of Forensic Radiology 67
– Oral and Maxillofacial Radiology in
Person Identification 68
– Radiographic Anatomic Landmarks of the Jaws 68
– Radiological Anatomical Features and the Spatial Relationship of the Teeth 70
– Radiology in Reconstructive Dental Identification 72
– Another Aspect of Radiology in Identification-frontal Sinuses 72
– Radiography in Mass Disaster Victim Identification (DVI) 73
– Age Estimation and Dental Radiology 74
– Pitfalls and Drawbacks in Age Determination 74
– Evaluation of Cranial Trauma Using Radiological Methods 75
– Fraud, Claims and Dental Radiology 75
– Contemplating Human Judgment 76
• Limitations of Dental Radiography 77
5. Age Estimation and Dental Methodology ................................................ 78

Nitul Jain, Sohail Lattoo
• Historical Perspective 79
• Need for Age Estimation 79
• Age Changes in Oral Cavity 80
– Soft Tissue Changes 80
– Dental Changes 80
– Hard Tissue Changes 81
• Terminologies 81
• Chronology of the Human Dentition 82
Contents xv
• Various Methods for Age Estimation 82

– Estimation of Age by Skeletal Means 83
– Estimation of Age by Teeth 84
• Steps of Age Estimation 97
– Visual Assessment 97
– Radiographs 97
– Extraction and Preparation of Single Teeth 97
– Dental Age Estimation by Means of Commonly Used Developmental Surveys 98
• Commonly Used Dental Developmental Surveys 99
– Schour and Massler Method (1940) 99
– Moorees Method (1963) 100
– Demirijian Seven-tooth System for Age Estimation 104
– Gustafson (1966) Mehod for Estimation of the Age 107
– Other Less Commonly Used Methods for Estimation of Dental Age 108
6. Bite Marks ................................................................................................ 110

Nitul Jain, Soniya Adyanthaya
• Historical Aspects 112
• The Legal Admissibility 113
• Skin as Registration Materials for Bite Marks 114
• Classification of Various Bite Mark Systems 115
• Typical Presentation and Composition of Bite Marks 117
– Component Injuries Seen in Bite Marks 117
– Location of Bite Marks 118
– The Classic Appearance 118
– Variations of the Prototypical Bite Mark 119
• Bite Mark Recognition 120
– Aging/Changes Over Time 120
– Variables Affecting Appearance of Bruises 120
– Range of Bite Mark Severity—The Bite Mark Severity and Significance Scale 121
– Distortion in Human Bite Marks 121
– General Principles Behind Identification of Bite Marks 125
– ABFO’s Recommended Procedure and Guidelines: Bite Mark Analysis Guidelines 126
– Forensic Physical Comparison of Exhibits 134
– Biological Techniques for Bite Mark Comparisons 135
– Experimental Marks 139
– Bite Marks in Inanimate Objects 139
– Preservation and Collection of Inanimate Evidence 140
• Differences in Bite Patterns of Child and Adults 143
– Non-accidental Injury to Children 143
• Bites, Bite Wound Infections, Prevention and Management 145
– Prevalence of Bites 145
– Nature of Bites 145
– Diagnosis of Infection 148
– Complications 148
xvi Textbook of Forensic Odontology
– Management 149

– Facial Bites 150
– Psychological Aspects of Bite Marks 152
7. Cheiloscopy and Palatoscopy ............................................................... 155

Gaurav Atreja
• Cheiloscopy 155
– Historical Review of Cheiloscopy 156
• Anatomical Aspects 156
– Analyzing and Recording Lip Prints 158
– Problems with Cheiloscopy 160
– Future Prospects of Cheiloscopy 161
• Palatoscopy 161
• Historical Review 161
• Anatomical Aspects 162
• Palatal Rugae Classifications 163
– Cormoy System 165
– Correia Classification 165
– Palatoscopy in Edentulous Cases 165
• Analyzing and Recording Palatal Rugae 166
– Genetic Influence on Palatal Rugae 167
• Problems with Palatoscopy 167
• Future Prospects 167
8. Forensic Facial Reconstruction ............................................................. 169

Nitul Jain, Sohail Lattoo, Vishwas Bhatia
• Daubert Standard 170
• Theoretic Foundations 171
• Types of Identification 172
• Types of Reconstructions 172
– Two-dimensional Reconstructions 172
– Three-dimensional Reconstructions 173
– Superimposition 173
• History 173
• Technique for Creating a Three-dimensional Clay Reconstruction 174
• Currently Used Methods 176
– Requirements for a Forensic Reconstruction of Soft Facial Parts 176
– Classic Manual Methods 176
– Graphic Methods 177
– Computer Aided Reconstruction of the Soft Facial Parts 177
• Problems with Facial Reconstruction 179
– Insufficient Tissue Thickness Data 179
– Lack of Methodological Standardization 179
– Subjectivity 180
• Facial Reconstruction and the Media 180
Contents xvii
9. Mass Disaster Victim Identification and Dentist’s Role ....................... 182

Ajay Telang, Anil Pandey
• What is a Disaster and a Mass Fatality Incident? 182
• Kinds of Disaster 182
• Need for the Preparedness 184
– The Historical Perspective 185
• The Ways a Dentist can be of Help in Case Need Arises in
Disaster Management 187
– How Dental Auxiliaries can Help 189
• Preparation for Unfortunate Disasters and Protocols 190
• Role of Dentists in Mass Disaster Forensics 190
– Evidence Protocols 191
• Phases of Response 191
– 1st Responder 191
– Stabilization 192
– Resolution 192
– Resolution of Site to Normal 192
• The Standard Operating Procedure 193
• Chain of Custody 193
• Evidence Collection and Preservation 194
• Dental Records and Mass Disasters 194
• Man Made Disasters 195
– Forensic Techniques and Evidence Sources in Specific Scenarios 195
– Chemical Scenario 196
– Biologic Agents 197
– Nuclear/Radiologic Event 198
– Explosive Events 199
• Dental Radiography in Mass Disasters 202
– Field Equipment for Mass Disasters 202
– Commingled, Skeletonized, Carbonized, and Mutilated Remains 202
10. Child Abuse, Neglect and Domestic Violence: Role of a Dentist ........ 204
Abhishek Singhania, Shikha Atreja
• Child Abuse in India and Indian Statistics 205
– Physical Abuse 206
– Sexual Abuse 206
– Emotional Abuse and Girl Child Neglect 207
• Bruises 207
• Pathogenesis of Contusions and Factors Affecting the Development and
Appearance of a Bruise 207
• Characteristic Bruises 209
• Conditions that may be Confused with Abusive Bruising 210
• Legal Matters Regarding Child Abuse and Neglect 212
– The Constitution of India 212
– International Conventions and Declarations 213
xviii Textbook of Forensic Odontology
• Recognizing Child Abuse/Neglect 214

• Detecting Child Abuse in the Dental Office 214
– Case History 214
– General Physical Findings 216
– Findings on Dental Examination 216
– Typical Oral Lesions 216
– Bruises Resulting from Physical Child Abuse 219
• Reporting Child Abuse or Neglect 221
• Critical Steps in Investigating and Interviewing the Possible Victim 221
• Photo Documentation 222
• Techniques to Help Visualize Bruising 223
• Dating Bruises and Associated Misconceptions and Limitations 224
• Domestic Violence and Battered Women 225
Annexures ................................................................................................ 227

Annexure I 227
Annexure II 228
Annexure III 229
Index ......................................................................................................... 231
Chapter 1 $
Forensic Sciences: The Historical 1
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Perspective and Branches a
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Nitul Jain O
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^ Chapter Overview
Identification parameters
Historical aspects
n Most famous contributors to Forensic Sciences
What is a forensic dentist ?
Events and advances
INTRODUCTION interaction with others. Additionally, automated

payment systems can allow rent and bill paying to
Bodies may remain undiscovered until they are continue long after death . The discovery of
wholly or partially skeletonized for a number of skeletonized or partially skeletonized remains in
reasons. Some bodies are deliberately concealed dwellings raises numerous social and legal questions
after death, whereas for others, death occurs in that must be addressed as part of a coronial
isolated or inaccessible areas . However , a investigation .
proportion of severely decomposed bodies are However, the effects of decomposition can
found in the deceased’s own home months, or even complicate the autopsy and render some routine
years after death ( Fig. 1.1 ) . Sometimes, these cases procedures, such as organ histology, less useful . CD
receive extensive media coverage and the sadness o
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of the circumstances may be seen as an indictment
on society and on responsible authorities. Long CD
delays in the discovery of bodies in houses often
occur because the deceased was socially isolated in
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life . Factors such as mental and physical illness or
disability, drug and alcohol addiction, or trauma
from previous abuse can contribute to , or
accompany, a person’s disengagement from society. CO
Modern conveniences , such as telephone
banking, 24 hours shopping and internet access, Fig . 1.1 : Decomposed body showing human remains
can also help to eliminate the need for physical after a catastrophe
2 Textbook of Forensic Odontology

The passage of time can also cause difficulties at Each of the questions are correlated. Most
other levels of the investigation since the investigations involve several “autopsies”, one of
recollections of witnesses potentially fade, and the victim(s), one of the scene, and one of the
death scenes may become contaminated and circumstances of injury and/or death. These
altered. “autopsies” are designed to discover and preserve
Given the complexity of the medicolegal evidence, document that evidence, analyze that
investigation required of these cases, it is preferable evidence, and apply that evidence towards
for a combination of specialists to address the major reconstructing the events leading to the injury
questions raised by the coroner or other relevant and/or death. Most such investigations focus on
authority. There are a variety of techniques available physical evidence that is deposited or transferred
from forensic pathology, anthropology, odontology from victim to perpetrator and vice versa. This
and entomology that may help to establish the presumed relationship is known as Locard’s
deceased’s identity, cause of death, factors principle and is the basis for much of what is
contributing to death and the timing of death. attempted in the fields of criminalistics and forensic
Forensic identifications by their nature are chemistry.
multidisciplinary team efforts relying on positive The development and application of molecular
identification methodologies as well as presumptive biology techniques, especially DNA profiling,
or exclusionary methodologies. Typically, this reflects this principle and the current reliance on
effort involves the cooperation and coordination technology in medicolegal investigations.
of law enforcement officials, forensic pathologists,
forensic odontologists, forensic anthropologists, IDENTIFICATION PARAMETERS
serologists, criminalists, and other specialists as Legal certification of an individual’s identity is
deemed necessary. In each discipline, there is the based on a number of parameters most of which
need to develop scientific evidence relative to the are centered about the individual’s appearance and
questions of fact regarding identification in a personal effects. As such, many persons are buried
defensible manner grounded on general rules of or cremated based on a visual identification or other
acceptance, reliability and relevance. presumptive identification methods. Where
Most techniques applied are used by all or most possible, a positive identification is preferred to a
of the disciplines, often for slightly different presumptive identification in such medicolegal
purposes. In the forensic sciences, a great deal of cases. Positive identifications traditionally involve
effort is spent on the identity or confirmation of a comparison of pre and postmortem data which
identity of the victim(s) and perpetrator(s). This are considered unique to the individual. These
labor intensive aspect of a medicolegal investigation methods include (Figs 1.2A to C):
focuses on the six major questions, asked in any 1. Dental comparisons,
such forensic investigation: 2. Fingerprints, palm prints, and footprints,
1. Who is the victim? 3. DNA identifications, and
2. What are the injuries? 4. Radiographic superimpositions (vertebrae,
3. How were the injuries sustained? cranial structures including frontal sinuses, pelvic
4. Where did the injuries occur? structures, bone trabeculae and prosthesis).
5. When did the injuries occur? Presumptive identifications, which include
6. If the injuries were caused by another person, visual recognition, personal effects, serology,
by whom? anthropometric data, and medical history do not
Forensic Sciences: The Historical Perspective and Branches 3

usually identify unique characteristics of the
individual but rather present a series of general or
class characteristics which may exclude others based
on race, sex, build, age, blood group, etc. Most
positive identifications today are based on dental
examinations and fingerprints and are fundamental
procedures in medicolegal death investigations
including mass disasters. The development of DNA
analysis is providing investigators with yet another
very important tool in the identification process.
The identification of unknown deceased persons
A
is the primary focus of the forensic odontologist.
This is usually achieved by comparison of the ante-
mortem dental records and postmortem dental
charts. There is usually copious circumstantial
evidence to suggest identity when people are found
deceased in their homes; however, formal
confirmation is still required to eliminate doubt.
Locating the treating dentist can be time
consuming and sometimes impossible in cases
involving socially isolated people, as they may not
have visited a dentist for many years (if at all). Also,
the dentist may be located far from where now
B they live, either interstate or overseas. However,
despite the inherent difficulties, a search for treating
dentists should always be attempted. This is
especially true where no relatives can be located to
provide a DNA sample for comparative analysis.
Odontologists may also examine the teeth and
orofacial skeleton for trauma. They may potentially
identify chips, breaks or recent tooth loss that can
indicate antemortem trauma to the mouth. Such
injuries could be sustained either as a result of non-
accidental or accidental trauma. Odontologists can
also examine the structure of the teeth and jaws,
and degree of dental attrition for clues that may
support anthropological age estimates.
HISTORICAL ASPECTS
C
The word Forensic is derived from the Latin
Figs 1.2A to C: One of the identification parameters used for forens(is): of or belonging to the forum, public,
human identification, (A) Fingerprints, (B) Foot prints, (C) Palm
prints equivalent to for(um) forum + ens — of, belonging

to + ic. By extension it came to also mean the late sixteenth and early seventeenth centuries
disputative, argumentative, rhetorical, belonging and, after 1650, lectures on legal medicine were
to debate or discussion. From there it is but a small given in Germany and France. The first book on
step to the modern definition of forensic as medical jurisprudence in the English language
pertaining to, connected with, or used in courts appeared in 1788 and 19 years later the first Regius
of judicature or public discussion and debate. Thus Chair in Forensic Medicine was recognized by the
the forensic sciences encompass the application of Crown at the University of Edinburgh. The English
specialized scientific and/or technical knowledge coroner’s system was imported to the colonies in
to questions of civil and criminal law, especially in North America in 1607, and it was not until 1871
court proceedings. Forensic Medicine has come that Massachusetts, later followed by New York
to be recognized as a special science or discipline and other jurisdictions, established a medical
that deals with relationships and applications of examiner system. Upon this base of professionalism
medical facts and knowledge to legal problems. in death investigation, supported by the framework
Some prefer to call it legal medicine or medical of solid scientific and technical advances during
jurisprudence. the twentieth century, was erected the modern
Evidence of the origin of legal or forensic structure of forensic medicine which covers a
medicine can be found in records of ancient people heterogeneous, sometimes loosely related, family
some thousands of years ago, when occasionally a of numerous disciplines or subspecialties sharing a
law appears to influence medicine or medicine is common interest.
found to influence or modify a law. The Egyptian, Forensic dentistry can be defined in many ways.
Imhotep, may have been the first to apply both One of the more elegant definitions is simply that
the law and medicine to his surroundings. forensic dentistry represents the overlap between
Hammurabi codified medical law circa 2200 BC, the dental and the legal professions.
and medicolegal issues were covered in early Jewish There is an extensive history of the distinctive
law. Later, other civilizations — the Greeks, ancient nature of tooth arrangement with legal implications.
India, the Roman Empire—evolved jurisprudential As no two fingers are identical, neither two mouth
standards involving medical fact or opinion. Early nor two teeth are exactly identical. Identification of
cultures recognized the desirability of controlling human remains by dental characteristics is a long
the organization, duties, and liabilities of the standing and well established component of forensic
medical profession. They also were acquainted with science.
the importance of the knowledge and opinion of Right through history, the human dentition has
the medical person in the legal consideration of been used numerous times in identifying individuals.
issues of great moment such as the use of drugs or Harvey (1973) has traced one of the earliest
poisons, the duration of pregnancy, virginity, recorded incidences of dental identification to 66
superfetation, the prognosis of wounds in different AD, when the severed head of the wife of Roman
body locations (a physician determined that only emperor Nero was identified by a rival from her black
one of Caesar’s 23 stab wounds was fatal), sterility anterior tooth. In (1193) AD, the Maharaja of
and impotence, sexual deviation, and suspicious Kannauj, Jai Chandra Rathor was identified by his
death. Early in the sixteenth century a separate false teeth following his death in a battle. The
discipline of forensic medicine began to emerge. English king Charles ‘the bold’, who also died in
New codes of law required expert medical battle in 1477, was identified from his dental
testimony in trials of certain types of crime or civil features, courtesy the court physician who identified
action. The first medicolegal books appeared in his two recently extracted teeth (Furness, 1972).

Paul Revere is credited as being the first dentist to
identify a person from dental features (Luntz, 1970).
He identified his friend Joseph Warren, a victim in
the American Revolution in 1775 from a silver and
ivory bridge which he had prepared.
Gustafson (1962) suggests that the role of
forensic odontology in human identification came
to prominence only towards the end of the 19th
century, after two major fires in Europe. The first
occurred in 1881, when the ‘Ring Theatre’ in
Vienna was destroyed during a performance, with
449 casualties. The second, the Charity Bazaar fire
in Paris in 1897, resulted in the deaths of 127
people. In both these events, dental features were
used for identification.
According to Harvey (1973), one of the dentists
who assisted the identifications in Paris was a Cuban
named Oscar Amoedo. In 1898, he wrote one of
the first books on forensic odontology, L’art
Dentaire en Medicine Legale, and is considered a
pioneer of modern forensic dentistry.
According to Suzuki however, the first course A
in forensic dentistry was probably conducted by
Professor Sadanori Mita of Japan as early as 1903.
The correspondence course outlined “methods of
examination, evaluation and classification of bite
marks and the differences between ante- and post-
mortem appearances”. This course subsequently
formed the basis of his lectures at Tokyo Dental
College between 1922 and 1936.
Forensic dentists in the 20th century have made
major contributions in identification: notable
among the cases are (Figs 1.3A and B) Adolph
Hilter (1945), Zia–ul–Haq (1988) and Rajiv
Gandhi (1991).
Apart from dental identification, forensic
odontology is also applied in the investigation of
crimes caused by the dentition, such as bite marks
(Fig. 1.4). Bite marks are a common feature of B
sex crimes and violent fights. They may also occur
Figs 1.3A and B: (A) German ruler Adolf Hitler, whose
on objects such as chewing gum or chocolate that identification was done because of his dental prosthesis,
may be found at a crime scene. (B) Rajiv Gandhi

As a result of its versatile use, forensic dentists
are considered an integral part of the forensic team
of experts.
EVENTS AND ADVANCES

Keiser-Nielsen assessed the uniqueness of teeth
mathematically.
Sognnaes et al (1982), demonstrated the
uniqueness of bite marks even in identical twins
by computer comparison.
Vale et al (1976) indicated at least 6 possible
Fig. 1.4: Multiple bite marks on a victim’s leg showing an positions of each tooth to demonstrate indi-
important parameter of identification for the culprit
viduality. Fellingham and coworkers have
calculated that there are 1.8 × 10 19 possible
Bite marks, however, are not a recent discovery. combinations of the 32 teeth being intact,
As early as the 6th century AD, the Indian sage decayed, missing or filled.
Vatsyayana had devoted an entire chapter on ‘love Sweet and Pretty considered the size, shape and
bites,’ with a detailed classification in the book pattern of the incisal or biting edges of upper and
Kama Sutra (Harvey, 1973). lower anterior teeth to be specific to an individual.
In medieval Britain, during the reign of William In the past, bite mark evidence was analyzed by
I (1027–1087 AD), green wax seals with the the use of the transparent overlay technique. This
impression of the king’s teeth were implanted on method uses a clear thin sheet of acetate paper laid
state documents to avoid falsification and indicate over a photographic transparency or print of the
the authenticity of the seal. inflicted area. The marks of the bite are traced on
The use of bite marks as evidence in court can paper and compared with the tracing of the incisal
be traced back to 1692 in the United States. and cutting edges of the teeth of a suspect. By this
Harvey (1973) cites a 1906 case where, a burglar method persons could be included or excluded as
was convicted in Britain because his dental models possible suspects.
matched the marks left on cheese found at the crime Transilluminating the tissue and intensification
scene. Subsequently there have been numerous of the image have produced sharp image details of
cases that made use of bite marks with varying damage to the tissue caused by biting forces.
degrees of success. Therefore, bite marks remained Transillumination is easily adopted for use with a
a contentious area of forensic sciences. However, cadaver but is of limited value with the living victim
over the later half of the 20th century, bite mark of a bite.
procedures have greatly advanced and it is now The xeroradiographic enhancement of the
routinely used in court proceedings in the West. incisal edge is apparent. The impression left by the
Its objective application as evidence in crime can incisal edges can be accurately compared with the
have far reaching implications for the society in dentition producing the original bite.
general and criminology in particular. Videotape analysis of bite mark evidence was
Forensic dentists also handle bite marks caused introduced in a California court. Photography and
by animals. This requires a basic knowledge of videotaping of the evidence at right angles are
various animal dentitions, the study of which is absolutely necessary. Many hours of editing are
known as comparative anatomy. needed to achieve results from the videotape.

David TJ et al have used scanning electron
microscopy in bite mark analysis. With the use of
SEM, what appeared to be class characteristics were
clearly identified as individual characteristics.
David Sweet proposed a computer-based
technique for the production of life sized bite mark
comparison overlays. This method allows objective
selection of the biting surfaces of a suspect’s teeth
from dental study casts, which can be used in bite
mark analysis.
Over the later half of the 20th century, bite mark
procedures have greatly advanced and are now
routinely used in court proceedings in the West.
Its objective application as evidence in crime can
have far reaching implications for the society in
A
general and criminology in particular.
MOST FAMOUS CONTRIBUTORS TO

FORENSIC SCIENCES
1813, Mathiew Orfila: Father of modern toxicology,
made significant contributions to the development
of tests for the presence of blood in a forensic context
and is credited as the first to attempt the use of a
microscope in the assessment of blood and semen
stains.
1835, Henry Goddard, of Scotland Yard’s
Police, first used bullet comparison to catch a
murderer.
1879, Bertillon began to develop the science of
anthropometry
B
1891, Hans Gross, (Fig. 1.5A) coined the word
Criminalistics Figs 1.5A and B: (A) Hans Gross, the important contributor
to the field of forensic sciences. (B) Karl Landsteiner, who
1900, Karl Landsteiner (Fig. 1.5B) first discovered discovered the most commonly used blood grouping system
human blood groups and was awarded the Nobel
Prize for his work in 1930. Formed the basis of all
subsequent work.
1928, Locard’s Exchange Principle (Fig. 1.6),
according to which whenever two objects come
into contact there is always a transfer of material.
1977, Masato Soba, a latent print examiner was
the first to develop latent prints intentionally by
“Super glue (r)” fuming. Fig. 1.6: The Locard exchange principle

1998, FBI DNA database—NIDIS, enabling individual’s dental structures. Forensic odontology
interstate cooperation in linking crimes, was put plays a major role in identification on man made
into practice. or natural disasters events that result in fatalities
2000, CODIS (Combined DNA Index System) that may not be identifiable through conventional
Identification system used tracking suspects by means as fingerprints. Relies on sound knowledge
DNA profiling of teeth, jaws and incorporates dental anatomy,
histology, radiography, pathology, dental material
WHAT IS A FORENSIC DENTIST? and developmental anatomy.
A forensic dentist is first a scientist. When he applies It delves into:
his scientific knowledge to assist juries, attorneys, 1. Identifying unknown human remains through
and judges in understanding science, he is a forensic dental records
dentist. Forensic scientists are thinkers, good with 2. Assisting at the location of the mass disaster
details, good with putting pieces of a puzzle 3. Eliciting the ethnicity and assisting in building
together, and curious. They may work in up a picture of lifestyle and diet of skeletal remains
laboratories, go out to crime scenes or teach in 4. Determining the gender of unidentified
colleges and universities. 5. Age estimation of both the living and deceased
6. Recognition and analysis of bite marks found
Importance
on victims of attack
Primarily deals with identification based on 7. Presenting evidence in court as an expert
recognition of unique features present in an witness.
Fig. 1.7: The ten branches of Forensic Sciences, as recognized by AAFS


The American academy of forensic sciences Forensic anthropologists: Identify individuals killed
recognizes 10 areas of forensic endeavor (Fig. 1.7): in disasters resulting in the death and mutilation
1. Criminalistics of bodies
2. Engineering science Forensic psychiatry and behavior sciences: Address a
3. General jurisprudence broad range of legal issues. In criminal law, such
4. Odontology issues as competence (e.g. competency to stand
5. Pathology/biology trial and to testify) and the assessment of mental
6. Psychiatry illness or innocence by reason of mental illness or
7. Behavior science defect are the focus.
8. Questioned documents Questioned documents: The document examiner
9. Toxicology discovers and proves the facts concerning
10. Physical anthropology documents and related material, such as ink, paper,
Criminalistics: Analyze, compare, identify, and toner from a copier or fax, and ribbons, such as
interpret physical evidence. Involved in area of from a typewriter. Questions such as: Who wrote
laboratory testing of various types of physical this? Is this a true signature? Has this document
evidence, including biologic fluids, DNA and been altered? Are there additions and/or erasures
suspicious chemicals. on this check?
Engineering science: Structural aspects of crime/ Toxicology: the study of harmful effects of chemicals
accident scene. Applies the principles of or drugs on living systems. It primarily deals with
mathematics and science for to the purpose of the the medicolegal aspects of toxicology.
law. How could the accident have happened? Why
did the airplane crash? BIBLIOGRAPHY
General jurisprudence: Application of science to
1. Archer MS, et al. Social isolation and delayed
assist courts in resolving questions of fact in
discovery of bodies in houses: The value of forensic
criminal and civil trials. pathology, anthropology, odontology and
Forensic dentistry (odontology): A vital branch of entomology in the medicolegal investigation.
forensic science that involves the application of Forensic Science International 2005;151:259-65.
dental science to the identification of unknown 2. Fairgrieve SI, SEM Analysis of incinerated teeth as
human remains and bite marks, using both physical an aid to positive identification. J Forensic Sci.
1994;39(2):557-65.
and biological dental evidence.
Pathology: The study of disease: Pathologists study 3. Melissa N. The role of the dentist at crime scenes.
Dent Clin N Am 2007;51:837-56.
disease by performing an autopsy and examining
4. Pretty IA, Sweet. A look at forensic dentistry—Part 1:
the tissues removed, Analysis of fluids taken from The role of teeth in the determination of human
the body, such as blood or urine. identity. British Dental Journal 2001;190:359-66.
Chapter 2 $
1
Forensic Odontology and its Applications 3*
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^ Chapter Overview
Definition
Dental identification
Principles and phases of dental identification
Reconstructive postmortem: Dental profiling
Bite marks Opinion from forensic anthropologists
n Identification Role of DNA molecule in identification
n Comparative dental identification
As we enter a new millennium, society is faced with DEFINITION

fresh challenges in every conceivable area. Despite
“ That branch of dentistry which , in interest of
leaps in modern technology, medical breakthroughs
justice deals with proper handling and examination
and the geographical changes that the last century of dental evidence, and with the proper evaluation
has brought , crime still persists in all aspects of our and presentation of dental findings”.
lives. Violent and heinous activities that shatter
the lives of victims, their friends and families
— FDI recognizes Wo distinct areas,
identification and bite marks
occur everyday. Often, little can be done to repair
such damage. The apprehension and subsequent DENTAL IDENTIFICATION
CD
prosecution of the perpetrator ( s ) is essential to Based on theory that all individuals are unique o
LU
maintain law and order. Through the specialty of All humans are born with anomalies or acquire
forensic odontology, dentistry plays a small but artifacts.
CT3
significant role in dais process. By identifying the -O

• An anomaly is a unique congenital condition ( e.g.
victims of crime and disaster through dental records, mesiodens, missing lateral incisor, spina bifida ) CD
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dentists assist those involved in crime investigation. • An artifact is man made alteration ( dental
Always pan of a bigger team, such personnel are
dedicated to the common principles of all those
restorations , extracted tooth , scar, tattoo,
appendectomy ).
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involved in forensic casework: the rights of the dead
and those who survive them. The most common Types of Identification
role of the forensic dentist is the identification of The identification is of two basic types: Unknown
deceased individuals. and Confirmation
Forensic Odontology and its Applications 11
Bite Marks five surfaces, for a possible total of 160 surfaces.

Each surface has its own characteristics and may
This is also based on the fact that no two dentitions have fillings, crowns, extractions, bridges, etc. In
are identical. addition to the teeth we see in our mouths, the
Bite mark has traditionally been defined as roots and bone around them are specific to each
“a pattern injury”: That is any injury in which person.” Given all of these parameters, it is safe
the instrument of injury can be determined and to say that the physical make-up of each person’s
possibly may be individualized as the weapon dentition is unique.
making the injury. That’s why of all the above mentioned reasons
A bite mark is an injury to skin in which the that a dentist, possessing the vast knowledge of
instruments of the injury are teeth. The injury is oro-facial tissues may be better able to answer the
a contusion caused by the rupture of small blood questions arising during a death investigation,
vessels as the individual teeth compress the tissue. where all other forensic ancilliary techniques have
In contrast to finger prints, which leave a definite been failed to conclude on an unknown identity.
ridge marks, bite marks leave blurred contusions, Three types of personal identification
which tend to leak in surrounding tissues. circumstances that use teeth, jaws and oro-facial
characteristics exist in forensic odontology.
Identification 1. Comparative dental identification: The
most frequently performed examination is
Why a Dentist for Identification? a comparative identification that is used to
A dentist is the best person to solve the mysteries establish (to a high degree of certainty) that the
of crime because of the following reasons, which remains of a decedent and a person represented
he can deal in a better way than others. As all of us by antemortem (before death) dental records
know that teeth are the hardest substance in body are the same individual. Information from the
and these may be only tissue available to identify body or circumstances usually contains clues as
after surviving most of insults and consequences to who has died.
encountered at death and during decomposition 2. Reconstructive postmortem dental profiling: In
(explosions, accidental trauma, aircraft crashes). those cases where antemortem records are not
Various authors have said tooth to be more available, and no clues to the possible identity
unique than the DNA. Identification, using dental exist, a postmortem (after death) dental profile
impressions is an invaluable tool. Most scientists is completed by the forensic dentist suggesting
agree that bite marks are even more unique than characteristics of the individual likely to narrow
DNA—Identical twins share the same genetic the search for the antemortem materials.
makeup, but their dental impressions will differ. 3. Others (mainly DNA profiling methods) when
Tooth has been used as the cornerstone in no other evidence remains apart form a small
positive identification of living/deceased persons tissue fragments.
using the unique traits and characteristics of teeth
and jaw. Also, using the forensic techniques in
dental tissue are the most challenging aspect of
Comparative Dental Identification
this discipline. When body is too fragmented/mutilated/
“There are 28 teeth, plus four wisdom teeth, in incinerated, identification by next of kin i.e.
an adult’s dentition,” Delattre says, “each tooth has (visual recognition) may give false positive or false
negative results. (Figs 2.1A to C). Circumstantial clinical photographs, study casts, ortho/prostho

evidences including personal possessions (wallets, appliances, mouth guards all can be used.
jewelry) and context of scene may suggest who Congenital/acquired characteristics are compared.
it is that has died. Antemortem records for this Discrepancies may also be seen, but should be
person is sought for. Intra/extra oral radiographs, explainable.
Dental identification of humans occurs for a
number of different reasons and in a number of
different situations (see Table 2.1).
a. The bodies of victims of violent crimes,
fires, motor vehicle accidents and work place
accidents, can be disfigured to such an extent
that identification by a family member is neither
reliable nor desirable.
b. Persons who have been deceased for some time
prior to discovery and those found in water
also present unpleasant and difficult visual
identifications.
c. Dental identifications have always played a key
role in natural and manmade disaster situations
and in particular the mass casualties normally
associated with aviation
d. Because of the lack of a comprehensive
fingerprint database, dental identification
continues to be crucial in the United Kingdom.
An overarching principle is recognition and
evaluation of certain changes over time like
radiological comparisons of progression of carious
lesions, changes in alveolar bone contours (see
Table 2.2).
Principles and Phases of Dental
Identification
Typically, human remains are found and reported
to the police who then initiate a request for dental
identification. Often a presumptive or tentative
identification is available (i.e. wallet or driving
license may be found on the body) and this will
enable antemortem records to be located. In other
instances, the geographical location in which the
body is found or other physical characteristics and
Figs 2.1A to C: (A and B) Decomposed human remains
in various kind of assaults making identification almost circumstantial evidence, may enable a putative
impossible, (C) Skeltonized human remains found in a grave identification to be made, frequently using data
Table 2.1: Common reasons for identification of found human remains

Criminal Typically an investigation to a criminal death cannot begin until the victim has been positively
identified
Marriage Individuals from many religious backgrounds cannot remarry unless their partners are confirmed
decreased
Monetary The payment of pensions, life assurance and other benefits relies upon positive confirmation of
death
Burial Many religions require that a positive identification be made prior to burial in geographical sites
Social Society’s duty to preserve human rights and dignity beyond life begins with the basic premise of
an identity
Closure The identification of individuals missing for prolonged periods can bring sorrowful relief to family
members
Source: IA Pretty, Sweet. A look of forensic dentistry—Part 1: The role of teeth in the determination of human
identity. British Dental Journal 2001;190:359-66.
Table 2.2: Features examined during the comparative dental identification. This extensive list represents the
complexity of these cases, particularly in those instances in which restorative treatment is absent or minimal
Teeth b. Attrition, abrasion, erosion Periapical pathology

Teeth present c. Atypical variations, enamel a. Abscess, granuloma or cysts
a. Erupted pearls, peg laterals etc. b. Cementomas
b. Unerupted d. Dentigerous cyst c. Condensing osteitis
c. Impacted Root morphology Dental restorations
Missing teeth a. Size 1. Metallic
a. Congenitally b. Shape a. Non-full coverage
b. Lost antemortem c. Number b. Full coverage
c. Lost postmortem d. Divergence of roots 2. Non-metallic
Root morphology a. Non-full coverage
Tooth type
a. Dilaceration b. Laminates
a. Permanent
b. Root fracture c. Full coverage
b. Deciduous
c. Hypercementosis 3. Dental implants
c. Mixed
4. Bridges
d. Retained primary d. Root resorption
e. Root hemisections 5. Partial and full removable pros-
e. Supernumerary
thesis
Tooth position Pulp chamber/root canal morphol-
a. Malposition ogy Periodontal tissues
a. Size, shape and number Gingival morphology and pathology
Crown morphology
b. Secondary dentine a. Contour, recession, focal/
a. Size and shape
b. Enamel thickness Pulp chamber/root canal pathology diffuse, enlargements, inter
c. Contact points a. Pulp stones, dystrophic calcifica- proximal craters
d. Racial variatlons tion b. Color – inflammatory changes,
b. Root canal therapy physiological (racial) or patho
Crown pathology
c. Retrofills logical pigmentations
a. Caries
d. Apicectomy c. Plaque and calculus deposits
Contd...
Contd...

Periodontal ligament morphology Anatomical features b. Pathology
and pathology Maxillary sinus Temperomandibular joint
a. Thickness a. Size, shape, cysts a. Size, shape
b. Widening b. Foreign bodies, fistula b. Hypertrophy/atrophy
c. Lateral periodontal cysts and c. Relationship to teeth c. Ankylosis, fracture
similar d. Arthritic changes
Anterior nasal spine
Alveolar process and lamina dura a. Incisive canal (size, shape, cyst) Other pathologies
a. Height, contour, density of b. Median palatal suture a. Developmental cysts
crestal bone b. Salivary gland pathology
Mandibular canal
b. Thickness of interradicular bone c. Reactive/neoplastic
a. Mental foramen
c. Exostoses, tori d. Metabolic bone disease
b. Diameter, anomalous
d. Pattern of lamina dura e. Focal or dilfuse radiopacities
c. Relationship to adjacent struc-
e. Bone loss (horizontal/vertical) f. Evidence of surgery
tures
f. Trabecular bone pattern and g. Trauma – wires, surgical pins
bone islands Coronoid and condylar processes
etc.
g. Residual root fragments a. Size and shape
Source: IA Pretty, Sweet. A look of forensic dentistry—Part 1: The role of teeth in the determination of human
identity. British Dental Journal 2001;190:359-66.
from the missing persons’ database. Antemortem 2. Preliminary evaluation: After comprehensive
records are then obtained from the dentist of consultation, the forensic odontologist should
record. a. Establish exactly what is being requested
Dental comparisons have high degree of reliability b. Parameters of postmortem examination
and simplicity. Teeth are most durable organ c. Ascertain nature of death and reason for dental
in body that can be heated to temperatures of input.
1600°C without appreciable loss of microstructure Because most of corpses are unidentifiable by other
(Figs 2.2A to E). means, they are likely to be decomposed/burned/
The dentist acts as a consultant to the medical completely skeltonized. Knowing situation in advance
examiner only when requested by the certifying can help to prepare for the type of disfigurement.
One must also, ensure that antemortem records are
official. He should always consider necessary
being obtained for comparison at later stage. The
armamentarium before proceeding. Excision of
examiner should also make necessary arrangement
facial tissues when necessary to remove maxilla/
for suitable radiographs of corpse.
mandible should occur with expressed concurrence
of pathologist. The entire process should take place 3. Postmortem examination: Typically done after
in following phased manners. pathologist completes autopsy and possibly after
other experts, such as forensic anthropologists,
Phases radiologists. It is prudent to initiate examination
of corpse before viewing ante-mortem information.
1. Comprehensive consultation: This is done in
It is in many ways similar to living person’s
order to fulfill the need to establish characteristics examination except for limited access because of
of situation, and also to begin making appropriate rigidity of corpse (rigor mortis, refrigeration or
arrangement for next steps. decomposition). If excision of jaws is necessary,

Figs 2.2A to E: (A) Tooth fragments recovered after a burn

episode, (B) Jaw fragments form a burnt corpse, (C to E)
Tooth remains after an experimental exposure of teeth to a
temperature of approximately 1000°C
Le-fort osteotomy of maxilla and a horizontal features may point out to some one’s identity that is

or tangential osteotomy of ascending ramus of who it is most likely to be? Then after proper legal
mandible posterior to the last molar tooth is proceedings the dentist whom the deceased most
preferred. Since teeth may be brittle in burned likely might have visited before death is located,
cases, they need to be reinforced with cyanoacrylate and any information pertaining to the deceased is
cement, polyvinyl cement, or clear acrylic spray sought after (antemortem records). All available
paint prior to examination. materials from all the dentists, medical records,
Radiographic examination: Charting of dental/ hospitals is charted and translated on forms.
soft tissues/hard tissues findings are then completed Universal system is (Figs 2.4A and B)
on standardized forms. predominantly used in USA, while FDI system
(Fig. 2.5) is followed in the rest of the world and
4. Antemortem investigation and data collection:
is also recommended by WHO. Bitewing views are
Often clues from personal effects, (Figs 2.3A
particularly more helpful. It is important to always
and B) history, tattoos, scars, ethnicity, sex or other
ask for original records. Other types of records-
casts, prosthesis, photographs, appliances, digital
records are also investigated.
Figs 2.3A and B: (A) An ancient file photo showing various

kind of traits of that particular era embedded in the dentition, A
(B) A bridge recovered from the prehistorical era showing the
splinting of the teeth by wire Fig. 2.4A

B
Fig. 2.4B Fig. 2.5: FDI system of nomenclature for permanent

Figs 2.4A and B: (A) Universal system for nomenclature of dentition
permanent dentition, (B) Palmar system for nomenclature of
permanent dentition
mentioned comparisons, then the morphology of

5. Comparison and conclusion: Once all the AM/ coronal/root portions of teeth, size/shape of pulp
PM records are obtained and charted, results can be chamber along with any pathosis, size/location
compared and a conclusion (Figs 2.6A and B) can of nerve canals, foramina, sinuses and TMJ can
be reached. It is vital to complete all identification compared. But rarely these are definitive solitary
procedures before the body is cremated. Note features to make an identity.
any potential discrepancies and develop suitable The forensic dentist produces the postmortem
explanation for the same. Cases in which dentists/ record by careful charting and written descriptions
dental staff can fraud by billing for the procedures of the dental structures and radiographs. If the
that were not performed should also be kept in ante-mortem records are available at this time,
mind. postmortem radiographs should be taken to
Most commonly comparisons are made based replicate the type and angle of these. Radiographs
on individual teeth and dental restorations should be marked with a rubber-dam punch to
encompassed along with presence/absence of indicate antemortem and postmortem to prevent
teeth, tooth positions, recent extractions and confusion—one hole for antemortem films and two
eruption conditions. If there are no sufficient above holes for postmortem films.
1. Positive identification: The antemortem and

postmortem data match in sufficient detail, with
no unexplainable discrepancies, to establish that
they are from the same individual.
2. Possible identification: The antemortem and
postmortem data have consistent features but,
because of the quality of either the postmortem
remains or the antemortem evidence, it is not
possible to establish identity positively.
3. Insufficient evidence: The available information
is insufficient to form the basis for a conclusion.
4. Exclusion: The antemortem and postmortem
data are clearly inconsistent.
It is important to note that there is no minimum
number of concordant points or features that are
required for a positive identification. In many cases
a single tooth can be used for identification if it
contains sufficient unique features. Equally, a full-
mouth series of radiographs may not reveal sufficient
detail to render a positive conclusion. The discretion
of identification lies with the odontologist who must
be prepared to justify the conclusions in court, surely
the ultimate in peer-review.
Reconstructive Postmortem:
Dental Profiling
When circumstantial evidences required to establish
a presumptive identification are not available; it is
necessary to assess personal features such as:
a. Age at death—prenatal/young/adult,
b. Sex, and
c. Race/ethnicity, along with opinion from
forensic anthropologists and associated findings.
These conclusions can be used to estimate who
Figs 2.6A and B: (A) Radiograph showing the comparisons the decedent most likely is—It narrows down the
of ante-mortem and postmortem bite wing radiographs, (B)
Picture showing the anthropological comparisons of human search, likely antemortem records are obtained.
remains
Age
A range of conclusions can be reached when
reporting a dental identification. The American Pathologic age; related to various conditions and
Board of Forensic Odontology recommends that disease process that results in deterioration of many
these be limited to the following four conclusions: tissues over time. Dental experts can estimate this by

Fig. 2.7: Attrition reflecting an aging phenomenon
examining for arthritic changes in TMJ, attritional

wear (Fig. 2.7) of teeth, root dentine transparency.
Physiologic age; determined by natural/
expected changes that occur through growth and
development. Examination of development of roots
(apical closure) (Figs 2.8A and B) and comparison
with tables that record the amount of development
vs age.
Chronologic age (the time from birth to death)
age that investigators are most interested in. The
detailed descriptions of various methods for age
estimation in different age groups are provided
in another chapter of this title, “age estimation”.
Readers are advised to please refer to the same for
all details and procedures.
Sex (Fig. 2.9)

Forensic odontology tells us a lot about
determination of age from various methods. In
addition to determination of age, sex can also be
determined from the teeth. Various features of teeth, Figs 2.8A and B: (A) An IOPA showing the open apices of
like morphology, crown size, root lengths etc. are 1st and 2nd permanent molars, (B) Another IOPA showing
the open apices of maxillary incisor
characteristic for male and female sexes. There are
also differences in the skull patterns. These will help
a forensic odontologist to identify the sex. New life. However, differentiation of sexes by skeletal
developments like PCR amplification etc. will assist radiology is unreliable until after puberty. It is
in accurately determining the sex of the remains. then that the sexual characteristics discernible
Also, it has been pointed out that skeletal by radiography begin to appear. In general, the
development maturation in females is accelerated male skeleton is more robust and heavier, with
over that of males after the third or fourth year of more prominent attachment for muscles and
resorption and virtual disappearance of the outer

table and diploë of the parietal bones.
Forensic odontology plays an important role in
establishing the sex of victims with bodies mutilated
beyond recognition due to major mass disasters.
However it is not possible to determine the sex
of an individual from the morphologic appearance
of teeth alone. Although previously assumed that
Fig. 2.9: Male and female logos larger teeth are male characteristics have been
disapproved.
tendons. With aging, there is a tendency for Sex differences in dentition are based largely
more degenerative and hyperostotic changes in on tooth size and shape. Male teeth are usually
the male skeleton. Male long bones are about larger, whereas female canines are more pointed
110% the length of female long bones. The male and a narrower buccolingual width (Fig. 2.11).
femoral head is larger in all dimensions. All of these
general findings are helpful but not definitive in
establishing the sex of unidentified human remains.
There are certain skeletal components, and both
skeletal and extra-skeletal findings, which are more
useful in determining sex.
Role of Skull and Mandible (Figs 2.10A and B)

Figs 2.10A and B: Graphical representation showing the
Bony characteristics of the skull and mandible characteristic differences between male and female skull. The
may be useful in assigning sexual identification differences are highlighted by darker and solid lines
to unknown remains. The male skull tends to
range from mesocephalic to dolichocephalic; the
female skull is more likely to be mesocephalic to
brachycephalic. The male has a larger brow or
supraorbital ridge and a more sloping forehead.
The male zygomatic arch is wider and heavier.
The male inion or nuchal crest is prominent.
The male mastoid process is larger and heavier.
The male mandible is larger and more rugged
with a wide ascending ramus. Male orbits tend to
be larger and higher. The inferior nasal spine is
longer in the male. Hyperostosis interna frontalis
is an overgrowth of the inner table of the frontal
bone, often florid, found almost exclusively in
middle-aged or older females and is a valuable
characteristic for sex determination. Parietal
thinning is a condition of postmenopausal females Fig. 2.11: Smile close-up photographs of female (upper)
in which profound osteoporosis causes symmetrical and male (lower) patients
There also appear to be greater differences are, therefore, population specific, and do not apply

in size between maxillary central and lateral to the world at large.
incisors in females as compared to males. Seno Amongst teeth, mandibular canines show
and Ishizu reported in 1973 on the use of the greatest dimensional difference with larger teeth in
Y chromosome in dental pulp to determine sex males than in females. Premolars, first and second
differences. Success in sexing unknown remains molars as well as maxillary incisors are also known
based on this technique have resulted in several to have significant differences.
published accounts. In 1984, Mudd reported on (B) Sex determination using canine dimorphism: In
the use of the Y chromosome in hair specimens. the field of forensic odontology, permanent canine
Sundick in 1985 reported on sex determination teeth and their arch width (distance between the
by Y chromosome detection in unidentified canine tips) contribute to sex identification through
remains at the annual meeting of the American dimorphism. The study of permanent mandibular
Academy of Forensic Sciences in Las Vegas. Each and maxillary canine teeth offers certain advantages
of these studies involved the detection of the Y in that they are the least extracted teeth, are less
chromosome using quinacrine and fluorescent affected by periodontal disease and the last teeth to
microscopy. This microscopic approach to be extracted in respect of age (Bossert and Marks,
sexing would appear more reliable to the forensic 1956; Krogh, 1968).
odontologist than metrics, at least on difficult, The dimensions of canine teeth have been
incomplete remains. More recently, there have studied by several methods, including Fourier
been a number of articles in the forensic literature analysis (Minzuno, 1990), Moire topography
reporting the successful isolation of sex-specific (Suzuki et al, 1984) and the measurement of linear
banding patterns in DNA profiles of the X and Y dimensions such as mesiodistal width, bucco-
chromosomes developed from fresh and degraded lingual width and inciso-cervical height (Garn et
specimens. All reports indicate the need for high al, 1967; Anderson and Thompson, 1973; Rao et
molecular weight genomic DNA. al, 1988). The use of Fourier analysis and Moire
topography were limited to small samples whereas
Classification of Methods measurement of the linear dimensions of canine
teeth was used in large populations because it is
1. Visual method or clinical method.
simple, reliable, inexpensive and easy to perform.
2. Microscopic methods.
A study by Anderson and Thompson (1973)
3. Advanced methods.
showed that mandibular canine width and inter-
1. Visual/Clinical Methods canine distance was greater in males than in females
and permitted a 74.3 percent correct classification
(A) Sex differences in tooth size: Teeth may be of sex.
used for differentiating sex by measuring their Garn et al (1973) studied sexual dimorphism
mesiodistal and buccolingual dimensions. This is by measuring the mesiodistal width of canine teeth
of special importance in young individuals where in different ethnic groups. They concluded that
skeletal secondary sexual characters have not yet the magnitude of canine teeth sexual dimorphism
developed. Studies show significant differences varies among different ethnic groups. Furthermore,
between male and female permanent and deciduous the mandibular canine showed a greater degree of
tooth crown dimension. One is reminded that sexual dimorphism than the maxillary canine.
tooth size, or odontometrics, is under considerable Sherfudhin H et al (1996) investigated the
influence of the environment. Such measurements occurrence of canine tooth dimorphism in Indian
subjects and compared the use of two statistical be done with 80 percent accuracy by measuring

methods of evaluation. These were the methods root length and crown diameters.
of NG Rao and co-workers published in 1988
(D) Dental index: In addition to absolute tooth
and quadratic discriminant analysis for correct
size, tooth proportions have been suggested for
classification of sex. Parameters considered were: (i)
differentiating the sexes. Aitchison presented
the mesiodistal width of maxillary and mandibular
the ‘incisor index’ (Ii), which is calculated by
canines, (ii) the maxillary canine arch width
the formula Ii = [MDI2/MDI1] × 100, where
(intercanine distance) and (iii) the mandibular
MDI2 is the maximum mesiodistal diameter of the
canine arch width.
maxillary lateral incisor and MDI1 is the maximum
The results indicated significant dimorphism of
mesiodistal diameter of the central incisor. This
the maxillary and mandibular canine teeth. When
index is higher in males, confirming the suggestion
the results of the arch widths were subjected to
of Schrantz and Bartha that the lateral incisor is
the two statistical methods, differing results were
obtained in the accuracy of sex classification. distinctly smaller than the central incisor in females.
The percentage of correct classifications of sex Another index, the ‘mandibular canine index’
was higher when using quadratic discriminant proposed by Rao and associates has given an
analysis. In another study, Iscan Kedici (2003) accurate indication of sex in an Indian population.
could accurately establish sex in 77 percent of the Using the mesiodistal (m-d) dimension of the
cases using maxillary and mandibular canines, and mandibular canines, these researchers obtained
mandibular second molar. the formula:
The role of the maxillary canine arch width in [(Mean m-d canine dimension + (Mean m-d
establishing sex identity has not been reported in canine dimension in female + SD) in males – SD)]/2
the literature. The value obtained using this formula was 7.1,
The sexual dimorphism specific to canines has i.e. 7.1 mm is the maximum possible mesiodistal
been explained by Eimerl and DeVore on the basis dimension of mandibular canines in females. The
of their function which, from an evolutionary same dimension is greater in males. The success
point of view, is different from other teeth. During rate of determining sex using the above formula
the evolution of primates, there was a transfer was close to 89 percent. However, relative to the
of aggressive function from the canines in apes near 100 percent accuracy using pelvis and skull,
to the fingers in man. Until this transfer was sexing by odontometrics is relatively poor.
complete, survival of the species was dependant (E) Odontometric differences: The odontometric
on the canines, especially those of males. Of late, difference between males and females is generally
researchers are trying to determine the influence of explained as a result of greater genetic expression
the X- and Y-chromosomes on tooth morphology.
in males. Following is the table showing the
While the role of sex chromosomes in dental
odontometric difference between males and
development has been proved, Scott considers that
females (see Table 2.3).
there is little dimorphism apparent at a phenotypic
Iscan and Kedici caution that an overlap exists
level.
between male and female tooth dimensions, and
(C) Root length and crown diameter: Using optical this makes accurate diagnosis of sex challenging,
scanner and radiogrammetric measurements on even for experienced dentists. They emphasize that
mandibular permanent teeth sex determination can success is greater when all available teeth are used.
Table 2.3: Showing the odontometric difference

between males and females
Tooth No. Mesiodistal Buccolingual

Male Female Male Female
11 8.9 8.5 7.1 7.0
12 7.0 6.65 6.5 6.2
13 8.3 7.6 8.4 7.9
14 6.9 6.8 9.3 8.9
15 6.7 6.65 9.8 9.3
16 11.0 10.6 11.0 10.9
17 10.4 9.9 11.0 10.7
41 5.5 5.3 6.2 6.1
42 6.1 5.9 6.5 6.5
43 7.2 6.6 7.55 7.4
44 7.1 7.0 7.9 7.6
45 7.4 6.9 8.6 8.2
46 11.1 10.8 10.4 10.2
47 10.5 10.2 10.3 9.9
Source: M Hemanth et al. Sex determination using Fig. 2.12: Picture showing the sexual dimorphism in
human canines
dental tissue. Medico-Legal update Vol 8, No. 2(2008-
07_2008-12)
undergoing active division. Presence or absence
(F) Tooth morphology and sexing: In addition to the of X chromosome can be studied from buccal
canines being the most sexually dimorphic teeth in smears, skin biopsy, blood, cartilage, hair root
terms of size, Scott and Turner II highlight that sheath, and tooth pulp. After death it persists for
the ‘Distal Accessory Ridge’, a non-metric feature variable periods depending upon the humidity
on the canine” is the most (Fig. 2.12) sexually and temperature in which tissue has remained.
dimorphic crown trait in the human dentition, with X chromatin and intra-nuclear structure is also
males showing significantly higher frequencies and known as Barr body (Figs 2.13A and B) as it was
more pronounced expression than females”. Rao first discovered by Barr and Bertam (1949). It is
and Rao have reported greater incidence of four- present as a mass usually lying against the nuclear
cusps (absence of the distobuccal cusp or distal membrane in the females.
cusp) on the mandibular first molar in females It was found that in cases after fires, high
(40.6 percent) compared to males (16.2 percent) impact crashes and explosions fragmentation and
in a south Indian population. They cite Anderson thermal trauma renders other methods impossible
and Thomas who opine that the reduction in the to determine sex of the remains except the above
number of cusps is a reflection of an evolutionary said method from pulp. Pulp tissue cells become
trend towards overall reduction in the size of the embedded firmly into the dried fibrosis matrix.
lower face, with male apparently resisting this trend. Duffy et al have shown that Barr bodies and
2. Microscopic Methods F bodies of Y chromosomes are preserved in
Sex determination using barr bodies. dehydrated pulp tissues upto one year and pulp
Sex can also be determined by the study of X tissues retain sex diagnostic characteristics when
and Y chromosomes in the cells which are not heated upto 100°C for 1 hour.
no organic solvents, and did not require multiple

tube transfers. The extraction of DNA from dental
pulp using this method was as efficient, or more
so, than using proteinase K and phenol-chloroform
extraction. In a study by Tsuchimochi T et al
(2002), they used Chelex method to extract DNA
from the dental pulp and amplified it with PCR
and typing at Y-chromosomal loci to determine the
effects of temperature on the sex determination of
the teeth.
Hanaoka et al (1996) conducted a study to
determine sex from blood and teeth by PCR
amplification of the alphoid satellite family using
amplification of X (131 bp) and Y (172 bp) specific
sequences in males and Y specific sequences in
females. It was showed to be a useful method in
determining the sex of an individual.
Sivagami and coworkers (2000) prepared DNA
from teeth by ultrasonication, and subsequent PCR
amplification, they obtained 100 percent success
in determining the sex of the individual.
(B) Sex determination from the enamel protein:
Amelogenin or AMEL is a major matrix proteins
Figs 2.13A and B: Microscopic appearance of Barr bodies in found in the human enamel. It has a different
the squamous epithelial cells obtained from the buccal mucosa signature (or size and pattern of the nucleotide
sequence) in male and female enamel.
3. Advanced Methods The AMEL gene that encodes for female
(A) Sex determination using PCR: Polymerase amelogenin is located on the X chromosome and
chain reaction (PCR) is a method of amplifying AMEL gene that encodes for male amelogenin is
small quantities of relatively short target sequences located on the Y chromosome. The female has two
identical AMEL genes or alleles, whereas the male
of DNA using sequence-specific oligonucleotide
primers and thermostable Taq DNA polymerase. has two different AMEL genes. This can be used
The teeth can withstand high temperature and to determine the sex of the remains with very small
are used for personal identification in forensic samples of DNA.
medicine. In the case of few teeth or missing dental
Race
records, there is not enough information to identify
the person. The dental pulp enclosed by the hard The world has traditionally been divided into six
tissue is not influenced by temperature, unlike the prominent geographic races (Figs 2.14A and B):
buccal mucous membrane, saliva and calculus. White, Black, East Asian, Melanesian/Australian,
A procedure utilizing Chelex 100, chelating Native American and Polynesian.
resin, was adapted to extract DNA from dental However, now a days this is not a qualitative
pulp. The procedure was simple and rapid, involved nature because many more hybrid conditions exist

Figs 2.14A and B: Composite pictures showing the various races of the world. Note that many
of the differences lie within the facial middle third area
than are described above. No single or combination Race determination in skeletal remains
of trait can be considered completely diagnostic. traditionally focuses on craniofacial characteristics
Assessment of skeletal aspects of corpse by physical such as the proportions of the orbital and nasal
anthropologists can be helpful. Generally speaking, areas, nasal aperture characteristics, lower nasal
assessment of certain anatomic landmarks is done border features, lower facial prognathism, palate
and compared with published standards form, cheekbone contours and incisor shoveling.
Many of the best traits are found in mid face St Hoyme and Iscan in 1989 reviewed the
skeleton including the following: determinants of sex and race relative to accuracy
• Area of nose, mouth and cheek bones and assumptions in reconstructions of life from the
• Shape of cranium, lateral projection of zygomatic skeleton. For each of the osteological clues, they
arches pointed out the need to consider:
• Shape, contour of orbits and nasal aperture 1. Its basic etiology: Whether it is primarily
• Shape of dental arches biochemical, hormonal, or activity-related in
• Facial profiles order to predict its variation pattern,
Certain dental traits as— shovel shaped incisors, 2. Its range of variation by sex in various racial/
multiple cusps on lower premolar, cusp of carabelli. ethnic groups,
3. Its manifestation by age: The age at which

it appears and its pattern of change from
childhood to old age,
4. How it is influenced by health, nutrition,
occupation, or other circumstances of an
individual’s life,
5. Whether there are secular changes in its
expression, and
6. Whether the characteristics are real, but
temporary.
From a dental perspective, both the mandible
and dentition reflect racial characteristics. Projecting
chins (Fig. 2.15) are found in Europeans and some
Asiatics. Rounded, almost receding, chins are found
in Australian aborigines and in some South Pacific
Islanders. Most African and Afro-American chins
are intermediate. General jaw shape corresponds
with general skull shape. Prognathous palates are
associated with long, narrow mandibles with low
rami; whereas large bizygomatic widths with wide
mandibles have deep rami and significant gonial
flare. The greatest eversion is found in Eskimos
and Amerindians.
Rocker jaws seem associated with Hawaiian
crania. These general characteristics reflect relative
ethnic dental markers. According to these authors,
the most useful racial clue in dentition is “shovel-
shaped” incisors found in most Asiatic Mongoloids
Fig. 2.15: Graphical picture emphasizing characteristic
and Amerindians and in less than 10 percent of differences in the skull between humans of diverse population
whites and blacks. Tooth size and shape including ancestry in frontal and lateral views. AA: Caucasoid; BB:
Negroid; CC: Mongoloid
shovel tooth incisors, Carabelli’s cusp (Figs 2.16A
and B) or tubercle, enamel pearls, and dental pulp
shape (taurodontism vs cynodontism) (Fig. 2.17)
have been listed as racial determinants. The form of the palate and the shape of the
Carabelli’s tubercle or cusp is an anomalous dental arches are subject to considerable variation.
cuspule on the mesiolingual surface of maxillary Stewart in 1946 described these forms as ovoid,
incisors appearing in 50 percent of American “U” shaped, and horseshoe-shaped. Martin and
whites, 34 percent of Afro-Americans, and 5 to Saller in 1956 described these forms as semicircular,
20 percent of Amerindians. Taurodontism or “bull half ellipse, paraboloid, and broken angular line.
toothness”, especially in maxillary molars, enamel The proportions of the palate and the associated
pearls on premolars, and the frequent congenital dental arches are indicated by the palatal index,
lack of upper third molars, are commonly noted the ratio of the width to the length of the palate
features in Mongoloids. (width/length × 100). The resulting decimal

Figs 2.16A and B: Cusp of carabelli, located on the mesioplatal aspect of permanent maxillary molars
a. Below 80,
b. 80 to 85, and
c. Above 85.
An index of less than 80 indicates an elongated
narrow palate typical of aboriginal Australians,
Kaffirs and Zulus. Most Europeans and Amerindians
have middle to high indices whereas numerous
Orientals and some Pacific islanders have high
palatal indices, indicating a short, rounded
palate. In general, there are large-toothed and
small-toothed races. Aboriginal Australians, the
Melanesians, and the American Indians including
Fig. 2.17: Taurodontism or bull-shaped tooth, an atavistic the Eskimos tend to be large-toothed, with wide
feature as shown by enlarged pulp space and root canals in
the bitewing radiograph crowns. The Lapps and Bushmen are small people
with small teeth. American blacks tend to have large
fraction approaches 100.0 as the palate becomes crowns. Skull measurements have been used by
wider and shorter. The anthropometric divisions many examiners as a basis for racial determination.
of this index are: In South America, the Bonwill triangle, an
equilateral mandibular triangle connecting is noteworthy not only for its success but also

the apex of the mesial contact areas of the two because it utilized several complementary methods
central mandibular central incisors with the of identification. The process of facial restoration
two mandibular condyles, has been used on the and the importance of physiognomic details is well
assumption that the studied population groups known, largely based on the work of Krogman,
are not mixed and retain consistent hereditary and has been used since by a number of forensic
characteristics. investigators, especially anthropologists and police
According to Stewart, metric means of cranial departments, with reasonable success. Caldwell
race determination usually follow the discriminant also compared the facial reconstruction studies of
analyses of Howells and Giles-Elliot. Dental Rathbun et al, Lenorovitz and Sussman, and Zavala.
decay and occlusal wear, often attributed to Rathbun et al emphasized the eyes, lips, nasal form,
advancing technology and increased carbohydrate and hair style as the most significant facial features
consumption, are not confirmed when a number of in recognition. Lenorovitz and Sussman listed skin,
groups are studied such as prehistoric Amerindians, hair, skin color, ears, face shape, eyebrows, eyes,
or Southeastern Asians, and ancient Hawaiians. nose, lips, eye color, chin age, and cheeks in order of
However, cultural usages are often helpful such importance to visual recognition. Zavala expanded
as black stains from betel nut consumption in that list twice-fold. These characteristics are also
Indonesia and other southeastern Asian regions the same features which composite computer or
or teeth with excessive slanted wear resulting overlay techniques such as the Identikit utilize
from pulling fibrous, siliceous fern fronds in in facial reconstructions. These efforts have also
native peoples from South Pacific areas. Removal, led to further computerized techniques such as
modification, or decoration of anterior teeth can computer age progression studies which have
be useful indicators of sex or race. These cultural proven to be a valuable identification technique
characteristics often reflect geographic ethnic in missing persons investigations. Fierro discussed
patterns. this technique in a comprehensive review of human
These craniofacial and dental issues take on some identification problems in unknown decedents
relevance when efforts are made to reconstruct and the variety of techniques used to resolve these
likely visages based on skeletal craniofacial problems. Computer age progression has been
characteristics. Caldwell described four current actively used by the FBI and by the National Center
methods of facial reconstruction: for Missing and Exploited Children. In contrast,
1. Modeling in clay directly on the skull (three- computerized regression studies, that is taking a
dimensional), visage and scientifically relating it to earlier ages
2. Constr uction of ar tists’ drawings (two of the individual are not currently available.
dimensional), Scott and Turner II suggested unique dental
3. Restoration of disrupted or damaged tissues, and features that have evolved over time as a result of
4. Photographic or portrait superimpositions. genetic and environmental influences in different
Webster et al. reported on the identification of population groups.
human remains using photographic reconstructions Dental features used to describe these differences
in two methods, comparative and superimpositions. are broadly categorized as:
This report used photographs, portraits, and • Metric (size), not much important
dental studies to confirm the identifications. It • Non metric (shape/features)
More than 30 non-metric features of both Harris and McKee in 1990, studied tooth

crown and root have been analyzed—Scott and mineralization characteristics in blacks and whites
Turner II. from the southern US in individuals ranging
in age from 3.5 to 13 years. They found that
Crown females develop more rapidly than males, and that
Shovelling/double shoveling, Carrabelle’s feature, blacks are nearly twice as sexually dimorphic (7.2
Lower molar groove pattern (+, Y, X), Odontome, percent) as whites (3.7 percent). Within each sex,
Lateral incisor variants, Premolar lingual cusp, blacks achieved mineralization stages significantly
Parastyle, Protostylid, Premolar lingual cusp. earlier, by approximately 5 percent, than whites.
Anthropologists also appear more eager to use a
Root variety of observations to assist them in obtaining
a dental age with a skeletal age for comparison.
Two rooted upper premolar/molar, Two rooted Sexing parameters generally in use involve classical
lower canine, Tomes root, Single rooted lower anthropometric measurements. Rogers in the
molar. “Testimony of Teeth: Forensic aspects of human
Based on above features, various races in the dentition”, reviewed the efforts of many authors
world have been found to possess following features to use the human dentition for determinations of
unique to them as exemplified below: age, sex, race, and individualization. He focused
European/West and South Asians—4 cusped lower on several useful categories:
2nd molars, two rooted lower canine, Carrabelle’s 1. Heredity—Size and genetic peculiarities,
feature, 3 cusped upper 2nd molar 2. Wear characteristics,
East Asians — Shovelling, odontome, 3 rooted 3. Pathology—Caries and periodontitis, and
lower 1st molars, 3 cusped upper 2nd molars, single 4. Restorations—Dental fillings and prostheses,
rooted lower 2nd molars. such as crowns, bridges and dentures.
This approach represents a composite analysis of
Opinion from Forensic general features and is useful for presumptive sorting
Anthropologists of unknown remains. In 1976, Burns and Maples
reported on three parameters of dental aging:
For a number of practical reasons, many formative, degenerative, and histological. The
forensic odontologists have resisted pressures to formative parameter includes tooth mineralization,
characterize an unknown dentition by age, race, crown completion, eruption of the crown, and
or sex except in general terms. Lasker and Lee complementary roots. Degenerative measurements
and Aitchison, often referenced, both described include tooth wear, tooth color, and periodontal
racial traits in the human dentition. Even aging attachments. Histological assessments include the
methodologies appear equally shared among forensic degree of secondary dentin deposition, cementum
odontologists, anthropologists, pathologists, apposition, root resorption, and root transparency.
and often radiologists. Both anthropologists and The histological measurements and grading follow
radiologists rely heavily on radiographic evidence Gustafson’s efforts. In 1978, Taylor published
of aging, dental eruption patterns, and changes in a text on variation in tooth morphology relative
the facial structures with age such as the angle of the to anthropologic and forensic aspects which
mandible, zygomatic arches, and lateral pterygoid emphasized the structural qualitative rather than
plates. quantitative differences of teeth and dentition.
Taylor, in studying variations in dental patterns, Other Methods of Dental Identification

suggested six parameters for evaluation:
The two processes described above, comparative
1. Type of tooth structure—Family characteristics,
identification and postmortem profiling, represent
2. Personal characteristics found throughout a
the most common methods of dental identification.
dentition—Crowns, occlusal ridges, cusps, and
However, in some instances more novel and
root robusticity, as well as branching patterns,
innovative techniques have been applied. There
furcation, and fusion,
3. Imposed characteristics based on the anatomical have been a number of requests from individuals
relationships of the crowns and roots, and dental organizations over the years to insist
4. Complexity factors such as tubercles, pits, that dental prostheses are labelled with the patient’s
additional ridges, grooves and fissures, name or a unique number. Labeled dentures
5. Acquired characteristics resulting from differences (Fig. 2.18) can be of great assistance in the
during tooth formation such as hypoplasia, identification of individuals.
pathology, trauma, function, personal habits, and Unlabeled dentures have been recovered from
restorations, and finally patients and then fitted to casts retained by the
6. Ethnic considerations. treating dentist or laboratory, and this has been
Rogers and Taylor, both anthropologists, rely an accepted method of identification. Other dental
heavily on general dental structural characteristics appliances, such as removable orthodontic braces
and their relationship to the environment and have also been used for identification purposes.
cultural modifications. Whittaker describes a case where a removable
Shown below are the various established cranial orthodontic appliance was used to identify a victim
anatomical landmarks associated with the race and of a house fire. Authors have also described the
sexual dimorphism (Tables 2.4, 2.5 and 2.6). use of palatal rugae patterns rendered on dental
Table 2.4: Showing skeletal anthropologic variations associated with sexual characteristics of the skull
Parameter Male Female

Size Large Small
Glabellar ridges Pronounced Not developed
Mastoid process Large Small
Occipital area Pronounced muscle lines Minimal muscle lines
Mandible Larger, broader ramus Smaller
Forehead Steeper/slopes vertically Rounded/more vertical
Table 2.5: Showing skeletal anthropologic variations associated with racial characteristics of the skull
Parameter White Black Asian/Native American

Width Narrow Narrow Broad
Height High Low Intermediate
Profile Straight Prognathic Intermediate
Orbit Triangular/teardrop Square Circular
Nasal opening Tapered Wide Rounded
Palate narrow wide Intermediate
Table 2.6: Showing the morphological features for racial assessment of the skull and mandible

Feature Caucasoid Negroid Mongoloid
General configuration Mesocephalic Dolichocephalic Brachycephalic
Saggital contour Round Coronal flat or notching Arched
Parietal bossing +–++ 0 +++
Bite Slight overbite Prognathic Even
Face Long, narrow Prognathic Flat
Orbits Rectangular Oval Rounded
Intraorbital distance Inermediate Wide Wide
Nasal aperture Narrow, oval Round Wide with inferior gully
Inferior nasal spine Sharp Short or troughed Dull
Nasal bones Intermediate Short, depressed Prominent
Zygomatic arches or Slight, retreating Slight retreating Prominent, inferior
malar prominence projection
Mandibular angle Slightly obtuse Obtuse Nearly right angle
Chin, mental process ++ – +
restoration and then traced this back to a prison

where the filling was placed. Dental records secured
the identification of the individual. In another case,
it was possible to identify Kevlar fibers that had
been placed within a lower denture to reinforce
it. This rare procedure enabled an identification
of the wearer who was a victim of homicide.
Role of DNA Molecule in

Identification
Except for identical twins, everyone’s DNA is
different. The application of DNA analysis to
individualize biologic evidence is quite similar
to specific point of references on the human
body that are accepted broadly as being visually
Fig. 2.18: Labeled denture, showing the name of the wearer distinctive(height, hair, color). The molecular
and the unique identification number. Such incorporated
features may be of immense value in case of unfortunate biologists targets specific point of reference on the
events for the purpose of identification human genome that are accepted broadly as being
biochemically distinctive. The variation in sequence
casts to compare with found remains. Positive of four nucleotides provides the basis for its unique
identifications have resulted from this technique. role in identification.
Dental materials have provided clues to assist When conventional dental identification
identification. One of the authors has used SEM- methods fail, this biological material can provide
EDX to identify the composition of a glass-ionomer the necessary link to prove identity. With the
advent of the polymerase chain reaction (PCR), provided the basis for most dental identifications.

a technique that allows amplification of DNA at Massive head trauma or decapitation may render
pre-selected, specific sites, this source of evidence dental identification impossible. Consequently,
is becoming increasingly popular with investigators. not all remains can be identified through dental
Comparison of DNA preserved in and extracted comparison techniques.
from the teeth of an unidentified individual can Dental identification takes advantage of the
be made to a known antemortem sample (stored polymorphic nature of the hardest structures in the
blood, hairbrush, clothing, cervical smear, biopsy, body—precisely those structures which are most
etc) or to a parent or sibling. likely to remain available for identification purposes.
Forensic identification is based on finding Although dental structures are more likely to
differences: Polymorphisms between different survive traumatic and decompositional changes
individuals. These differences can take many than other traditional means of identification such
forms, such as differences in facial appearance, as fingerprints, scars, facial appearance, etc. DNA
differences in ear lobe conformation, differences has a still greater likelihood of survival. Any tissue
in retinal arterial structure, differences in hair or bone fragment can be used for DNA testing,
color, differences in height, etc. Some variations with the possible exception of those which have
are unique and some are not. Indeed, individual undergone severe incineration or prolonged
variation is a tenet of biology. Fingerprint friction water (particularly saltwater) immersion. Perhaps
ridge patterns and dentition are useful for most significantly, body fragments, unless of a
identification precisely because they are different hand with fingerprints, a portion of a jaw with
in each individual. Polymorphisms can either be teeth, or an articulable limb, will not ordinarily be
acquired or inherited. A surgical scar is an obvious identified except by laboratory tissue identification
example of an acquired identifier. The friction ridge techniques.
patterns of fingerprints have an obvious genetic A common obstacle to fingerprint and dental
component, but are predominantly established identification is the lack of antemortem data for
from local perturbations during fetal development, comparison. The common availability of families
hence identical twins have different dermatoglyphics. as sources of reference material for comparison
Most acquired features used for identification may purposes is a particularly important aspect of
change with time, for example dental features can DNA identification. Furthermore, dental and
change over time. The polymorphisms within fingerprint identification are relatively slow and
the DNA molecule are the basis for all inherited tedious in a large mass disaster. Future DNA
polymorphisms and they do not change over the testing technologies will permit high-volume,
lifetime of an individual. low-cost testing. In significant mass disasters,
Although dental identification is an excellent the speed of batch laboratory testing may prove
and convenient means of positive identification, critical. For many years, tissue identifications
there are limitations to its use. Dental identification could only be accomplished by traditional
requires the availability of a good quality, reasonably serologic markers, particularly ABO blood group
up-to-date dental radiograph. The dentist or typing. DNA testing is far superior to those other
orthodontist who has the radiograph in his file must tissue-typing techniques for a variety of reasons.
be found. Due to the water fluoridation programs DNA is the basis for all blood group types, red
in many of the countries, there are now fewer dental cell antigens, and protein isoenzymes. Due to the
restorations in younger people. Restorations have degeneracy of the genetic code, there will always
be more polymorphisms in DNA than in the Ultraviolet light, extreme pH, severe heat,

resultant phenotypes. The discriminatory power microbial contamination and certain environmental
of DNA is far greater than any set of traditional conditions (high humidity) can damage molecular
markers, including HLA typing. Traditional arrangement and make DNA unsuitable for
markers typically yield values of one in thousands, analysis. Most collection and preservation protocols
whereas DNA tests often yield values of one in for DNA evidence focus on providing a cool, dark,
millions. DNA testing can be performed on any dry environment, secure from sources of chemical/
tissue or fluid. DNA tests, particularly PCR-based biological contamination.
DNA tests, are more sensitive than traditional Human DNA: This is found in two main cellular
serologic markers. DNA tests can be performed on organelles that is nucleus and mitochondria,
providing an unique opportunity to forensic
specimens which are far older than is the case with
odontologists for DNA profiling of the deceased.
traditional markers and DNA is less susceptible to
Each of these have unique properties as summarized
environmental insults.
herein.
Forensic DNA profiling methods such as PCR
technique to amplify small amounts of recovered The DNA Molecule
DNA at specific genetic loci are sensitive enough
to discriminate one individual from all others with Basic Structure (Figs 2.19A and B)
a high level of confidence by starting with only 1 The basis for all inheritance is found within
ng or less of target DNA. the DNA genome of cells. This information is
A

B
Figs 2.19A and B: The basic genomic structure showing the DNA and chromosomes
coded within the chemical structure of the DNA is no DNA, in red blood cells.) When body tissues
molecule or, more accurately, the set of DNA have decomposed, the structures of the enamel,
molecules known as the genome. Nucleotide dentine and pulp complex persist. It is necessary to
bases are arranged in specific sequences within extract the DNA from the calcified tissues. Teeth
the chemical structural scaffolding. Only four represent an excellent source of genomic DNA.
bases (adenine, cytosine, guanine, and thymine) Indeed, many authors have found that even root-
make up the genetic alphabet that produces the filled teeth supply sufficient biological material for
words, sentences, paragraphs, and chapters which PCR analysis
are eventually read into proteins that comprise
biological organisms. These bases are present in Mitochondrial DNA (Mt DNA) (Fig. 2.20)
pairs in a complementary fashion to form base pairs, Not only is DNA present within chromosomes in
such that every A is paired with a T, every C with the nuclei of cells, but DNA is also present in the
a G, and vice versa. The consequence of this base mitochondria of cells. Mitochondria are known
pairing is that half of the molecule can be stripped as the powerhouses of the cells as they are the
away from the other half and the base sequence of primary machinery for accomplishing oxidative
one strand can be used to determine the sequence metabolism. Tens, hundreds, or even thousands
of the opposite strand, or to create a specific DNA of mitochondria are present within a single cell
hybridization probe. and each mitochondrion may contain several
mitochondrial “DNA particles”. Consequently,
Genomic DNA
a cell contains only one copy of nuclear DNA,
Genomic DNA is found in the nucleus of each cell but literally thousands of copies of the 16,000 bp
and represents the DNA source for most forensic mitochondrial DNA (MtDNA) sequence; hence a
applications, (there are no nuclei, and hence there mitochondrial DNA type can be obtained when the
Stability of DNA

DNA is a robust molecule which can tolerate
a remarkable range of temperature, pH, salt,
and other factors that destroy classical serologic
markers. Validation testing in forensic science
laboratories has shown that DNA mixed with
detergents, oil, gasoline, and other adulterants
did not alter its typing characteristics. Indeed, it is
this ruggedness which allows DNA longevity and
has permitted DNA typing of Egyptian mummies
and 30-million-year-old insects preserved in amber.
Bone or tissues that have been in soil environments
for extended lengths of time often yield no DNA
Fig. 2.20: The mitochondrial DNA, which is only
inheritable from the mother typing results by traditional means, especially
when the soil is moist. However, even relatively
nuclear DNA type cannot be. Since no significant ancient skeletal remains may yield an informative
regions of repetitive DNA exist in MtDNA, only mitochondrial DNA sequence.
sequence polymorphisms are typed. The region of
DNA Polymorphisms
MtDNA which is analyzed for human identification
is the noncoding region known as the displacement DNA polymorphisms can be length-based or
loop (D-loop) or control region. The degree of sequence-based. Length-based polymorphisms are
polymorphism in the D-loop is so great that direct a characteristic of repetitive DNA that generally
sequencing may be the most efficient method of does not code for any protein (so-called “junk”
typing MtDNA, although a commercial dot/blot DNA). DNA fragments vary in size between
system is in development. Another unique feature individuals due to the presence of variable numbers
of MtDNA is its mode of inheritance—one half of of tandem repeats (VNTRs); i.e. a core of 7 bases
nuclear DNA is from the mother and one half from may be repeated 3 times in one individual or 12
the father. Mitochondria are inherited in a strictly times in the next individual. Traditional restriction
mother-to-child manner; there is no paternal fragment length polymorphism (RFLP) analysis, as is
contribution. Because there is no recombination commonly associated with the DNA testing in crime
and because only a single (unpaired) copy is labs, involves cut fragments (restriction fragments)
present in the cell, an exact sequence match is which include internal VNTR regions (loci) and
anticipated. Accordingly, MtDNA can be traced thus vary in fragment length. VNTR fragments can
through a family via maternal lineages for many also be amplified instead of cut, hence, amplified
generations. Mitochondrial DNA sequencing has fragment length polymorphisms (AmpFLPs). DNA
great application to severely decomposed and identity information is found not only in fragment
skeletonized remains. However, the discriminatory length variation, but also within the DNA sequence
power is limited; discriminatory powers are often of of similarly sized DNA fragments.
the order of one in a hundred. Very few laboratories Sequence polymorphisms consist of difference,
are performing this kind of testing at this point changes in one or more bases in a DNA sequence
in time. at a particular location in the genome. Sequence
variations can manifest as regions of alternative is of limited value in testing cadaveric tissue

alleles or base substitutions additions, or deletions. for identification of human remains, unless the
Most sequence polymorphisms are mere point remains are fresh.
mutations. They may be found in coding or
noncoding DNA. Sequence polymorphisms can be PCR Methods
detected by DNA probes or by direct sequencing. The polymerase chain reaction (PCR) is a method
of copying or “amplifying” a particular segment
DNA Typing Methods
of DNA. A few strands or even a single strand of
RFLP Methods: The DNA typing method that was DNA can be used to reproduce millions of copies
first described, and most commonly employed by of target DNA fragments. Kary Mullis (Fig. 2.21)
crime labs initially, is known as restriction fragment was awarded the Nobel Prize in 1993 for the
length polymorphism (RFLP) analysis. The six discovery of the PCR process, which has led to a
steps in RFLP testing include: revolution in the life sciences. PCR amplification
1. Extraction of DNA from a biologic source (Figs 2.22A and B) is a sample preparation
2. Cutting the DNA into relatively small fragments technique which enables further testing to detect
at specific sites with “restriction enzymes” various polymorphisms. Non-amplified DNA
3. Separating the fragments by size using agarose becomes undetectable against the amplified
gel electrophoresis background target sequence. PCR testing is not
4. Transferring and immobilizing the separated only very sensitive, but it is quicker, less labor
DNA fragments onto a nylon membrane intensive, and less tedious than RFLP testing.
5. Denaturation of the DNA into single strands and Most significantly for remains identification, it is
hybridization to radioisotopically-labeled probes often successful even though the tissue specimen
(small fragments of single-stranded DNA)
6. Autoradiography, in which an X-ray film is
placed over the membrane for several days,
resulting in exposure of the film at the point of
the probe.
The RFLP testing is often called “Southern
blotting” because the DNA transfer technique
was first described by Professor Southern.
Typically, RFLP testing will take several weeks
to perform. For every probing, the membrane is
stripped of the previous probe and rehybridized
and autoradiography performed anew. However,
alternatives to radioisotopic labels now exist,
particularly chemiluminescent and fluorescent
probe labels, which permit much faster testing.
Unfortunately, RFLP is not useful where
the DNA is degraded, because random
fragmentation thwarts detection of a specific
Fig. 2.21: The most notable contributor to the field of medicine
large uncut fragment population. Since DNA and biology, Karry Mullis, the author behind the invention of
rapidly breaks down after death, RFLP testing PCR technique

Fig. 2.23: Results obtained after PCR on a agarose gel
Dot/Blots (Fig. 2.23 )

Sequence information can be obtained through
the use of DNA probes. A DNA probe is a small
piece of single-stranded DNA (oligonucleotide)
which will bind to another single-stranded DNA
with the complementary sequence. A sequence-
specific oligonucleotide (SSO) probe, also known
as an allele specific oligonucleotide (ASO) probe,
is a single-stranded DNA fragment sufficiently long
to confer specificity, but short enough to bind only
to the exact sequence complement. Commercial
kits, i.e. DQ-alpha and Poly-Marker systems,
are based on a dot/blot format for SSO typing
and are currently in use by many crime labs. The
resultant dot/blot strip has a series of spots that
turn blue if the reaction is positive and in this way
give a series of yes/no results. These dot/blot tests
are quite rapid and work reasonably well despite
sample degradation, but do not harbor the same
discriminatory power as RFLP tests.
AmpFLPs and STRs

Figs 2.22A and B: (A) The PCR machine, (B) The pattern
obtained after PCR and Fluorescent labeling technique VNTR polymorphisms can be typed by both RFLP
showing the specific banding at specific levels and by PCR methods. Since smaller loci are desired
for amplification, generally the VNTR loci typed
is degraded because only a few copies of relatively by PCR methods are different from those that are
short segments need to remain intact. However, typed using RFLP methods. Regions with core
PCR testing is susceptible to inhibition and the repeat sequences greater than 7 base-pairs (bp)
potential for cross contamination. have been called “minisatellite” or “long tandem
repeat” (LTR) regions. Those with core repeat blood cells carry the DNA, ample DNA is present

sequences of approximately 3 to 7 bp are called for testing. Due to the settling out of white blood
“microsatellite” or “short tandem repeat” (STR) cells, clotted blood may not be a good source of
regions. Dinucleotide repeats are not generally DNA.
used in forensic science laboratories due to the Blood is a good culture medium and bacterial
artifactual production of so-called “shadow” and growth may render blood samples useless. Virtually
“stutter” bands. any tissue can be used successfully for DNA typing
The shorter STR fragments are generally purposes. Brain tissue is said to be a particularly
preferable for a variety of technical reasons. A good source in intermediate post-mortem time
number of STR systems are available for use in periods. Hard tissues (bone and teeth) are the best
identification, and commercial kits are available. source of DNA in cases of advanced decomposition.
These STR systems work well despite significant The specimens should be kept cold or preferably
degradation and are quite amenable to automation. frozen (although repeated freezing and thawing is
Sufficient numbers of STR systems can be not good). Desiccation, even simple air drying, may
performed to achieve discriminatory powers similar be an adequate method of storage of some DNA
to current RFLP testing. The British and Canadian specimens, e.g. bloodstains and bone. Tissues in
crime labs are moving towards using STR systems formalin are not optimal, but can often be used for
exclusively. PCR-based DNA testing. No tissues or biologic
fluids should be discarded as inadequate without
Specimen Selection, Collection, and first attempting DNA testing. Due to the degree
Preservation of sensitivity of PCR-based technologies, great care
DNA can be isolated and tested from virtually should be taken to prevent contamination of one
any postmortem tissue, although after death it specimen by other sources of DNA. Specimens
will undergo progressive fragmentation. DNA is should be collected with gloves and pristine
generally broken down (degraded) into fragments instruments. Fresh tissues should be collected by
through autolytic and bacterial enzymes, specifically an incisional biopsy technique, where possible.
DNases. Nevertheless, the sequence information Similarly, laboratory testing should be carried out
is still present within the DNA fragments and with particular precautions against the possibility of
therefore the information is not completely lost contamination, including separating the pre-PCR
despite the fairly extensive fragmentation which sample preparation area from the post-PCR analysis
occurs from decomposition. However, not all DNA area.
testing is appropriate or possible when the DNA
Dental DNA Evidences
is degraded. Traditional RFLP testing will require
non-degraded high molecular weight DNA, Teeth themselves can be excellent sources of
whereas PCR-based analysis can be performed on DNA. In fact, the same reasons that permit the
degraded samples and mitochondrial DNA can be survival of teeth for dental identification similarly
obtained from skeletal remains when nuclear DNA protect the DNA within teeth. Accordingly, teeth
cannot. In relatively fresh cadavers, unclotted blood are a better source of DNA than skeletal bones,
(EDTA anti-coagulated in a purple-top tube) is the which are better than soft tissues in cases of much
preferable source of DNA. Although heme is an decomposed remains. DNA is present in the
inhibitor of PCR, laboratories are accustomed to vascular pulp of the tooth, but it is also found
blood as a DNA specimen and although only white throughout the tooth in varying levels, particularly
in the odontoblastic processes, accessory canals, through the cervical root subjacent to the cemento-

and cellular cementum. Most information necessary enamel junction, preserving most restorations for
for traditional dental identification is present in the traditional dental comparison purposes. Although
crown (enamel and dentin) of the tooth. somewhat greater amounts of DNA are obtained by
Two important conclusions can be withdrawn crushing the entire tooth, this conservative method
from this DNA profiling methods: of sampling DNA from teeth has been found to be
1. In a reconstructive profile —Sex of the decedent quite adequate and also it is crucial in cases where
through analysis of Amelogenin sex linked gene. preservation of sampled tooth is important as in
2. Direct/indirect reference sample—Through mass fatality incidents.
comparisons of DNA from the found body.
B. Cr yogenic grinding: Requires following
instruments and equipments (Fig. 2.24)
Obtaining the Dental DNA
• Freezer mill (2 to 4 minutes)
A. Conservative approach: Sectioning of teeth • Liquid nitrogen
and opening the crown to extirpate the pulp. • Lysis buffers
Consequently, a tooth can be sectioned horizontally • PCR.
Fig. 2.24: The process of cryogenic grinding, showing the apparatus, freezer mill, an oscillator
and the powder obtained after such procedure
DNA profiling: Multiplexing-analyze many genetic particularly in closed populations. Reconstruction

loci simultaneously, requires smaller sample, faster from scattered relatives is often possible, but the
than previous methods such as restriction fragment statistical inference is substantially diminished.
length polymorphism. Mitochondrial DNA analysis must be performed on
Cryogenic grinding is used to extract DNA maternal kindred (mothers, siblings, children only
from calcified tissues such as teeth. The first step in in the case of a female), but unlike nuclear DNA
extraction of DNA from bone or teeth is to break identification, it can be performed even in distant
up the tissue to expose the DNA to the extraction relatives (maternal aunts and uncles, children of
medium. Early techniques involved the fracturing sisters). It is not always possible or desirable to use
of bone by freezing it in liquid nitrogen, but families for reference specimens. Sometimes family
subsequent protocols specify breaking the tissue members are no longer alive. Sometimes the family
with a mortar and pestle and then grinding the members are not known or their whereabouts
tissue into a coarse powder in a grinding mill. In cannot be determined. Some individuals are
a freezer mill a ferromagnetic plunger is oscillated adopted into their families and therefore the family
back-and-forth in alternating electric current. is not appropriate as reference specimens. Often
Liquid nitrogen is used to cool the sample, which it is awkward to approach families on the mere
results in making it extremely brittle and also possibility of an identification. Except in the case
protects DNA from heat degradation. The tooth of mitochondrial DNA sequence comparisons,
is reduced to a powder to increase surface area and pedigree analysis permits only inferential and less
expose trapped cells to biochemical agents that compelling conclusions than a sample from the
release DNA into solution. Protocols have differed individual himself.
in requiring or not requiring a decalcification step. Furthermore, mutations render occasional
But many authors have found that decalcification identifications problematic. Rather than secondary
is not only unnecessary, but approximately half reference samples from family members, primary
of the DNA is lost through the dilution and DNA specimens of the individual may be available
imperfect recovery involved. The next step in most from toothbrushes, biopsies or tissue slides archived
protocols is incubation in a proteinase-K solution in a hospital’s pathology department, from stored
to enzymatically digest proteins and release the blood donations, from licked envelopes and stamps,
DNA. After incubation in a buffer solution, or in the case of mitochondrial DNA from locks
standard DNA extraction procedures may then be of baby hair or clippings from an electric shaver.
performed. All states in US require the taking of bloodstains
from infants for phenylketonuria (PKU) testing;
Reference Samples/Databases some state health departments store these cards
The lack of an antemortem dental X-ray or for significant periods of time.
fingerprint record is the most common reason for Not only can DNA be obtained from teeth for
the inability to obtain identification by traditional primary identification, but it can also be obtained for
identification methods, whereas reference specimens reference DNA purposes. Numerous cases are there
for DNA testing are generally available from family in which teeth have been identified, and the DNA
members. Specimens from the spouse and children from the tooth used as a reference DNA source to
will permit “reverse paternity” testing using nuclear identify other tissue fragments. The majority of
DNA probes. Parental specimens, and possibly states now have legislation creating DNA databases
those from siblings, will permit identification, of convicted sex and violent offenders; other states
will likely enact such legislation. These state DNA opponents to DNA profiling raise are (1) adequacy

databanks will be linked by the FBI’s National of genetic interpretations; (2) quality assurance
DNA Identification Index (also known as the of testing procedures; and (3) the inference of
Combined DNA Index System or CODIS) and will unfairness to defendants.
include a file for unidentified and missing persons.
This computer system is separate and apart from Adequacy of Genetic Interpretations
the NCIC. Due to the tremendous utility of DNA After a proponent has successfully proffered
identification, the military established the DOD evidence establishing the DNA technique and
DNA Registry for the purpose of human remains that sound laboratory procedures were followed,
identification. The DNA Registry is comprised of there must be a scientifically reliable method of
the Armed Forces DNA Identification Laboratory determining the probabilities or frequency of
and the DOD DNA Specimen Repository. By the a matching profile. The purpose of frequency
year 2001 in USA, all active duty military members estimates is to give meaning to the match by
had their buccal swabs and dried bloodstain DNA showing the likelihood that an unrelated person
specimen cards on their file. The DNA Registry has in the reference population would be a chance
already proven itself to be of great benefit. With the match. As the NRC noted, it is meaningless “to
establishment of the DNA Registry, the military’s say that two patterns match, without providing any
duplicate panograph program will be phased out. scientifically valid estimate (or, at least, an upper
DNA identification represents a significant new bound) of the frequency with which such matches
adjunct to traditional methods of identification. might occur by chance”.
To develop their frequency estimates, forensic
Problems Applying DNA Test Results
laboratories establish databases of analyzed blood
Irrespective of the analytical approach general specimens (usually several hundred) of different
acceptance or relevancy courts, legal commentators, ethnic groups from different parts of the US. By
and the treatise writers generally agree DNA profiling, using its RFLP radioactive probes on the samples,
as a novel scientific procedure, has received broad the laboratory creates band patterns or images on
support and has been admitted into evidence. the autoradiograph. Each band represents one
Professor Imwinkelried, concludes that courts have particular match allele. The bands are then grouped
been receptive to the technology and most have by the size of DNA fragments and then placed into
found DNA typing a trustworthy technique. If there “bins” for purposes of comparing the percentage
are shortcomings in which technicians conduct DNA of the public that has that band. The percentage
tests, such shortcomings do not affect the admissibility of bands falling into a particular bin is established
of the test results, only the weight a judge or jury as the percentage of the population possessing
should accord it. Hence, a judge or jury might give that particular allele. The percentages for each
little or no weight at all to the expert’s testimony. allele, reflected in each “probe” in the “series”
The success of the application of DNA profiling performed for a particular DNA analysis, are
in the identification of defendants, by its very multiplied together. That result is then multiplied
nature, depends largely on a case-by-case analysis. by, reflecting the composition of an individual’s
This approach is in keeping with Judge Cox’s DNA from the combination of each parent’s DNA.
classification that some novel scientific evidence The result of this final multiplication is the statistical
can neither be accepted nor rejected outright. probability of that particular DNA being repeated
However, the most frequent challenges that in the general population.
Bibliography 6. Hemath M, Vidya M, Nanda prasad. Bhavana VK.

Sex determination using dental tissue. Medico-
1. Adams BJ. Establishing personal identification Legal update. Vol. 8, No. 2 (2008-07_2008-12).
based on specific patterns of missing, filled, and 7. Hutchison CA, Newbold JE, Potter SS, Edgell MH.
unrestored teeth, J Forensic Sci. 2003; 48:487-96. Maternal inheritance of mammalian mitochondrial
2. American Board of Forensic Odontology. Body DNA. Nature 1980;251:536-8.
identification guidelines. J Am Dent Assoc 1994; 8. MacLean D, Kogon S, Stitt S. Validation of dental
125:1244-54. radiographs for human ID, Int. Dent. J. 1994;39:
3. Andersen L, Juhl M, Solheim T, Borrman H. 1195-1200.
Odontological identification of fire victims po- 9. Marella GL, Rossi P. An approach to identification
tentialities and limitations. Int J Legal Med 1995; by means of dental prostheses in a burnt corpse. J
107:229-34. Forensic Odontostomatol 1999;17:16-9.
4. Burris BG, Harris EF. Identification of race and 10. Steyn M, Iscan MY. Sexual dimorphism in the crania
sex from palate dimensions. J Forensic Sci 1998; and mandibles of South African whites. Forensic Sci
43:959-63. Int 1998;98:9-16.
5. Clark DH. An analysis of the value of forensic od- 11. Sweet D, Hildebrand D. Recovery of DNA from
ontology in ten mass disasters. Int Dent J 1994; human teeth by cryogenic grinding, Journal of
44:241-50. Forensic Sciences 1998 Nov;43(6):1199-1202.
3

Dental Records and Forensic
Photography
Nitul Jain, Gaurav Atreja
Chapter Overview
 Long-term storage of dental records  Forensic photography
The production, retention and release of clear and absent in 14 percent, less than half (48 percent
accurate patient records are essential part of the were considered satisfactory).
dentist’s professional responsibility. Success in this In another observational study on the quality
task will assist the dentist’s medicolegal claim and of dental records, Swedish researchers found a large
can assist the police and coroners in the correct discrepancy in the quality of examined records. In
identification of individuals. Dental professionals the study they examined ten years worth of patient
are compelled by law and duty of care to produce records which had been submitted for the purposes
and maintain adequate patient records. With the of forensic identification. A startling statistic is that
increasing awareness amongst the general public ten percent of the patients were identified
of legal issues surrounding health care, and with incorrectly on their records! Other areas of concern
the worrying rise in malpractice cases, a thorough included signatures in only five percent of records
knowledge of dental record issues is essential for and the documentation of a treatment plan in only
any practitioner—especially those who are just eight percent. These simple mistakes can lead to
beginning their careers. errors of treatment, confusion when transferring
records and opens the practitioner to criticism
INTRODUCTION should a medicolegal claim be made against them.
The ability of clinical practitioners to produce and

What is a Patient Record?
maintain good dental records is essential to good
quality patient care as well as being a legal In brief, the patient’s record is the complete story
obligation. Unfortunately dental records are often of the history, physical examination, diagnosis,
unsatisfactory. A study performed by two Regional treatment and care of a patient. The record may
Dental officers in the UK identified charting as consist of several different elements; common ones
inaccurate in 38 percent of examined records and include written notes, radiographs, study models,

referral letters, consultants’ reports, clinical B. Medical history—Thorough investigation to
photographs, results of special investigations, drug include a minimum of:
prescriptions, laboratory prescriptions, patient • Name and phone number of physician
identification information and comprehensive • Dentists’ own evaluation of patient’s general
medical history (Figs 3.1A to C). Clearly this is a health and appearance
large amount of information and it is essential that • List of systemic disease—Diabetes, rheumatic
a practitioner maintains this in an easily accessible fever, hepatitis etc.
manner. • Any ongoing medical treatment
Within the written notes the established • Any bleeding disorders, drug allergies,
minimum information is: • Smoking and alcohol history
A. Identification data—Name, date of birth, phone • Any cardiac disorders.
numbers and emergency contact information. C. Relevant family medical history.
Fig. 3.1A: A typical case history performa

Dental Records and Forensic Photography 45

Fig. 3.1B: Antemortem dental record performa
D. Pregnancy history in case of female patients. and expanded version, appropriate to the dentists,
E. Dental history. is given below:
F. Clinical examination to include an accurate 1. Use a consistent style for entries—The
charting: appearance of the record is enhanced by using
• Diagnosis the same color and type of pen, use the same
• Treatment plan abbreviations and notations etc.
• Documentation of informed consent. 2. Date and explain any corrections—It may be
a fatal error in a malpractice case if records
Creation and Maintenance of a Patient appear doctored in any way. These
Record
unexplained corrections can undermine the
Lawney describes a simple ten step procedure to credibility of the entire record and of the
ensure that your records are adequate. A modified treating dentist.

Fig. 3.1C: Postmortem dental record performa
3. Use single-line crossout—This preserves the 5. Use ink—Pencil can fade and opens up the
integrity of the record and shows that you have question of whether or not the records have
nothing to hide. been altered.
4. Do not use correction fluids—Not only is this 6. Write legibly—An illegible record may be as
messy, but it is conspicuous and may indicate bad as no record at all. Difficult to read entries
that there has been an attempt to hide can lead to guesswork by others and this may
information. not be favorable to you.

7. Express concerns about patient needs—By
doing this you are documenting that you have
listened, empathized, understood and acted
upon the wishes of your patient. It also enables
an explanation to be given should a patients’
wishes be unobtainable or unrealistic and can
help instantly diffuse a malpractice case. Use
Fig. 3. 2A: An example of complete radiograph records
quotations to indicate patient comments as
distinct from your own.
8. Never write derogator y remarks in the
record—Superfluous entries only serve to
convey a feeling of unprofessionalism and may
give doubts to the overall credibility of the
remainder of the record. Negative views about
patients, such as their failure to follow your
advice or attend appointments, should be
recorded in a dispassionate and objective
manner.
9. Document fully—There is no need to be
sparse with notes, a detailed explanation is
always better than one lacking information.
It is important to note, however, that each
entry should pertain directly to patient care.
10. Only use accepted abbreviations for
treatments—This is helpful both in a
malpractice situation and also when
transferring records to a different dentist for Fig. 3.2B: A spine radiograph obtained from patient’s
referral, prior approval or a change in dentist previous physician
of record.
11. Collate documents—Insurance details and only 40 percent of the radiographs were identifiable
other materials from third parties should be to the patient. In the NHS system (UK) the most
separate from those items which pertain common technique for radiograph storage is in a
directly to patient care. small envelope with the patient’s details, type of
12. Maintain a chronological order—The use of radiograph and date listed on the front. The
a hole punch and metal retainer clips in the patient’s record can quickly become filled with
top of the record may be helpful to keep loose these envelopes and establishing a time line can be
sheets organized. difficult and confusing, especially when endodontic
By following these steps the production of films become co-mingled with diagnostic films. A
accurate and defensible records is possible. mounting method can be a more effective solution
to radiograph storage. This mount will easily fit
Radiographs Keeping (Figs 3.2A and B) within the patient’s record sleeve.
The production, storage and documentation of A common problem experienced when viewing
radiographs is highly variable. In the Swedish study a patient’s radiographic histor y is that of

degradation of the films. This is usually due to A. Treatment records, X-rays, study models (Figs
processing errors, especially a failure to properly 3.3A and B) and correspondence retained for
fix and rinse the films. This is most frequently found 11 years after the completion of treatment
on those films used for endodontic procedures as B. For children, retention of records until the
the developing is often hurried and commonly self- patient is 25 years old
developing films are used. C. Orthodontic models- (Fig. 3.4) retain the
As well as the need for accurate, well-stored and original pre and postoperative models perma-
documented radiographs, the frequency of nently, discard any intermediates after a period
radiographic examination is also important. A of 5 years.
patient’s record that is lacking up-to-date The storage area of these records should be
radiographs may jeopardize a malpractice case and secure and access strictly controlled. By following
is against the patient’s best interest. There are these guidelines, the dental records of a patient will
established guidelines for the frequency of be available for you should a claim ever be made.
radiographic examination. These guidelines should
be modified for the individual patient’s
requirements, based on caries risk and presence or
absence of periodontal disease and other
pathologies.
Like all parts of the dental record, radiographs
should be stored for 11 years or up to the age of
25, in the case of children, for protection against
the 1987 Consumer Protection Act (UK).
Retention of Patient Records

A
The NHS Terms of Service state that dental records
should be kept for a period of two years. The
Regulations state that treatment records,
radiographs, photographs and study models should
be retained after the completion of any course of
treatment and care under a continuing care or
capitation arrangement for this period. However,
a patient has the right to raise an action for damages
based on accusations of negligence or breach of
contract. There are strict time limits applied to such
actions.
It is therefore possible that a claim for negligence
could happen many years after the event, and that
retention of records for the minimum two years is
inadequate. The defense organizations suggest that
records be kept permanently. This is often impossible
due to space constraints and so the advice given by B
defense organization (UK) is as follows: Figs 3.3A and B: Well-mounted and articulated casts

Fig. 3.4: Composite diagram showing various types of dental records that may be useful in
the case need arises for the identification
LONG-TERM STORAGE OF Access to Patient Records
DENTAL RECORDS Patients, their legal representatives and police

officers may gain access to dental records. The
For records which are dormant, and yet need to
Access to Health Records Act 1990 (UK) provides
be retained, computer technology provides an
the following legislation:
economical solution. The use of high density,
removable storage media, such as Iomega Zip disks, Personal inspection—A patient can request to see
allows large quantites of data to be stored easily their notes and be guided by the dentist through
and economically. Paper records and radiographs the contents with explanations of terminology and
can simply be scanned into a personal computer technical language.
using a desktop scanner. This data is then Photocopies—A dentist can provide a photocopy of
compressed using technologies such as JPEG, the notes if the patient requests so in writing. The
enabling many records to be stored on a single record photocopy must be provided within 21 days
disk. Commonly used programs such as Adobe of the request or within 40 days if no treatment
Photoshop contain the JPEG compression system. has been carried out in the past 40 days. Only
Should the record ever be needed again then the details of the record from 1st November 1991 can
files can simply be printed to a high quality laser be provided under this Act, however, it may be
printer. By using these techniques the dentist can necessary to provide earlier entries to explain
protect themselves from malpractice claims without subsequent treatment.
using valuble storage space. The removal of inactive The dentist may charge reasonable photocopy
files streamlines the filing system leading to an and postal charges. When asked by a patient for
improvement in record system efficiency. access to records, a caring attitude and prompt

delivery may well help prevent any future claim. If or remove a patient’s records without their consent.
the request for disclosure of notes comes from a However, the law allows for special circumstances
solicitor then this may indicate that the patient and it is reasonable to hand over an individual’s
intends to take legal action. Not all of the treatment record if it enables them to be identified or
record is relevant to the matter in question and so excluded. The consent of the nearest relative or
always consult your defense organization prior to estate executor may also be sought if required.
releasing any documents in this situation. As an The availability of contemporaneous and clear
additional note it must be remembered that the notes is essential in forensic dental identification If
Data Protection Act 1984 allows patients to view notes are incorrect or dated, this can complicate
any information about themselves held on and even negate a positive identification. It is in
computer, following a written request. such situations where the errors highlighted by
Borrman and others can cause crucial mistakes to
Forensic Uses of Patient Records be made. When a request for records is received
Forensic dentistry is the overlap of the dental and the entire record is useful, including such items as
legal professions. The most common element of lab prescriptions and study models. Many
forensic dentistry that a general practitioner is likely documented cases have used the unique pattern
to encounter is supply antemortem (before death) of the palatal rugae recorded on an orthodontic
records to aid in human identification. Forensic study model to identify a young individuals with
dentists are frequently called upon to identify the no dental restorations.
remains of individuals who cannot be identified The police may require access to an individual’s
visually. This encompasses a large number of situations record for another criminal matter. They may, for
such as burnt, grossly decomposed or mutilated example, want to see an appointment book to
remains. The identification is normally carried out establish an alibi or time line. In these circumstances
by the comparison of antemortem (before death) and a warrant is required, if the patient has not agreed
postmortem (after death) records. to the release, as it can be argued that the release
The identification of deceased individual is an of notes in this instance is not in the patient’s best
essential element in the process of death interest.
certification and is a crucial component in the
Confidentiality of Records
investigation of homicides or other sudden deaths.
It is vital to have expeditious and accurate Dentists are in a privileged position to learn much
identification both for police officers and relatives. about patients and this knowledge is acquired
Until identification can be confirmed, estates under the assumption that it is confidential.
cannot be settled, death benefits cannot be paid Confidentiality encourages open and honest
and surviving spouses are unable to remarry. communication, enhancing the dentist-patient.
Perhaps of most impor tance is that the relationship, and encourages respect for patient
identification of the dead is an essential component autonomy and privacy. Confidentiality is taken very
of the grieving process and is a necessary part of seriously by professional bodies and an alleged
human dignity in a civilized society. breach of this trust would be investigated by the
The police officers in charge of the case will Professional Conduct Committee of the General
normally call upon the dentist to provide details Dental Council (UK).
of dental records. It must be remembered that There are circumstances in which information
police officers have no statutory rights to inspect can be disclosed, and they include:

1. Sharing of relevant information with other health Indian Scenario and Lacunae in the System
care professionals involved in a patient’s As published in the journal of Indian Dentist
treatment.
Research and Review, issue 2, September 2007,
2. Information may be passed to a third part if the
the total number of dental colleges in world is
patient or legal adviser gives written consent,
approximately 960. Out of these 960 dental
e.g. an insurance company.
colleges, around 260 dental colleges, that is a
3. Where information is requested about a deceased
staggering 26 percent of the total are alone present
patient and consent of the estate or relative is
in India. Also, India has got a population which is
sought and the investigation of sudden,
supposed to be one fifth of the world.
suspicious or unexplained deaths.
Unfortunately our country also happens to be one
4. Information required in the preparation of legal
of the countries in the world where there are
repor ts containing only relevant dental
maximum number of causalities arising out of
treatments.
terrorist attacks, fire disasters, horrific bombing
5. Investigation of sudden, suspicious or unexplained
incidents and lastly the curse of Mother Nature in
deaths.
terms of earthquake, floods and landslides.
6. Access to dental records by the police. Search
Given the above considerations, it is clear that
and seizure warrants may not include dental
many of the causalities arising because of the above
records, and therefore should be carefully
situations, do not get their identity and hence their
checked.
grieved families never get any thing that can console
7. Clinical research protocols and peer review
them of the loss they suffered.
procedures. The name of the patient must be
We have so many numbers of dental clinics and
kept confidential. If information is to be used
dental colleges and hospitals in India, still it does
for teaching purposes then the patient’s consent
not help us out to resolve the identity crisis in such
must be obtained.
happenings. Because scenario in India is not the
The area of confidentiality of children’s dental
same as it is in the western countries. So the
information can be confusing. Those individuals
tremendous vast potentiality of dental records in
of 16 years and older should be considered adults,
the identification protocol does not help out to
however for those 16 and under, the dentist still
come to any conclusion in case of such events. So
has a duty of care and therefore confidentiality to
the question arises where are we lagging behind.
the child. This duty is combined with a duty to
Answers to all the above questions become clear
the parents, especially in the area of consent to
as because of the reasons mentioned below:
treatment. Children who are victims of abuse
require special management and the dentist may 1. Not many people in India visit dentist even once
have an overriding responsibility to break in their life.
confidentiality and report their findings to the 2. Records are not kept and even if kept, are not
appropriate authorities. Special guidelines exist for maintained for a long time.
AIDS/HIV and sexually transmitted diseases. Strict 3. Inability to locate the dentist in case of any
confidentiality must be maintained when dealing causality and subsequently obtain AM records.
with these individuals. Disclosure of such 4. Poor quality of AM records/non availability.
information could lead to a complaint of serious 5. Patients treated on emergency basis may have
professional misconduct. few records.

6. There is no law and rule in India, which FORENSIC PHOTOGRAPHY
reinforces the dental record keeping mandatory.
7. Lack of funding to sustain and maintain the Need for the Photography
records. Accurate photography is crucial to forensic
8. Also, at present no specialization in the field of investigation as a means of documenting evidence.
forensic odontology. The need to photographically record injur y
With above considerations, it is clear that a patterns as they appear on skin is paramount to
dentist can be an important source for providing the odontologist and pathologist. Since vast
valuable data to answer questions that arise during amounts of time often elapse between the
a death investigation. As a tooth can withstand commission of a crime and the trial of the
insults where all other tissues may not survive to perpetrator, photographs frequently are the only
be recognized, the importance of such tooth can permanent record of the injuries to the victims.
be of interest in identification of persons, provided Therefore, it is imperative that the forensic
good ante mortem records are available. investigator be able to properly photograph injury
There are fewer AM records available particularly patterns as a means of preserving such evidence.
in our set-ups, we need to keep an accurate and Photography is one of the most important
ordered dental records of all the patients which may applied protocols of forensic dentistr y. The
be of immense value in unfortunate events, thus demands on the photographer can be great,
making us to serve people even better with more especially in situations where an injury is the only
responsibility and care. evidence tying a suspect to the crime. Time,
Thus, when nothing remains out of a body, patience, and preparation in forensic photography
except for a fragment of tooth, identifying the are requirements for successful pattern injury
person to whom it does belongs to, may at least documentation. While often frustrating and time
make something at last to be returned to the consuming, when done properly the results yield
grieved families (Fig. 3.5). good evidence, bringing with it a sense of
accomplishment and satisfaction that the forensic
dentist has made a significant contribution to the
case. Developing the skills necessary to competently
document these injuries with visible and nonvisible
light is one of the great challenges in forensic
dentistry.
The Technical Considerations

The process of photographically recording images
on film, videotape, or other media occurs through
the capture of electromagnetic radiation (light) of
specific wavelengths. These wavelengths, measured
in millionths of millimeters, are referred to as
nanometers and abbreviated as (nm). Photographic
images are recorded on photographic films which
Fig. 3.5: A recovered bridge from the remains of a victim of
are sensitive to light wavelengths in the range of
a disaster, making the identification easier 250 to 900 nm. Visible light, which comprises the

range of (Fig. 3.6) electromagnetic radiation seen of the electromagnetic radiation hits the skin and
by the naked human eye, is from 400 to 760 nm bounces back from it. It is this reflection of visible
in range. Most modern camera equipment and film light that accounts for the colors seen by the human
is specifically designed to record images seen in eye. Not all light energy on an object is reflected.
the visible range of light. In the visible spectrum, Some of the light can be absorbed.
the image is recorded on the film as it is seen by The second of these is the absorption of light
the eye through the lens when the lens is focused by an object that makes it appear black. The action
on the image. It is also possible to record images of the absorption of light associated with the injury
specifically illuminated in the shorter ultraviolet being photographed is significant in nonvisible
range (210 to 400 nm), and longer infrared range light photography.
(750 to 900 nm) wavelengths. A third reaction of light striking skin is the
Because ultraviolet and infrared light are outside transmission and scattering of the energy associated
the visible range of electromagnetic radiation, they with the light through successive layers of cells until
are commonly referred to as “non-visible light”. the energy of the light has dissipated. The final
Photography using non visible light requires special reaction that occurs when light energy strikes an
techniques to record the injury. It may also require object is a molecular excitation called fluorescence.
some minor focusing adjustments, called “focus Excitation at the molecular level causes the emission
shifts”, to correct for the optical properties of lenses of a faint glow that lasts only as long as the
which were designed for visible light photography. excitation energy is applied to the object. Once
the excitation energy is spent, the fluorescent glow
The Basic Optics of Photographic Process
ceases. Fluorescence is not readily seen because of
When light strikes skin, four basic events occur. The the short duration of the emittance, lasting only
first of these is reflection, which occurs when some about 100 ns and because the reflected light energy
Fig. 3. 6: Light spectrum


is so much greater that it over whelms any Types and Techniques
fluorescent light detectable by the naked eye. When When presented with an injury, the forensic dentist
light strikes human skin, all four of the previously or investigator must decide
mentioned events occur simultaneously.
Depending on the wavelength of the source of the a. What information the injury may contain?
b. The extent of the injury, and
incident light and the configuration of the camera,
it is possible to record, individually, any of the four c. How best to photographically record it?
reactions of skin to light energy. Ultraviolet light As previously mentioned, preserving the detail
only penetrates a few microns (thousandths of of the injury with photographs may involve a
millimeters) into skin whereas infrared light can combination of color and black and white visible
penetrate skin to a depth of up to 3 mm (Fig. 3.7). light photographs as well as the use of the non-
What is usually seen when visible light strikes visible ultraviolet and infrared photographs.
the skin is reflected light energy. What is not seen,
however, is the light energy that is absorbed by The Standard Technique
the skin. By varying the wavelength of incident The photographer should develop a standard
light used for illumination and setting up the technique which includes orientation photographs
appropriate configuration of the camera, lens, showing where the injury occurred on the body.
filters, and film, it is possible to photograph any of Additionally, this protocol should include close-
the four events which occur. This ability creates an up photographs for detail, (Figs 3.8A to C) and
opportunity for interesting pictures, especially photographs, placing the lighting source (flash and
when looking at bruises and other injuries to skin. light guide) at different angles in relation to the
Sharp surface details can be seen with ultraviolet injury. Photographs should be taken with and
light, while images well below the surface of the without a scale. The use of a scale serves as a
skin can be seen using infrared light. The reference to record the relative size of the injuries
techniques and photographic protocol for in the photographs. While there are a number of
documenting injuries to human skin in visible and acceptable scales, including coins, when
nonvisible light will be described. unavailability of appropriate scales occurs, many
forensic investigators use the ABFO No. 2 (Fig.
3.9) scale in their photographs. This right-angled
scale was developed by a photogrammetrist (Mr
William Hyzer) and a forensic dentist (Dr Thomas
Krauss) for the purpose of minimizing
photographic distortion and assuring accuracy in
measurement. It has a black, white, and gray scale
for color correctness, as well as three perfect circles
and metric scales.
The photographer should retain the original
scale used in the photograph in the event
enlargement to life-sized reproductions becomes
necessary. It is essential that the standard technique
developed by the forensic photographer includes
Fig. 3.7: A graphical representation illustrating the penetration
of various types of wavelengths of light into the skin exposing many photographs for each case. One

Fig. 3.8A: A color orientation picture of patient highlighting the Fig. 3.8C: A B/W picture, taken in order to see the details
site of injury and its overall relationship to the surrounding of injury which may be masked in the color picture
tissues
Fig. 3.8B: A close-up picture of the same patient to Fig. 3.9: ABFO Scale No. 2 “(ABFO: American Board of
illustrate the injury in more detail Forensic Odontology)
should not be hesitant about using several rolls of technique are used routinely, easier to perform and
film for a photo shoot. a mere more standardized adaptation to what we
use in our day to day life, while others are more
Types of Technique complex, requiring a thorough knowledge of optics
Various types of photographic technique are and its principles, along with the advanced
available today in order to cater the different need knowledge of various kind of camera systems, lens
arising out of different situations. Some of these properties, and the processing techniques. In this

part of the chapter, described first will be the and infrared wave energy from fogging visible light
simpler technique followed by the more complex photographs, modern day manufacturers produce
other techniques. Following is the list of various coated lenses and filtered flash units, allowing only
techniques that are used in forensic photography. visible light to reach the film. Most 35 mm cameras
1. Visible light photography have serious size limitations when it comes to
a. Digital photography recording life-size images. The limitation comes
b. Visible light color photography from the small area of film (24 mm × 35 mm
c. Visible light black and white photography rectangle) which records the image. Since there
2. Alternate light imaging (ALI) and fluorescent are very few objects which will fit into that small
techniques area, considerable enlargement of the photographs
3. Non-visible light photography may be necessary to see the injuries life-sized. Since
a. Reflective long-wavelength ultraviolet (UVA) evaluations and comparisons of the injuries to the
photography teeth, weapons, or tools which created them are
b. Infrared photography often done in direct relation to the life-sized object,
it is necessary to have photographs that can be
Visible Light Photography enlarged to life-size without loss of the detail
necessary for the comparison.
By far, the most common type of photography Film manufacturers have designed photographic
utilized today is photography using visible light, films that record light wavelengths from 250 to
both in color and black and white. Manufacturers 700 nm. Special infrared films are available that
of photographic equipment and films develop and can record photographs taken in light from 250
market equipment and supplies that are specifically to 900 nm. Choosing the proper film is critical for
designed to have an optimal performance in the successfully recording the detail of an injury. The
400 to 760 nm range of the electromagnetic film must be sensitive to the wavelength of light
spectrum. For the photographer wishing to take being used to photograph the injury or no image
pictures in this range of light energy, there is will appear when the film is developed. There are
relatively little practice required to ensure highly many quality photographic negative films
detailed and sharply focused photographs. manufactured, both in color and black and white.
Many 35 mm SLR cameras available today are In addition to the photosensitivity range of the
considered “automatic” point-and-shoot cameras. film, the correct film speed must also be
By definition, the object to be photographed is determined. Films come with a rating, referred to
viewed through the lens and the camera as the ASA/ISO number, which serves as an
automatically adjusts the focus and exposure indicator of the amount of light energy necessary
variables before exposing the film. However, to properly expose the film. The higher the ASA/
depending on the type of film used and the ISO number, the faster the film; in other words,
spectrum of electromagnetic radiation to which the less light is needed to expose an image. Films with
film has sensitivity, it can become possible to “fog” high-speed ratings (ASA 1600 or 3200) require
(alter or distort) a visible light exposure with very little light energy exposure, but caution must
ultraviolet and infrared light. With visible light be exercised. The higher the ASA/ISO number,
photographic techniques, ultraviolet light may the lower the grain density on the film where the
cause color shifts toward an undesirable bluish tint image is recorded, which translates into less
in the photographs, while infrared light may create versatility during enlarging. Large-grain fast films
more red tints than desired. To prevent ultraviolet tend to produce prints which appear to lose focal

sharpness and detail as they are enlarged toward
their normal limits, i.e. life-sized or 1:1. Just as
there are good and bad attributes for high-speed
films, slower speed films can also have limitations.
Using a film speed that is too slow for the amount
of available light will result in an underexposed
picture that may also lack clarity and detail. There
are some situations where the photographer does
need to underexpose for better detail, particularly
during fluorescent photography. The basic
recommendation is to use the slowest film speed
which will have the most grain density for the
lighting present. Problems caused by having the
wrong film or improper lighting may be minimized
by bracketing the exposures over a wide range of A
camera settings (bracketing means to expose
individual photographs in a range of f-stops and
shutter speeds).
a. Digital Photography (Figs 3.10A and B): This
technique utilizes a special computer hard disk in
the camera that stores the images as digital
information. These images can be later written to
CD-ROM for storage. The advantage of digital
photography is that the image can then be
immediately viewed on a computer monitor or
printed on a color printer. The image could also
be transferred to traditional photographic films.
This technology works superbly for color and black
and white visible light photographs, but requires
B
special computer chips for non-visible light
photographs. Figs 3.10 A and B: Types of digital and SLR cameras
available in the markets
Before approaching any photographic subject
for close-up documentation of either a injury
pattern or tool mark, remember to take an
photographs using a macro lens should be taken,
orientation shot. For example, in photographing
both with and without a scale in place. If the camera
a bite mark, typically a few preliminary photos
has a macro lens and is used for close-ups, be certain
would be taken at a distance which includes the
the scale is in the same focal plane of the object
location and orientation of the bite mark relative
being photographed before exposing the film.
to its position on the body. This is to communicate
to subsequent observers exactly where the injury b. Visible Light Color Photography: Advancements
occurred and its positional orientation. After the in design and manufacture of modern 35 mm
orientation photos, numerous close-up cameras have greatly simplified color photography.

These cameras have the capability to photograph
objects with great accuracy and precise color detail.
As discussed previously, the lenses have coatings
and the flash units are filtered to direct only visible
light to the film. Modern films record the images
in brilliant colors and sharp detail. The most critical
variables to consider when taking still photographs
in color are (1) the type of the film and (2) the
intensity of the light present when the film is
exposed.
Color visible light photography is by far the most
common type of photography used today. Modern Fig. 3.11: A normal close-up color picture of the bite mark
with correct placement of ABFO Scale No. 2
cameras readily available today are manufactured and
configured to take photographs using (Fig. 3.11)
visible light. There are generally no special
requirements or equipment needs assuming there
is enough visible light energy available to properly
record the image on the film. When choosing the
type of film, use the lowest speed film possible for
the lighting available and proceed to take orientation
exposures, gradually moving to the specific site of
the injury. With routine color slide or print film
illuminated by flash, a film of ASA 100 is generally
adequate for close-up photography. To insure color A
accuracy, it would be helpful to include a color
correction guide in one or more of the exposures.
One popular color correction guide is the Macbeth
Color Chart (Figs 3.12A and B), which is available
in camera shops. Use of this guide will allow the
film processing lab to correct the color temperature
of the negative to the real color composition of the
image before printing the photograph.
c. Visible Light Black and White Photography:
Changing from color film to black and white film,
the forensic photographer proceeds to re- B
photograph the injury. Use the same orientation
and standard technique that was used when the Figs 3.12A and B: Macbeth color charts used for color
correction purposes
color photographs were taken. In order to simplify
this process, many photographers maintain two
complete camera systems, with interchangeable record the injury with black and white photographs
bodies; one loaded with color film, the other with when color photographs of the same injury were
black and white. It may seem redundant to re- just taken—or is it?

This is because of the fact that the human eye is phosphorescence, as well as other electrochemical
very adapt at seeing images in color. Because of phenomena like bioluminescence.
the color information processed optically by the The technique requires an alternate light source
retina, other important details of the injury may which is capable of producing the monochromatic
be overlooked. When the injury is photographed beam. The particular wavelength one tunes to
in black and white, the eye is not distracted by the depends upon what trace evidence the forensic
color composition of the injury and the normal investigator is seeking. There are optimal
surrounding areas. Consequently, this absence of wavelengths for different applications; therefore the
color allows the viewer to see more detail in the color (frequency) of the light and blocking filters
injury. When exposing film for black and white will vary. Research and investigation of pattern
photographs, the same criteria for exposing color injuries on human skin has shown that peak
photographs are followed. In many situations there fluorescence of the epidermis occurs at 430 to 460
may only be one chance for photographs. If that is
nm, and is blue in coloration. Most of what strikes
the case, take a minimum of three or four rolls of
the surface of the skin is reflected. Of the rest, about
black and white and color photographs, bracketed
30 percent penetrates below the surface. Some of
widely, and illuminated from different angles.
it gets scattered, some is absorbed, and some is
Alternate Light Imaging (ALI) and Fluorescent remitted as fluorescent light. The natural light-
Techniques absorbing organic components of tissue are called
chromophores. Examples of chromophores are
The field of forensic investigation has seen a hemoglobin, bilirubin and melanin.
tremendous growth in the utilization of alternate
Since the fluorescent light is always less bright
light imaging for both locating and photographing than the incident light, one must observe the
latent evidence. Fingerprints, serological fluids left fluorescence of an object with filters which allow
behind at a crime scene (blood, semen, saliva), types only the fluorescent light through to the eye and
of ink used to counterfeit or falsify documents, and block the more powerful reflected source light.
bruises or other pattern injuries left on human skin Principles and techniques previously described
that were sustained during violent crimes can now are used in fluorescent photography. Light returning
be more easily detected and also transformed into to the film must be filtered to allow only the
exciting and important exhibits with the utilization fluorescent image to be captured on the film
of fluorescence. The application of this new emulsion. In documenting injury patterns, this
technique has numerous titles. For simplicity, here filtration is accomplished with a yellow filter such as
it will be referred to as alternate light imaging the Kodak gelatin 15 filter which blocks light
(ALI). The technique of photographing evidence transmission in the 400 to 500 nm range.
with alternate light is called fluorescent Fluorescent photography is best accomplished
photography. successfully in complete darkness, where all other
Fluorescence: It is the stimulation and emission of sources of light are eliminated. One can imagine
radiation from a subject by the impact of higher the difficulty in setting up and capturing this kind
of photo, especially when the exposure times can
energy radiation upon it.
range up to 2 to 4 seconds in length and the subject
Luminescence: It is a general term for the emission is alive and moving. Use of a tripod-mounted camera
of radiation that incorporates both fluorescence and is mandatory.

It has been shown that slightly underexposing investigator is improved detail and visibility of
the film will produce better results than the actual the subject matter.
metered exposure. This is true because during 2. Fibers which are not easily located under normal
longer exposures even the fluorescent light coming light can become like beacons as they fluoresce
back to the film is still bright enough to wash out under alternate light.
some of the fine detail in the injury at the so-called 3. Gunshot residue on a dark background can be
“correct” exposure factor. Several variables can made to stand out as though it were
influence the photographic protocol and photographed against a white background with
parameters of exposure. Skin color (amount of the employment of ALI
melanin), skin thickness, wound healing response, 4. Illegal narcotic drugs such as rock cocaine or a
light intensity, film speed, and location of the injury latent fingerprint which may have otherwise
are but a few factors which affect the exposure gone undetected, can not only be located but
times. Thick skin as found on the palm of the hand may become crucial evidence by using ALI
and sole of the foot fluoresces more than the thin 5. For documenting injuries to victims of violent
skin covering the face. Darkly pigmented skin will and sexual crimes or human abuse, fluorescent
require longer exposure times than lighter skin photography using ALI will frequently provide
because more light is absorbed by the melanin more information about the actual pattern
pigmentation of the (Fig. 3.13A) darker skin. injury than one would observe under normal
Persons who bruise easily, such as the elderly, will flash photography.
produce injuries which may require shorter
exposure times due to the thinness of the skin; but Non-visible Light Photography
one can also expect longer exposures when greater
The photographic requirements for recording
hemorrhaging occurs beneath the skin since the
injuries on film using non-visible light become
blood absorbs light.
somewhat more complex. The appearance of the
Advantages of using ALI: injury using nonvisible light illumination cannot
1. The primary advantage which alternate light be seen by the naked eye. Therefore, special
imaging (ALI) impar ts to the forensic techniques must be employed to record the injury
on film and then print the image on photographic
paper for viewing in visible light. Just as in ALI,
these techniques require that band-pass filters be
used. They are placed between the injury and the
film, usually in front of the lens of the camera. The
filters allow only the selected wavelengths of light
to pass to the film. It is important that several
factors be considered when attempting to
photograph injuries in non-visible light:
First, one must consider the type of film being
used. The film’s photo emulsion must be sensitive
to the light wavelength the filter is allowing it to
“see”. Additionally, the light source must be strong
Fig. 3. 13A: Special photograph of the same bite mark case
as shown in the picture 3.11 with an alternate source of
enough to expose the film. The camera’s exposure
fluorescent light settings (f -stop and shutter speeds) must be set to

properly bracket for the type of light being used. experimentation to determine their acceptability
The camera’s ASA/ISO value must be correctly in infrared photography
set for the film being used, and the lens must be 2. Tungsten lamps: Used routinely in forensic
focused correctly for the type of nonvisible investigations. The brighter the Kelvin value,
radiation being used. generally the more IR output.
There are two major problems encountered with 3. Quartz-halogen lamps: Good source of IR
nonvisible light photography. First, it is difficult to radiation if unfiltered; more readily available and
acquire a predictable light source that emits enough easy to use.
of the desired wavelength to adequately illuminate
the injury being photographed. Second, the exact Focus Shift
amount of focal shift to produce a sharp photograph After securing a source of predictable nonvisible
must be determined. Developing confidence and light illumination, the problem of focus shift must
getting predictable results in nonvisible light be addressed. By definition, focus shift is “the
photography will require some trial and error distance between the visible focus and either the
experimentation. Available and predictable sources infrared or ultraviolet focus”. Focus shift is
of nonvisible lighting are listed below for both necessary because nonvisible wavelengths do not
ultraviolet and infrared photography. behave in the same way as visible light as they pass
Ultraviolet (UV) Light Sources through a compound lens. The focal length of a
1. Sunlight: A good source of long UV light but lens is specific to a given wavelength of light. Most
not practical for situations requiring indoor or lenses are chromatically corrected to work within
night-time exposures. the 400 to 700 nm wavelengths (visible light).
2. Fluorescent tubes: Routinely used for indoor When the light energy falls outside of the visible
lighting; some useful UV emission. The best of spectrum, the optimal visual focus is no longer the
these types of lights is known as a “black light”, optimally focused point for the nonvisible light
which emits good UV radiation; the brighter energy used to expose the film.
the better. While some manufacturers have developed
3. Mercury vapor lights: Particularly useful in achromatic lenses which act to bring two different
lighting small areas with intense UV light. wavelengths to a single coincident focus, many
Problems include long warm-up time for the readily available chromatic lenses may require a focus
light and limited availability. shift for nonvisible light wavelengths. Kodak has
4. Flash units: Many older units provide adequate suggested the easiest method, and the one
UV light emission. Some newer units emit a recommended to be tried first. It is their opinion
measurable amount of UV but will require that the focus shift required for ultraviolet
experimentation to determine the correct photographs may be accounted for by simply
output. increasing the depth of field. The recommendation
5. Combination fluorescent/black light: This light is to decrease the lens aperture at least two stops if
combines the emission of the two light sources shooting from wide open. Since the construction
in one light fixture; commonly known as a of compound lenses used in 35-mm photography
Wood’s lamp. can be so different, Kodak suggests that test
Infrared (IR) Light Sources exposures at various aperture settings be performed
1. Flash units: Most commercial flash units emit to determine the exact change for an individual lens.
sufficient IR light to be adequate, but require The downside to this modification is that it may

significantly alter exposure times, lighting, and film b. Infrared Photography
speed. Other authors have suggested small focus Just as in reflective UV photography, infrared
shifts by turning the focusing ring slightly from the photography also requires special techniques. The
visible focus position. The majority of modern high- infrared band of light is at the opposite end of the
quality achromatic compound lenses have a focus light spectr um from the ultraviolet band.
color correction to achieve sharp photos. Ultraviolet light is about one half of the wave length
of infrared light. Because infrared is longer it
a. Reflective Long-Wavelength Ultraviolet (UVA)
penetrates up to 3 mm below the surface of the
Photography
skin. Since the depth of the injury recorded with
Ultraviolet photography is used by the forensic
the infrared technique is below the surface, the
photographer primarily for two reasons: The first
infrared focus point will not be the same as the
is to increase the observed detail of the surface of
visible focus point (Fig. 3.13B). Just as in UV
the injury. The second reason is to recapture an
photography, some allowance must be made for
injury on film after the injury has “healed” and is
the differences in these focus points. After
no longer visible to the human eye. This second
obtaining a through-the-lens focus, the lens must
use occurs because ultraviolet light is strongly
be moved slightly away from the injury. In other
absorbed by pigment in the skin. Any area of the
words, the lens-to-object distance must be
injur y having excess pigmentation when
increased (moved back) from the visible focus
compared to the surrounding normal tissue will
point, thereby making the correction. By using an
be recorded with excellent results using reflective
aperture setting of f-11 or smaller to increase the
ultraviolet photography. It is also possible to
depth of field, the discrepancy in focus points will
photograph a healed injury up to several months
be minimized. Fortunately, many lenses are marked
after the injury.
with a small dot (usually red) on the lens that
Ultraviolet light does not appreciably penetrate
indicates the infrared focus shift point. The
the surface of skin, so photographs are taken using
photographer simply observes reference lines on
lower numbered f-stops that do not have too much
the focusing ring of the lens which indicate the
depth of field at the focused distance. Bracketing
normal focus position, and moves the red dot to
exposures sequentially from f-4.5 to f-11, at shutter
that location to acquire the correction.
speeds of 1/125 to 2 seconds for each f-stop with
Exposing infrared photographs requires several
the Kodak Wratten 18A band-pass filter in front of
special considerations over conventional visible
the lens should be included in the standard
technique. The resultant photographs will contain
detail “seen” by ultraviolet light. It is mandatory
that the camera be mounted on a tripod before
taking ultraviolet photographs due to the long
exposure times. The UV exposed film records the
unseen information contained in the affected area
of the injured skin which later becomes visible to
the human eye on the photographic print, assuming
that proper UV photographic techniques were
applied to the injury. Changing the position (angle)
of the UV light source relative to the injury, while
keeping the camera perpendicular to the injury, will
frequently allow surface details to be enhanced. Fig. 3.13B: Same picture taken with the infrared cameras.

light photographs. The first is the camera setup. photo session. Nor should the lack of an image be
Unlike most films commercially available, Kodak interpreted incorrectly as though nothing was
high-speed infrared film does not come with a present. Additional sessions may be required to re-
preset ASA/ISO speed rating. Each photographer’s photograph the injury to successfully capture it on
camera equipment should be tested in trial sessions film.
to determine the optimum speed setting for the
technique. Many cameras work best in the ASA/ Handling of Photographic Evidence
ISO range of 25 to 64. Whatever speed found best The photographs documenting a victim’s injuries
should be noted and marked on the surface of the may become part of the legal system and, as such,
canister containing the film so that it is processed are subject to chain of evidence rules. This requires
correctly for developing and printing. Kodak an accountability as to what individuals had
suggests that the infrared film “can advantageously possession of the evidence from the time it was
be developed for a 30 percent increase over the collected until it is marked and introduced into
average time. The additional fog is negligible and the legal system. As part of the standard technique,
the resultant pattern is strengthened”. the forensic photographer should routinely mark
Just as in the UV technique, infrared illuminated each photograph with a categorizing system,
photography records the part of the injury “seen” usually consisting of numbers or letters which
with non-visible light on a film emulsion, that when include the case number, as well as an identifying
developed, will be viewable in the photographic mark of the forensic photographer. This can be his
prints. Because of that fact, the injury documented or her initials or a signature, so that the photo-
with infrared technique will not appear the same graphs can be identified as originals and the chain
as photographs taken using visible light. of evidence maintained.
The majority of biological infrared images are It is strongly suggested that the forensic
formed from details not on the outside of the photographer should not part with the original
subject. This accounts for the misty appearance of negatives. Under no circumstances should both the
many infrared reflection records. Successful infrared negatives and prints be out of the possession of
photography is a trial and error process, particularly the photographer. If through carelessness they
when dealing with injury patterns. Since there is became “lost”, there could potentially be no
no way to know what injury detail is being recorded photographic evidence of the injuries and no way
to recover from the mistake.
using this nonvisible light technique, wide
bracketing and many exposures are highly
recommended. If the injury did not cause sufficient BIBLIOGRAPHY
damage to the deeper skin tissues, i.e. no bleeding
1. Arheart KL, Pretty IA. Results of the 4th ABFO
below the surface of the injured skin, or if the Bitemark Workshop, 1999, For Sci. Int. 2001;124:
surface of the injured skin is too thick for the 104-11.
infrared light to penetrate to find the site of the 2. Golden G. Use of alternative light source
bleeding, there may be no infrared detail recorded illumination in bite mark photography. J. Forensic
in the photographs. No image appearing on the Sci. 1994;39(3).
3. Guidelines for bitemark analysis, American Board
developed film and subsequent photographic prints
of Forensic Odontology. J Am Dent Assoc.
should not be interpreted as a failure of the 1986;112:383-6.
technique. Expectations of 100 percent success 4. Robbins SL, Angell M, Kuman V. Inflammation
with the technique are not realistic. One should and repair. Basic Pathology, 3rd ed.; WB Saunders,
not be discouraged as a result of a non-productive Philadelphia 1981;28.
4

Oral and Maxillofacial Radiology: An
Approach to Forensic Aspects
Vishal Saxena
Chapter Overview
 Radiology and Forensic Sciences  Limitations of Dental Radiography

 Scope of Forensic Radiology
RADIOLOGY AND FORENSIC SCIENCES

By its very nature, the science of radiology solves
mysteries as it reveals deep within the body hidden
secrets that are otherwise inaccessible to exposure.
This potential was obvious from the first few
images Röntgen produced in those first fateful
50 days in Würzburg. The discovery of “a new
kind of ray” while working alone in the laboratory
on an autumn afternoon firmly established the
place of Wilhelm Conrad Röntgen (Fig. 4.1A)
among the great investigative scientists of all time.
Working with his screens and plates, Röntgen
made all of the fundamental observations that
were the basis for his first two papers on the “X” Fig. 4.1A: Sir Wilhelm Roentgen, the person behind the
invention of X- rays
rays: so named because “X” was the symbol for
the unknown. It is no wonder then, that on
January 23, 1896 a large crowd of representative
scientists and members of the Society, university first and only lecture on the X-ray (Fig. 4.1B).
faculty and students, city of ficials, and How ever some credit Professor A W Wright of
representatives from the army filled the Yale University with being the first American to
auditorium of the Physical Institute for Röntgen’s produce an X-ray image.
Oral and Maxillofacial Radiology: An Approach to Forensic Aspects 65

The first instance, in which a Roentgenogram
was brought to court in England was a personal
injury case tried by Mr Justice Hawkins and a
special jury in Nottingham.
The first civil case in which X-ray evidence was
accepted into a US court took place in Denver.
The first criminal case in the US involving
X-rays was the October, 1897 Haynes murder trial
in Watertown, New York. The victim was shot in
the jaw with a .32 caliber bullet. Another foreign
object was discovered lodged in the back of the
head. Was this a second bullet or a fragment from
the first? Dr Gilbert Cannon gave testimony on
Fig. 4.1B: The first radiograph taken by sir W Roentgen. The
radiograph shown is of wife of Roentgen. Note the image of the findings of the roentgenogram (not a second
the ring worn by the lady bullet) which subsequently was accepted as
evidence by Judge Wright.
In Februar y, 1896 W Koenig was taking
intraoral films of the teeth, leading the way for the
Historical Perspectives science of Forensic Odontology which has
Actually, the first court case involving the X-rays flourished only since the 1940s. The case of Adolph
in North America commenced on Christmas Eve, Hitler dates from that decade. Hitler had many
1895 (three days before Röntgen submitted his residual physical symptoms and disabilities.
first communication to the Physical-Medicine Persistent headaches finally forced him to follow
Society of Würzburg). the advice of his otolaryngologist, Dr Paul Giesler.
In Montreal, Mr George Holder shattered the On September 19th he was driven to an army field
peace of that wintry evening by shooting in the hospital at Rastenburg where three roent-
leg of Mr Tolson Cunning. Attempts to locate the genograms of his skull were obtained. Those films
bullet by probing failed; the wound healed but survived the war; Hitler (Fig. 4.2), of course, did
remained symptomatic. A professor of physics at not – although speculation and rumors abounded
McGill University, John Cox, was requested by that he had somehow escaped. The dental work
Cunning’s surgeon Dr RC Kirkpatrick, to make displayed on Hitler's roentgenograms (Figs 4.3A
an X-ray photograph of the wounded extremity. to C) was quite distinctive, however, and the
In the physics lecture theater appropriate Russians were able to make comparison with the
equipment was assembled and, with a 45 minute burned remains found in the ruins of the
exposure, a plate was obtained which showed the chancellery garden. Although positive identification
flattened bullet lying between the tibia and fibula. was made by this dental comparison, the Russians
Dr Kirkpatrick removed the bullet, and Mr kept secret this information for more than two
Cunning was discharged 10 days later. The X-ray decades.
plate was submitted to the court during the trial,
with the subsequent conviction of Mr Holder for Dental Radiology and Forensic Sciences
attempted murder. He was sentenced to 14 years In 1923, the first practical X-ray machine for dental
in the penitentiary. use was introduced. Film for intraoral radiographs

B
Fig. 4.2: Adolf Hitler during his last days
A C
Fig. 4.3A: Postmortem radiograph of the lower jaw remains Figs 4.3B and C: The Antemortem radiographs of the skull of
obtained form Hitler’s corpse. Note the telephonic bridge Hitler. Note the well placed restorations within both of the
fabricated within his mandibular arch arches
was developed 10 years earlier by Kodak. Each film in the 1949 fire on board the steamship Noronic
had to be hand wrapped. The earliest case of an which burned in Toronto.
identification on an unknown decedent made Today, radiographs are routinely used to identify
through comparison of sinuses in skull radiographs unknown decedents, individually and in mass
was published in 1926. The first reported use of disasters, and have confirmed identifications in such
dental radiography in a forensic identification notable cases as Adolf Hitler, Josef Mengele, and
occurred in 1943. Dental radiology was used to Lee Harvey Oswald.
help identify 72 of the 119 victims who perished

Radiology has been used extensively in
conventional dental identification, anatomically
based identification and identification using
maxillofacial skeletal landmarks such as the frontal
sinus (Figs 4.4A and B). Examples of these are
well documented in the literature.
This chapter is devoted to revisit the methods
where radiographic methods may be used to
determine identity using the teeth, the root
structures and the frontal sinuses. Additionally
suggestions are offered for management of
radiography in mass disasters and cases where age A
determination is required. Computer assisted
tomography can be used in the assessment of the
degree of fit of a weapon to a wound in cases of
blunt force skull injury and plane films can assist
in depicting the pattern of postmortem skull
fractures. Microcomputed tomography has been
used in matching weapons to wounds in sharp force
injury cases. There are gaps in the science where
radiological methods are used.
SCOPE OF FORENSIC RADIOLOGY

Forensic radiology, as do all other academic and
scientific disciplines, rests on the sometimes
unsteady four-legged stool of service, education,
research, and administration. The scope of forensic
applications of diagnostic medical radiology as B
currently understood and practiced is summarized Figs 4.4A and B: Water’s view of the skull for the
in the following table. As the field of diagnostic visualization of the sinuses
radiology has undergone rapid expansion in
technology and utilization in the past quarter-
century, so may the range of forensic applications
burgeon in the near future. The following fields 2. Non-accidental
are the main areas of interests harboring a. Osseous injury
tremendous scope in forensic radiology. b. Missiles and foreign bodies
c. Other trauma
I. Service d. Other causes
A. Determination of identity C. Criminal litigation
B. Evaluation of injury and death 1. Fatal
1. Accidental 2. Nonfatal

D. Civil litigation f. Make a decision as to whether the materials
1. Fatal provided allow the observer to make a positive
2. Nonfatal identification, a possible identification or a
E. Administrative proceedings negative assessment (no identification).
II. Education In the absence of dental radiographs, dental
III. Research charts may be used. The issue in using dental charts
IV. Administration is their veracity. There are numerous incidents of
dental fraud reported in the lay press. Clearly,
Oral and Maxillofacial Radiology in written records may be falsified outright.
Person Identification Alternately there can be honest errors in written
Dental identification was used prior to Roentgen's records and in recorded treatments. Radiographic
discovery of X-rays on November 8, 1895. The first records provide objective evidence of the
recorded use of radiographic techniques in anatomical conditions and the dental treatment
identification was by Schuller in 1921. provided up to the point in time. Most cases of
Radiographically assisted dental identification may be comparative identification use radiographic
comparative or reconstructive in type. The former evidence of dental intervention (restorations, root
“compares” radiographs exposed prior to death to fillings, crowns, and extractions) (Figs 4.5A and
those exposed after death. Reconstructive B) as common points of identification.
identification may use radiographs as an aid in the Less commonly anatomical features are used as
generation of a biological profile of a person for whom concordant points. Dental interventions, especially
the putative identity remains unknown. Comparative restorative ones, in many cases provide unique
identification utilizing dental radiographs is now identifiers that are common in antemortem and
common in the evaluation of human remains. When postmortem examinations.
the identity is suspected, and comparative means of
identification are contemplated, the basic algorithm Objectives in Radiographic Comparisons
for dental radiographic identification is:
The objective of using radiographs in identification
a. Examine the antemortem radiographs for
is to compare and evaluate similarities between
quality, type and time of examination;
antemortem and postmortem films. The tasks for
b. Examine the postmortem specimen and expose
the forensic investigator include six steps:
radiographs that will duplicate the areas of
i. Securing antemortem radiographs
interest seen in the antemortem films using
ii. Making postmortem radiographs
similar image geometry, suitable exposure
factors and archival processing; iii. Comparing meaningful features (those which
c. Use a system of marking or mounting the films are stable and distinctive)
so that their identity as postmortem or ante iv. Accounting for discrepancies
mortem films is known; v. Assessing uniqueness
d. Visually analyze the radiographs, taking into vi. Verbalizing the degree of confidence in the
account ancillary information such as dental identification.
chart notations, dental models and photographs;
Radiographic Anatomic Landmarks of the
e. Tabulate the points of concordance and explain,
Jaws (Fig. 4.6A)
if possible, discordant points between the ante
mor tem and postmor tem radiographic Fixed anatomic features are present in all
examinations; individuals. These landmarks are relatively similar

A
Fig. 4.6A: Skull showing the various anatomical landmarks
B
Figs 4.5A and B: Picture and radiograph of the patient

showing crown, bridge and the restorations Fig. 4.6B: Mandible bone
in most people and, unless showing distinctive Mandibular Landmarks (Fig. 4.6B)
variation, should not be considered as individual The mandibular canal is a tubular canal running
identifiers. These landmarks are not always visible centrally within the body of each hemimandible
in radiographs due to technical and anatomic
and appearing as a linear radiolucency outlined
variations. both superiorly and inferiorly by a thin opaque

border. It begins at the mandibular foramen located fits into the glenoid fossa of the temporal bone to
in the middle of the ramus, running below the teeth form the temporomandibular joint.
and terminating as the mental foramen, a circular
lucency near the apex of the second premolar. The Maxillary Landmarks (Fig. 4.6C)
mandibular nerve and vessels are the contents of The incisive foramen is a circular opening in the
this canal. The genial tubercles are the bony palatal midline between the apices of the central
attachments for several muscles. They appear as an incisors. Superimposition of the radiopaque nasal
oval radiopacity sometimes showing a central spine on its superior border renders a heart-shaped
radiolucency (lingual foramen) below the roots of rather than circular radiolucency to the foramen.
the central incisors in the mandibular midline. The There is variability in the size of this structure. The
internal and external oblique ridges are opaque floor of the nasal cavity and the maxillary sinuses
bony ridges in the superior part of the posterior are visible in dental radiographs. From the maxillary
body extending diagonally toward the anterior midline above the incisor roots, the floor of the
ramus. The external ridge is buccal and more nasal cavity slopes superiorly as it extends distally
superior than the lingual internal ridge, which is at toward the long canine root. The maxillary sinus
the level of molar root apices. The coronoid process presents as a radiolucency extending from the distal
is a flat triangular protrusion of bone extending aspect of the canine root to the second molar. Its
superiorly from the anterior ramus. It is the area lower border is scalloped and dental roots often
of attachment of the temporalis muscle. Extending project into the sinus floor. The malar bone and
superiorly from the posterior ramus is the condylar inferior border of the zygomatic arch may be
neck to which is attached the mushroom-shaped projected over the sinus in the molar region,
condylar head. The “valley” in-between the two appearing as a U-shaped opacity.
“hills” formed by the coronoid process and
condylar neck is the sigmoid notch. The condyle Radiological Anatomical Features and the
Spatial Relationship of the Teeth (Fig. 4.6D)
In the Western world, water fluoridation and
improved dental care have resulted in a decrease
in dental caries. This decrease is associated with a
concomitant decrease in the number of restorative
Fig. 4.6C: Skull with mandible removed highlighting the Fig. 4.6D: An OPG showing various normal
maxillary bone anatomic landmarks

interventions. If there is no evidence of dental Radiographically visible anatomical structures one
intervention then the forensic odontologist must to another. It requires no information from the
rely on anatomical structures common between crowns of the teeth, so it is also useful in macerated
ante mortem and post mortem radiographic and partially incinerated remains where the clinical
examinations. crowns may be damaged or lost.
Such anatomical features might include: The points of concordance are gained by
• Crown morphology, evaluating the alignment of the periodontal
• Root shape, size and curvatures, ligament spaces, lamina dura, pulp chamber walls
• Pulpal morphology, and and root edges as seen on posterior films. Films
• The spatial relationship between the teeth. are digitized and a horizontal section is “cut” from
The radiographic depiction of tooth morphology either the ante mortem or post mortem radiograph.
is highly dependent on image geometry. Small It is then positioned over the corresponding
changes in horizontal or vertical beam angulation anatomical area of its opposite radiograph.
may result in critical differences in the radiographic The degree of concordance and points of
appearance of comparators. Additionally, while it is discordance can then be assessed. With the advent
reasonable to assume that some anatomical of the desktop scanner and digital radiographs this
structures might not change with time (e.g. crown process has been made easier. The technique is not
morphology, root dilaceration and taurodontism) usable in comparisons within or between the mixed
others may change over time (pulp morphology dentition and other states of the dentition and
(Figs 4.7A and B) and alveolar bone pattern). There orthodontic tooth movement or extractions in the
have been no convincing long-term studies of the antemor tem to postmor tem radiographic
relative stability of individual anatomical dental examinations may limit its use as may protracted
features as seen on radiographs. Aside from relying antemortem to postmortem radiographic intervals.
on solitary dental anatomical observations it is When using the Digital Dental Radiographic
possible to match antemortem to postmortem Identification (DDRI) technique there are
radiographic examinations using the spatial numerous occasions where it is difficult to recreate
relationships of the posterior teeth one to another. the ante mortem image geometry on the post
This concept relies upon the alignment of mortem films. This may require numerous attempts
Fig. 4.7A: A bite wing radiograph showing Fig. 4.7B: Trabecular pattern of mandibular bone,
the pulpal morphology (E—Enamel, D—Dentin, P—Pulp)
Another Aspect of Radiology in

using altered vertical and horizontal beam-
angulations and object film placements. A device Identification-frontal Sinuses
has been developed to aid in the recreation of the Skeletal identification is recognized as a valid means
ante mortem image geometry for these spatial of body identification in long bones. However, the
relationship issues or even in cases where the ante facial bones are more difficult to use for radiological
mortem images suggest a major differential from body identification because of their innate
the norm. anatomical complexity, the comparative rarity of
antemortem radiographic radiographs and the large
Radiology in Reconstructive Dental number of overlapping structures in the
Identification radiographic projections of these structures. One
Most agencies consider reconstr uctive maxillofacial anatomical structure that is amenable
identification only when there are no putative to comparison between antemortem and post-
identification or antemortem records available. This mortem radiographs is the frontal sinus (Fig. 4.8).
often occurs in cases of found human remains It may be used because it is commonly exposed in
where the body has been skeletonized or missing “sinus series” investigations; it is sandwiched
for long periods of time. Clinical and radiographic between the internal and external surfaces of the
examinations can help to recreate a profile of the frontal bone; the view commonly used to
individual prior to death. demonstrate it, the occipitomental or “Waters”
There are at least two other means by which oral view provides an excellent radiographic depiction
radiological examination may aid in reconstructive of it since its shadow is cast over the flat posterior
identification. The first is to assess and define the calvarium.
angulation of anterior teeth that have been lost post Culber t and Law per formed the first
mortem. The second is to examine reassembled radiographic comparison of paranasal sinuses in
macerated remains prior to facial approximation
exercises. It is common for teeth to be lost following
death. If remains are to be processed for facial
approximation it is useful for the professionals
involved to have information on the state of the
dentition and the alignment of the anterior teeth.
Radiographic examination of the dental sockets of
anterior teeth in two dimensions (antero-posteriorly
and occlusally) affords the reconstructive dentist or
facial approximation scientist information as to the
number and alignment of anterior teeth, the
presence of periodontal bone loss and periapical
disease that can make the facial approximation more
accurate.
Occasionally skulls that have been macerated
require reassembly. In these instances it is important
that the forensic odontologist be consulted so that
a thorough clinical and radiographic examination Fig. 4.8: AP view of the skull showing the frontal
may be undertaken. sinuses in detail

body identification although these were of the to perform than periapical radiographs in the
mastoid air cells and the identification was deceased than posterior periapical radiographs
confirmed in part by the decedents dental of each quadrant. In life the bitewing
restorations. Since then others have undertaken radiographs might be of different angulation;
frontal sinus identification and have found that it however, in the deceased the film may be held
has been highly useful. Christensen (2004) in a position that allows almost exact duplication
questioned the scientific validity and potential error of bitewing image geometry.
rates of using frontal sinuses for body identification Occlusal size film is underutilized in all
in light of the Dauber t vs Merrel-Dow identification procedures but especially so in
Pharmaceuticals decision by the United States mass disaster where it can replace many views
Supreme Court. Perhaps it would be prudent to with one film. A common maxim applied to
undertake an experiment in which a line-up of forensic photography is equally valid to forensic
possible matches and definite mismatches was dental radiography “when in doubt max out.”
included with matching antemor tem and This means take more radiographs at the
postmortem radiographs. postmortem than the bare minimum. It is much
The use of dr y skulls and “pretend” simpler to expose a complete series of films at
antemortem and postmortem radiographs would the first examination than it is to have to retrieve
not possess the requisite external validity of a decent the body for further radiographic examination
clinical study. Alternately the potentially matching or alternately attempt reconciliation with minimal
frontal sinus images could be examined by a qualified post mortem radiographic evidence. If the body
radiologist conversant in the radiographic anatomy is suspected to be a sub-adult or child a full mouth
of the region. In any case up to ten percent of series of radiographs should be made in order
persons may have no frontal sinuses to evaluate. that age-stratification can be accurate. Failure
to do so will limit the forensic odontologist from
Radiography in Mass Disaster Victim
later estimating age and may again necessitate
Identification (DVI)
body retrieval and re-examination.
Dental radiography as objective evidence provides b. If an assembly line approach is used for post
an invaluable means of person identification in mass mortem evaluation, dental radiographs should
casualty incidents. Dental identifications continue be exposed prior to the detailed dental
to be a rapid and accurate means of establishing examination and charting. If this is done, the
identity in such situations. They provide objective examiners can use the radiographs in the
data for reconciliation of antemor tem and charting and coding procedure up-front rather
postmor tem records. However, from a than modifying their charting or coding later.
postmortem standpoint there are numerous factors c. If analog films are used it is extremely important
that must be kept in mind: that photographic chemistry be monitored,
a. In DVI incidents, the purpose of the replenished and replaced regularly. Processors
radiographic examination is not to diagnose need to be emptied, cleaned and serviced
disease. Considerable latitude should be given regularly whether they are used or not.
therefore to the types of postmor tem Photographic chemistry will deteriorate even if
radiographic examinations to be undertaken. it is not being used. If a large number of
For example, bitewing radiographs, a simple radiographic examinations are done chemistry
procedure in the living, are much more difficult will need to be replenished more frequently.

Failure to do so will result in films that may odontologist can assist the investigation by
look excellent at the time of the autopsy but narrowing down the population age group to
deteriorate rapidly-perhaps prior to the which the deceased belonged. This being said it is
reconciliation process. It would be prudent to just as important to avoid narrowing down the
digitize analog films on a flat bed transparency estimated age in a found set of remains so as to
scanner and store them electronically. not cast too narrow a net and exclude possible
d. If digital radiographs are to be used it is vital matches from missing person files.
that they are “transportable” from location to
location and stored in a common format such Pitfalls and Drawbacks in Age Determination
as JPEG or similar. Additionally, redundant In those cases where a single live individual claims
back-up drives must also be available and to be below the age of majority such as adult
updated regularly. persons claiming to be juveniles, illegal refugee
e. Whether analog or digital films are used it would claimants, etcetera, radiological examination of the
be prudent to have a radiological quality control teeth might be used to try and pin-point the exact
officer to catch errors such as cone-cuts, under age. This is a far more difficult exercise in some
or over exposure, under or over development cases such as in those persons who are very close
and mounting errors. This person could also to the legal age for being declared an adult. In age
monitor processor function and maintenance estimation in live individuals the goal may be to
and radiation safety issues. Few mass disasters narrow the age range to a single point. This is very
are handled using dental office quality lead difficult. If we make the assumption that the
shielding and it is important that radiation safety radiological maturation of the teeth fits some form
aspects of gathering postmortem data be of normal distribution, and there is little evidence
adequate. It is possible to “rescue” sub-optimal for this in many ethnic groups, then the following
radiographs; however, the time to do this is not question might be legitimately posed:
in the middle of a DVI incident.
Where does that Claimant Fit on that Normal
Age Estimation and Dental Radiology Distribution?
It is well recognized that in the sub-adult Can we morally make life-changing decisions about
estimation of the age of subject, deceased or not that person based in part on dental radiographic
may be attempted by examination of the features attributed to age?
maturation of the primar y and permanent There are other pitfalls in using radiology in age
dentition. There are dozens of published papers determination. The first one is the radiological
on age determination. In cases where the sample examination used on the unknown individual that
cannot be destroyed, radiology is often used to we are going to compare to the reference sample.
assess age. It is obviously unethical to remove teeth There is a tendency to forget that panoramic
from live persons so non-invasive techniques need radiographs, which are often used in this procedure
to be used in those instances as well. are not plane radiographs. They are tomographs.
The goal of age determination in found human As such they have a focal trough and anything that
remains is to assist in the development of the lies outside the focal trough will be blurred. It
biological profile of the deceased. If radiological follows that if teeth that are being used to assess the
examination demonstrates incomplete formation dental age of a subject are out of the focal trough
of the permanent dentition then the forensic then there may be misestimation of the dental age.

Prior to any study in which panoramic calvaria. Post mortem radiography of skull fractures
radiographs are used, there should be a screening is complicated because of the amount of anatomical
of the image by a radiologist for image quality. This superimposition. Something as simple as a modified
is infrequently done. Even if a tooth lies within Parma radiographic approach in which the
the focal trough, if it is tipped in a bucco-lingual collimator of the dental unit is removed and the
direction its root end may lie outside the focal exit port of the dental X-ray unit is placed abutting
trough and provide a misleading radiological the side contralateral to the skull fracture can
conception of the true clinical situation. There are provide excellent, simply produced radiograph
numerous studies where third molar root depictions of calvarial fractures. If a putative
development is used as a determinant of age; weapon is found, the weapon can be compared to
however, it is the most variable in its development impressed injuries in the skull. This is difficult
and the study that forms the bedrock for the stages because it requires numerous comparisons; the use
of root development is now over 30 years old. of CT scanning which is difficult to obtain in many
There have been in excess of 100 papers since mortuaries; if the weapon is metallic, which it
using Demirjian's stages or variants of his technique invariably is, requires the production of models of
to different populations, a fact that may be invalid
the weapon in Type IV dental stone and on
on the face of it because Demirjian's reference
occasion either retention of the skull bones
sample was, by and large, French-Canadian
themselves or fabrication of the models of the skull.
children developing in the 1960s and 1970s. It is
Further research in this area is likely to use such
reasonable to assume that both radiological
sophisticated imaging and may, in the future form
techniques have changed since then and other
part of virtual autopsy techniques.
ethnic and racial groups may have their own
differing maturation rates. The other radiological
Fraud, Claims and Dental Radiology
variable that must be considered is the degree of
overlapping soft tissue and hard tissue coverage in If a practitioner is going to commit fraud there is
the radiograph of either the known reference little that can be done to prevent it. In a study by
sample or the unknown case. Estimation of the Tsang et al, it was demonstrated that digital
pulpal widths and height on intraoral radiographic manipulation of radiographs to produce disease
films and to a lesser extent panoramic radiographs that was not present on the original films was
is influenced by the amount of hard and soft tissue successful in misleading third party insurers to
present from the end of the collimator tube to the provide care the patient did not need. Although
image plane. Simply put, a “thicker” or “denser” the images in this study were digitally altered, the
patient will have proportionally smaller pulp widths images submitted to the insurance companies were
than a slender radiolucent one even though the ultimately of the analog (film) variety. It has been
pulps are of the same size. This is because since successfully argued that the same goal could
radiographs are not photographs but rather two- have been accomplished using analog images of
dimensional representations of three-dimensional another patient; however, the fluidity of digital
objects. images should be of concern to honest
practitioners, state funding agencies, third party
Evaluation of Cranial Trauma Using insurers and patients themselves.
Radiological Methods Radiographic evidence of caries and restorations
Radiology has been used to demonstrate fracture may be readily added to radiographic images and
patterns in blunt-force trauma of the human this “evidence” of disease or treatment could

subsequently be covered with restorations with (twisting of the film). The resultant images could
nobody but the perpetrator any the wiser, just as then be shown to a series of observers to
troubling is the general lack of radiological determine the percentage that result in correct
knowledge of litigants in malpractice cases, their identification, inability to identify or false
attorneys and even dental regulatory authorities. identification. Sensitivity, specificity and error
In the Western world there is an increasing number rates from this process could thus be calculated.
of patients who sue their dentist for actual or c. There need to be more populations studied for
perceived negligence. There are only three pieces age determination to provide reference material
of evidence that will solve these cases: the written for different ethnic groups and the ones
record, radiographs and other objective data such currently used as base-line reference material
as models and photographs. If radiographs are used need to be updated.
as evidence, it would be prudent to obtain the d. The technique of using CT scans for either blunt
expert opinion of a dental radiologist. There are force calvarial trauma of sharp-force trauma
many studies that need to be undertaken in order where weapons are compared to wounds needs
to improve the scientific base from which forensic to be refined. It is unlikely that enough case
odontologists operate. These include the following: material exists to support this at any one centre.
a. There are no data on determining the stability For this reason either a cadaveric study, which
of dental anatomical landmarks over protracted carries with it the weakness that the bone was
periods of time. A study such as this one could not vital at the time of the injury; or an in vivo
use radiographs of live individuals that are animal study which might have associated ethical
followed by a single practitioner or clinic. The or anatomical problems makes this a problem.
antemortem and postmortem images could in To design a study that is meaningful is large
actuality be substituted with high quality enough to calculate error rates, and possessing
radiographic images exposed at specific time external validity is a daunting task.
intervals established either prospectively or e. For cases where age determination is required
retrospectively. Such images could then be careful quality control of reference sample and
shown to a series of observers to determine the unknown sample radiographs should be
percentage that result in correct identification, undertaken. Additionally further testing on the
influence of soft tissue and hard tissue
inability to identify or false identification.
dimensions might need to be taken into account
Sensitivity, specificity and error rates from this
for techniques that primarily use radiological
process could thus be calculated.
methods to assist age determination.
b. There are no data on just how poor radiographic
image geometry can be before it disallows
identification. In order to calculate the influence Contemplating Human Judgment
of radiographic error on the ability to accurately There is a tendency in light of Daubert and other
determine the identity of a known antemortem decisions to give little credence to the concept of
case, studies could be done using restorations competent clinical judgment. There is also a
placed in cadaveric material in which various tendency in clinical medicine towards evidence-
degrees of image geometry error are introduced. based medicine. However, neither will wholly
Such alterations would include changes in replace the clinical judgment of a competent
horizontal angulation; changes in vertical practitioner — whatever the discipline. In a study
angulation; changes in both horizontal and evaluating the accuracy of age determination it was
vertical angulations; changes in the film plane found that a study in which a practitioner made an

educated guess of the age of the deceased was more side of a tooth cannot be distinguished from those
accurate than more “sophisticated” technical on the tongue side. Fillings can be obscured by
methods. superimposition of other fillings in the same tooth.
Solheim and Sundnes performed age estimation The various metals used in dentistry cannot be
very well using a relatively simple visual assessment. distinguished; all are radiopaque. A dentist,
Ten Cate et al used yellow coloration of the root however, would recognize outline patterns
as a means of age estimation and found that trained associated with the various metals. Radiolucent
observers performed this task quite well. areas in teeth can represent decay, nonmetallic
It is often implied that we need to perform some esthetic fillings, congenital defects, physical/
sort of a physical test on “something” in order to chemical injuries, or artifacts. Differentiation of
be assured that we are getting “the right answer”. these conditions is important yet radiographically
Radiologists make clinical decisions based on the difficult. Artifacts and disparities produced by
interpretation of radiographic images on a daily improper angulation, orientation, exposure,
basis. This author would like to see more processing, labeling, and storage present potential
investigation into the accuracy of the trained difficulties which must be controlled.
human observer in forensic cases as well as technical
development. There are interesting technologies BIBLIOGRAPHY
on the horizon such as automated dental
1. Cameriere R, Ferrante L. Accuracy of age
identification systems; however, ultimately it is the
estimation in children using radiograph of
clinician that has to sign off on the decision,
developing teeth. Forensic Science International
whatever technique is used to arrive there. No 176.2008;173-7.
technological advance can appear in court for cross- 2. Maber M, Liversidge HM, Hector MP. Accuracy
examination. of age estimation of radiographic methods using
developing teeth. Forensic Science International
LIMITATIONS OF DENTAL RADIOGRAPHY 159S.2006;S68-S73.
3. Wood RE. Review, Forensic aspects of maxillofacial
A radiograph represents two-dimensional shadows radiology. Forensic Science International 159S.
of three-dimensional objects. Fillings on the cheek 2006;S47-S55.
Chapter 5 $
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Age Estimation and Dental Methodology a
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Nitul Jain, Sohail Lattoo 03

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^ Chapter Overview
Historical perspective
Need for age estimation
Chronology of human dentition
Various methods for age estimation
Age changes in oral cavity Steps of age estimation
n Terminologies Commonly used dental developmental surveys
INTRODUCTION verification of chronological age is required in

order to be entitled to civil rights and social
Age is one of the essential factors in establishing benefits. In archaeological search , esdmadon of
the identity of the person. Estimation of the human age at death for skeletal remains serves as an aid
age is a procedure adopted by anthropologists, in palaeo- demography ( Fig . 5.1 ) .
archaeologists and forensic scientists. Examination A forensic dentist carries a considerable
of teeth in many ways form a unique part of responsibility, since his scientific opinion is frequently
human body e . g. they are most durable and asked when all other paths of identification have
resilient part of the skeleton . The science dealing been exhausted . There are instances in which teeth
with establishing identity of a person by teeth are the only preserved human remains and present
is popularly known as Forensic Odontology or the only means for age determination in order to CD
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Forensic Dentistry. narrow down the search within die missing person’s
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Forensic odontologists are often confronted file and enable a more efficient approach . In these CT3
with the problem of determining the age of cases final identification may depend on specific -O
unknown bodies, as well as living persons . odontological matching of pre and postmortem CD
Age estimation is of great importance for the E
dental data , DNA- typing and fingerprinting.
identification of unknown bodies or skeletal Teeth have the benefit to be preserved long after
remains of accidents and crimes as well in disaster other tissues, even bone, have disintegrated and CO
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_
victims. In the case of living people who have also unlike bones they can be examined directly in
no acceptable identification documents, such living individual. However, one must not forget
as refugees, adopted children of unknown age , that the more parameters taken into account the
Age Estimation and Dental Methodology 79
he meant the permanent molar erupting after the

two deciduous teeth.
The first known attempts which used teeth as
an indicator of age originate from England. In the
early 19th century, because of economic depression
of the industrial revolution, juvenile work and
criminality were serious social problems. The social
legislation provided that no child under 9 years of
age should be employed, while children under 13
should not work more than nine hours the day. The
limit for criminal responsibility was seven years of
age. However, there was not a registration of birth,
thus making the proof of date of birth difficult. Up
to this time the determination of age was based
mostly on the calculation of height.
In 1836, AT Thomson who was one of the
pioneers of medical jurisprudence claims that
Fig. 5.1: Skeletal remains of the human may necessitate
the approximate age estimation for paleodemography children, where the first permanent molars had not
erupted, it was certain that they had not reached
the age of seven. The first scientific study was
more accurate the determination of age is. For this
presented in 1837 by Edwin Saunders, in which he
reason clues from dentition must be correlated with
points out that dentition is a more reliable standard
clues found in the bones.
than height for determination of age.
In this particular chapter, the important methods
In 1872, Wedl made the first observations of
of age estimation are highlighted. The approach,
changes with age in the permanent dentition and
the advantages and disadvantages of each technique
described fatty degeneration, calcification, colloid
are discussed giving an emphasis on the methods
deposits, netlike atrophy and pigment deposits in
applied most. Then the steps that a forensic dentist
the pulp tissue and a notable diminution in the size
should follow in order to estimate the age are
of the pulp cavity due to continued deposits of new
presented. Finally the latest developments and
dentine layers.
speculations upon age estimation methods are also
notified.
Need for Age Estimation
Historical Perspective It constitutes an important part of the investigation
of bodies or skeleton in forensic investigation and
The use of teeth as age indicator dates back to 19th
archeology, e.g. aborted fetus, a severely mutilated
century. In Britain at that time the law decreed that
mass disaster victim.
children under seven years were not responsible
for any crime they may have committed. Thomson Living person requiring age determination for:
(1836) a forensic medical expert stated: “If • Birth certificate is not available or if records are
the third molar has not protruded, there is no suspected.
hesitation in affirming that the culprit has not • To determine whether child has attained age of
passed his seventh birthday”. By the third molar criminal responsibility.
• Assessment in case individual is either unwilling Soft Tissue Changes

or unable to reveal his identity
• Epithelium becomes thinner and a flattening of
• In case of disputed marriages, where, marrying
the epithelium-connective tissue interface is seen.
couple are supposed to be below the legal
• Marked Reduction in filiform papillae.
permissible age limits.
• Development of nodular varicose veins on
Dead persons require age determination for undersurface of tongue
• In mass disasters to help identification • Development of vascular nodules and nevi on
• In epidemiological surveys to know mortality lip and cheeks.
indices of various diseases • Sebaceous gland of lip and cheek increases with
• Age of aborted fetus age
• Minor salivary glands show marked atrophy with
Age Changes in Oral Cavity fibrous replacement.
Following is the list of the changes that follow in
the oral cavity as human being ages. Age changes Dental Changes (Figs 5.2A and B)
in oral cavity may be divided into following three
categories: • Apical migration of dento-gingival junction and
1. Soft tissue changes eventually the cemental surface of the tooth is
2. Dental changes exposed.
3. Hard tissue changes • Dystrophic calcification of central pulp
A

B
Figs 5.2A and B: Pictures showing the various changes in the dentition of a person throughout his life time
• Secondary dentin and dead tracts • Mandible

• Attrition – Young - soft.
• Gingival recession – In adult - thicker and hard.
• Cemental apposition – As age advances - thinner and brittle. Also,
cortical bone of lamina dura becomes thicker
Hard Tissue Changes and more irregular
• Articular eminence flattens.
• Condylar head rests more backward in glenoid Terminologies
fossa. • Pathologic age: This is related to various
• Mental foramen comes close to upper border of conditions and disease process that results in
mandible. deterioration of many tissues over time. Dental
• Mandibular angle (Figs 5.3A and B) experts can estimate this by examining for
– At birth - obtuse (near 180°) – Arthritic changes in TMJ
– In adult age - about 90° – Attritional wear of teeth
– In old age - around 140° – Root dentine transparency
Chronology of the Human Dentition

Tooth First Evidence Crown Eruption Root
of Calcification Completed Completed
Central incisor 3–4 mos in utero 4 mos 7½ mos 1½–2 yrs
Upper Lateral incisor 4½ mos in utero 5 mos 8 mos 1½–2 yrs
jaw Canine 5¼ mos in utero 9 mos 16–20 mos 2½–3 yrs
First molar 5 mos in utero 6 mos 12–16 mos 2–2½ yrs
Second molar 6 mos in utero 10–12 mos 20–30 mos 3 yrs
Deciduous
dentition Central incisor 4½ mos in utero 4 mos 6½ mos 1½–2 yrs
Lower Lateral incisor 4½ mos in utero 4¼ mos 7 mos 1½–2 yrs
jaw Canine 5 mos in utero 9 mos 16–20 mos 2½–3 yrs
First molar 5 mos in utero 6 mos 12–16 mos 2–2½ yrs
Second molar 6 mos in utero 10–12 mos 20–30 mos 3 yrs.

Central incisor 3–4 mos 4–5 yrs 7–8 yrs 10 yrs
Lateral incisor 10 mos 4–5 yrs 8–9 yrs 11 yrs
Canine 4–5 mos 6–7 yrs 11–12 yrs 13–15 yrs
Upper First premolar 1½–1¾ mos 5–6 yrs 10–11 yrs 12–13 yrs
jaw Second premolar 2–2¼ mos 6–7 yrs 10–12 yrs 12–14 yrs
First molar At birth 2½–3 yrs 6–7 yrs 9–10 yrs
Second molar 2½–3 mos 7–8 yrs 12–13 yrs 14–16 yrs
Third molar 7–9 mos 12–16 yrs 17–21 yrs 18–25 yrs
Permanent
dentition Central incisor 3–4 mos 4–5 yrs 6–7 yrs 9 yrs
Lateral incisor 3–4 mos 4–5 yrs 7–8 yrs 10 yrs
Canine 4–5 mos 6–7 yrs 9–10 yrs 12–14 yrs
Lower First premolar 1¾–2 yrs 5–6 yrs 10–12 yrs 12–13 yrs
jaw Second premolar 2¼–2½ yrs 6–7 yrs 11–12 yrs 13–14 yrs
First molar At birth 2½–3 yrs 6–7 yrs 9–10 yrs
Second molar 2½–3 yrs 7–8 yrs 11–13 yrs 15–15 yrs
Third molar 8–10 yrs 12–16 yrs 17–21 yrs 18–25 yrs
• Physiologic age: It is primarily determined by Various Methods for Age
natural/expected changes that occur through
growth and development, for example
Estimation
– Examination of development of roots (apical Basically there are two major means by which age
closure) and comparison with tables that of a person under consideration can be estimated.
record the amount of development vs age. These methods may be broadly divided into two
• Chronologic age (the time from birth to death): categories:
This is the age that investigators are most 1. Estimation of age by skeletal means
interested in. 2. Estimation of age by teeth.

A
Figs 5.3A and B: Gradual changes in the mandibular bone of a person as he matures from a kid to fully mature adult and
later on to an old age. Note the typical changes at angle of the mandible, height of alveolar process and width of ramus
Estimation of Age by Skeletal Means D. Ossification of hand and wrist bones (Figs 5.4A
The various methods for estimation of age by skeletal and B)
means are available, some of which are mentioned E. Closure of Skull sutures and palatine sutures
below. These procedures are quite elaborative, (Later life).
because of which it is beyond the scope of this title Determination of age at time of death is an
to give emphasis on each one. Mentioned below here important step toward identification of unknown
are only the names of the procedures by which age remains. Age can be established with considerable
can be estimated, details of these can be obtained accuracy by roentgenography of the skeleton from
from other relevant titles of the subject the time of its appearance about the 20th week of
A. Analysis of length of long bones. gestation until early adulthood. This is possible
B. Epiphyseal union. due to the complex but dependable system by
C. Closure of frontanelle. which the osseous framework of the body develops,

A B
Figs 5.4A and B: (A) Radiograph of wrist bones, (B) Graphical diagram representing the typical timings and areas
of ossification of wrist bones, whose assessment may give clues to the age of a person
grows, and matures. Most of the 206 bones of • High survivability of teeth exposed to severe
the human adult skeleton develop in cartilage physical factors, such as fire and water immersion,
precursors or anlagen from one or more primary make assessment of developing teeth the method
centers (Fig. 5.5) of ossification (which make up of choice in forensic age estimation.
the shaft or diaphysis of a long bone, the centrum
of an axial or round bone) and secondary centers
which develop the articular ends of the bones
(epiphyses) or nonarticular processes (apophyses)
for attachment of muscles, ligaments, and tendons.
The appearance of these centers, and the fusion
of secondary centers with the primary, follow
a timetable allowing rather precise aging if
appropriate skeletal parts are available for evaluation.
Estimation of Age by Teeth

• Most authorities have agreed that data derived
from developing dentition is most accurate
means of age estimation (Garn et al.,1959; Fig. 5.5: Graphical picture representing the development
Stewart 1963; Liliequest and Lundberg 1971). and areas of ossification in the long bones
Further depending on the probable age group, in the posterior elements of the spine often are the

we have different approaches for estimation of age first skeletal components seen radiologically as a
of person under scenario, which can be broadly chain of densities or “string of beads” sometimes
divided into five major groups. accompanied by tiny rib shadows. The base of the
1. Age assessment in prenatal child skull and long bones may be visualized between
2. Age assessment in neonatal and early postnatal 20 and 25 weeks if not obscured by maternal gas,
child bones, or other tissues. The ossification center for
3. Age assessment upto 14 years the calcaneus appears between 24 and 26 weeks
4. Age assessment upto 21 years of gestation, followed in 2 weeks by the center for
5. Age assessment after 21 years. the talus. In the live fetus, intrauterine movement
often obliterates the image of these small parts.
Age Assessment in Prenatal Child Between 36 and 40 weeks the distal femoral
epiphysis, followed by the proximal tibial epiphysis,
Various methods available are as following: will appear. Before obstetrical ultrasonography, this
A. Haase’s rule was the best method of determining fetal maturity.
B. Size of bones for age estimation The distal femoral epiphysis will be found in 90
C. Krause and Jorden charts (1965) percent or more of term fetuses, the proximal tibial
epiphysis in 85 percent or more.
A. Haase’s Rule
B. Size of Bones for Age Estimation
• Age assessment is based on the fetal size (crown
of the head to the heel of foot within body with I. Based on basilar part of occipital bone
body laid out straight). Before 7 to 7½ lunar month: Sagittal length (In
• Fetal size = (No. of lunar months)2 = Up to 5th the midline from spheno-occipital synchondrosis
lunar month to foramen magnum) > Width (between lateral
• Fetal size = No. of lunar months X 5 = after 5th tubercles).
lunar month. After 7 to 7½ lunar month: Width > Sagittal
Fetal age can be measured by crown-rump length.
measurements, fetal length, femoral length, II. Based on the temporal bone
biparietal diameter, or skeletal maturation. Fetal Before 7 lunar months: Temporal bone consists of
parts and soft tissues, if extrauterine, are small 3 separate elements—squamous part, petrous part
enough that radiological magnification will not and tympanic ring.
be a major problem in view of the rather wide After 7 lunar months fusion starts: At the end
range of standard deviations for the various fetal of 10 lunar months fusion is complete and may be
measurements, most of which nowadays are taken as sign of full term fetus.
based on real-time intrauterine measurements by C. Krause and Jorden (1965)
ultrasonography.
Intrauterine fetuses imaged roentgeno Age Estimation at Neonatal and Early
graphically will be magnified. Under ideal Post-natal Life
conditions, the intrauterine fetal skeleton may be Incremental pattern of calcification of teeth:
seen as early as the 10th week of gestation, but in • Calculated mainly by the histological technique,
practice it is not often visualized before the 18th by using incremental pattern of calcification of
or 20th week. The ossification centers that appear individual developing teeth.
• Schour and Hoffman (1939) measured the rate

of apposition of enamel and dentin and found
this to be 16 µm per 24 hour period. Armed
with this fact age can be estimated.
• The best known incremental disturbance is
neonatal line (Figs 5.6A and B) present in
deciduous teeth and permanent 1st molar. The
amount of dentin deposited over this line can
be taken as criteria to estimate the age. Also if
neonatal line is present it indicates a live birth.
• Other methods:
– Dry weight method of Stack (1960)
– Radiographic interpretation of mineralization
- Non mutilating.
– Van der Linden and Duterloo (1976)—
photographic standards of developing teeth.
Also at birth the primary ossification centers
(diaphyses) of the long bones of the extremities,
including the hands and feet, are present. The
vertebral bodies and posterior elements have begun
their process of ossification, as have the scapulae,
pelvic, clavicles, base of the skull, calvaria, and facial A
bones.
Age Assessment up to 14 Years

• Sequence of eruption of both deciduous and
permanent teeth are best way to acess age.
• Radiographical and histological means.
• Schour and Massler(1940) charts are the one
commonly used.
Age Assessment up to 21 Years
• 3rd molar is only tooth on the eruptive path. B
(Figs 5.7A and B)
Figs 5.6A and B: Neonatal lines are shown in both enamel
• Radiographical and er uption sequence as well as dentin of the tooth structure, highlighted by the
observation can predict age. black and white arrows
• Commonly used—Schour and Massler(1940)
chart and Gustafson (1971) table.
• Moorees et al. 1963, indicated that the crown Age Assessment after 21 Years
formation stages for third molar tooth display Several techniques are described in literature that
less variation than root formation stages. addresses age estimation in adults. In general
and the procedure must not impair the health of

the affected person. Tooth development and the
sequence of eruption have been used extensively as a
method of age estimation in children and adolescents.
In adults, following completion of the
growth period, age estimation by morphological
methods becomes difficult and particularly
when nondestructive methods are used, it is not
sufficiently accurate. Previously the methods of
choice in adults were, theoretically, the method
according to Gustafson and its modifications.
A
These techniques are destructive, need extracted
teeth and can be used only in dead. Gustafson’s
optimistic standard deviation of ±3.4 years has
never been confirmed. Also Johanson’s standard
deviation of ±5.6 years seems to be too optimistic.
Investigation has shown that a standard deviation
of around ±10 years is normal for most methods,
while others report that these methods have 95
percent confidence intervals of approximately
±12 years at best. The formulae are generally
B
most accurate around 40 to 50 years and with
Figs 5.7A and B: Clinical and radiographic pictures showing increasing inaccuracy in younger and especially in
the erupting third permanent molars, which is usually between
18 to 25 years of the age older age groups. Also another difficulty is that
there is a pronounced tendency for over estimation
of younger persons and underestimation of older
the methods are divided into three categories. persons.
The morphological, the radiological and the A. Morphological Methods
biochemical methods, which are all based on
In the morphological methods belong all these
degenerative processes, observed in the dental
that use morphological criteria. The samples can
structures. The methods described below are
be observed sectioned or unsectioned with the eye.
reproducible and rather accurate methods,
At this category belong the methods suggested by:
some of which are non-destructive for the tooth
• Gustafson (1950),
substance.
• Dalitz (1962),
The estimation of chronological age in
• Bang and Ramm (1970),
living human beings and dead persons has been
• Johanson (1971),
performed by forensic dentists for almost more
• Maples (1978), and
than 50 years.
• Solheim (1993).
An optimum method for age determination
in living individuals should fulfill the following Gustafson (1950): The first technique for age
conditions: age determination in all age groups estimation on teeth based on a systematic and
statistical approach was published by Gustafson Various codes given for assessment of above 6

(1950). Once dental development is complete, values and their scoring criterions are enlisted here.
through assessment of age and function, the (Figs 5.8C to H)
dental structures undergo changes. Gustafson A = Attrition—loss of substances on the occlusal
(1950) and Thoma (1944) described the age surface with teeth on the opposite jaw.
changes occurring in the dental tissues and noted S = Amount of secondary dentin.
attrition of the enamel, sclerosis of the dentin, P = Periodontitis resulting in recession and
denticles in the pulp, deposition of cementum, exposure of root.
continuous eruption of the teeth and alternations C = Apposition of cementum
in the perioodontal structures (periodontitis). After R = Resorption
observing ground sections of adult human teeth, T = Transparency—dentinal canal are filled with
he designed diagrams of six changes related to age. mineralized tissue.
These age-related changes were as following: Attrition scoring sheet
• Attrition of the meisal or occlusal surfaces due
A0.0 — No visible attrition on occlusal or incisal
to mastication. surfaces.
• Periodontitis. A0.5 — Minute attrition
• Secondary dentine. A1.0 — Attrition only around the half of enamel
• Cementum apposition. thickness
• Root resorption. A1.5 — Only a very thin layer of enamel is left with
• Transparency of the root. the dentin not exposed
Gustafson suggested the last two changes. In A2.0 — The dentin has been attrited to a small
the method proposed each sign was ranked and extent
allotted 0, 1, 2, 3 points (Figs 5.8A and B) A2.5 — The attrition has reached halfway through
according to degree of development. In forensic the dentin
dentistry Gustafson’s method of age estimation is A3.0 — Attrition has reached through the whole
the best known and most commonly referred to layer of dentine and the original pulp
Kvall (2006). cavity has been reached.
A
Fig. 5.8A

D
C F
Figs 5.8B to F

G H
Figs 5.8G and H

Figs 5.8A to H: (A) Gustafson’s grading and scoring criterion for determination of the age of a person based on regressive
alterations of the teeth, as noted in the chart shown above; (B) Graphical representation of various regressive alterations
of tooth to asses the score of Gustafson’s scheme as shown in chart above; (C) Gground section of the tooth showing the
attrition, physiological and mechanical wearing away of the tooth structure; (D) Picture showing the deposition of the secondary
dentine, that is the dentin deposited after the completion of the root formation; (E) Cemental deposition at the peri-apex of the
tooth; (F) Ground section of the tooth showing the root resorption at the peri-apical areas; (G) Root transperacncy arising in the
ground section of the tooth because of the sclerosis of the dentinal tubules (deposition of the calcium salts within the dentinal
tubules); (H) Graphical representation of the tooth structure to acess the degree of root transparency in the ground sections
Gingival recession scoring chart/periodontitis S1.0 — Moderate amount of secondary dentin

• That is the distance from CEJ to the gingival at the roof of the pulp chamber which is
attachment. covering half the crown portion of pulp
• It is done with the help of a periodontal probe. space.
S1.5 — Moderate amount of secondary dentine
P0.0 — Normal periodontium at the pulp chamber which is covering the
P0.5 — A small retraction from cemento-enamel- Complete crown portion of pulp space.
junction S2.0 — The entire crown portion of pulp space as
P1.0 — A retraction of about two millimeters well as some root portion of pulp space is
P1.5 — A retraction of about 4 to 7 mm filled with secondary dentin.
P2.0 — About 10 mm S2.5 — Almost half of pulp space is filed with
P2.5 — About 15 mm secondary dentin.
P3.0 — Only some millimeter of the root is still S3.0 — More than two third of pulp is filled with
surrounded by a periodontium secondary dentin
Secondary dentin scoring chart Cemental apposition chart
S0.0 — No secondary dentin formation C0.5 — Very mild cemental thickening at the apical
S0.5 — Mild degree of secondary dentin deposited area
at the roof of the pulp chamber, Covering C1.0 — Cemental thickening which is 1/4 of the
1/4 of the crown portion of the pulp space. root length area
C1.5 — Cemental thickening of about 1/3 of root

length area
C2.0 — About 1/2 of root length, cemental
apposition seen
C2.5 — Cemental apposition is more than 1/2 but
less than 2/3 of root length area
C3.0 — More than 2/3 of root length area is
affected by cemental apposition
Root resorption scoring chart
R0.5 — Small resorptions on only one place
R1.0 — Resorption on two or more places without
getting very deep
R1.5 — Extensive resorptions
R2.0 — Deep and wide resorption
R2.5 — Resorption practically over the whole Fig. 5.9: The chart to obtain the age of person under
surface investigation by calculating the scores of all changes as notified
by the Gustafson and plotting them against the standard graph
R3.0 — Resorption going into the dentin
Root transparency scoring chart
T0.0 — No transparency The exact equation calculated was: y = 11.43 +
T0.5 — Very mild amount at the apex 4 - 56x, where y = age and x = points according
T1.0 — Mild areas of transparency less than 1/4 to the formula above. The error of estimation as
of root length calculated by Gustafson (1950) was ±3.6 years
T1.5 — Transparency is less than 1/3 of root but (Gustafson, 1947).
more than 1/4 Gustafson’s method has for many years been
T2.0 — More than 1/3 and less than 1/2 of root used by forensic odontologists in actual cases. At
length the same time it has been criticized for a number
T2.5 — More than 1/2 of root length and less of reasons.
than 2/3
T3.0 — More than 2/3 of root shows transparency. Disadvantages:
The point values of each age-change are added 1. It can not be used in living person, only in dead
according to the following formula: when extraction of a tooth is allowed.
2. The assessment of the scores is the result of a
An + Pn + Sn + Cn + Rn + Tn = points
subjective evaluation of the changes.
It was found that an increase in points 3. Too many age related changes needed to be
corresponded to an increase in age and that it was considered making the method time-consuming.
possible to draw a regression line for the correlation 4. Periodontitis is often impossible to determine
between age and points. In order to estimate the due to decomposition of soft tissue.
age of an individual, the point value is entered 5. One regression line is given for all teeth ignoring
in the graph and the corresponding age is found eruption time and morphological differences for
(Fig. 5. 9). the various teeth.
6. The method assumes that all six criteria are age using a greater number of teeth does not necessarily

changes of equal importance. Also it ignores increase the accuracy of the determination. This
any possibility of interrelationship between the over-ruled Gustafson who considered that his error
criteria themselves. in estimation would decrease when more teeth are
7. Another problem stated was that the size of examined. Dalitz’s method results in a standard
the material was small and consisted of only 40 deviation in age determination of ±6 years.
teeth, while many of them originated from the The regression equation suggested by Dalitz
same patient. Since, the variation of age-related (1962) was:
changes in teeth from the same individual E′ = 8.691 + 5.146A′ + 5.338P′ + 1.866S′
is evidently less than in teeth form different + 8.411T′
individuals, this affects the statistical analysis and
Disadvantages:
contributed to even more favorable deviation.
Also the regression formula was incorrectly The improvement is that Dalitz used weights for
calculated. Malpes and Rice (1978), Dalitz each factor. One of the problems is that it does
(1962) found the new formula: Y = 13.45 + not take into account bicuspids and molar teeth.
4.25 X. This is critical for the application of the method
since in many cases the only teeth left are molars
Dalitz (1962): Dalitz in 1962 re-examined and bicuspids as a result of severe external force.
Gustafson’s method and suggested a 5 point system
from 0 to 4, give a slightly greater accuracy. His Johanson: Gustafson’s technique had been improved
results showed that root resorption and secondary first by Dalitz in 1962 and finally by Johanson in
cementum formation could be disregarded. The 1971. The improvements implemented by Johanson
other criteria, attrition, periodontitis, secondary are actually the most appreciated among forensic
dentine deposition and transparency of the root of odontologists. He differentiated for seven different
the 12 anterior teeth, are related appreciably to age stages (Fig. 5.10); instead of four originally and
and to a similar degree. Dalitz suggested that it is evaluated for the same six criteria, mentioned
preferable to use up to 4 of the 12 anterior teeth earlier, attrition (A), secondary dentine formation
from the one individual for age estimation, but if (S), periodontal attachment loss (P), cement
Fig. 5.10: The graphical picture depicting the calculation of various scores as per
of Johnson’s method of age determinations
apposition (C), root resorption (R) and apical Advantages:

translucency (T). Johanson made a more detailed 1. A great advantage of the method is that good
study of the root transparency and stated that it results are obtained by measuring intact roots
is more clear when the thickness of the ground only.
section of the tooth was 0.25 mm. The following 2. The measuring of one factor-degree of root
formula was recommended: transparency-makes the method simple and
Age = 11.02 + (5.14*A) + (2.3*S) + (4.14*P) rather fast compared to previous methods.
+ (3.71*C) + (5.57*R) + (8.98*T) 3. It is an objective method because it is not based
Bang and Ramm (1970): Bang and Ramm on a point system but on measurements.
(1970) suggested a totally new approach in age 4. It can be applied without previous extensive
estimation. They found that the root dentine training or expensive equipment. Also no
appears to become transparent during the third differences were found between living and
decade starting at the tip of the root and advancing dead persons in the degree of root transparency
coronally with age. and storage of specimens in 10 percent neutral
This alteration is believed to be caused by a formaldehyde caused no significant changes.
reduction of the diameter of the dentinal tubules Various studies have been made about the
caused by increasing intratubular calcification. influence of different conditions upon the degree
The examination of the teeth is done in two ways. of root transparency. Gustafson (1947) and
First the teeth were examined unhurt and then, Nalbandian et al. pointed out that root transparency
400 micrometer thick labio-lingual sections were is less influenced by pathological processes, while
cut. The total length of the root was measured Bang and Ramm found the opposite. Kvaal
buccally in the midline from the cemento-enamel (2005) states that studies in archaeology show
junction to the apex. The transparent root dentin root transparency to be reduced in the presence
was measured from the apex of the root in coronal of metal. Also according to Reppien (2006) root
direction to the borderline between transparent and transparency increases in diabetes and drug addicts
opaque dentin. Maples (1978).
From the material collected, they found that
it was difficult to make accurate measurements in Maples (1978): Maples (1978) suggested the use
molars and bicuspids and thus the survey included of only two criteria of the total six Gustafson
only incisors and cuspids. In spite the difficulties recommended-secondary dentine formation and
a small number of molars and bicuspids were root transparency, in order to make the method
examined. The mesial and distal roots showed more simple and accurate. The results of his
good correlation in the degree of root transparency. research showed that root resorption was negatively
However, there was difference between mesial, correlated to age. Elimination of root resorption
distal and palatal roots. improved the results and the error of the estimate
For practical reasons Bang and Ramm (1970) was reduced 20 to 30 percent. Periodontitis was
recommend the exclusion of upper first premolars not used because it was difficult to determine it
and all the molars in order to arrive at the best long after soft tissue decomposition. In the same
estimation. They also suggest 2 different equations, way attrition was excluded because differences
one when the transparent length is less than or equal among populations were found as a result of diet
to 9 mm and a second when it exceeds 9 mm. habits or abnormal occlusion.
Advantages: sex as factor depends upon the condition of skeletal

1. As said before the method requires the scoring remains. The reported formulae are recommended
of secondary dentin and root transparency. for deceased bodies for identification purposes (un-
This means that teeth with broken crowns, no sectioned teeth) and in archeology.
evidence of periodontal attachment and lost B. Radiological Methods
cementum may still give accurate age estimates.
Dental radiographs have been used quite recently
2. Also the technique can be used on other
in dental age estimation methods for adults.
populations, contemporary and prehistoric, with
Kvaal and Solheim were the pioneers on this
less fear that dietary differences will decrease the
subject. They estimated the age of an adult from
estimation. Since, secondary dentin and root
measurements of the size of the pulp on full mouth
transparency; are easy to evaluate, observer error
dental radiographs, without tooth extraction and
may be lessened.
destruction. The size of the dental pulp cavity is
Solheim (1993): For age estimation Solheim reduced as a result of secondary dentine deposit,
(1993) used five of the changes that Gustafson so the measurements of this reduction can be used
recommended (attrition, secondar y dentin, as an indicator of age.
periodontitis, cementum apposition and root Kvaal and Solheim presented a method where
transparency) and added another three new radiological and morphological measurements
changes which showed significant correlation in are combined in order to estimate the age of an
different types of teeth. The three new age-related individual. Using the radiographs they measured
changes were surface roughness, color and sex. pulp length and width as well as root length and
Solheim after examining a collection of 1000 teeth, width. Then different ratios between the root and
excluding molars came down to good correlation pulp were measured. These ratios were found to
between age and the whole number of changes. be significant correlated with age. They also found
He found that mandibular canines and second inclusion of the length of the apical translucency
premolars had the weakest relationship between and penodontical retraction in some types of teeth.
the parameters and age, so when possible it was The results showed the strongest correlation with
recommended to avoid the use of these teeth. Two age to be in the ratio between the width of the pulp
sets of formulas were presented, one including sex and the root.
and color and the other without them, because This may indicate that the rate of deposition
these factors were not always determinable in of dentine on the mesial and distal walls is more
deceased individuals. closely related to age than that on the roof of the
In Solheim’s (1993) study there was a variety pulp cavity. However, the correlation between age
of origin of teeth (cadavers, forensic cases, living) and the ratios between pulp and the root length was
which might better reflect the biological variation. significant for only maxillary cuspids and premolar.
Compared with teeth from living individuals, The method is non-destructive and can be applied
teeth removed from deceased bodies were darker, in living people or dry skeletal material, where
possibly owing to the changes or reactions to the single-rooted teeth are often loose in the jaw or
environment after death. The finding indicates the can be removed easily. It can be employed when
need for cautiousness in using color as a factor in the preservation of the material is requested, as in
estimating the age of a corpse and this depends archeological studies and in forensic investigations.
upon the condition of the teeth. In order to Formulae for premolars showed a stronger
estimate color a shade guide is needed. Regarding correlation with age and this may be an advantage,
because these teeth are less prone to damage by parallel technique should be used, because if the

trauma or fire and also more often retained in film is at an angle to the root the ratio will be
skeletal material. Also the measurements require a influenced resulting in wrong estimation. For this
fairly short time compared to methods where the reason when dealing with orthopantomographs
teeth have to be sectioned. (OPG) the patient should be correctly positioned
Kvaal (1995) however proposed a method based to the X-ray machine. In many cases the bone
totally on radiographic measurements (periapical overshadowed the apical third of the tooth, so that
radiographs) and did not depend on other the width from this area of the tooth could not be
factors such as root transparency and periodontal measured with sufficient accuracy. This necessitates
retraction, thus not requiring extraction of teeth. the use of a stereomicroscope. Rotated teeth,
Measurements on dental radiographs may be a teeth with enamel overlap, teeth with restorations,
non-invasive technique for estimating the age of cavities, attrition and periapical pathological
adults, both living and dead in forensic work and processes cannot be used. With all the restrictions
in archaeological studies. mentioned above in the older age groups it was
Regression formulae for all six teeth together was difficult to find patients who retained all the six
proposed and also for each one of the 6 different teeth that were measured in their study.
teeth (11/21, 12/22, 15/25, 32/42, 33/43, Vandevoort et al reported a morphometric
34/44). According to the survey there was a better method pilot study using microfocused computer
age estimation when several teeth were included. tomography (CT) on extracted teeth to compare
Maxillary first premolars and molars were excluded pulp-tooth ratios in the determination of age.
because accurate measurements were difficult to Yang et al. (2006) using cone-beam CT scanning
perform. In order to compensate for differences acquired the 3D images of teeth in living individuals.
because of magnification and angulation on the Using the 3D images the ratio of pulp/tooth
radiographs, ratios of measurements were used. volume can be calculated. Promising results for
Also correlation between age and the ratio of tooth age estimation based on the pulp/tooth volume
to root length was insignificant to all types of teeth, ratio were obtained
indicating that attrition on the occlusal surface was
so weak that it could not be related to age. As in the C. Biochemical Methods
previous survey the width ratio was found to have a Racemization of aspartic acid in human teeth:
stronger correlation than the length ratio. The biochemical methods are based upon the
Bosnians et al (2005) applied the original racemization of amino acids. The racemization of
formulas of Kvaal’s technique (1995) using amino acids is a reversible first-order reaction and is
measurements made on panoramic radiographs relatively rapid in living tissues in which metabolism
instead from the typical periapical radiographs is slow. Aspartic acid has been reported to have the
as originally described. The age estimations highest racemization rate of all amino acids and to
were comparable to those based on the original be stored during aging. In particular, L-aspartic
technique. acids are conversed to D-aspartic acids and thus the
Kvaal states that when dealing with radiographs levels of D-aspartic acid in human enamel, dentine
several complicating factors are encountered since and cementum increase with age. The D/L ratio
the curved arch of the jaws is projected on to a flat has been shown to be highly correlated with age.
film thus giving a certain amount of distortion. Helfman and Bada were the first that reported
When periapical radiographs must be taken, the studies that focused on the racemization of amino
acids and obtained a significant correlation between age, thus facilitating age estimation. However, for

age and ratio of D-/L-enantiomers in aspartic accurate results the performance of biopsies must
acid in enamel and coronal dentine. Ohtani and occur under strictly standardized conditions.
Yamamoto (1987) showed that even higher The specimens taken by the biopsy technique
correlations were obtainable using longitudinal were approximately 1mm in diameter and 1
sections of whole dentine. Ohtani et al (1995) mm long. Specimens were taken from posterior
applied the racemization method to cementum, teeth (molars). These amounts of dentine proved
which has higher water content. sufficient for the determination of the extent
The racemization rates of the cementum, enamel of aspartic acid racemization in all cases. The
and dentine samples showed that cementum had cavities were then treated with conventional filling
the fastest reaction, followed by dentine and materials. The only cases in which the technique
then enamel. This may be because cementum is was not applicable were in teeth with extensively
surrounded by periodontal tissue and dentine and destroyed crowns. In these cases, the biopsies had
possibly has a highly environmental temperature, to be taken in deeper dentine layers, often close to
which would speed up the rate of reaction, as filling materials or carious lesions.
well as a known higher water content. Also the As said before, in order to use the formulas
cementum was found to have a relative irregularity proposed by Ritz et al. (1995), the biopsies must
of the increase in the D/L ratio compared with that be taken from a specific region of the tooth. The
of dentine. As dentine is covered with cementum, study showed that the biopsy layer had a significant
enamel and periodontal tissue, it is presumably influence on the results, since the extension of
exposed to a relatively constant environment. In aspartic acid racemization is higher in deep layers.
addition, the D/L ratio in dentine is assumed to The biopsy technique is a low-risk procedure
increase linearly with aging (Ohtani et al. 1995). that causes only minor discomfort to the affected
Although, cementum showed the fastest reaction, person.
dentine showed the highest correlation with
Others
actual age. The results show that in cementum
the racemization reaction proceeds in a relatively Incremental lines analysis: The premise for
constant manner and that cementum is, like incremental line analysis in identification efforts
dentine, a tissue that has low metabolism. As a is based on the fact that these lines have the
result the racemization method with cementum is, same pattern in an individual whose enamel
as with dentine, sufficiently useful for precise age formed at the same time in a given dentition. The
estimation. different teeth developing in one individual give
Ritz et al (1995) used the racemization the same pattern of incremental lines which is
method in dentinal biopsy specimens in order to distinct from that of another individual, in effect
estimate the age of living individuals. This method creating a “fingerprint” of enamel development
emerged from the need to identify the age of living specific to the individual. Incremental line
individuals without extracting teeth. In Germany analysis is usually done on ground sections of
for example extraction of a tooth exclusively for longitudinally sectioned dentition which results
age estimation when it is not medically indicated in the destruction of the dental structures. The
is regarded as ethically and legally problematic. Skinner and Anderson study is unique in that
The results were hopeful and showed a close ground sections were not used. Reconstructed
relationship between the extent of aspartic acid crowns were embedded in crystal clear polyester
racemization in dentinal biopsy specimens and casting resin with Fiber-tek catalyst and allowed to
cure. They were then longitudinally sectioned at

180 to 200 µm with a Buehler-Isomet low-speed
saw with a diamond wafering blade. The mounted
sections were examined and photographed at ×
20 magnification with ordinary and polarized
light. Composite photographs were then created
showing the entire labial/buccal enamel to
homologize striae between teeth. Limitations
in incremental line age determinations appear
age dependent. Lipsinic et al. studied the
A
correlation of age and incremental lines in the
cementum of human teeth and found that direct
predictions of age based on these lines generally
underestimated the age of older specimens. There
was, however, correlation between the number of
lines and age. These authors concluded that such
studies would have greater usefulness if a large
enough population group was studied and that a
computer-generated formula resulted.
B
Figs 5.11A and B: IOPA and OPG are mainly used for
Steps of Age Estimation calculation of the age as per of radiographic means of age
determination
Kvaal (2006) describes the approach using different
methods in order to reach to relatively accurate
estimation. minimal handling of the remains to avoid further
destructions of tissue.
Visual Assessment Extraction and Preparation of Single Teeth
Initially a gross “clinical” examination ought to be Age estimation methods that cause irreversible
performed which include the condition of the soft destructions of tissues are used last. Different
tissues as well as the dentition. Dental attrition, methods require single intact teeth, half sectioned
tooth colour and stains, periodontal status as teeth, or ground sections (Fig. 5.12).
well as quantity and quality of dental restoration It is recommended that age is calculated using
may be employed. From this visual impression an preferable two independent scientific methods.
experienced dentist may give a good estimate of This may either be one method using the whole
chronological age. dentition, selected teeth from the dentition or the
same method applied to two or more teeth from the
Radiographs (Figs 5.11A and B)
same dentition (Kvaal, 2006). In all cases repetitive
Periapical radiographs or orthopan-tomographs measurements should be made in order to verify
(OPG) will give additional information in the size the reproducibility of the calculations performed.
of the pulp. In cases of fragile tissue e.g. burnt The final age estimate ought to be based on the
bodies or skeletal remains from archaeological results of the methods and the initial visual age
excavations the radiographs ought to be made with assessment.
odontologist to apply different techniques and

not to stick to one age estimation technique thus
providing a more reliable result.
Following (Table 5.1) are the recommended
dental Age estimation procedures in adults (ASFO,
2007)
Dental Age Estimation by Means of

Commonly Used Developmental Surveys
By these methods, dental age is estimated by
comparing the dental development status of
a person of an unknown age with published
Fig. 5.12: Picture showing the stone and methods to developmental survey. It basically consists of three
prepare the ground sections of the teeth necessary steps:
A. Collection of appropriate data
To this direction the following software B. Use of Appropriate dental development survey
program was developed. Dental age calculating C. Evaluation
software. Willems, in year 2000 developed a
Collection of Appropriate Data
software program in order to automate dental age
calculations. The program is named “Dental Age • Thorough history (living) and antemortem data
Estimation”. It includes the most accurate and (for dead individuals).
often referenced morphological and radiological • Clinical examination (in both living and dead
techniques that are reported in literature and individuals)
which demand extensive calculations. The great 1. General examination of person
advantage of the program is the immediate 2. Examination of oral cavity and dentition.
dental age estimation results and the avoidance of • Radiographic examination: Radiographs taken
calculating errors. All that is needed is to measure should enable one to use the method that he/
the required parameters and enter their values she has decided to use.
into the program. Also it enables the forensic • Histological examination
Table 5.1: Recommended dental age estimated procedure in adults (ASFO, 2007)
Status Examination type Specific techiniques of methods

Living Radiographs/Morphological Kroad and softenin (dental radiographs)
Extracted tooth-biochemical Aapartic acid racenization
Post-formation changes Johanson sectioning
Post-formation changes Lamindin et al. (1992)
Deceased Biochemical Aspartic acid recemization
Anthropological/Historical
Collection
Skeletal Non-Destructive Kvaal/Solheim Intact Methods
ASFO: American Society of Forensic Odontology

• Other relevant information • Make a final complete assessment of the most

– Impression for study model likely chronologic age
– Dental photography
Appropriate data should be obtained from the Commonly used Dental
subject ideally in a form similar to that used in the
development survey chosen
Developmental Surveys
The most commonly used dental developmental
Appropriate Dental Development Survey surveys are outlined here, with their descriptive
• Use as many appropriate parameters as possible. charts as well.
• Use methods as originally described in the 1. Schour and Massler method (1940)
literature. 2. Moorees method (1963)
• Use as many teeth as possible. 3. Demirijian seven-tooth system for age estimation
4. Gustafson method (1966)
Evaluation
Schour and Massler Method (1940)
• Assess if the methods are appropriate in relation
to the individual. • Published numerical development charts for
• Assess factors which may have influenced tooth deciduous and permanent tooth.
development or ageing. • Periodically updated by ADA.
• Assess especially if pathologic factors or other Figure showing development of deciduous teeth
may have influenced the findings (Fig. 5.13).
Fig. 5.13: Schour and Massler charts showing the timings of various events in morphogenesis of deciduous dentitions

Fig. 5.14: Schour and Massler charts showing the timings of various events in morphogenesis of permanent dentitions
Figure showing development of maxillary and Disadvantage
mandibular permanent teeth (Fig. 5.14).
1. It do not separate survey for males and females.
Figure showing Schour and Massler chart of
2. Range obtained with this survey is from 2 to 15
dental development. Chart shown produced by
years.
ADA (1982) (Figs 5.15A and B).
Moorees Method (1963)
Advantages
• Defined 14 stages of mineralization for
Easy comparison with either radiographs or
developing single and multi-rooted permanent
individually removed developing teeth.
teeth.

Fig. 5.15A: Schour and Massler (as produced by ADA) charts showing the timings of eruptions
of deciduous dentitions and a corresponding age calculation

Fig. 5.15B: Schour and Massler (as produced by ADA) charts showing the timings of eruptions
of permanent dentitions and a corresponding age calculation

Fig. 5.16: Stages of development of a single rooted tooth Fig. 5.17: Stages of development of a multi-rooted tooth
as shown by Morees et al as shown by Morees et al
Figure showing stages of tooth formation Note: Code symbols are same as for single rooted
for single rooted teeth (Moorees et al 1963) dev. with addition of Cli initial cleft formation.
(Fig. 5.16).
Highlights of the Moorees method (1963)
Note: Abbreviations stand for
Ci Initial cusp formation • Earliest age of survey is 6 months.
Cco Coalescence of cusps • Includes development of mandibular third
Coc Cusp outline complete
molar.
Cr1/2 Crown half complete
• Has a standard deviation of ± 2
Cr3/4 Crown ¾ complete
• Teeth emerged clinically at R3/4 stage
Crc Crown complete
• Difference in crown formation between sexes
Ri Initial root formation
R1/4 Root length one quarter are minimal.
R1/2 Root length one half • In case of root development female developed
R3/4 Root length three quarters ahead of males.
Rc Root length complete • Greatest sexual dimorphism is expressed in the
A1/2 Apex half closed mandibular canines, females being upto 11
Ac Apical closure complete months ahead of male in development
Figure showing stages of tooth formation Figure showing development of female incisors
for multi-rooted teeth (Moorees et al 1963) from Moorees et al. 1963 with mean age standard
(Fig. 5.17). deviation ± 2 (Fig. 5.18).

Fig. 5.18: Development of incisor as per of the chronology of the events told by Morees et al
Demirijian Seven-tooth System for Age Right and left oblique radiographs together with
Estimation right and left lower occlusal oblique films OR
Technique: Following procedure needs to be Rotational tomographs.
followed in order to calculate the age of a person
using this particular technique. Calculation of Maturity Score
Seven teeth must be used, i.e. mandibular left or
Radiographs right incisors, canines, premolars, 1st and 2nd
Take an IOPA of left and right mandibular incisors, molars. In case of any tooth missing corresponding
canines, premolars, 1st and 2nd molars OR tooth of opposite side should be substituted. Use
Stage Description

A In both uniradicular and multiradicular teeth, a
beginning of calcification is seen at the superior
level of the crypt, in the form of an inverted cone or
cones. There is no fusion of these calcified points.
B Fusion of the calcified points forms one or several
cusps, which unite to give a regularly outlined
occlusal surface.
C a Enamel formation is complete at the occlusal
surface. Its extension and convergence toward
the cervical region is seen.
b The beginning of a dentinal deposit is seen.
c The outline of the pulp chamber has a curved
shape at the occlusal border.
D a The crown formation is completed down to the
cementoenamel junction.
b The superior border of the pulp chamber in
uniradicular teeth has a definite curved form,
being concave toward the cervical region. The
projection of the pulp horns, if present, gives an
outline like: an umbrella top. In molars, the pulp
chamber has a trapezoidal form.
c Beginning of root formation is seen in the form
of a spicule.
E Uniradicular teeth.
a The walls of the pulp chamber now form straight
lines, whose continuity is broken by the presence
of the pulp horn, which is larger than in the
previous stage.
b The root length is less than the crown height.
Molars
a Initial formation of the radicular bifurcation is
Fig. 5.19A: Graphical pictures showing the stages of tooth seen in the form of either a calcified point or a
development as per of Dermijian semilunar shape.
b The root length is still less than the crown height.
pictorial guide together with reference to written F Uniradicular teeth
criteria, determine the mineralization stage of a The walls of the pulp chamber now form a more
or less isosceles triangle.
tooth. The apex ends in a funnel shape.
Figure showing pictorial guide to mineralization b The root lengrh is equal to or greater than the
crown height.
assessment (Fig. 5.19A). Molars
Figure showing mineralization assessment of a The calcified region of the bifurcation has
development teeth (Fig. 5.19B). developed further down from its semi lunar stage
to give the roots a more definite and distinct
A. Mark X in appropriate square of chart for outline, with funnel-shaped endings.
recording mineralization stages (or zero if b The root length is equal to or greater than the
crown height.
mineralization is absent) as shown here in the G a The walls of the root canals are now parallel
following table (Table 5.2). (distal root in molars).
b The apical ends of the root canals are still partially
B. For each completed square, convert X into
open (distal root in molars).
number using self weighed score table for dental H a The apical end of the roor canal is completely
stages and add the numbers to find the total closed (distal root in molars).
b The periodontal membrane has a uniform width
score i.e. the maturity score, as shown in table around the root and the apex.
below (Table 5. 3).
Fig. 5.19B: Chart showing the detailed illustrations of the
Add the numbers to find the total score i.e. the various stages of tooth development as per of the graphical
maturity score picture shown in previous figure by Dermijian
Table 5.2: Showing the chart to record the mineralization stages

Stage Mandible
I1 I2 C PM1 PM2 M1 M2
A
B 
C
D
E
F
G
H
Table 5.3: Showing self-weighed scores for dental stages, seven teeth
Tooth Stages
0 A B C D E F G H
Boys
M2 0.0 1.7 3.1 5.4 8.6 11.4 12.4 12.8 13.6
M1 0.0 5.3 7.5 10.3 13.9 16.8
PM2 0.0 1.5 2.7 5.2 8.0 10.8 12.0 12.5 13.2
PM1 0.0 4.0 6.3 9.4 13.2 14.9 15.5 16.1
C 0.0 4.0 7.8 10.1 11.4 12.0
I2 0.0 2.8 5.4 7.7 10.5 13.2
I1 0.0 4.3 6.3 8.2 11.2 15.1
Girls
M2 0.0 1.8 3.1 5.4 9.0 11.7 12.8 13.2 13.8
M1 0.0 3.5 5.6 8.4 12.5 15.4
PM2 0.0 1.7 2.9 5.4 8.6 11.1 12.3 12.8 13.3
PM1 0.0 3.1 5.2 8.8 12.6 14.3 14.9 15.5
C 0.0 3.7 7.3 10.0 11.8 12.5
I2 0.0 2.8 5.3 8.1 11.2 13.8
I1 0.0 4.4 6.3 8.5 12.0 15.8
Reading Graph
Figure showing graph with locating of score on
• Locate maturity score on y axis of graphs
Y axis of the graph (Fig. 5.19C).
• Locate the intersection of maturity score with
50th percentile curve. Figure showing graphs giving percentiles for age
• Drop a perpendicular to the x axis to locate the and maturity score for girls (Fig. 5.19D).
median age. Figure showing graphs giving percentiles for age
• Repeat for other percentile curves. and maturity score for boys (Fig. 5.19E).

Fig. 5.19C: Figure showing Graph with locating of score Fig. 5.19E: Figure showing Graphs giving percentiles for
on Y axis of the graph age and maturity score for boys
Table 5.4: Showing format for entering age determi-

nant results
Percentile Age
97
90
50
10
5
2. Inter-observer variation may be as high as

20 to 25 percent.
3. Mandibular teeth are required for this particular
Fig. 5.19D: Figure showing Graphs giving percentiles for process and also 3rd molars are not included in
age and maturity score for girls this study
Results Gustafson (1966) Mehod for Estimation

Record the results in the form of table (Table 5.4). of the Age
Drawbacks of the Demirijian Seven-tooth a. Gustafson developed a comprehensive compact

System for Age Estimation: chart of dental development. However this chart
1. Developmental difference between males and does not differentiate between male and female.
females are not usually apparent until 5 years. He divided the dental development into the
of age. following four stages.
b. 4 stages of development teeth tend to darken with age. In the method

I. Mineralization starts for dental age estimation suggested by Solheim,
II. Crown completes who proposed 10 formulas for different teeth,
III. Eruption dental color contributed to 7 of these formulas.
IV. Root complete In addition, changes in tooth color have been
Figure showing Gustafson’s (1966) chart of observed in human populations of different
formation and eruption of deciduous and permanent postmortem intervals. The most common method
teeth (excluding 3rd molars) (Fig. 5.20). to estimate dental color is to compare color in the
specimen with dental shade guides. Nevertheless,
Other Less Commonly Used Methods for
Estimation of Dental Age the use of tooth color for age estimation in forensic
odontology is limited by difficulties with objective
Objective Measurement of Dental Color for Age measurements. In an attempt to develop a more
Estimation by Spectroradiometry objective method, various scientists have used a
Tooth color estimation is also of interest in forensic spectroradiometry technique to measure dental
odontology. Several authors have reported that color changes in order to avoid the bias inherent
Fig. 5.20: Figure showing Gustafson’s (1966) chart of formation and eruption of deciduous
and permanent teeth (excluding 3rd molars)
in observer subjectivity. Of particular interest reliability. In all cases reproducible and reliable

are differences in dental color depending on the estimation results are possible when the appropriate
condition of the body and the postmortem interval. methods for each case are properly applied and
S. Martin-de las Heras et al have concluded that used. Error is present in every approach. For
spectroradiometry may be an objective and useful this reason when investigating a case the forensic
tool to determine dentine color, and may provide odontologist should apply different techniques
forensic odontologists with a complementary available and perform repetitive measurements and
method to calculate the chronological age in recent calculations in order to reach to reliable conclusion.
corpses. Moreover, determination of dentin color Research into age estimation is ongoing. Forensic
by spectroradiometry could be used in combination odontologists should continually watch the
with other morphological methods in order to scientific presentations and journals that report new
improve the accuracy to estimate the age. developments and validate or challenge existing
techniques.
Summary
Age is one of the essential factors in establishing
Bibliography
the identity of the person. Age estimation is a 1. Cameriere R, Ferrante L. Accuracy of age
sub discipline of forensic sciences and should be estimation in children using radiograph of
an important part of every identification process, developing teeth. Forensic Science International.
especially when information relating to the 2008;176:173-7.
2. Gustafson G. Age determination from teeth;
deceased is unavailable. Different factors have been
Journal of American Dental Association. 1980;41:
used for age estimation but none has withstood the
45-54.
test of time. Teeth are considered as optimal for 3. Lipsinic FE, Paunovic F, Houston GD, Robinson
this purpose. Examination of teeth in many way F. Correlation of age and incremental lines in
form a unique part of human body as they are most the cementum of human teeth, J. Forensic Sci.
durable and resilient part of the skeleton. 1986;31:982-9.
The estimation should be as accurate as possible 4. Maber M, Liversidge HM, Hector MP. Accuracy
since it narrows down the search within the police of age estimation of radiographic methods using
Missing Persons files and enables a more efficient developing teeth. Forensic Science International
and time saving approach. Age estimation is of 2006;159S:S68-S73.
broader importance in forensic medicine, not only 5. Meinl A, et al. Comparison of the validity of three
dental methods for the estimation of age at death
for identification purposes of deceased victims, but
Forensic Science International. 2008;178:96-105.
also in connection with crimes and accidents.
6. Mesotten K Dental age estimation and third molars:
In addition, chronological age is important in
a preliminary study Forensic Science International.
most societies for school attendance, social benefits, 2002;129:110-5.
employment and marriage.Denial maturity 7. Phrabhakaran N. Age estimation using third molar
has played an important role in estimating the development. J. Pathol. 1995;17:31-4.
chronological ages of the individuals because of 8. Pillai PS, Bhaskar G. Age Estimation from the teeth
the reported low variability of dental indicators. using Gustafson’s method-A Study in India; Journal
Different techniques and numerous studies of Forensic Science 1974;3:135-41.
have been published for age estimation, each one 9. Singh A. Age estimation from the physiological
demonstrating various accuracy, precision and changes of teeth. JIAFM. 2004;26(3).
Chapter 6 $
1
3*
Bite Marks a
j
CD
O
LU
Nitul Jain, Soniya Adyanthaya

_
03
Q
^ Chapter Overview
Historical aspects
Legal admissibility
Bite marks recognition
Difference in bite patterns of child and adults
Skin as registration material Bites , bite wound infections , prevention and
Classification of various bite marks systems management
Typical presentation and composition of bite
marks
INTRODUCTION
Although bites and biting have been around as
long as animals with teeth have inhabited the
planet , the science of bite mark identification
is comparatively new and potentially valuable .
Identifying human remains by dental characteristics
is a well established component of forensic sciences
with a definite scientific basis .
CD
However, the whole arena of bite marks is a O
LU
recent and still controversial pat of this discipline.
CT3
In mortal combat situations, such as the violence
-O
associated with life and death, struggles between
assailants and victims, the teeth are often used as a CD
E
weapon. Indeed , using the teeth to inflict serious Fig . 6.1 : The ear bite inflicted by Mike Tyson during the
injury on an attacker may be the only available sports of wrestling to his competitor
defensive method for a victim ( Fig . 6.1 ) .
co
Q
_
Alternatively, it is well known that assailants an expression of dominance, rage and animalistic
in sexual attacks, including sexual homicide, rape behavior. The teeth are a significant component
and child sexual abuse, often bite their victims as of our natural arsenal . It is suspected that many
Bite Marks 111
dentists have seldom considered their patients’ prosecution of accused suspects. Currently, there is

teeth as such effective weapons! no agreement among forensic odontologists about
Teeth are often used as weapons when one the individuality (uniqueness) of the dentition or
person attacks another or when a victim tries to the behavior of human skin during biting. Although
ward off an assailant. It is relatively simple to these issues have never been proven scientifically,
record the evidence from the injury and the teeth much research is currently underway in an attempt
for comparison of the shapes, sizes and pattern that to prove the suspicion that each human dentition is
are present. However, this comparative analysis is unique. The sizes, shapes and pattern of the biting
often very difficult, especially since human skin is edges of the anterior teeth that are arranged in the
curved, elastic, distortable and undergoing edema. upper and lower dental arcades are thought to be
In many cases, though, conclusions can be specific to that individual. This is mainly caused by
reached about any role a suspect may have played the sequence of eruption of anterior and posterior
in a crime. Additionally, traces of saliva deposited teeth. Canines must force their way into the dental
during biting can be recovered to acquire DNA arch, which often results in bodily movement,
evidence and this can be analyzed to determine who rotation and displacement of other teeth. The
contributed this biological evidence. If dentists are resulting configuration of the dentition produces
aware of the various methods to collect and preserve an identifiable pattern that may be compared
bite mark evidence from victims and suspects, it may with similar patterns found on bitten objects to
be possible for them to assist the justice system to determine the likelihood that a specific individual
identify and prosecute violent offenders. has left their calling card. The importance of bite
This form of forensic evidence demonstrates marks as an invaluable tool in criminal assaults and
how human bite marks are used by courts to answer victim forensic identification lies in fact that no two
important questions that may arise during the dentitions are identical (Fig 6.2).
Fig. 6.2: Composite pictures showing the various types of dentition in human beings, reflecting the uniqueness in each
A pattern injury: Bite marks are patterned Indentured Servants: Debtors coming from

injury that is any injury in which the instrument Britain or Europe to America to work as servants
of injury can be determined and possibly may be verified their agreements by biting the seal on the
individualized as the weapon making the injury. pact in stead of a signatures and became known
A bite mark is an injury to skin in which the as so.
instruments of the injury are teeth. In contrast to
The Doyle Case: Even though using bite mark
finger prints, which leave a definite ridge marks,
evidence began around 1870, the first published
bite marks leave blurred contusions, which tend
account involving a conviction based on bite marks
to leak in surrounding tissues (Figs 6.3A and B).
as evidence was in the case of Doyle vs State, which
• It may be caused by humans or animals
occurred in Texas in 1954. The bite mark in this
• Must be differentiated from animal bite
case was on a piece of cheese found at the crime
• May be on tissues, food items or other objects
scene of a burglary. The defendant was later asked
• It is a Primititive type of assault, which may
to bite another piece of cheese for comparison. A
highlight;
firearms examiner and a dentist evaluated the bite
– Aggressive or sexual behavior,
marks independently and both concluded that the
– Form of self-defense,
marks were made by the same set of teeth. The
– In children, biting is a form of expression when
conviction in this case set the stage for bite marks
verbal communication fails,
found on objects and skin to be used as evidence
– Playground altercations or sports
in future cases.
competition.
Another landmark case was People vs Marx,
According to Dr Brown, investigating bite marks
which occurred in California in 1975. A woman
is greatest technical challenge to forensic dentists.
was murdered by strangulation after being sexually
assaulted. She was bitten several times on her nose.
Historical Aspects Walter Marx was identified as a suspect and dental
Wax Seal: William the Conqueror reportedly impressions were made of his teeth. Impressions
validated royal documents by biting into a wax and photographs were also taken of the woman’s
with his characteristic dentition. injured nose. These samples along with other
models and casts were evaluated using a variety of
A B
Figs 6.3A and B: Bite marks appearing as blurred contusions on some of the incidences of bite marks
Bite Marks 113
techniques, including two-dimensional and three- became known as “Frye Test”. Frye test required 3

dimensional comparisons, and acetate overlays. components for admissibility; these were:
Three experts testified that the bite marks on the • The principle must be demonstrable
woman’s nose were indeed made by Marx and he • It must have been sufficiently established
was convicted of voluntary manslaughter. • It must have gained the general acceptance of
The first person to whom real credit must experts working in the particular scientific field
be given for having published an analysis of a (s) to which the evidence belongs.
bite-mark case is Sorup, in 1924. The method 1st case involving admissibility of bite mark
used he called “odontoscopy” analogous to the evidence was 1954 Texas case, Doyle vs State.
fingerprint identification called “dactyloscopy”. In a landmark 1975 case, People vs Marx, the
Presumably the first case involving a bite mark California Court of Appeals concluded that, bite
that led to a conviction sustained on appeal was a mark analysis was generally acceptable in the proper
1972 rape case, Illinosis vs Johnson. Several famous scientific community and thus admissible, in spite
cases, most notably Theodore “Ted” Bundy’s serial of the court’s acknowledgement that “there is no
murder trial, (Fig. 6.4) made bite marks a high- established science of identifying a person from bite
profile item with excessive media attention. marks”.
The definitions of bite marks by various authors:
The Legal Admissibility MacDonald:
The relevance and admissibility of new forms A mark caused by the teeth either alone or in
of scientific evidence depend upon their combination with other mouth parts.
general acceptance in the scientific community. ABFO: (American Board of Forensic Odontology)
Identification by fingerprint comparison was A physical alteration in a medium caused by the
accepted first in USA courts in 1911 only on contact of teeth.
the basis of its general and common use and Or
acceptance. In 1923, the justification for admitting A representative pattern left in an object or tissue
scientific evidence was established as a standard that by the dental structures of an animal or human.
The Overlying Principle

Bite mark analysis is based on two postulates:
a. The dental characteristics of anterior teeth
involved in biting are unique amongst individuals,
and
b. This asserted uniqueness is transferred and
recorded in the injury.
The debate over the uniqueness of human
teeth is probably one of the fiercest in current
forensic dental discourse. Many forensic dentists,
appellants, and lawyers have questioned the
validity of dental uniqueness determination and
demand to know from testifying experts, the
Fig. 6.4: The famous and most notable serial killer Ted Bundy
relative frequency of dental features identified in
whose bite marks on the victims led him to behind the bars bite marks.
The first article to consider the statistical nature A distinction must be drawn from the ability

of dental uniqueness was published by MacFarlane of a forensic dentist to identify an individual from
and Sutherland in 1974. The authors began by their dentition by using radiographs and dental
differentiating between “positive” and “negative” records and the science of bite mark analysis. Dental
features of the dentition. A positive feature was identification, as opposed to bite mark identification,
described as the presence of a tooth with a certain utilizes the number, shape, type, and placement of
rotation or other individualizing feature. A negative dental restorations, root canal therapies, unusual
feature was the absence of a tooth. This study pathoses, root morphology, trabecular bone pattern
concentrated on the positive features that occurred and sinus morphology.
on the anterior teeth (canine to canine, maxillary Bite marks are important because of the
and mandibular). Patients were selected from following properties bite marks possess:
an outpatient clinic and in total 200 study casts 1. More unique than DNA
(maxillary and mandibular) were produced. The 2. Identical twins share the same genetic makeup,
authors only studied the dental casts, not bite marks but their dental impressions will differ.
that would have been produced by such casts. “There are 28 teeth, plus four wisdom teeth, in
The investigators noted the number and an adult’s dentition”, Delattre says “Each tooth has
shape of each tooth, the presence of any incisal five surfaces, for a possible total of 160 surfaces.
restoration, relationship of teeth to arch form, and Each surface has its own characteristics and may
tooth rotation (four categories). The amount and have fillings, crowns, extractions, bridges, etc. In
degree of detail recorded in the bitten surface may addition to the teeth we see in our mouths, the
vary from case to case. And, even if it is assumed roots and bone around them are specific to each
that the dentition is individual enough to warrant person.” Given all of these parameters, it is safe
use in forensic contexts, it is not known if this to say that the physical make-up of each person’s
individuality is recorded specifically enough in dentition is unique.
the injury. In situations where sufficient detail Fellingham and coworkers have calculated that
is available, it may be possible to identify the there are 1.8 × 10 19 possible combinations of 32
biter to the exclusion of all others. Perhaps more teeth being intact, decayed, missing or filled.
significantly, it is possible to exclude suspects that Sweet and Pretty considered the size, shape and
did not leave the bite mark. pattern of the incisal/biting edge of upper and
Also, every member of the dental clinic team — lower anterior teeth to be specific to an individual.
from the receptionist and assistant to the dentist Rawson and associate mathematically calculated
should become familiar with the appearances and that the biting edge of 12 anterior teeth can be
presentations of bite-mark evidence. These injuries arranged in 1.3 × 10 26 different ways.
are often associated with physical and sexual abuse
of children, spouses and elders. Moreover, the Skin as Registration Materials
evidence is usually easily observed in the dental for Bite Marks
office during regular patient visits. Recognition and The considerable variation of bite mark presentations
reporting of such injuries to specific authorities that on human skin brings the accuracy of skin as a
are equipped to investigate such suspicions may end registration material into doubt. While many
the episodic pattern of abuse and stop the cycle of studies have examined the accuracy of bite marks
violence from which many victims are not able to on other substrates, such as cheese, apples, sandwiches,
escape. and soap, studies pertaining to human skin are
Bite Marks 115
relatively scarce. This represents both the most biting. The edematous response of skin to trauma

debated area of substrate accuracy and the most is likely to stiffen the area, thus rendering it more
commonly bitten material. stable. However, the subsequent resorption of this
Skin is a poor registration material since it is fluid will cause a large amount of distortion. They
highly variable in terms of anatomical location, concluded that the changes in bite mark appearance
underlying musculature, or fat, curvature, and are likely to be greater as the injury grows older.
looseness or adherence to underlying tissues. Skin This was found equally applicable to both living
and dead victims.
is highly visco-elastic, which allows stretching to
occur during either the biting process or when
evidence is collected. Classification of Various Bite
In 1971, DeVore issued a preliminary report Mark Systems
describing studies performed on the variability of
The various systems have been proposed depending
bite marks found on skin. The experiment involved
upon; biting agent, material bitten, and degree of
the inking of human skin (living volunteers) using
biting. Along with these, there are other systems
a stamp with two concentrically placed circles with
proposed by Cameron and Sims, MacDonald and
intersecting lines. Following the analysis of the Webster.
photographs it was found that in all cases there Depending upon biting agent, bite marks may
was an expansion or shrinkage of the stamp, with be caused by:
a maximum linear expansion of 60 percent at one • Human
location. The design of the stamp permitted the – Children
investigators to examine the distortion in both size – Adults
and direction. DeVore concluded that, due to the • Animal
level of distortion found, photographic images – Mammals
of a bite mark in comparative analysis should be – Reptiles
used only if the exact position of the body can – Fish
be replicated. The placement of a body in such a • Mechanical
position is usually impossible, as the exact position – Denture
of the body during an attack is rarely known. – Saw blade tooth marks
• Others
DeVore stated that further research to investigate
the effect of postmortem changes on skin distortion Depending on material bitten
were required. • Skin
– Human
In 1974, researchers from the Bioengineering
– Animal
Unit of the University of Strathclyde examined
• Perishable items
the features of the biting process likely to impact
– Food items
upon the appearance of bite marks on human
• Non-perishable
skin. They described the differing characteristics – Object
of skin from a variety of anatomical locations; e.g.
Langer’s Lines represent directional differences in Depending on degree of biting
the degree of extensibility of skin. Like DeVore, Definite bite marks: Direct application of pressure
they emphasized the importance of body location by biting edges causing tissue damage.
during biting as the directional variations or tension Amorous bite mark: Made in amorous situations,
lines will alter with movement. The report also tend to be made slowly with absence of movement
described distortion that can occur in skin after between teeth and tissues.
• Lower teeth marks— when teeth are pressed

into tissue with a gradually increasing pressure.
• Upper teeth— forms a series of arches where the
tissue is sucked into mouth and pressed against
back of the teeth with tongue.
Aggressive bite marks: Shows scraping, tearing or
avulsion
• Usually involves ears, nose or breasts
• Difficult to interpret.
Cameron and Sims classification: It is relatively
simple, and broad encompassing, it classifies bite Fig. 6.5A: Bite marks left on chocolate cake. Note the
penetration of the teeth
marks in two categories, that is:
Depending on the Agents
• Human
• Animal
Depending on the materials bitten
• Skin, body tissue
• Foodstuff
• Other materials
MacDonald’s classification: It is one of the most
cited, mainly pertinent to human bite marks.
Tooth pressure marks: Marks produced on tissue as
a result of direct application of pressure by teeth.
Tongue pressure marks: When tongue presses the
tissue against rigid area such as lingual surfaces of
teeth and palatal rugae. There is a combination of
sucking and tongue thrusting involved. Fig. 6.5B: Bite marks on hard food stuff like apples
Tooth scrape marks: Marks caused due to scraping

of teeth across the bitten material. Usually present
as scratches and abrasions.
Webster’s classification: This system classifies bite
marks made in foodstuffs (Figs 6.5A to C).
Type I: Food item fractures readily with limited
depth of tooth penetration, e.g. hard chocolate.
Type II: Fracture of fragment of food item with
considerable penetration of teeth, e.g. bite marks
in apple and other firm fruits.
Type III: Complete or near complete penetration Fig. 6.5C: Bite marks penetrating through the full thickness
of the food item with slide marks e.g. cheese. of softer materials like cheese
Bite Marks 117
Typical Presentation and

Composition of Bite Marks
Any discussion on recognition should be preceded
by a brief review of the classification of charac-
teristics observed within the injury. Evidence is
often compared with tool mark evidence when
attempting to show a narrowing of the focus from
the big picture (i.e. a patterned injury on skin) to
the smallest details discovered (i.e. defect for an
individual tooth). A
Component Injuries Seen in Bite Marks

Abrasions (scrapes), contusions (bruises), lace-
rations (tears), ecchymosis, petechiae, avulsion,
indentations (depressions), erythema (redness)
and (Figs 6.6A and B) punctures might be seen in
bite marks. Their meaning and strict definitions are
found in medical dictionaries and forensic medical
texts and should not be altered. An incision is a
cut made by a sharp instrument and, although
mentioned in the bitemark literature, it is not an
appropriate term to describe the lacerations made B
by incisors. Figs 6.6A and B: Various components in a bite marks,
The term latent injury or wound was preferred reflecting bleeding, contusions, ecchymosis and lacerations
over occult or trace wound when referring to an
injury which is not visible but can be brought out characteristics of incisors (rectangles) differentiates
by special techniques. them from canines (circles or triangles) (Fig. 6.7).
A characteristic, as applied to a human bite If we define the class characteristics of human
mark, is a distinguishing feature, trait or pattern bites, we can differentiate them from animal bites.
within the bite mark and is delineated as a class or Via class characteristics, we differentiate the adult
an individual characteristic. from the child bite or mandibular from maxillary
arch. The original term “class characteristic” was
Characteristics to look for
applied to tool marks and its definition has been
Class characteristics: A feature, trait or pattern modified to make it more applicable to bite marks.
preferentially seen in, or reflective of, a given group. So these features allow ascertaining whether bite
For example, the finding of linear or rectangular mark produced is formed by:
contusions at the midline of a bite mark arch • An adult vs a child bite
is a class characteristic of human incisor teeth. • Maxillary from mandibular arch
“Incisors” represent the class in this case. The • Human vs animal/non-dental
value of identifying class characteristics is that, Next is to determine which teeth are present in
when seen, they enable us to identify the group the pattern, as each tooth has class traits of its own
from which they originate. For instance, the class like
• Incisors — rectangular marks, confidence level that a particular suspect made the

• Canines — triangular or rectangular, bite mark. In a nutshell, these are the deviations
• Bicuspids often with figure of ‘8’ and from standard class characteristics and may be
• Molars —spherical or point-shaped. grouped as underlined.
Individual characteristics: Individual characteri • Anatomical,
stic: a feature, trait or pattern that represents an • Physiological,
individual variation rather than an expected finding • Iatrogenic,
within a defined group. An example of this is a • Traumatic
rotated tooth (Fig. 6.8). The value of individual For example, dental characteristics such as
characteristics is that they differentiate between enamel fractures, rotated tooth, talon cusps or
individuals and help identify the perpetrator. The restorations. The principle is similar in someway
number, specificity and accurate reproduction to the forensic anthropology osteobiography
of these individual characteristics determine the approach to a skeleton, in that an individual’s life
history or, perhaps more appropriately, medical
history is written in their bone.
Location of Bite Marks

Human bite marks are most often found on the
skin of victims, and they may be found on almost
all parts of the human body. Females are most often
bitten on the breasts and legs during sexual attacks,
whereas bites on males are commonly seen on the
arms and shoulders. In defensive circumstances, as
when the arms are held up to ward off an attacker,
Fig. 6. 7: The class characteristics of the teeth of the occlusal
surfaces appearing in bite marks, incisors—square shaped,
the arms and hands are often bitten. Following are
canine—triangular, and premolars/ molars appearing in fig the most common location of the bite marks in
of eight various types of crimes (Fig. 6. 9).
Sexual crimes: Breast, abdomen, nipple, thigh, back
and shoulders
Fight and violence: Extremities, any area of body
Animal bites: Exposed skin surfaces, extremities
Self defense: Extremities.
Homosexual activity: Axillary bites and bite patterns
on the back, shoulder and genitalia.
Child abuse: Bitten in areas of the face, particularly
cheek, ears and nose.
The Classic Appearance

Fig. 6.8: The individual variation of teeth in various humans, like
diastema, spacing, crowding, rotated tooth, mammelons etc.
The injury commonly present as circular/elliptic
pattern injury, divided into two distinct halves
Bite Marks 119
representing both arches. Following the periphery Variations of the Prototypical Bite Mark

of the arches are a series of individual abrasions,
Variations include additions, subtractions and
contusions, and/or lacerations reflecting the size,
distortions.
shape, arrangement, and distribution of the class
characteristics of the contacting surfaces of the
human dentition. Petechiae, punctures, erythema A. Additional Features
and avulsions may be seen as well, but when present Central ecchymosis (central contusion) —
usually are concurrent or superimposed with the When found, these are caused by two possible
bruise or abrasion appearance (Fig. 6.10). phenomena:
Commonly there is an area of Ecchymosis a. Positive pressure from the closing of teeth with
contained within the defining shape of bite mark disruption of small vessels.
either at centre or periphery. This extravascular b. Negative pressure caused by suction and tongue
bleeding is caused by pressure from the teeth as thrusting.
they compress the tissue inward from the perimeter
of the mark. Individual arches most frequently are Linear abrasions, contusions or striations — These
produced by anterior six teeth, but may be by all as represent marks made by either slipping of teeth
well. Occasionally a double bite can be observed. against skin or by imprinting of the lingual surfaces
Pattern of clothing or interposing material may of teeth. The term drag marks is in common usage
be superimposed. Size of pattern must fit within to describe the movement between the teeth and
known parameters of human dentition (from the skin while lingual markings is an appropriate
pediatric to mixed to adults). term when the anatomy of the lingual surfaces
The diameter of the injury typically ranges are identified. Other acceptable descriptive terms
from 25 to 40 mm. But because of reaction include radial or sunburst pattern.
within tissues, shrinkage in deceased victims or
putrefactive swelling in others, a reliance on size
may give false negative conclusions.
Fig. 6.9: Composite picture showing the various locations Fig. 6.10: A picture of classic bite on human tissue showing
of bite marks, which may be on any body surfaces or parts two semicircular arches with various teeth occlusal morphology
depending on the type of the assaults present
Double bite — A “bite within a bite” occurring It should be the standard operating procedure

when skin slips after an initial contact of the teeth for the collection of evidence to continue for as
and then the teeth contact again a second time. long as it shows change. The healing dynamics
B. Partial Bite marks: These types of bite marks of bruising observed has not been studied
may be produced by one-arched (half bites) sufficiently, so poorly understood. Langolis and
or one to few teeth. Apart from this unilateral Gresham concluded that it would seem unlikely
(one-sided) marks may also be produced due that a bruise could be reliably aged upon from
to incomplete dentition, uneven pressure or appearance alone.
skewed bite.
C. Indistinct/Faded bite marks: these are formed Variables Affecting Appearance of Bruises
by fused Arches — collective pressure of teeth
1. Structure and vascularity: depending upon
leaves arched rings without showing individual the area of tissue bitten and its vascularity and
tooth marks. anatomy, the appearance of bite marks may differ
Solid-ring pattern is not apparent because significantly for example eyes and palms have
erythema or contusion fills the entire center different vascular dynamics and hence wound
leaving a filled, discolored, circular mark. dynamics will also be different. Vascular tissue
D. Superimposed or Multiple bites. over bone bruises more and where as children
E. Avulsive bites. and elderly bruise more easily, because of loose
delicate skin in former and loss of SC tissue in
Bite Mark Recognition latter. Also a deep subcutaneous tissue injury
Recognition is of paramount importance. Many may prolong bleeding time.
injuries go undiscovered. Victims might fear 2. Metabolic rate: It is often seen that females
repercussions that reporting such incidents bruise more than males, and also obese people
may bring. It may present in a variety of ways. do bruise more than leaner people.
Although the prototypic or textbook bite mark 3. Victim’s state of health: Victims of attack if
can be described, it does not exist in real practical having hypertension, coagulation disorder,
sense. No bite mark containing all ideal features or taking medication (Aspirin, Steroids—
that experts might agree on collectively has been delay healing) also bleed significantly more
demonstrated/published till date. The old adage, than apparent normal healthy counter parts.
“one can not ever have enough evidence” applies Sometimes bruise may appear at instant or take
to all forensic applications, especially the forensic as long as 48 hours, related to time required for
extravascular blood to reach surface (AM injury
bite mark analysis.
may be revealed at PM).
Aging/Changes Over Time 4. Skin pigmentation: Affects observation.
In 1973, Harvey stated that the external physical 5. Environmental conditions: Lights, temperature,
appearance of bite marks changed with time. interpretation.
Bite Marks 121
Ageing/changes over time as determined by color of the bruise after infliction of bite mark

injury (Fig. 6.11)
Published findings on color changes in bruises
Fig. 6.11: The chart showing the various published findings on color changes in
injured human tissue as a result of bite marks
Keys to color coding incised. Unlikely to be confused with any other

• R—red, injury mechanism— High forensic significance.
• P—purple, e. Partial avulsion of tissue, some lacerations
• G—green, present indicating teeth as the probable cause
• Y—yellow, of the injury—Moderate forensic significance.
• V—violet, f. Complete avulsion of tissue, possibly some
• P/—black scalloping of the injury margins suggested that
teeth may have been responsible for the injury.
Range of Bite Mark Severity—The Bite mark May not be an obvious bite injury—Low forensic
Severity and Significance Scale
significance.
(Figs 6.12A to F)
a. Very mild bruising, no individual tooth marks Distortion in Human Bite Marks
present, diffuse arches visible, may be caused
The occurrence of distortion in human bite marks
by something other than teeth — Low forensic
is well recognized. A forensic classification of
significance
distortion is suggested which is based upon the
b. Obvious bruising with individual, discrete areas
causative factors and their inter-relationships.
associated with teeth, skin remains intact—
There are several factors that contribute to
Moderate forensic significance
the character of the bite mark. These include
c. Very obvious bruising with small lacerations
associated with teeth on the most severe aspects the resiliency of the matter bitten, the degree
of the injury, likely to be assessed as definite bite of pressure applied during the bite, the time
mark— High significance lapse between when the bite is produced and
d. Numerous areas of laceration, with some the examination, whether the person is living or
bruising, some areas of the wound may be deceased.

A D
B E
C F
Figs 6.12A to F: The range of severity of bite marks on human tissue on a grade scale of 1 to 6,
along with their forensic significance
Bite Marks 123
A recurring difficulty in analysis arises from Skin is an elastic medium capable of dist-

the distortion, which is a variable feature of bite ortion due to pressure and reconstituting to its
marks. In the context of a bite mark, distortion original contour when the pressure is removed.
may modify the appearance of a bite, or the Skin tension, due to elastic fibers in the dermis,
photo-graphs of a bite, such that it is not an exact varies depending on age and anatomical location.
mirror image of the features of the mouth of the The phenomenon of stretching and relaxing
biter. Distortion may complicate or even preclude produces a variable degree of tissue distortion
proper comparison of the bite mark and the causal in all bite marks. Tissue distortion can also arise
dentition. due to edema produced in response to biting.
Distortion can occur at different stages in the The quantity of tissue available for biting is also
causation and the investigation of bite marks. It a contri-butory factor in tissue distortion. When a
may occur at the time of biting defined as primary quantity of tissue is taken into the mouth, this may
distortion. Distortion may occur subsequent to the produce “tenting” of the tissue, which results in
bite being made or introduced at the stage when dimensional changes in the skin.
the bite mark is being examined or recorded which
is defined as secondary distortion. Secondary Distortion
Primary Distortion There are three categories of secondary distortion.

Time-related distortion occurs when a bite changes
The two main components of primary distortion with time elapsed subsequent to the bite being
are the dynamics of the biting process (dynamic made. The other two categories of secondary
distortion) and the detailed features of the tissue distortion, posture distortion and photographic
being bitten (tissue distortion). Dynamic and
tissue distortion are complex and unpredictable
pheno-mena, which are closely related because of
their simultaneous occurrence during the episode
of contact between the dentition and the skin.
Distortion may be produced by the dynamics of
the action of biting (Fig. 6.13). The degree of
movement between the teeth and the bitten tissue
can range from essentially nil in static bite marks to
extreme in tooth scrape marks. Dynamic distortion
is proportional to the degree of movement. The
dynamic event is composed of multiple component
movements by the assailant and/or the victim
during the episode of contact between the
dentition and the skin. Every episode of contact is a
unique event. Accordingly, a dentition can produce
bite marks, which exhibit variations in appearance.
In cases of multiple bite marks produced by a
single dentition in one victim the bite marks vary
in appearance due to the unique dynamics of each Fig. 6.13: The primary distortion of bite marks
biting episode. (for details see the text)
distortion occur during examination and evidence Reconstruction of the victim’s known body

recording. position at the time of biting or the reconstruction
Time-related distortion can take different forms. of a range of positional possibilities is most
Where there is a laceration or where a segment of applicable to the live victim. In cases involving a
tissue has been bitten off, the subsequent healing dead victim, the body position is unknown and
can involve changes, particularly tissue contraction, the reconstruction of a range of body positions is
which can modify the dimensions and detail of not so readily achieved. Therefore, the potential
the bite. Bruise changes with time can result in occurrence of posture distortion may be more
migration of part of the bruise to a slightly different difficult to account for in dead victims.
anatomical location. The bruise may also diffuse Distortion may be produced by the photo-
variably giving an altered shape. graphic method of recording the bite mark.
Posture distortion occurs when the bite mark Photographic distortion arises as a result of the
is viewed or recorded in a position, which is influence of the angle of the film to the mark and
different from the position of the tissue at the body curvature. The ideal photographic angle is 90
time of biting (Figs 6.14A and B). The degree degree with the camera perpendicular to the center
of posture distortion depends on the variation of the bite mark. This angle produces parallelism
in body position and anatomical location. The between the film plane and the bite mark plane
greater the variation in body positions between the and consequently photographic distortion is
time of biting and evidence recording, the greater insignificant. Variation from the perpendicular will
the likely degree of posture distortion. Different produce photographic distortion in proportion to
anatomical locations potentially demonstrate the extent of the variation. In effect, moving the
varying degrees of posture distortion. Marked camera to one side or the other of the bite mark
posture distortion can be observed in a limb creates photographic parallax.
depending on the degree of flexion and extension There are four categories of photographic
and in the female breast depending on the arm distortion:
position and body position. Posture distortion
Type I distortion
during photography, is necessary to attempt to
This occurs when the scale and bite mark are on the
reconstruct the victim’s body position at the
same plane, but the camera is not parallel to them.
time of biting. Clearly this ideal is not always
This is also called off-angle distortion (perspective
possible and if not, it is suggested that bite
distortion). This type of distortion can be corrected
marks are photographed in a range of positional
digitally.
possibilities.
Type II distortion
If the scale is not on the same plane as the bite mark,
rectifying the scale adversely affects the proportions
of the injury pattern.
Type III distortion

In some cases, one leg of a two dimensional scale
has perspective distortion, but the other leg does
not. In this situation, only the non-distorted leg
Figs 6.14A and B: The secondary distortion of bite marks of the scale is used for the rectification and resizes
(for details see the text) procedures.
Bite Marks 125
Type IV distortion analysis relies progressively more on distinctive

In type IV distortion, the scale itself may be bent features. The role of superimposition techniques
or skewed. There can be forensic value if the scale is to ensure that there is sufficient correspondence
is relatively flat in the area directly adjacent to the between the sizes and positions of the teeth of an
bite mark. accused.
The American Board of Forensic Odontology All types of distortion complicate the process
(ABFO) Bite Mark Guidelines Committee of matching marks to dentition, thus making it
suggested that a circular scale should be included in important to understand the distortion.
photographs, to permit accurate calculations of the
photographic angle and to allow correction for any General Principles Behind Identification of
distortion caused by improper angulations. If the Bite Marks
roundness of the circular scale was re-established in The scientific basis is rooted in the premises of
the superimposition process, then the photographic the individuality of human dentition and belief that
distortion in the bite mark was also corrected. This no two humans have identical dentitions in regard
suggestion resulted in the development of the to size, shape and alignment. Similar to fingerprint
bite mark standard reference scale — ABFO No. and DNA analysis, with one major exception, that
2. The plane of the scale must be parallel to the they can be expressed quantitatively as a numerical
bite mark plane and on the same level. For more probability based on databases, while individuality
detailed discussion on phtotgraphy in bite marks of dentition is commonly observed, there is no
cases, readers are advised to see the chapter titled database to express it quantitatively.
“Dental Records and Forensic Photography”. As mentioned earlier, the first person to whom
According to Rawson et al a curved body real credit must be given for having published an
surface, which allows visualization of the entire analysis of a bite mark case is Sorup. The method
bite mark, has a surface angle too small to produce used he called “odontoscopy,” analogous to the
significant photographic distortion. This statement fingerprint identification called “dactyloscopy.”
can only be made if the entire bite mark can be By this method, plaster casts of the teeth of the
visualized from one direction. If the body curvature suspect are obtained, dried, and varnished, after
is so great as to obscure part of the bite mark, then which the incisal edges and occlusal surfaces are
the surface angle is large enough to cause significant coated with printer’s ink. Upon this inked surface
photographic distortion and multiple photographs a sheet of moistened paper is pressed, and a print
would have to be taken of the various parts of the is transferred from it to transparent paper. This
bite mark. print is placed over a life-size photograph of the
The degree of distortion present in a bite mark bite mark and compared.
is variable and affects arch size and shape. Clearly, During the process of bite mark analysis,
size-matching techniques are only applicable to bite the unique characteristics of a suspected biter’s
marks exhibiting minimal distortion. The incidences dentition are compared with patterns observed
of discrete morphological points of comparison in the bitten skin, two simultaneous and opposite
or distinctive features in a bite mark are the most paths develops.
significant criteria in bite mark analysis. This is Inclusive path: Strong and consistent linking
partly due to their relative immunity to distortion. in tooth by tooth and arch by arch comparison
As the degree of distortion increases, bite mark between suspect and the victim.
Exclusive path: Suspected biter’s dentition show • Impression

no linking with the patterns recorded. • Excision of bite mark in deceased victim.
Various author’s experience suggests that 2. Evidence collection from the bite suspect
exclusionar y pathway is accomplished more • Clinical examination
frequently and easily. • Photographs
Human skin is not fixed and rigid; one must • Impressions
acknowledge that the dynamics of biting process • Bite-sample.
together with the location of bite on the body 3. Bite mark analysis and scoring.
affects the pattern of resulting injury and its
usefulness in the process. Also skin is not a good Evidence Collection from the Bite Victim
impression medium and that the skin distortion
In private general practice we do not often have
occurs at the movement bitten, investigator should
the opportunity to deal for collecting evidence
be mindful about the level of distortion.
from bite victims. It is the detectives at the scene
It has been suggested by the experts that the
of the crime, pathologists at autopsy or medical
forensic dentist charged with collection of bite
personnel who find most bites. But since physical
mark evidence should not be the same dentist that
and biological evidence from a bite mark begins
makes the impression of the suspected biter. Stone
to deteriorate soon after the bite is inflicted,
dental models should be referred to using letters
all dentists should be familiar with the general
or numbers instead of names. If dentists are aware
principles of evidence collection. This is especially
of the various methods to collect and preserve bite
mark evidence from victims and suspects it may true for dentists that deal with patient populations
be possible for them to assist the justice system that may potentially contain victims of domestic
to identify and prosecute violent offenders. Con- violence, in which bites are often discovered.
clusions can be reached about any role a suspect Practitioners should make every effort to accurately
may have played in a crime. It is important not and precisely preserve the evidence as soon as
to inflate its value in attempting to increase its it is discovered using the following techniques,
significance to the trier of the fact. and not wait until others with more experience
can be consulted or summoned. The best or only
ABFO’s Recommended Procedure and opportunity to collect the evidence may be when it
Guidelines: Bite Mark Analysis Guidelines is first presented and observed. If a dentist finds a
patterned injury that is suspected to be a bite mark,
The following chain and custody of events reflects
it should be reported to the police or social welfare
the opinion and procedures to be followed in a
agency with local jurisdiction. Then, the dentist
manner whenever a dentist/forensic odontologist
should complete the following list of procedures
is called upon for an investigation of the case
to properly collect the evidence:
involving bite marks. It should consist of three
major steps: a. The first aid
1. Evidence collection from the bite victim, first The best or only opportunity to collect the
consisting of: evidence may be when it is first presented and
• First aid observed. Prompt medical attention should
• Preliminary examination and documentation be provided for the living victim since human
• Photographs bites have a higher potential for infection (HIV,
• Saliva swabs Hepatitis –B), than animal bites (rabies). Injuries
Bite Marks 127
that disrupt the integrity of the skin’s surface injury. If these individual characteristics are not

should be treated as soon as possible. If suspected, present in the teeth, or if they are not recorded
it should be reported to the police or social welfare well in the injury, the overall forensic significance
agency. Then, the dentist should complete the of the bite mark is reduced.
following list of procedures to properly collect It is very important during initial examination
the evidence. of the injury to be certain that an artefact, such as
an ECG electrode applied by emergency medical
b. Preliminary examination and documentation:
personnel, did not cause the pattern or that some
The dentist should record and describe:
object other than teeth has caused a circular or
Identification data elliptical injury. Some authors have witnessed burns
Case number, agency, name of examiner(s) from the end of a hair curling iron (Fig. 6.15) and
Location of bite mark patterns from the end of a lead pipe that closely
Anatomical location or object bitten resembled bite marks. These could be differentiated
Surface contour (e.g. flat, curved or irregular) by the absence of class characteristics caused by
Tissue characteristics (elasticity, vascularity) human teeth in each case.
Shape, color, and size of the injury The injuries caused by teeth can range from
Type of injur y, e.g. cuts, bruises, abrasion,
bruises to scrapes and cuts or lacerations. Certainly,
contusion, avulsion
it is possible for enough force to be generated to
Other Information as indicated.
allow penetration of the biting edges of the teeth
Along with above said features dentist should into the deep layers of the skin. If much time
also determine that can the difference between elapses from the moment of injury to the time of
marks from the upper and lower teeth be made. discovery, the diffuse nature of bruises and the
Three-dimensional characteristics, and any other changes associated with injuries over a period of
unusual conditions found should also be described. time may further diminish the evidentiary value.
Vertical and horizontal dimensions of the bite mark This is especially true in the case of living bite
should be noted, preferably in the metric system. victims but also in deceased individuals.
Bite marks with high evidentiary value that
can be used in comparisons with the suspect’s
teeth will include marks from specific teeth that
accurately record distinct traits. It is possible
to identify specific types of teeth by their class
characteristics. For example, incisors produce
rectangular injuries and canines produce triangular
injuries. But it is necessary to have individual
characteristics recorded in the bite mark to be
able to identify positively the perpetrator. Use,
misuse and abuse of the teeth result in unique
features that are referred to as accidental or
individual traits. Such characteristics include
fractures, rotations, attritional wear, congenital
malformations, etc. When these are recorded in
the injury it may be possible to compare them to Fig. 6.15: The artifactual marks left on the
identify the specific teeth (person) that caused the fore arm by a hair curling iron rod
c. Photographic documentation of the bite site: in black and white. Take extensive orientation and

Guidelines of the ABFO Digital Enhancement close-up photographs (Figs 6.16A to E). Color
Committee or specialty filters may be used to record the bite
The bite site should be photographed using site in addition to unfiltered photographs. Alternative
conventional photography and following the methods of illumination may be used. Video/digital
guidelines as described in the ABFO Bite mark imaging may be used in addition to conventional
Analysis Guidelines. The actual photographic photography. A tripod, focusing rail, bellows or
procedures should be performed by the forensic other devices may be utilized.
dentist or under the odontologist’s direction to The ABFO no. 2 (Fig. 6.17) reference ruler
insure accurate and complete documentation of is recommended in bite mark photography. The
the bite site. placement of the scale should follow the guidelines
Using 35 mm film, start with general orientation as established in the ABFO Bite mark Analysis
and move on to close-up photographs using an Guidelines. Be certain that the camera is positioned
intraoral camera with a macro lens and take both directly over the injury site. The long axis of the
color and black-and-white photos, as color may lens should be perpendicular to the bitten skin to
block eyes to see subtle changes that may be seen reduce perspective distortion in the photographs.
A B C
D E
Fig. 6.16A to E: The ABFO recommended pictures of a bite mark victim, including his orientation;
close up, black and white, color and special photographs
Bite Marks 129
With living victims, serial pictures are taken over Digital photography is used only as an adjunctive,

several days for documentation of healing of the as their legal admissibility is doubtful and limited.
wound. For more details readers are advised to In certain cases of extensive tissue damage special
please go through the chapter devoted to forensic photographs are used in order to reveal deep
photography for better understanding of the wound patterns and detailed surface topography
subject. of the wound.
Lighting Non-visible light photography: UV light: Do not
Off angle lighting using a point flash is the most penetrate deep in skin and is reflected back as a
common form of lighting and should be utilized highly detailed surface image of skin, containing
whenever possible. A light source perpendicular additional data about teeth
to the bite site can be utilized in addition to off Infra red: Does penetrate skin for a few mm. with
angle lighting; however, care should be taken to this, it is possible to create an image of injury
prevent light reflection from obliterating mark as it appears below the surface of skin. Infra red
details in photograph due to “wash out” due to photography captures bleeding pattern below skin.
light reflection. A light source parallel to the bite
site can be utilized in addition to off angle lighting. d. Saliva swabs
A ring flash, natural light and/or overhead diffuse Saliva will have been deposited on the skin during
lighting can be utilized to off angle lighting. biting or sucking and this should be collected and
analyzed, the aim being solely the collection of
Special photographs: Generally visible light cells for DNA. Swabs should be taken as soon as
photography is used in practice with slowest possible after the bite is inflicted and before the area
film of speed < 100 (ASA speed< 100), because is cleaned or washed. If it can be determined that
of high grain density and sharper details even at the bite was inflicted through clothing, attempts
enlargement. should be made to seize the clothing for DNA
analysis. The following technique will maximize
the amount of DNA recovered.
Double swab method
First, a cotton swab moistened with distilled
water is employed to wash the surface that was
contacted by the tongue and lips using light
pressure and circular motions to wash the dried
saliva from the surface over a period of 7 to
10 seconds. Then, a second swab that is dry is
used to collect the remaining moisture that is
left on the skin by the first swab. Both swabs are
thoroughly air-dried at room temperature for at
least 45 minutes before they are released to police
authorities for testing.
The two swabs must be kept cool and dry to
Fig. 6.17: The ABFO Scale No. 2, to be used for
reduce the degradation of salivary DNA evidence
measurement of a bite mark size and the growth of bacteria that may contaminate
the samples and reduce their forensic value. Then

they should be submitted to the laboratory as soon
as possible for analysis. If the time until submission
is protracted, it is recommended that the swabs be
stored in a paper evidence envelope or box that will
allow air to continue to circulate around the swab
tips. (The swabs should not be sealed in plastic
bags or plastic containers). They are kept at room
temperature if submitted within 4 to 6 hours, or
refrigerated (not frozen) if stored longer than six
hours.
A DNA sample must also be collected from the
victim at this time to provide the opportunity for Fig. 6.18A: A sequence depicting the of recording of
comparison with the sample from the bite mark. registering a bite mark case Impression of a bite mark of
the culprit
This sample could consist of a buccal swab or a
sample of whole blood. The victim’s DNA profile
will enable analysis of any mixtures that are found
in the sample from the bite, which may involve
contributions from the depositor and the victim.
e. Impression
Indicated when indentations, depth or a 3-D
quality could be seen in injury. Fabricate an accurate
impression (Figs 6.18A to C) of the bitten surface
to record any irregularities produced by the teeth,
such as cuts, abrasions, etc. Use Vinyl polysiloxane,
Polyether or other impression material available
in the dental office that is recommended for fixed Fig. 6.18B: Pouring of master cast and looking for the
prosthetic applications. Dental acrylic or plaster details recorded
can be used as a rigid support for the impression

material; this will allow the impression to accurately
record the curvature of the skin. Make two casts
always, one working and another virgin. When a
self-inflicted bite is possible, impressions of the
individual’s teeth should be made.
f. Tissue Samples: Excising bite area
In the deceased, tissue specimens of the bite mark
should be retained whenever possible. The skin and
underlying muscle and adipose tissue with one inch
margins is removed for trans-illumination analysis
(Fig. 6.19). Most of the authors dealing with Fig. 6.18C: Comparison of cast of the suspect with the
examination of bite marks in human corpses have indentation marks left on the victim
Bite Marks 131
called attention to the possibility of shrinkage by Evidence Collection from the Bite Suspect

rigor mortis and the considerable shrinkage (nearly
Evidence collection from the bite suspect: As said
two-thirds) after the tissue with the bite marks has
earlier this chain of events must include clinical
been cut out.
examination, photographs, impressions and bite
This shrinkage takes place in spite of immediate
sample. The collection of dental exhibits for forensic
fixing of the skin flap in five percent formalin.
uses has been deemed to be an invasive procedure.
Before excision, an acrylic support ring should
Thus, dental impressions and bite samples that
be secured to the tissue sample to prevent tissue
are seized from a suspect are susceptible to strict
shrinkage. Excised tissue can be transilluminated
rules of evidence. Another dentist should always
by a shining light from dermal/inner side, it may
perform these events to eliminate any arising bias.
illustrates fine bleeding patterns.
A search warrant, court order or legal consent may
Buhtz and Erhardt, therefore, have recom-
be required before evidence is collected form the
mended that not only the skin flap but the whole
suspect. So they must be obtained either using
area with the underlying tissue should be cut out.
a court order (warrant) or with a signed and
In the case of a bite mark left in the breast of a
witnessed informed consent. Generally, suspects
female, the whole breast is to be removed. In the
are usually quite cooperative during the collection
case of a bite mark left in an arm or a leg of a corpse,
of physical exhibits. However, this is not always the
it is not sufficient to remove the actual tissue area
case and most commonly, the suspect is in custody
to the bone; instead, one must transect the arm or
and the dental examination takes place away from
leg and include a broad margin on both sides of
the practitioner’s dental office, perhaps in a jail or
the bite mark.
remand facility. So the dentist who is requested
to assist authorities to collect evidence should see
that provisions to ensure their personal security
are in place.
North American Courts have ruled that
collection of this type of evidence does not violate
the individual’s rights against self-incrimination
because he is not being required to testify against
himself, only to provide physical evidence that will
be used in a comparison. If the suspect refuses to
provide exhibits for comparison purposes, he may
be held in contempt until he complies. The Court
might issue an order in this instance to authorize
the use of force to obtain the exhibits. In the
United Kingdom, court orders are not available to
collect evidence by force. A jury is left to develop
their own conclusions if the suspect refuses to
submit to dental evidence collection procedures.
Fig. 6.19: An excised bite mark from a dead person in order The following exhibits and items of physical
to preserve the bitten tissue and in order to perform the test
of trans illumination. Note the acrylic ring tighten all around
evidence are recovered during examination of the
the excised tissue bite mark suspect.
a. Clinical examination and characteristics of the dentition. Accurate dental

The extraoral and intraoral structures are examined impression materials, such as vinyl polysiloxane
and significant findings are noted on a dental chart. or polyether should be used, although custom
Special attention is focused on the status of the special trays are seldom fabricated for the suspect.
general dental health, occlusion and mandibular It is recommended that two sets of study casts be
articulation. Results of a specific examination of produced using a hard stone, such as dental die
such things as: stone. All of the materials, including the trays,
• Maximum mouth opening impressions and casts are maintained in secure
• Tooth mobility, storage for eventual release to police authorities.
• Periodontal pocketing, The specific instructions for product handling and
• Dental charting of restorations,
material mixing that are recommended by the
• Diastema, fractures, caries and
manufacturer must be closely followed. Buccal
• Function of masticatory muscles are docu-
swabs from the suspect’s oral cavity is also taken.
mented
d. Bite sample
b. Photographs
Collect test bites from all suspects including victim,
Full facial and profile photographs are produced in
if bite mark occurred in an area of body where
addition to intra-oral exposures to depict the upper
and lower dental arches and frontal and lateral views victim could have bitten himself. Aluwax, base
of the teeth in occlusion (Fig. 6.20). A reference plate wax, Styrofoam may be used (Fig. 6. 21). In
scale to enable measurements to be taken from the case of avulsive injury, use thicker textured material
photographs should be included in the same plane like partially set impression material. It can also
as the teeth. be taken from stone model’s of biter’s teeth. This
exhibit should be photographed immediately after
c. Impressions
it is recorded. This will provide an opportunity
It is necessary to produce extremely accurate study
for future comparison of the photograph and the
casts of the teeth that record all of the physical traits
exhibit to verify that no distortion has occurred.
The suspect should be held in custody until
the quality and accuracy of all of the exhibits is
determined to be satisfactory.
Fig. 6.20: A composite highlighting the various photographs Fig. 6.21: A typical bite mark left on the styrofoam of the
of the suspect to be taken during the course of investigation, suspect. Styrofoam is commonly used for registration of the
viz. maxillary, mandibular arches separately, and in occlusion bite sample
with frontal and lateral views
Bite Marks 133
Bite Mark Analysis and Scoring Dr Rawson, a forensic dentist, two dental

students, and a statistician wrote arguably the most
An essential component of the determination
of the validity of bite mark analysis is that the cited and well-known bite mark paper describing
techniques used in the physical comparison an empirical experiment. In an attempt to prove
between suspect dentition and physical injury finally the uniqueness of the anterior segment of
have been assessed and found valid. One of the human teeth, Rawson examined 397 bites and
fundamental problems with this task is the wide applied a statistical probability theory to the results.
variety of techniques that have been described in
the literature. Techniques using confocal, reflex
and scanning electron microscopes, complex
computer systems, typing of oral bacteria, special
light sources, fingerprint dusting powder and
overlays have all been reported. It is a widely held
belief that while methods that are more esoteric
exist, the dominant technique for comparison of
exemplars is transparent overlays.
The lack of direction from the forensic dental
organizations, both European and American,
complicates this matter. The American Board of
Forensic Odontology (ABFO) has reported advice A
and guidance on many aspects of bite marks and
yet one of the most pivotal questions, i.e. what is
the best comparison technique to use, has not been
addressed.
Transparent overlays utilize materials found
in any dental office. The vast majority of forensic
dentists use techniques that utilize materials that
are inexpensive and easily obtainable, hence the
popularity of overlays (Figs 6.22A and B). There
are numerous techniques for the fabrication of
transparent overlays. Of all the techniques, an
examination of case reports and experiments reveals
that the xerographic and radiographic techniques
are the most popular.
The computer technique (Fig. 6.23) represents
the most accurate fabrication method with respect
to representation of rotation and area of the biting
edge. Various authors have concluded that the
fabrication methods that utilized the subjective B
process of hand tracing should not be used in
favour of techniques that are more objective. The Figs 6.22A and B: The overlay technique for transferring the
indented bite marks from the victim or from the cast of the
use of computer-generated techniques was advised suspect and its subsequent comparison with those of actual
over any other method. left bite marks
methods in the comparison of Bite mark evidence.

The purpose of bite mark analysis is to compare
the bite evidence with the suspect evidence and
to determine if correlation exists. Analysis usually
involves visualization and comparison, formation
of an opinion and often court testimony.
The responsibility of comparing the photo-
graphs of the bite pattern injury with the dentition
of the suspect rests with the forensic dentist.
Fig. 6.23: The more sophisticated technique of using
The foundation of bite mark analysis lies in the
computers in case of bite mark cases following premises:
1. Each individual’s dentition is presumed to be
Using this premise, the article then stated that the
unique.
probability of finding two sets of dentition with all
2. This presumed uniqueness is accurately recorded
six teeth in the same position was 1.4 × 1013. With in the characteristics of the injury on the skin
an assumed world population of 4 billion (4 × 109) or object. Consequently, bite mark evidence has
Rawson stated that a match at five teeth on a bite become legally accepted and admissible in courts
mark would be sufficient evidence to positively of law.
identify an individual as the biter to the exclusion 3. Numerous cases have involved bite mark
of all others. evidence in criminal proceedings
4. Criticism of bite mark evidence as a reliable
Forensic Physical Comparison of Exhibits scientific tool has been expressed due to the
subjective nature of comparative analysis.
It is simply the comparison of bite evidence to
The dynamics of biting make analysis of the
the suspect evidence to determine if a correlation
bite mark and its comparison to the suspect’s
exists. The most common methods to determine
teeth challenging. In addition to jaw movements,
if the suspect’s teeth caused the bite mark include
one needs to consider movement on part of the
techniques to compare the pattern of the teeth
victim, the flexibility of the bitten tissue, as well
(shape, size, position of teeth, individually and as distortion introduced during photography.
collectively) with similar traits and characteristics Bearing this in mind, one may proceed with the
present in life-sized photographs of the injury using analysis. It is important to consider uncommon
transparent overlays. These overlays have been
characteristics of the bite mark such as presence
produced using various techniques. or absence of a particular tooth, mesiodistal
The most accurate technique has been found to dimension, rotation, fracture, diastema, and other
be a method using a computer. Other comparison unusual features of the teeth as these may help in
methods include the direct comparison of the implicating a suspect.
suspect’s study casts with photographs of the bite Ideally, bite mark analysis should begin with a
mark, comparison of test bites produced from the qualitative and quantitative analysis in situ. This
suspect’s teeth with the actual bite mark, and the should be followed by the analysis of life sized or
use of radiographic imaging and scanning electron enlarged photographs. Models and impressions
microscopy. A 1994 survey of Diplomates of the of bite marks add to the evaluation. A separate
American Board of Forensic Odontology indicated qualitative and quantitative analysis of the models
that they presently use the following analytic and occlusal registrations from the suspect’s
Bite Marks 135
dentition should be performed at this stage; only 2. Computer software programmes such as Adobe

after these steps should one proceed towards Photoshop
comparison, as it avoids bias. 3. CAT scans.
The protocol for bite mark comparison is made The newer trends are moving towards the use
up of two broad categories: of computer software programs suggested by
i. The measurement of specific features of the Johansen and Bowers. A 3-D/CAD supported
bite mark and suspect’s dentition, called “metric photogrammetry approach developed by Thali and
analysis” coworkers holds promise for the future.
ii. Matching the pattern of injur y to the Based upon the 3D detailed representation of
configuration of teeth on the suspect’s dental the cast with the 3D topographic characteristics of
cast, called “pattern association”. the teeth, the interaction with the 3D documented
skin can be visualized and analyzed on the
Metric Analysis computer screen. It is possible to demonstrate
The following features captured in the bite mark the progression of the biting action and the
should be measured and recorded: development of the subsequent injury pattern.
• The length, width, and depth of the tooth Bite mark identification is based on the
• Overall size of the mark individuality of a dentition, which is used to
• Intercanine distance match a bite mark to a suspected perpetrator. This
• Spacing between tooth marks matching is based on a tooth-by-tooth and arch-to-
• Rotation from normal arch form arch comparison utilizing parameters of size, shape
A similar procedure is employed with the and alignment. The most common method used to
suspect’s casts. The measurements thus obtained analyze bite mark is carried out in 2D space. That
are compared to one another. Simple instruments means that the 3D information is preserved only
such as a vernier caliper may be used for obtaining two dimensionally with distortions.
the measurements. More recently, computer based
analysis such as Adobe Photoshop has also been Biological Techniques for Bite Mark
used. Metric analysis however, should not be used Comparisons
alone, but rather in conjunction with pattern
association. The biological basis of bite mark analysis has
centered on the recovery of salivary DNA and
Pattern Association Sweet has pioneered much of this work. While such
Pattern association involves direct methods and techniques offer an objective, scientifically validated
indirect methods of comparison. Direct method method of bite mark, analysis by the systems
is where the suspect’s models are placed directly employed are expensive and require extensive
over the photograph of the bite mark or the bite laboratory equipment and expertise.
mark itself, i.e. in situ. Bite registrations obtained A new technique that has attracted attention
from the suspect may also be compared with the is the genotyping of oral bacteria, mostly oral
actual bite mark. streptococci. With over 2000 species in an
Indirect method uses the following: individual’s mouth it is possible to develop a
1. Superimposing transparent overlays of the bacterial ‘fingerprint’ due to the diversity of such
suspect’s bite edges and the bite mark photograph populations.
Comparison Techniques

Bite mark comparison protocols include measure
ment and analysis of the pattern, size and shape of
teeth against similar characteristics observed in an
injury on skin or a mark on an object.
The comparison involves not only the use
of superimposition techniques but also, more
importantly; the collection of all the evidence, Fig. 6.24: Picture showing the comparison of the cast of the
including the physical features as well as the suspect to those of photograph of actual bite marks left on
dynamics of the bite and the compatibility of the the victim
features with the suspect’s teeth.

Whatever the techniques used the odontologist
must have confidence in the findings and be
prepared to demonstrate them clearly and simply slippage of the teeth, by placing the model directly
to the jury in the courtroom. over the breast of a deceased victim and dragging
The comparison techniques have been divided the model across the skin to demonstrate how the
into two categories life size and assisted comparisons. marks were produced in vivo. The entire procedure
Comparisons are made between life-size 1:1 was photographed, videotaped and produced as
photographs and a variety of tracings and overlays evidence.
or reproduction of the biting surfaces of the Furness described a method similar to that
suspect’s teeth. Assisted comparisons involve the used by fingerprint officers, where lines are used
use of microscopes of varying types, electronic, linking various points of correspondence between
the models and the teeth. The advantage of this
histological, radiographic and specialized
technique is that fine detail such as cervical margin
techniques including the use of experimental bite
indentations can be seen and compared.
marks.
The disadvantage is that the technique cannot
be used on grossly distorted marks, as the lines
Life-size Comparisons
will not tally and could require lengthy court
Life-size comparison is the most common type explanations.
undertaken by the odontologist using the life-size
Indirect methods
1:1 photographs with the models of the teeth.
Indirect comparison is made using transparent
Direct method overlays on which the biting surfaces of the teeth
The models are placed directly over the photographs are recorded; these are then placed directly over
and the concordant points demonstrated, e.g. the the marks on the photograph. This method was
fit of the incisal edges (Fig. 6.24). It is worth first used by Sorup in 1924 and cited by Strom.
remembering that the comparison is of a three- The most common methods used to compare a
dimensional model with a two-dimensional suspected biter’s dentition with a bite mark injury
photograph. An advantage of this method is that involve some form of overlay technique. Morgen
the model can be moved to illustrate the dynamics used photographs of the models to produce
of the bite by showing slippage and scraping. overlays. The photographic production of overlays
West and Friar used direct model-to-victim by various methods is the most reliable way of
comparisons to demonstrate marks caused by producing true reproduction of the dentition.
Bite Marks 137
Camerson and Sims in 1974 described a method stone casts, hand traced from wax impressions,

of using a closely adapted acetate film on the model xerographic method and radiopaque impression
and tracing the biting surfaces of the teeth on it. method) from dental casts, it was found that the
The use of photographic tracings can be computer based method was the most accurate
enhanced by using oblique lighting on the model followed by xerographic method. The radiopaque
to highlight specific features. impression method was found to be the least
Other methods such as pressing the teeth into accurate followed by the hand tracing from the
wax and photographing the indentations can dental casts.
produce accurate overlays. The indentations can Farrell et al used computerized axial tomography
be enhanced if sprinkled with radiopaque powder scanning to produce overlays of the dentition at
and radio graphed. varying depths, so that the teeth not involved
Overlays of the chewing surfaces of teeth can be initially in the bite were shown at the precise depth
obtained by: at which they began to be involved in the mark.
1. Tracing these surfaces on a sheet of transparent Despite this overabundance of methods a recent
acetate. survey of 72 odontologists found that over 90
2. A glass of photocopier machine and duplicating percent used some form of overlay as their sole
on transparencies or special paper method of pattern analysis.
3. Utilizing the computer, scanner, Adobe
Photoshop Assisted Comparisons
4. Radiographic technique using metal fillings
This approach to the comparison of bite mark and
painted into test bite indentations created in
dentition encompasses simple procedures such as
plaster or wax wafers
measurements of inter-canine distances as well as
5. Inking the incisal edges of anterior teeth on
complex electronic methods. These can be used
stone models of suspect’s teeth and imprinting
where the mark is either distorted or not clearly
the inked edges on various materials.
defined. Jacobsen and Keiser-Nielsen point out that
Use of hand tracings has been discontinued
any measurements taken should be from within the
largely in favor of less subjective methods.
arch and not between the arches. If overlay method
Overlays created using a computer; scanner and
fails to produce a clear result then other methods
Adobe Photoshop were found to be more accurate
may be tried. It should be noted that these methods
and less subjective (Fig. 6.25). Computer-based
technique for the production of life sized bite mark
comparison overlays allows accurate and objective
selection of the biting surfaces of a suspect’s
teeth from dental study casts. Images of the teeth
of interest can then be exported to transparent
acetate film. Comparison overlays produced by this
method are referred to as hollow volume overlays
since they record the perimeter of each tooth’s
biting edge, leaving the inner aspect of the tooth
blank.
In a study of comparison between five com-
monly used methods of overlay production Fig. 6.25: Another picture showing the similar comparisons
(computer based method, hand-traced from with the help of computers
are best used as confirmation of result rather than hemorrhagic density. This is a useful technique

a sole assessment. when the mark is very diffuse. Removal of the tissue
Tsutsumi and Furukawa described the use of a does involve some distortion, and steps must be
measuring instrument called a Vectron, which is taken to minimize it.
similar to a dental surveyor and measures distances Biopsy and histological examination of bite-
between fixed points, angles and radii. marks is confined to the deceased. Whittaker
Bang used stereo metric graphic analysis in refers to methods of staining for iron, other
mark investigation and produced a contour map of blood products, elastic fibers and collagen. He
features of the mark and suspect dentition. A visual also describes the use of histological techniques
representation is then available which is compared to establish whether the mark was inflicted ante or
electronically with the mark in terms of longitudinal postmortem.
contours and topographical features. Glass et al used histology to demonstrate the
Light, electron and split image microscopy can presence of microorganisms and calculus within
be used. Bang and David both described the use of the lesion, thereby confirming that the mark was
the scanning electron microscope (SEM) to good caused by teeth.
effect. The use of reflected, or direct, ultra violet
Ligthelm et al have added the reflex microscope photography can be of great value for three reasons.
to range of microscopes in use. • They provide greatly enhanced surface detail
SEM is capable of detecting individual charac- because a greater proportion of radiation of the
teristics due to its high level of resolution. Using wavelength used is reflected from the epidermis
SEM it has been demonstrated that a single class than is the spectrum of visible light.
characteristic contains individual charac-teristics. • They may enhance the clarity of outlines of
SEM may help to create an opinion that contains injuries due to their ability to record subtle
a higher degree of certainty that a specific set and even invisible pigmentary changes that are
of teeth made a certain set of marks. Various known to occur after injury
• They may be taken, sometimes to great effect,
electronic techniques such as splitting the image,
many weeks and, some claim, even months after
image stacking, bite edge enhancement etc can
injury and still provide useful evidence, since
be used.
the pigmentary changes referred to above take
Specialized Techniques some time to occur.
Although acceptance of bite mark evidence has
Xeroradiography and transillumination, as described
progressed, there is still a constant search for new
by Rawson et al and Dorion respectively are methods, which improve on the shortcomings of
specialized techniques that have been used in traditional techniques. Recent methods described
bite mark analysis. Both these techniques require include infrared and ultra violet photography,
the removal of the bitten tissue. In case of the scanning electron microscopy, computerized
xeroradiographic technique a layer of iodine image enhancement, radiographic techniques,
contrast material is used and radiographs of the stereo metric graphic plotting and the use of three-
mark are taken. Xeroradiography is only applicable dimensional measuring instruments. Shortcomings
when indentations are present. of these methods include inaccurate visual,
Transillumination utilizes the changed hemor- photographic or graphic matching and damage to
rhagic structure of the tissue, which is viewed under the bite mark due to certain procedures such as the
a light source that enhances the areas of varying making of impression.
Bite Marks 139
Experimental Marks

The use of experimental marks to analyze a bite
mark has been used as an aid to comparisons. They
stipulate that three criteria should be met before
undertaking experimental bite marks:
• The mark has been established as having made
by teeth
• A reliable reproduction, example: A photograph
• The circumstances under which the bite was
inflicted are known.
Vale et al made a rubber model of the part that
was bitten, in this case a nose, and produced similar A
marks using the suspect’s dentition on the model.
Many other materials have been used in attempts
to produce a skin like substance, such as baker’s
dough or pig-skin.
Bite Marks in Inanimate Objects

There are numerous examples in the literature of
criminals who have left impressions of their teeth at
the scene of a crime. The materials which are best
able to record such marks are cheese, chocolate
and metal tapes, where as those which present
considerable difficulties are softer materials such
as fruits, apples, cooked foodstuffs (Figs 6.26A
and B). The same recording procedures are used B
as have been described in the case of human flesh Figs 6.26A and B: Bite marks left in inanimate subjects at
so that the mark should be photographed under the scene of crime like those on food stuffs, like apple and
chocolates as shown here
standardized conditions and a description produced
of the type of dentition resulting in the mark.
If the services of a forensic dentist are not
immediately available, it may be necessary to material. In addition, brittle materials may fracture
preserve the material in which the mark was made. through the point of biting. A very useful technique
If it is foodstuff, the simplest and most effective may be to take silicone rubber impressions of
method is to wrap the object in slightly dampened the marks in some of these materials, and these
tissues and to then place in a sealed jar in the may be retained not only for analysis but for final
main body of a refrigerator at about +2°C. The presentation in court.
interpretation of the marks will differ from those Inanimate objects like cheese, fruits, bread,
seen in skin because during the biting of hard chewing gum in which tooth mark fall into three
objects the teeth slide through the foodstuff and broad categories.
produce not only marks relating to the incisal edges • Edible substances
but also gouges as the teeth travel through the • Objects that are habitually chewed
• Substances making contact with teeth during a. Photography

fall or skirmishes. Marks should be photographed from various
directions to show not only the point of tooth entry
Preservation and Collection of Inanimate but also the exposed parts. Photographic principles
Evidence for bite marks should be followed.
Saliva swabbing should be carried out and the b. Models
object should be examined for fingerprints, as it Stoddart described a method for making models of
must have been handled to reach the mouth. The perishable substances. For other inanimate objects,
preservation of foodstuffs is an urgent priority as modern two-stage crown and bridge impression
all food deteriorates once exposed to air. Criminals materials give satisfactory results. Depending on
are known to take bites out of apples or cheese, and the type of analysis required, models can be made
to leave chewing gum at the scene of the crime. using plaster, acrylic or composite restorative
For storage they suggested that the specimen be materials.
placed in a sealed plastic bag and kept refrigerated Analysis and Comparison in Inanimate Objects
until impressions and models can be taken from
it. For long term storage Rudland found that Analysis and comparison should follow the same
format as that for skin, i.e. a quantitative and
immersion in a medium of 5 percent glacial acetic
qualitative analysis of the marked object and the
acid, 40 percent formaldehyde solution and 70
subject’s dentition prior to a comparison being
percent ethanol in the ratio of 5:5:90 preserved
made.
apples for 10 years.
Having a life-size model of the teeth and model
It should be noted that the best marks are
of the object will enable a direct comparison to
produced on the skin of fruit and not in the fleshly
be made. Alternatively, if no suspect is available,
parts.
acrylic teeth can be shaped to fit the marks and
According to Webster and Mac Donald, cheese set up in. wax so that some idea of the dentition
will undergo a nine percent weight loss and eight responsible can be obtained. Comparison can also
percent shrinkage after exposure for 72 hours. This be made using overlays, photographs or any of
can be considerably reduced if the cheese is refrigerated the specialized techniques. Jonason et al used a
within this period. Layton describes a procedure for stereomicroscope to analyze the marks on a pipe
reproducing cheese bites in plaster of Paris. Chocolate stem. Mills placed a bullet directly onto articulated
is stable if refrigerated for up to one year. models of the suspect’s teeth to demonstrate how
Non-perishable substances: Non-perishable the marks were produced.
objects may reproduce marks well and dimensionally Bite marks in cheese, butter and chewing
stable. Some of the objects are include a bullet, gum are often difficult and sometimes impossible
to identify due to shortcomings in the present
pipe stems and soap. Care must be taken to store
techniques. The reflex microscope can be used
and handle these objects carefully; any careless
to evaluate and identify bite marks in inanimate
handling could introduce additional marks that
objects. Positive identification using the reflex
might invalidate the analysis.
microscope has become possible with a high level
of accuracy.
Long-Term Preservation
One of the most important features of the reflex
Long-term preservation can be achieved by two microscope is that non-contact measurements in
methods, photography or making models. three dimensions can be made directly of bite marks
Bite Marks 141
otherwise not suitable for taking measurements or quality to enable PCR-based typing of the DNA

impressions, such as butter. that is present in saliva from white blood cells and
possibly from sloughed epithelial cells. Significantly,
Habitual Chewing Marks since high-intensity alternative light sources and
Usually found on pipe stems, pencil and key bows. lasers are now widely used by the police to locate
Very often in harder substances only cusp marks stains from bodily fluids at the crime scene, saliva
are present, and if the object has been bitten stains deposited on skin—even in the absence of
repeatedly, isolating and differentiating these marks marks from teeth—can be found and recovered.
can prove difficult. Cusp marks made by human After analyzing the salivary DNA and establishing
canines, premolars and molars can be similar to the depositor’s DNA profile, this result can be
those produced by the dentition of dogs and cats. compared with the DNA profile of any suspects
obtained from buccal swabs containing saliva or
Bite Mark Pattern in 3-dimensional Settings whole blood taken using a lancet.
Foundation lies in the fact of overall relationship
of bite mark to the teeth that caused injury. We Terms Indicating Degree of Confidence that an
know that photos give 2-D architecture of 3-D Injury is a Bite mark
substances. Also it has been shown that one or Possible bite mark: An injury showing a pattern that
more teeth may imprint on skin before an adjacent may or may not be caused by teeth; could be caused
tooth begins to touch tissues, thus it is important by other factors but biting cannot be ruled out.
to understand that absence of an individual mark Criteria: General shape and size are present but
in injury pattern does not mean associated tooth distinctive features such as tooth marks are missing,
is missing, as the tooth may be below the occlusal incomplete or distorted or a few marks resembling
plane. In such a scenario study casts may provide tooth marks are present but the arch configuration
a substitute for the process. is missing.
Some effort has been made to standardize Probable bite mark: The pattern strongly suggests
the comparison procedures but, unfortunately, or supports origin from teeth but could conceivably
the conclusions are often based on the expert’s be caused by something else.
level of personal experience and judgement. The
Criteria: pattern shows some, basic, general
American Board of Forensic Odontology has
characteristics of teeth arranged around arches.
worked hard to establish guidelines for indepen-
dent examination of the same evidence by second Definite bite mark: There is no reasonable doubt
that teeth created the pattern; other possibilities
and third odontologists before the primary expert
were considered and excluded.
submits a final report. Regardless, many cases
have been disputed because of differing expert Criteria: Pattern conclusively illustrates (classic
opinions, attacks on the scientific basis of physical features) all the characteristics of dental arches
com-parisons because of the elasticity of skin and and human teeth in proper arrangement so that
the question of uniqueness of the human dentition. it is recognizable as an impression of the human
dentition.
Human Bites as Forensic Biological Evidence
Descriptions and Terms Used to Relate Bite
During the process of biting and also during
Mark to the Suspected Biter
kissing and sucking, saliva is deposited on the
skin’s surface. It has been shown that this trace Reasonable dental/Medical certainty: Beyond a
evidence is present in sufficient quantity and reasonable doubt.
Probable: More likely than not. If used to represent the odontologist’s

Exclusion: Ruled out. conclusion, the term “consistent with” should be
explained in the report or testimony as indicating
Inconclusive: Insufficient evidence to relate the bite
similarity but implying no degree of specificity to
mark to the suspected biter.
the match.
Terminologies Used in Analysis of Bite Mark Possible biter:
Cases Could have done it; may or may not have. Teeth
like the suspect’s could be expected to create a
Point
mark like the one examined but so could other
• A singular unit or feature available for comparison dentitions.
or evaluation
Criteria: There is a nonspecific similarity or a
• An area attributable to a tooth
similarity of class characteristics; match points are
• A way of counting features
general and/or few, and there are no incompatible
This term is used as a convenience in reports inconsistencies that would serve to exclude.
to address specific components of the bite mark
which are being compared to teeth. A point does Probable biter:
not imply any degree of specificity and not a Suspect most likely made the bite; most people in
characteristic. the population could not leave such a mark.
Criteria: Bite mark shows some degree of specificity
Concordant point: to the individual suspect’s teeth by virtue of a
• Point seen in both the bite mark and the sufficient number of concordant points including
suspect’s exemplars. some corresponding individual characteristics.
• Corresponding feature. There is an absence of any unexplainable
• Comparable element. discrepancies.
• Unit of similarity.
Reasonable medical certainty:
• Matching point. Highest order of certainty that suspect made the
Area of comparison: bite. The investigator is confident that the suspect
• A dynamic or specific region to be compared. made the mark. Perpetrator is identified for all
• A complex or pattern made up of a conglomerate practical and reasonable purposes by the bite mark.
of several points or a group of features. Any expert with similar training and experience,
evaluating the same evidence should come to the
Match: same conclusion of certainty. Any other opinion
• Nonspecific term indicating some degree of would be unreasonable.
concordance between a single feature.
• Combination of features or a whole case. Criteria: There is a concordance of sufficient
• An expression of similarity without stating distinctive, individual characteristics to confer
degree of probability or specificity. (virtual) uniqueness within the population
This term “match” or “positive match” should under consideration. There is absence of any
not be used as a definitive expression of an opinion unexplainable discrepancies.
in a Bite mark case. The term reasonable medical certainty conveys
the connotation of virtual certainty or beyond
Consistent (compatible) with:
Synonymous to “match”, a similarity is present but reasonable doubt. The term deliberately avoids
specificity is unstated. the message of unconditional certainty only in
Bite Marks 143
deference to the scientific maxim that one can never Contd...

be absolutely positive unless everyone in the world Same rotational position One/tooth
was examined or the expert was an eye witness. Vertical position One/tooth
The Board (ABFO), considers that a statement Spacing One/space
of absolute certainty such as “indeed, without a Inter-dental M- D width One/tooth
Features L-L width Three/tooth
doubt”, is un-provable and reckless. Reasonable
Incisal edge curvature Three/tooth
medical certainty represents the highest order
Other distinctive features Three/tooth
of confidence in a comparison. It is, however, Miscellaneous edentulous arch Three
acceptable to state that there is “no doubt in my
mind” (Table 6.1). Using the following guide for scoring:
The following list of Bite mark terminology 0- Excluded/no match
standards has been accepted by the American Board 1- Possible match/some similar features
of Forensic Odontology. 2- Probable match/several similar features
1. Terms assuring unconditional identification of 3- Definite match
a perpetrator, without doubt, on the basis of an
epidermal bite mark and an open population is Differences in Bite Patterns of
not sanctioned as a final conclusion. Child and Adults
2. Terms used in a different manner from the
The relationship of biter to victim is also complex.
recommended guidelines should be explained This relationship may be seen amongst adult to
in the body of a report or in testimony. adult, adult to child, child to adult or child to child.
3. Certain terms have been used in a non-uniform Both adults and children may self inflict bites in a
manner by odontologists. To prevent mis- surprisingly aggressive manner.
communication, the following terms, if used as Adults biting other adults or children will almost
a conclusion in a report or in testimony, should inevitably constitute criminal activity and may be
be explained: associated with actual or grievous bodily harm,
• Match; positive match. rape, and murder or child abuse. Common areas
• Consistent with. include head, neck, limbs and trunk.
• Compatible with. Most common age groups for these bite marks
• Unique. appears to be for;
4. The following terms should not be used to • Male victims: 4 to 10 years
describe bite marks: • Female victims: 11 to 14 years.
• Suck mark.
• Incised wound. Non-accidental Injury to Children
Table 6.1: Showing ABFO scoring criterion It is now almost 30 years since the first description
of the battered child syndrome and it is important
Features No. of Points
that dentists are aware of the possibility of child
Gross All teeth present One/arch abuse and have a knowledge of the key factors in
Size of arch consistent One/arch
its diagnosis. Police surgeons may also be involved
Shape of arch consistent One/arch
at an early stage of an investigation and if there
Tooth Same labio-lingual One/tooth
position position
are marks present on the child which have the
appearance of human bites, they may wish to call
Contd... in the services of a forensic dentist.
Human bites, be they from a child or an adult, by humans. Animals are capable of biting both

are usually oval or circular in shape. It may be the living and the dead. Bites from animals are
possible to distinguish between the halves of the rarely the object of bite mark analysis. About one
circle, having been produced by upper or lower percent of causalities in USA clinics are of bite
arches of the dentition, and it may ideally be marks (human or animal) (Fig. 6.27A). The teeth
possible to distinguish marks made by individual of animals leave patterned injuries that appear quite
teeth and even to pick up irregularities in those different from those created by human teeth. This
teeth. There may, in addition, be evidence of is especially true with dogs (Fig. 6.27B), which are
petechial haemorrhage in the centre of the circular predominant culprits in bites to humans who bite
bite. This is due to tongue pressure or suction at the
at a rate eight times more frequently than humans
time of the injury. It is essential that high quality
bite each other. However, such bites may need to
photographs are taken of the bites and these must
be analyzed in order to distinguish what species
be accompanied by standard centimetre scales. The
of animal may have been the attacker, or exclude
bite should be photographed as soon as possible
and it may be necessary to re-photograph at 12 or one or more animals when there is more than one
24-hour intervals. possible offender.
Although it may be difficult to determine, in Carnivorous animals, like dogs or tigers, use
some instances, whether a child has suffered non- their teeth in two distinct ways. They kill their prey
accidental injury (NAI), the presence of a human primarily using their canines and they tear and slice
bite mark is indicative of NAI. However, it must the flesh to produce digestible fragments. Human
be remembered that siblings may inflict an injury teeth are designed principally to cut and grind food
and indeed the child may self-inflict a bite mark which is usually previously prepared. Some people
providing the part of the body is accessible. The appear to revert to more primitive instincts and use
importance of the human adult bite in a non- their canines and incisors to inflict bites on victims.
accidental injury case is obvious. If it is present, The size and distribution of the animal’s teeth
non accidental injury by definition has occurred are likely to be very different to those of the
and the injury is one of the very few that may be human. For example, the bite of a dog consists, in
related to the assailant, providing the image of the principle, of four puncture wounds representing
bite contains sufficient characteristics. It is difficult
the perforation of the skin by the four large canines
to determine whether the incidence of NAI to
(Fig. 6.27C). The incisors are small and rarely
children is increasing but the forensic dentist is
leave a mark. The bite may be complicated by
certainly called to see more cases than in the past.
tearing of tissue. Smaller animals, such as rodents
In addition to human bites there may be extra-
oral injuries, such as bruising of the facial tissues, may produce small, horizontal puncture wounds
cigarette burns, lacerations and also intraoral from their razor sharp incisors but may also
injuries, including fractures of the teeth and/or jaw produce long lacerations of any length produced
bones. It has been said in the past that the ruptured by swinging their sharp incisors across the surface
labial frenum is indicative of non-accidental child of the skin.
injury but it is now recognised that there may be Cases have arisen where it has been necessary
other causes. to demonstrate that more than one dog has been
involved in a particular biting incident, and this may
Animal Bites be possible by careful measurement of inter-canine
When investigating bite marks it is important to widths. Distinguishing between animal bites requires
remember that they may not always be produced a knowledge of comparative dental anatomy but it
Bite Marks 145
Bites, Bite Wound Infections,

Prevention and Management
Prevalence of Bites
Bite wounds are among the commonest types of
trauma to which a man is subjected. In urban areas
dogs, cats and humans cause the majority of such
wounds. A large percentage of dog and human
bites are located on the face. Children often being
A the victims of family pets and to a lesser extent
to human bites. Biting of one human by another
is the third most common bite injury followed
by dogs and cats and was first reported in the
literature by Hultzen in 1910, who described an
infective sequel to a human bite. About one half
of the people in united states will be bitten by an
animal or human during their lifetime, and these
injuries account for one percent of all emergency
department admissions and cost more than 25
million dollars in health care expenses per year.
Studies found that the incidence in children is
B C
close to one human bite/600 pediatric emergency
Figs 6.27A to C: Bite marks resulting because of animal bites department visits. Bite wounds contaminated by
most notably, dogs, cats, and reptiles. Shown here in the first
picture is the bite marks because of a rattle snake and in the animal and human oral flora are relatively common.
third picture, because of a dog bite. Note the two puncture These may be infected by the organisms causing
wound resulting because of sharper canines of the dog
virulent infections, including rabies.
may be important, medicolegally, to determine the
type of animal concerned (Table 6.2). Nature of Bites
Depending on the ferocity and anatomical
Table 6.2: Showing characteristic differences in bite characteristics of the biter, the bite may either
patterns between human and animals be perforating, laceration, crushing, avulsive or
Characteristics Human Animal combinations of any of these. Bites can be described
in an ascending scale of severity; petechial,
Basic outline U shaped V shaped
hemorrhage, contusion, abrasion, laceration and
Area bitten Broad Elongated
Overall shape Somewhat Narrow in
avulsion.
circular/oval anterior aspect
Animal Bites
Morphology of Broad centrals, Broad laterals,
anteriors relatively narrow narrow centrals Dog bites
lateral incisors Dogs are responsible for the vast majority of animal
Canines Blunt Sharper bite wounds. Dog bite related mortality is a well
and deeper canine marks
recognized aspect of this problem, amounting to at
least 15 deaths per year in the United States. Dog girl in the Karimojong tribe of Uganda. A hyena

bites account for 80 to 90 percent of all animal attacked her, and her lips, nose and right maxillary
bites requiring medical care. The incidence rates region were avulsed, with loss of scalp. A crocodile
are significantly higher among children aged 0 to on the other hand may seize and crush, being eager
9 years especially among boys. to drag its whole victim under water rather than to
The peak incidence of dog bites occur in young bite off a portion.
children, most documented injuries have been to Human bites
the head, face or neck region, whereas in older Most common human bites occur during fights
children and adults dog bites most commonly whereas a substantial percentage is related to sexual
involve the limbs. Dogs are more likely to inflict activities. Human bites have been described to
superficial abrasions and lacerations. Dog bites occur in a number of situations, including overtly
wounds are frequently complicated with crush aggressive behavior, accidents and sexual activity.
injury as a result of high masticatory forces that The site of bite is an important variable in the risk
can be delivered by large breeds. Dog bites involve of infection.
a combination of penetrating and avulsive injuries.
They may be very disfiguring (Figs 6.28 and
6.29), and may also cause serious damage to the
eye and its adnexae. Injury in the region of the
medial canthus is common with damage to the
lacrimal system found in 15 of 16-periorbital dog
bites. A snap provoked pet dog may inflict a deep
perforation, even through a child’s skull; however,
the dog will often withdraw at once, and not tear
as a wild carnivore might.
Cat bites
Tend to occur on the arms, commonly affecting
women older than 20 years of age. Because Fig. 6.28: An injured victim with his treatment done
of their slender, sharp teeth, more often cause following an episode of a dog bite
deep puncture (Fig. 6.30) wounds. Cats inflict
punctures without tearing or avulsing, and like
other Felines may scratch as well as bite. Large
carnivores may inflict gross mutilations on their
victims, and treatment is often complicated by delay
in seeking expert management.
Bear bites
Govilla et al reported a case in which a bear bit
off 8 cm of jaw from the mandible of an Indian
woman; the avulsed jaw was brought to a surgeon,
but too late for implantation. Davis states that the
Fig. 6.29: A very severely disfiguring bite mark with a severity
North American bear typically bite the face or scalp.
of grade 6, carrying no forensic significance, left after a
Illukol has described her own experience as a small traumatic bite by an animal
Bite Marks 147
occur with human bites including hepatitis B and

C, tuberculosis, syphilis and tetanus.
Transmission of human immunodeficiency
virus following an accidental human bite has been
documented. A bite injury that transmits HIV
to the recipient could be classified as assault with
a deadly weapon. The risk of HIV transmission
following a bite injury is important to many groups
of people. The first are those who are likely to
be bitten as an occupational risk, such as police
officers, medical personnel and institutional staff.
The other group is represented by victims and
Fig. 6.30: A puncture wound reflecting a bite mark by an
perpetrators of crimes involving biting, both in
animal on the hand of a young victim attack and defense situations.
The severity of the bite injury is one factor that
The prominent parts of the face are usually is likely to increase the chance of HIV transmission.
bitten; the lips, nose and ears are often attacked To access the victim’s blood, a bite must break
and loss of tissue is common. The amount of tissue the skin: thus an abrasion or more severe injury
removed is limited by the size of the human mouth is required. Consideration must also be given to
and the anatomy of the dentition skin that is already broken. Studies show that the
Human bites include a specific type of wound, viral quantity in saliva is low or is supplemented by
the clenched fist injur y, which is sustained the presence of blood contamination. The source
by the attacker, most commonly to the third of this may be from undetectable micro lesions,
metacarpophalangeal joint of the dominant hand, trauma or periodontal disease.
as a result of a clenched fist against the teeth of the It is possible that a bite from an HIV infected
opponent. In the clenched fist injury, a laceration individual may transmit HIV. The likely risk of
of roughly 5mm occurs, typically in the third transmission is increased if; blood is present in
metacarpophalangeal joint. Some authors believe the oral cavity, the bite breaks the skin, the bite is
that a clenched fist injury is a separate entity from associated with a previous injury and the biter has
that of the bite mark and should be separated in a deficiency of anti HIV salivary elements (IgA
bite classifications. The reported infection rate of a deficient).
human bite varies. The infection rate for a bite to The recommendations for such bites are as
hand was 28 percent in one study, compared with follows: If an individual is bitten, treatment
only 4 percent for bites to the facial area. should be sought immediately and a risk analysis
Human bites are thought to be more serious performed. The use of prophylactic antiretroviral
than animal bites because of a higher incidence agents may be appropriate in such situations.
of infectious complications. Human saliva is Health care workers, caregivers, police officers
considered a more virulent inoculum, with bacterial and others at risk of bites should be aware of this
loads at the order of 108 per milliliter, which potential transmission route and use preventive
significantly increase in cases of periodontal disease measures such as hand and arm protection.
and oral sepsis. Transmission of several systemic Physicians and other health care workers who
bacterial and viral infections has been reported to care for patients who have sustained human bite
marks need a working protocol to ensure that these Various microbes have been implicated in

patients receive proper care. The earliest report of infection from dog bites, including staphylococcus
a human bite in medical literature is by Burnett aureus, Pasteurella multocida and anaerobic cocci,
in 1898, numerous authors have described their pseudomonas aeruginosa, staph epidermidis and
successes and failures in treating human bites. various streptococci. Pasteurella multocida may
cause acute local cellulitis and lymphangitis and
Diagnosis of Infection also has the capacity to cause meningitis and
Infected bite wounds are usually manifested by cerebral abscess. Capnocytophaga canimorsus,
pain, edema localized at the site of the injury a common isolate from the dog’s mouth, may
frequently associated with a purulent discharge and produce fulminant septicemia in patients who
possibly regional lymphadenitis. The latency period are immuno suppressed. Staphylococci and
between the bite and the appearance of the first strep-tococci have been isolated more frequently
symptoms of infection appears to be significantly from nonpurlent infections, whereas anaerobic
shorter for cat bites than for human and dog bites. organisms are more commonly associated with
abscesses both in dog and cat bite infections and
Radiological Assessment
in human infections.
Teeth can penetrate the skull, and the associated The bacteriology of dog and cat bite wounds
scalp wound may be alarming. It is therefore generally reflects, the oropharyngeal flora of the
necessary to obtain X-ray pictures of the skull or biting animal, as it is the animal saliva rather
facial skeleton in case of facial or calvarial bites. than the victim’s skin flora that seems to be the
Computed tomographic scans with appropriate major source of bacteria isolated from bite wound
window settings visualize small calvarial punctures cultures. Various bacteriae have been isolated
well, and show the depth of cerebral penetration from human bite wounds; staphylococcus aureus
and the presence of in driven bone. is found in 25 percent and anaerobic bacteria,
especially the bacteroides species, are found in
Microbiological Assessment greater than 50 percent of bite wounds.
Once the guidelines for bite mark analysis have Cultures are frequently recommended as
been addressed, all wounds should be smeared for standard procedures for all infected bite wounds.
gram stain analysis and cultured both aerobically As the bacteriology of bite wound infection has
and anaerobically. High-risk individuals should be been so extensively studied, cultures are probably
tested for hepatitis antigens and HIV. helpful only in cases of treatment failure or severe
The microbiology of bite wounds is polymicrobial. or high-risk infections.
Anaerobes usually account for the largest proportion
and include species such as Prevotella and Complications
Porphyromonas. Many of the anaerobes isolated
are beta lactamase producers. Bacteria in the wound will also hinder normal
A 22-month-old boy who, subsequent to a dog wound healing by enlarging the wound and
bite over the left maxilla, suffered infection of the competing for vital nutrients such as oxygen and
dental follicle of the primary canine with Pasteurella glucose needed for wound healing. This causes
multocida and this was the first case of an infected further tissue anoxia, the production of lactic acid,
dental follicle secondary to an animal bite. and further breakdown of the wound.
Bite Marks 149
Bite wounds may look innocuous initially; Tomasetti et al. while reporting 25 cases of

they frequently lead to infection that can progress human bite wounds of the face, stated that surgical
to more serious complications like cellulitis, treatment should be dependent upon the presence
osteomyelitis, septicemia and death. or absence of infection, the length of time from
Biting of buccal mucosa is a very frequent injury; initial trauma, and the size of the wound. His
emphysema causing puffing of the cheek through recommendation was that all recent, non-infected
a self-inflicted bite of the buccal mucosa has been wounds should be evaluated for primary closure.
reported. It is this recommendation that appears to be the
generally accepted concept of treatment now,
Management but many authors have added a restricted period
ranging from 12 to 84 hours after injury, beyond
Many individuals do not seek treatment for human which primary closure should not be considered.
bites because of embarrassment and possible legal In 1976, one author reported the use of
repercussions. hyaluronidase injections around the wound site, in
conjunction with conventional soft tissue wound
General repair, to successfully manage immediate primary
The management of human bite injuries is closure, grossly contaminated and/or locally
separated into two categories: infected wounds of the orofacial region. According
to McCarthy, when the patient is seen at a later
a) The care of adults with human bites and
stage with extensive tissue edema, crushed wound
b) The care of children with human bites
edges and with contused devitalized tissue, the
The treatment of bite wounds is two-fold:
purpose is to delay primary closure conditions for
adequate surgical debridement and appropriate
primary healing are more preferable. The technique
antibiotic treatment where indicated.
he recommends consists of limited debridement
All bite injuries should undergo early wound
to remove nonvital tissue, the application of wet
decontamination unless there are obvious signs
dressings and antibiotic therapy until there is
that infection is already present. The single
resolution of edema and a cleaner appearance of
most important step in prevention of infection
the wound. It is at this time that one could expect
is decontamination by forced irrigation using at that a closure would be successful. Ordinarily, this
least 200 ml of normal saline through a 19 gauge process takes three to five days.
needle. This has been shown to reduce wound Surgical repair should be undertaken using
infections very substantially. Lavage with dilute the standard soft tissue repair techniques. In
povidone-iodine or chlorhexidine solution may also the past, fear of infection often led to a policy
be used. If rabies is suspected, a viricide should be of delayed wound closure, with poor aesthetic
used. Antimicrobial prophylaxis for all bite wounds results. If the bite has amputated a piece of
is controversial, and depends on the age of the tissue, replantation is sometimes possible; the
wound and the extent and presence of patient risk amputated fragment should be washed in warm
factors such as asplenism, immunosuppression sterile saline and taken as soon as possible for
and immunocompromization. There has been a consideration by the micro surgeon. If there is
diversity of opinion with regard to the management any delay, the tissue should be kept cool but
of human bite wounds of the orofacial region. not frozen.
Facial Bites (Table 6.3) the development of felon or tendon sheath invasion.

The incidence of wound contamination by mouth
Peri-orbital bites
organisms is undoubtedly great due to the frequency
Standard ocular techniques are used to repair eyelid
of thumb sucking, hand nail biting, and other habits
wounds if less than six to eight hour. If there is
which bring saliva contact with wound.
marked tissue edema, hemorrhage or suspected of
The impact of the tooth produces a laceration
infection, operation must be postponed for two
over the knuckles of the index or middle fingers. It
to three days. Spinelli et al reported five cases in
is tiny but deep, frequently penetrating the extensor
which large pieces of eyelid had been bitten off in tendon and usually entering the joint. Pain on
passion or combat; the morsels were replaced and movement of the finger indicates the progression
survived though loss of cilia was seen when there of a septic arthritis. The joint mobility is restricted.
was delay in replantation. When the surgery was Lymphangitis may be present. In favorable cases
done within 14 hours, the cilia survived. surgical intervention brings relief and decrease the
temperature.
Bites of the lips
The lips were the leading sites of dog bites in Massive avulsive bites
reported series, being lacerated or amputated in In the case of bear bite reported by Govilla et al
63/148 bites. It is sometimes possible to replant the lower jaw was successfully reconstructed with
an amputated lip. Jeng et al replaced the vermillion a pectoralis major island flap containing a length
area of a lower lip after eight hours by reanastomosing of the rib.
one inferior labial artery and joining the other to the Craniocerebral bites
vein. The sharp teeth of a dog may perforate the infant’s
Bites of the nose calvarial bone and pierce the underlying cerebral
These are very disfiguringand in some communities cortex. Klein and Cohen reported a case where
carry cruel implications of punishment for domestic failure to explore the wound led to the develop-
or political crime. ment of a brain abscess, the organism responsible
being Pasteurella multocida.
Bites of the ear
These are relatively less disfiguring and indeed
Table 6.3: Classification of facial bite injuries
may be a source of mild pride when sustained in a (modified from Lackmann et al.)
combat. When a large piece of an ear has been bitten
off, microvascular repair may be warranted. But for Type Clinical Findings
a majority of the people, covering the area with the I Superficial injury without muscle involvement
by hair may be sufficient aesthetic management. IIA Deep injury with muscle involvement
IIB Full thickness injury of the cheek or lip with
Bites on knuckles/fingers o ral mucosal involvement (through and
The recognition of human bites on the body is through)
generally easy for, there are usually abrasions, IIIA Deep injury with tissue defect (complete avul-
contusions, petechiae and tooth marks present. Those sion)
on the nose, finger or knuckle may be more difficult IIIB Deep avulsive injury exposing nasal or auricu-
to recognize. Bites on the fingers are generally on lar cartilage
the distal phalanx. They vary from simple abrasion IVA Deep injury with severed facial nerve and or
to compound fractures. These are potentially parotid duct
IVB Deep injury with concomitant bone fracture
dangerous and should be kept under observation for
Bite Marks 151
In general, superficial injuries can be treated in perpetrator. The duration of this line of inquiry

the outpatient setting, whereas for type III and is apparently possible for several weeks post
IV injuries hospitalization is required for special deposition, depending on the materials containing
surgical care. the impressions and environmental factors. Two
parameters have been proposed, both based on
Prophylaxis successful efforts to sex bloodstains:
1. The presence and detection of sex chromatin
The first line antimicrobial is coamoxiclav
(Barr bodies in females, and F bodies in males);
when allergic to pencillin the options include
and
a combination of both metronidazole and
2. Sex hormone level determinations based on
azithromycin.
detectable quantities and ratios of testosterone
When bite is the cause of a facial injury it
and 17B-estradiol by radioimmunoassay (RIA).
is important to determine the immune status
The former parameter has been demonstrated
of the patient including the record of tetanus successfully in saliva stains; this author is unaware
immunization. Tetanus antitoxin should be given of any successful attempt to identify sex in saliva
to all patients. by means of hormonal ratios.
Rabies is endemic in most parts of world, Interpretation of such investigatory efforts must
except the United Kingdom, Ireland, Sweden, be dependent on an understanding of the possible
Taiwan, Japan and Australia, which are at present variations that might be encountered. Discre-
supposedly free. The virus is commonly transmitted pancies noted in tests for sex chromatin include:
by dog bites. A rabid animal may be unbelievably 1. Chromatin negative females, e.g. Turner’s
ferocious and can attack the head or face. The Syndrome and testicular feminization,
incubation period for rabies is typically 2 to 2. Chromatin positive males, e.g. Klinefelter’s
8 weeks, but much longer periods have been Syndrome, and
reported. A person bitten by a rabid animal will 3. Genetic mosaics.
obviously be under prolonged emotional strain, In each case, a sufficient number of nucleated
and should be counseled and reassured. In some cells must be obtained, fixed, and stained.
developed countries, domestic dogs and cats are Alcohol fixation and H and E stains have been
routinely vaccinated. used successfully for detection of Barr bodies
If a criminal act has been committed, it is the or “drumsticks” in materials containing at least
treating physician’s responsibility to notify the 100 nucleated cells. An aceto-orcein staining
proper authorities. Patients who are sexually abused process was described by Sanderson and Stewart
require proper legal counseling, and the physician in 1961. Determination of sex by DNA analysis
must report the incident to the law enforcement according to Sensabaugh and Blake is possible
agency. If a child is found to be accidentally biting by using PCR based on the characteristics of the
other children, the parents must be informed and mammalian sex chromosomes, X and Y. Normal
proper counseling offered. females have two X chromosomes and males have
an X and Y chromosome. The development of
Sex Determination in Bite Marks a mammalian embryo as male is determined by
genes on the Y chromosome and the phenotypic
The possibility of obtaining exfoliated buccal sex of individuals with an abnormal complement
epithelial cells in saliva on bite marks has increased of sex chromosomes depends only on the presence
the possibility of sex determination of the or absence of the Y chromosome. According to
various authors, a number of X and Y chromo- destructive- ness (tool marks). Suckling marks,

some-specific sequences have been identified and tearing and abrasion pattern are all important
serve as potential markers for sex determination. factors in identifying the psychological dynamics
Several PCR-based approaches have been used. and behavioral tracts of the biter.
The simplest is the amplification of a Y specific Due to a pattern of psychologically expressed
sequence; the presence of a PCR product indicates ritualism, the perpetrator will often inadvertently
the sample contains male cells. With this assay, the leave important psychological clues at the crime
absence of a product cannot be interpreted unless scene. After reviewing cases reported in the
there is an amplification control. An assay using the literature and after conducting psychological
DYZ1 repeat sequence for the Y marker and either interviews with perpetrators, three major groups of
an Alu repeat or DQA sequences as amplification perpetrators seem to be apparent. The first group is
controls is an example of such testing. motivated out of an anger track, the second group
Witt and Erikson described an assay using is motivated out of sadistic biting, and the third
both X and Y specific centromeric alphoid repeat is out of the more traditional “cannibal complex”
sequences as the chromosome markers. Ampli- motif.
fication of these two sequences employ different Based upon the physiological and psychological
primer sets but can be co-amplified. Male DNA materials, there emerge three major motivational
shows both X and Y PCR products, whereas categories in which bite mark evidence can be
female DNA shows only the X product. Gaensslen classified
et al. reported this application in 1992 on forensic 1. Anger — impulsive biting
specimens. 2. Sadistic biting
A third method, described by Aasen and 3. Ego — cannibalistic biting
Medrano amplifies both the X and Y specific
sequences using a single primer set. The human Anger—impulsive Biting
ZFY and ZFX genes possess regions of conserved
This is consistent with the overaggressive and
sequence permitting the design of primers capable
under controlled display of impulsive anger. This
of amplifying both. The two sequences are then
type of biter is often nettled by frustration and
distinguished by a sequence-specific restriction
incompetence while dealing with any conflict
assay using Hae III. The ZFX gene is marked by
situation.
a characteristic 400-base-pair fragment and the
When the biter reaches an apex of emotional
ZFY gene by a 317-base-pair fragment. Because
excitation, the situational loss of self-control allows
both sequences are amplified from the same set
for an impulsive act of revenge by inflicting a tool
of primers, the assay has a built-in control for the
mark bite on the victim.
amplification reaction from both sexes. The gene
Although biter may not derive specialized
sequences are also species-specific according to
satisfaction from inflicting the tool mark wound,
Aasen and Medrano.
his pleasure is derived from the ability to effectively
hurt and humiliate the victim by his “Wolf – like”
Psychological Aspects of Bite Marks ferocity.
Infliction of bite mark wounds represents highly
Sadistic Biting
complex thoughts and emotions expressed
through a screen of fantasy, the mortal state of In the continuum of sexual sadistic biting, the
the victim, location of wound sites, and stigmatic themes of blood, flesh, and object symbolization
Bite Marks 153
become important to the cultivated sensualization not flat and visual distortion may be present, often

of power of ripping, tearing, and utilizing the ability heightened by photographic distortion caused by
to render the victim helpless and incapacitated. By inadequate imaging techniques.
a protracted and ritualistic biting of the victim, Human dentitions, whilst possibly being unique
the aggressor can satisfy not only the cultivated in the sense of small nuances of tooth size, shape,
power symbols, but satiate his increasing lust for angulations and texture may not inflict unique
domination, control and omniscience. bite marks which can only record gross and not
Bite marks found in the most advanced forms of fine detail. If the victim survives, the injury may
sadism can range from an early fetishism for blood change due to infection or subsequent healing and
to the bite marks found on the internal organs from if the victim is deceased, putrefaction may introduce
an eviscerated body. distortion.
The forensic dentist will be asked to determine
Ego — cannibalistic Biting whether or not the injury is, in fact a human bite
The most vicious and destructive type of biting is mark? Is it compatible with an adult dentition
within this complex. In this category of biting, the and can the perpetrator be identified from the
assailant’s major thrust is to satiate ego demands by information present in the injury? What is the
annihilating, consuming and absorbing life essences optimum protocol available when an odontologists
from their victims. compares a suspect to a possible bite mark when
the DNA results are still pending?
Signature Implicants The purists would say the two fields—physical
In bite mark cases, when the wound indicant is matching and DNA analysis — are independent,
linked with the overall crime scene evidence, the this is despite the fact that physical matching of
signature theme of biting motivations can be bite marks is a non-science which was developed
examined for signs and symbols revealing stylized with little testing and no published error rate.
intents. Since the assailants often use central themes Alternatively, the statistical justification for DNA has
of aggression with personalized adaptations, a been scrutinized and approved. The frequencies in
psychology cannot make a “fingerprint” of the the population of polymorphic loci are also known.
crime, it can give signature importance to bite What the, should a prudent odontologists do
mark evidence in relationship to the crime. It is in this situation?
recognized that psychology cannot “Solve” cases, The temptation to create an opinion early in
but it can yield valuable information about the
an investigation is normal. Who wants to say
crime through examining the underlying structures that odontology cannot conclusively establish
and themes. To this goal, the psychological a bite mark as unique? The greater experience
understanding of bite mark evidence can and of one expert over another has been argued as a
should be used as a clarifying tool. guarantee of a “better” result. This is unproven
conjecture and serves as the single support for
The Pitfalls of Bite Mark Analysis Systems in
proponents of the non-science approach. How
Forensic Settings
does one weigh the importance of a single rotated
Human bites on skin are difficult to interpret tooth in a bite mark when the suspect has a
because skin is not a good ‘impression’ material, similar tooth?
moreover, victims may struggle and movement The value judgments range widely on the
will distort the image of the bite. Skin surfaces are value of this feature. This is not science. Instead,
statistical levels of confidence must be included in 2. American Board of Forensic Odontology. ABFO

this process. Until then, the DNA results are far Guidelines and Standards. In Bowers C M, Bell G
superior to the odontologist’s position. There is L (ed) Manual of Forensic Odontology. 3rd ed.
pp299, 334-353. Colorado Springs: American
no honest way to deny this. The majority of cases
Society of Forensic Odontology, 1995.
will be proven conclusively by the biological tests, 3. Dr. Shwetha Aacharya. Bite marks. Library
if they are performed. If the two independent tests dissertation submitted to Rajive Gandhi university
do not correlate, I hope odontologists will not of health sciences in partial fulfillment for the
rely on the theory that there were two assailants degree of masters of dental surgery in the speciality
involved in the same case-one biting and the other of Oral pathology at Bangalore, Karnatka, India
2005-2008.
spitting.
4. Guidelines for bite-mark analysis, American Board
of Forensic Odontology, J Am Dent Assoc 1986;
Summary 112:383-6.
5. John D. McDowell. A commentary on the current
1. Bite marks can be useful physical evidence. status of bite marks. Dental abstracts. Volume 54,
2. The effect of skin variability has not yet been Issue 1, 2009.
determined and further research is required in 6. Michael BC. Problem-based analysis of bite mark
this area. The distortion of various anatomical misidentifications: The role of DNA. Forensic
locations is subject to curvature, bone and Science International 2006;159S:S104-S109.
7. Pretty IA, Sweet D. Digital bite mark overlays—an
adipose deposits.
analysis of effectiveness, J For Sci 2001;46:1385-
3. Currently, digitally created overlays can be
9.
regarded as best practice although no official 8. Pretty IA, Sweet D. Anatomical locations of bite
recommendation has been made by either US marks and associated findings in 101 cases from the
or UK bodies. United States. J Forensic Sci 2000;45:812-4.
4. Care must be taken when expressing certainty, 9. Sweet D, Pretty IA. A look at forensic dentistry—
especially with regard to the product rule. Part 2: Teeth as weapons of violence— identification
of bite mark perpetrators BDJ, Volume 190, no. 8,
5. Forensic dentistry requires more research to
April 28, 2001.
investigate bite mark accuracy and reliability. 10. Sweet D, Lorente J A, Lorente M, Valenzuela A,
Villanueva E. PCR–based typing of DNA from
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1997;42:447-51.
1. Arhearta KL, Pretty IA. Results of the 4th ABFO 11. Vale G L, Noguchi TT. Anatomical distribution of
Bite mark Workshop—1999. Forensic Science human bite-marks in a series of 67 cases. J Forensic
International 2001;124:104-11. Sci. 1983;28:61-9.
7

Cheiloscopy and Palatoscopy
Gaurav Atreja
Chapter Overview
 Cheiloscopy  Classification
 Anatomical Aspects  Analyzing and recording palatal rugae
 Palatoscopy  Problems with palatoscopy
 Historical aspects  Future prospects
 Anatomical aspects
INTRODUCTION
In some particular circumstances, often related to
a criminal investigation, there can be other data,
which are important to the process of human
identification. Some of those data result from soft
oral and perioral tissue prints (Fig. 7.1).
In fact, lips, as well as the hard palate, are
known to have features that can lead to a person’s
identification. The study of lip prints is known
as Cheiloscopy; the study of hard palate anatomy
to establish someone’s identity is called Fig. 7.1: A lip print formed on the glass plate by oral and
Palatoscopy perioral soft tissues
CHEILOSCOPY possible to identify lip patterns as early as the 6th

Cheiloscopy, (from the Greek words cheilos, lips) week of intrauterine life.
is the name given to the lip print studies. The From that moment on, lip groove patterns rarely
importance is linked to the fact that lip prints are change, resisting many afflictions, such as herpetic
unique to one person, except in monozygotic lesions. In fact, only those pathologies that damage
twins. Like fingerprints and palatal rugae, lip the lip substance like burns, seem to rule out
grooves are permanent and unchangeable. It is cheiloscopic study.
Historical Review of Cheiloscopy

1902 First described by Fisher
1930 Diou de Lille developed some studies
which led to lip print use in criminology
1932 Edmond Locard, one of France’s greatest
criminologists, acknowledged the impor-
tance of cheiloscopy
1950 Le Moyer Snyder, in his book ‘‘Homicide
Investigation’’ mentioned the possibility
of using lip prints in the matter of human
identification
1960 Santos, suggested that the fissures and the
criss-cross lines in the lips could be divided Fig. 7.2: Vermillion border histology
into different groups
1972 Renaud, studied 4000 lip prints and
confirmed the singularity of each one,
supporting the idea of lip print singularity
The lips can be horizontal, elevated or depressed
Suzuki and Tsuchihashi in their study, over a
and, according to their thickness, it is possible to
long period of time, confirmed not only lip print
identify the following four groups: also, illustrated
singularity, but also lip response to trauma; in fact,
in the diagram below is the pictorial representation
these authors observed that after healing, the lip
of the same (Fig. 7.3).
pattern was equal to that before the injur y
1. Thin lips (common in the European, Caucasian)
occurred.
2. Medium lips (from 8 to 10 mm, are the most
ANATOMICAL ASPECTS common type)
3. Thick or very thick lips (usually having an
Lips are highly sensitive mobile folds, composed inversion of the lip cord and are usually seen in
of skin, muscle, glands and mucous membrane Negroes)
(Fig. 7.2). Anatomically, whether covered with 4. Mix lips (usually seen in Orientals)
skin or mucosa, the surface that forms the oral Various classification system proposed for the
sphincter is the lip area. There are two different cheiloscopy study are:
kinds of lip covering—skin or mucosa. When the A. Suzuki and Tsuchihashi classification
two meet, a white wavy line is formed – the labial B. Renaud classification.
cord – which is quite prominent in Negroes. C. Martin Santos classification.
Where identification is concerned, the mucosal D Afchar-Bayat classification.
area holds the most interest. This area, also called E. Jose Maria Dominguez classification.
Klein’s zone, is covered with wrinkles and grooves
that form a characteristic pattern— the lip print. A. Suzuki and Tsuchihashi Classification
However, this is not the only area that deserves (Table 7.1)
careful study. In fact, in cheiloscopy, one should
These authors considered six (Fig. 7.4) different
also analyze lip anatomy, considering their thickness
types of grooves, as seen in the following table.
and the position.
Cheiloscopy and Palatoscopy 157

Fig. 7.3: Chief types of lip pattern in world population
Table 7.1: Suzuki and Tsuchihashi classification In the lower lip, it is done the other way around,
using capital letters to classify the grooves, and small
Classification Groove type
letters to separate left from right sides.
Type I Complete vertical
Type I' Incomplete vertical C. Afchar-Bayat Lip Prints Classification
Type II Bracnched
Type III Intersected This classification, dated from 1979, is based on a
Type IV Reticular pattern six-type groove organization, as seen in the table
Type V Irregular below (Table 7.3).
D. Jose´ Maria Dominguez Classification

B. Renaud Classification
This is a classification based on the one made by
This is, probably, the most complete classification. Suzuki and T. suchihashi. In the grooves classified
The lips are studied in halves (left and right), and as Type II of Suzuki and Tsuchihashi, the author
every groove, according to its form, has a number. and his co-workers observed, with some frequency,
A formula is then elaborated using capital letters a slight variation: they observed that branched
to describe the upper lip left (L) and right (R) sides, grooves often divided upwards in the upper lip,
and small letters to classify each groove (Table 7.2). and downwards in the lower, as reported by Suzuki

Table 7.3: Afchar-Bayat lip prints classification
Classification Groove type

A1 Vertical and straight grooves covering
whole lips
A2 Like the former, but not covering the
whole lip
B1 Straight branched grooves
B2 Angulated branched grooves
C Converging grooves
D Reticular pattern grooves
E Other grooves
Fig. 7.4: Suzuki and Tsushihashi classification of

various lip types
Table 7.2: Renaud classification
Classification Groove type Fig. 7.5: Lip print on a coffee mug

A Complete vertical
B Incomplete vertical cups (Fig. 7.5) or even cigarette buts. Sometimes
C Complete Bifurcated lip prints will be seen as lipstick smears. Lipsticks
D Incomplete Bifurcated are complex substances, which have in their
E Complete branched constitution, several compounds, oils or waxes;
F Incomplete branched color of the lipsticks is due to organic inks and
G Reticular pattern inorganic pigments.
H X or Coma form However, all lip prints are important, even the
I Horizontal ones that are not visible. In fact, this complex
J Other forms (ellipse, triangle) process is not restricted to studying visible prints,
but also the latent ones. The vermillion border of
the lips has minor salivary and sebaceous glands
and Tsuchihashi; but they also realise that some which, together with the moisturizing done by the
grooves, the so called II0 type branched the other tongue, leads to the possibility of the existence of
way around. latent lip prints.
When searching for lip prints, one must always
Analyzing and Recording Lip Prints
consider that not all lipstick smears are colored; in
Lip prints can link a subject to a specific location if fact, in recent years the cosmetic industry has been
found on clothes or other objects, such as glasses, developing new lipsticks which do not leave a

visible smear or mark when they come in contact be analyzed in order to determine its constitution.
with different items—these are called persistent About 65 percent of lipsticks share the same
lipsticks. ingredients, however some are different and this
A group of Spanish investigators has studied difference can provide the identification of the
latent lip prints and concluded that they could be lipstick manufacturer.
studied in a similar way to fingerprints, using similar
techniques. In fact, even when located on Lip Prints can be Recorded in
“difficult” surfaces (such as porous or multicolored a Number of Ways
ones), latent prints can be easily seen using If located on a non-porous surface, lip prints can
fluorescent dyes (Fig. 7.6). be photographed and enlarged. Using transparent
When dealing with lip prints from persistent overlays, it is possible to make an overlay tracing.
lipsticks, one must always remember that persistent As previously referred to, the development of lip
lipsticks have minimal oil content and therefore, prints can be made using several substances known
their development using conventional powders as developers, such as aluminium powder, silver
(developers) might not be effective. Lysochromes metallic powder, silver nitrate powder, plumb
should then be used since they have the ability to carbonate powder, fat black aniline dyer or cobalt
dye fatty acids and are very effective when used on oxide.
long-lasting lipstick prints, even on porous surfaces. All lip prints contain lipids which make their
In this manner, latent lip prints should always be development possible by using lysochromes dyes
considered when processing a crime scene, even if (Sudan III, Oil Red O, Sudan Black) (Figs 7.7A
there are no traces of lipstick. to D). Sometimes, the use of fluorescent reagents
Processing lip prints depends on the anatomical, is necessary, especially when the color of the
morphological and histological tissue features of developer and the color of the surface on which
lips. Observation should be the first step using the lip print lies are the same, or when the lip print
white and ultraviolet light. Photographs should be is an old brand.
made prior to any processing in order to protect
the evidence. Developers Commonly Used are–
According to FBI guidelines latent prints should
Plumb carbonate: Over smooth, polished, metallic
be photographed individually with an identification
or plastic surfaces. Its only limitation is its use over
label and a scale; each step in the sequence must
white surfaces, use black marphill powder in such
be photographed. If lipstick is present, it should
cases
Silver nitrate: Non ideal surfaces, such as untreated
wood or cardboard
DFO and Ninhydrin: Porous surfaces
Cyanoacrylate dye: On plastic or waxed surfaces,
or on vinyl gloves
Cyanoacrilate dye or an iodine spray reagent: In
photographs, latent prints can be developed
Lips may also be studied and recorded in order
Fig. 7.6: Lip print visualized after fluorescent examination to allow a proper comparative analysis. Although

Fig. 7.7A: Latent lip print visualized after using a developer Fig. 7.7B: Latent lip print visualized after using
black powder on a cotton fabric after 30 days a developer oil red O
Fig. 7.7C: Another lip print visualized after using a Fig. 7.7D: Lip print obtained after using Sudan black dye
developer oil red O
lips can be photographed directly, covering them method used in taking the print. If lipstick is used,
with lipstick allows better groove visualization. The the amount can also affect the print. This problem
lip prints should be recorded, making several however, can be solved if recordings are made until
recordings until all transfer mediums are exhausted. all of the substance is used.
Then, prints are covered with transparent overlays Manual register of the overlay is another problem,
and, when using a magnifying lens, a trace can be due to the possibility of some subjectivity. Another
successfully done factor to be considered is the existence of some
pathological conditions (lymphangioma, congenital
Problems with Cheiloscopy lip fistula, lip seleroderma, Merkelson-Rosenthal
Lip print is produced by a substantially mobile syndrome, syphilis, angular cheilitis, among others),
portion of the lip. This fact alone explains the which can invalidate the cheiloscopic study.
reason why the same person can produce different One must also consider the possibility of
lip prints, according to the pressure, direction and post-mortem changes of lip prints from cadavers

with various causes of death. It should also be The natural process of decomposition;
pointed out that only in very limited circumstances, Scavenger animal actions;
is there antemortem data referring to lip prints, The circumstances in which death occurred.
which obviously impairs a comparative study where Palatoscopy, or palatal rugoscopy, is the name
necro identification is concerned. The main feature given to the study of palatal rugae in order to
for dental identification is the existence of ante establish a person's identity.
mortem data, which cannot be expected in Due to anatomical position, it is unlikely that
cheiloscopy. Therefore, the only use of cheiloscopy the study of palatal rugae could be used in the
will be to relate lip prints to the lips that produced process of linking a suspect to a crime scene. On
them the other hand, palatoscopy may be used as a
necro-identification technique. As previously
Future Prospects of Cheiloscopy mentioned, it will be in these par ticular
Cheiloscopy is interesting mostly in identifying the circumstances that palatoscopy is most valuable.
living, since it can be the only way to link somebody The possibility of finding antemortem data
to someone or to a specific location. However, supports this idea. Nowadays, palatal rugae
although lip prints have previously been used in a patterns are considered a viable alternative for
court of law, its use is not consensual and some identification purposes. Some investigators aim
authors believe further evidence is needed to to assess its feasibility with the aid of a computer
confirm their uniqueness. In fact, lip print use is and a software program. The results so far are
controversial and rare. good, but expected to be better.
The FBI has used this kind of evidence only in In fact, the Brazilian Aeronautic Minister
a single case in order to obtain a positive demands palatal rugoscopy of all its pilots, in order
identification. Nowadays, new research allows for to ensure their identification in case of accident.
cheiloscopy use in a court of law in the USA.
Recent studies also point out other possibilities HISTORICAL REVIEW
namely, DNA detection in latent lip prints where
some researchers are trying to relate characteristic 1897 Kuppler was the first person to study palatal
lip patterns with a person's gender. Another aspect anatomy to identify racial anatomic
that might be interesting to study is the possibility features.
of using identifiable lip prints obtained from the 1932 Palatal rugoscopy was first proposed in
1932, by a Spanish investigator called
skin of assault and murder victims, in a similar way to
Trobo Hermosa.
what has already been done with latent finger prints.
1937 Carrea developed a detailed study and
PALATOSCOPY established a way to classify palatal rugae
One year later, Da Silva proposed another
Identifying live or dead people is often a difficult classification.
and time consuming process. Identifying living 1946 Martins dos Santos presented a practical
people is sometimes difficult because people do classification based on rugae location.
not normally wish to be identified. Therefore, in 1983 Brinon, following the studies of Carrea,
order to achieve this goal, people disguise their divided palatal rugae into two groups
presence in various ways. Identifying the dead raises (fundamental and specific) in a similar way
a whole different set of problems, which relate to; to that done with fingerprints.

In this manner, dactiloscopy and Palatoscopy
were united as similar methods based on the same
scientific principles and are sometimes comple-
mentary: For instance, Palatoscopy can be of special
interest in those cases where there are no fingers
to be studied (burned bodies or bodies in severe
decomposition).
ANATOMICAL ASPECTS
The surface of the oral mucosa is mostly flat and
smooth without grooves or (Figs 7.8A to C)
crests, this happens in order to achieve the best Fig. 7.8A: A clinical picture of palatal rugae
performance in oral functions. Nevertheless, there
are some exceptions, like back of the tongue, which
is covered with papillae; the anterior portion of
the palatal mucosa, having a dense system of rugae,
firmly attached to the underling bone. Palatal rugae
are irregular, asymmetric ridges of mucous
membrane extending lateral from the incisive
papilla and the anterior part of the median palatal
raphe whose purpose is to facilitate food
transportation through the oral cavity, prevent loss
of food from the mouth and participate in the
chewing process. Due to the presence of gustatory
and tactile receptors, they contribute to the
perception of taste, the texture of food qualities
and tongue position. Generally, there is no bilateral
symmetry in the number of primary rugae or in
their distribution from the midline. It has been
found that there are slightly more rugae in males
and on the left side in both genders.
Their role in human oral function seems to be
increasingly less important, which might explain why
their development time is retarded. Palatal rugae
are formed in the 3rd month in utero from the hard
connective tissue covering the bone. Once formed,
they do not undergo any changes except in length,
due to normal growth, remaining in the same
Figs 7.8B and C: Cast showing the palatine rugae
position through out an entire person's life. Not
even diseases, chemical aggression or trauma seem Investigations have been carried out to study
to be able to change palatal rugae form. the thermal effects and the decomposition changes
PALATAL RUGAE CLASSIFICATIONS

on the palatal rugae of burn victims with pan facial
third degree burns, and have concluded that most
The supposed uniqueness and overall stability of
victims did not sustain any palatal rugae pattern
palatal rugae suggest their use for forensic
changes, and when changes were noted, they were
less pronounced than in the generalized body state. identification. Palatal rugae are used in human
Furthermore, the ability of palatal rugae to resist identification not only due to their singularity and
decomposition changes for up to seven days after unchangeable nature, but also due to other
death was also noted. However, some events can advantages, namely their low utilization costs.
contribute to changes in rugae pattern, including Researchers have found the task of classification a
extreme finger sucking in infancy and persistent difficult aspect of rugae studies. The subjective
pressure due to orthodontic treatment. nature of observation and interpretation within and
Nevertheless, in most cases, one must account between observers poses a problem. Nowadays,
for palatal rugae persistency. Camargo et al have there are several known palatal rugae classifications.
referred that, in gingival graft surgery, the selection However, according to several authors, Lysell, in
of the palatal donor site should avoid the rugae 1955, developed the first classification system for
areas because they may persist in the grafted tissue. palatal rugae pairs:
However, extractions may produce a local effect Various classification system proposed for
on the direction of the rugae. In fact, palatal rugae Palatoscopy are as outlined below:
stability is considered an important factor when A. Carrea classification
teeth are extracted as has been demonstrated in B. Martins dos Santos classification
several studies, which point out the stability of the C. Lo´pez de Le´on classification
rugae medial points over the lateral points. These
D. Da Silva classification
features where first noticed in 1967, by Peavy and
E. Trobo classification
Kendrick, who said, the closer the rugae are to the
F. Basauri classification
teeth, the more prone they are to stretch in the
direction that their associated teeth move. In
Carrea Palatal Rugae Classification
addition to these findings of the importance of
using medial points, it has been said that the more This author divides palatal rugae into four different
posterior rugae are less susceptible to changes with types, as shown in below (Table 7.4). Palatal rugae
tooth movement, being the third palatal rugae pair are classified only according to their form and no
in particular the most stable reference. Other formula (rugogram) is developed.
studies however, point out that the first rugae is
the most stable. Many authors however believe that Martins Dos Santos Classification
further studies are needed in order to define which
Based on the form and position of each palatal
rugae is the most stable. The occurrence, number
rugae, this classification indicates and characterizes
and arrangement of palatal rugae in mammals are
species-specific. In humans they are asymmetrical, the following (Table 7.5):
which is an exclusive feature of human beings. Table 7.4: Carrea palatal rugae classification
According to English's studies, palatal rugae
patterns are suf ficiently characteristic to Classification Rugae type
discriminate between individuals. In fact, these Type I Posterior- anterior directed rugae
authors found it legitimate to base identification Type II Rugae perpendicular to the raphe
upon their comparison, allowing for human Type III Anterior- posterior directed rugae
identification even in extreme circumstances. Type IV Rugae directed in several directions

Table 7.5: Martins dos Santos classification Table 7.6: Da Silva palatal rugae classification
Rugae type Anterior position Other positions Classification Rugae type

Point P 0 1. Line
Line L 1 2. Curve
Curve C 2 3. Angle
Angle A 3 4. Circle
Circle C 4 5. Wavy
Sinuous S 5 6. Point
Bifurcated B 6
Trifurcated T 7
Table 7.7: Trobo classification
Interrupt I 8
Anomaly An 9 Classification Rugae type
Type-A Point
Type-B Line
One initial rugae; the most anterior one on the Type-C Curve
right side is represented by a capital letter. Type-D Angle
Several complementary rugae; the other right Type-E Sinuous
Type-F Circle
rugae are represented by numbers; One subinitial
rugae; the most anterior one on the left side is
represented by a capital letter; Several sub- Da Silva Palatal Rugae Classification
complementary rugae; the other left rugae are
In this classification, palatal rugae are divided into
represented by numbers. The numbers and letters
two groups: simple, from 1 to 6 and composed,
given to each rugae, relate to its form and can be
resulting from two or more simple rugae. They
seen in Table 7.5.
are named according to each rugae number. It is
possible to classify each ruga individually
Lo´Pez De Le´On Classification
(describing its form), but also to describe all the
Dating from 1924, this classification has only palatal rugae system (describing each ruga type
historic relevance. The author proposed the number), making this a difficult classification to
existence of a link between a person's personality use (Table 7.6).
and palatal rugae morphology. In this manner,
there were four known types of palatal rugae: Trobo Classification
B—Bilious personality rugae; This classification also divides rugae into two
N—Nervous personality rugae; groups: Simple ruga, classified from A to F and
S—Sanguinary personality rugae; composed rugae, classified with the letter X.
L—Lymphatic personality rugae. Composed rugae result from two or more simple
The letters B, N, L, and S, stand for the different rugae unions. The rugogram is made from right
personalities. The letters l and r stand for the left to left, beginning with the principal ruga (the one
and right side of the palate, and are followed by a closest to the raphae), which is classified with a
number, which specifies the palatal rugae number capital letter. The following rugae are classified with
on each side. For instances, a possible rugogram small letters. Finally, the left side of the palate is
would be Br6; Bl8. described using the same criteria (Table 7.7).
Basauri Classification

and subinitial rugae) are classified by a letter and
Like the Trobo classification, this is a very easy the other right and left (complementar and
classification to use. It distinguishes between the subcomplementar rugae) are assigned numbers.
principal rugae, which is the more anterior one
Palatoscopy in Edentulous Cases
(labeled with letters) and the accessory rugae,
which concerns all the remaining rugae (labeled When a victim has no teeth, information for use in
with numbers), as seen in Table. The rugogram is personal identification based on methods available
elaborated beginning from the right side of the in forensic odontology is much more limited than
palate (Table 7.8). in the case of dentate victims. For edentulous
victims, (Fig. 7.9) some identification methods
Cormoy System are available, such as comparing the anatomy of
This system classifies palatal rugae according to the Paranasal sinuses and comparing bony patterns
their size, in: seen on radiographs.
1. Principal rugae (over 5 mm); Furthermore, the victims' dentures themselves,
2. Accessory rugae (ranging from 3 to 4 mm); can provide us with more personal information with
3. Fragmental rugae (with less than 3 mm length). regard to denture making, denture materials, and
The form (line, curve, and angle), origin (medial their unique shapes, for use as antemortem data or
extremity) and direction of each ruga are also postmortem evidence (Fig. 7.10). Among the
described. Possible ramifications are also pointed evidence taken from an edentulous victim, a palatal
out. Rugae that share the same origin, interrupted rugae pattern is one of the unique and relatively
rugae and the incisive papilla are described as well. obtainable morphological features, and the pattern
It is a very complete system. However, its use does can be taken not only directly from the hard palate,
not lead to rugogram elaboration, which makes but also from the mucosal surface of the dentures.
the managing and processing of data difficult.
Correia Classification
Rugae are labeled with numbers or letters,
according to their form. The rugogram is formed
like a fractional equation. The right side is the
numerator and the left side is the denominator.
The first right and the first left palatal rugae (initial
Table 7.8: Basauri classification
Principal rugae Accessory rugae Rugae anatomy

classification classification
A 1 Point
B 2 Line
C 3 Angle
D 4 Sinuous
E 5 Curve
F 6 Circle
Fig. 7.9: Radiograph of an edentulous patient
X 7 Polymorphic
showing paranasal sinuses

These features are mainly due to the shape of the
edentulous palate itself and rarely due to the
dentures, and could lead to difficulties in finding
unique points for use in matching rugae patterns.
These findings as notified by the authors suggest
that an appropriate selection of cases, taking into
consideration the above misleading shapes, may
establish an increased rate of accuracy for
identification with this method, thereby bringing
the percentage of correct matches closer to 100 in
edentulous cases, which is also the percentage of
correct matches previously reported in dentate cases.
The use of teeth in postmortem identification
has gained prominence over the last half-century;
the rugae are well protected by the lips, buccal pad
of fat and teeth and hence, survive postmortem
Fig. 7.10: Mucosal surface of maxillary denture showing
palatine rugae
insults. Postmortem dental identification is,
however, not possible in the edentulous and palatal
rugae can be used as a supplement in such instances.
Application of palatal rugae patterns to personal ID
was 1st suggested by Allen in 1889. Subsequently, Thus, palatal rugae appear to possess the features
its usefulness has mainly been established in dentate of an ideal forensic identification parameter because
cases. In contrast, the usefulness of this method for of their:
edentulous victims has not yet been fully established. 1. Uniqueness,
Thomas and Wyk proposed the usefulness of 2. Postmortem resistance and
rugae pattern for personal identification by 3. Stability
comparing its morphological features with the In addition, rugae pattern may be specific to
victim's dentures. They successfully identified a racial groups facilitating population identification
severely burnt edentulous body by comparing the (which may be required post-disasters).
rugae to those on the victim's old denture
ANALYZING AND RECORDING
indicating, among other things, that rugae are
stable in adult life. However, Jacob and Shalla PALATAL RUGAE
doubted its usefulness because the accuracy of
identification based on palatal rugae tracings was There are several ways to analyse palatal rugae.
only 79 percent in their trials. Intraoral inspection is probably the most used and
M Ohtani et al in their study analyzed the also the easiest and the cheapest. However, it can
incidence of obtaining a correct match in such create difficulties if a future comparative exam is
edentulous case, revealed that there were three required. A more detailed and exact study, as well
major misleading shapes that could give rise to a as the need to preserve evidence may justify oral
low rate of correct matches; these are: photography or oral impressions. Calcorrugoscopy,
1. Severely low and poorly demarcated eminences or the overlay print of palatal rugae in a maxillary
of rugae, cast, can be used in order to perform comparative
2. Change of palatal height, and analysis. Other more complex techniques are also
3. Non-complex rugae pattern. available. By using stereoscopy, for example, one

can obtain a three dimensional image of palatal rugae established such as records found in dental practice
anatomy. It is based on the analysis of two pictures in different forms (dental casts, old prosthetic
taken with the same camera, from two different maxillary devices and intraoral photographs).
points, using special equipment. Another technique However, palatoscopy might not be so useful in
is the sterophotogrammetry which, by using a special crime scene investigations in the linking of suspects
device called Traster Marker, allows for an accurate to crime scenes. In fact, this kind of evidence is
determination of the length and position of every not expected to be found in such circumstances.
single palatal rugae. However, due to its simplicity, Another aspect of palatoscopy that one must
price and reliability, the study of maxillary dental consider is the possibility of rugae pattern forgery.
casts is the most used technique. In a case report, Gitto et al. described a method
where palatal rugae were added to a complete
Genetic Influence on Palatal Rugae denture in order to improve speech patterns in
some patients. This process can lead to false identity
Population differences pose the question as to how exclusion due to misleading antemortem data.
much is attributable to genetic differences and how
much is the result of environmental affects. While
intraoral environmental influences such as denture FUTURE PROSPECTS
wearing, tooth malposition and palatal pathology As with cheiloscopy, other aspects of palatoscopy
are considered to affect rugae pattern, some have been studied. For instances, Thomas et al. have
consider it “ver y unlikely” that they affect worked on the possible use of palatal ruga patterns
formation of rugae and believe rugae pattern is in paternity determination. This possibility was first
genetically controlled. Furthermore, twin studies suggested by Lysell. However, there were no
show that rugae pattern has an underlying genetic findings to link the two aspects. Kratzsch and Opitz
basis. According to Luke, the rugae develop as developed a study in cleft patients whose results
localised regions of epithelial proliferation and suggest that palatal rugae, in combination with
thickening. Fibroblasts and collagen fibres then measuring points of the cleft palate, can serve to
accumulate in the connective tissue beneath the depict changes occurring in the anterior palate
thickened epithelium and assume distinct during various stages of therapy and growth. These
orientation. “The fibres running anteroposteriorly findings suggest that some facial changes can be
within the core and in concentric curves across the expected when studying specific rugae patterns. Few
base of each ruga” determine their orientation. It studies using palatal rugae as a means of forensic
is plausible that certain, as yet unidentified, genes identification are found in literature. However, the
influence orientation of the collagen fibres during idea of rugae being unique to an individual is
embryogenesis and post-natal growth and govern promising and deserves further investigation.
rugae pattern in different populations. Hence,
rugae shape may be used as genetic markers for
further research on population groups. BIBLIOGRAPHY
1. Burris BG, Harris EF. Identification of race and
PROBLEMS WITH PALATOSCOPY sex from palate dimensions, J Forensic Sci.
1998;43(5):959-63.
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interest in human identification. In fact, contrary by fluorescence observation and purge-and-trap gas
to lip prints, it is possible to have antemortem data chromatography, Forensic Sci Int. 1998;96:1-10.

3. English WR, Robinson SF, Summitt JB, et al. 9. Maki Ohtani, et al. Indication and limitations of
Individuality of human palatal rugae, J Forensic Sci. using palatal rugae for personal identification in
1988;33:718-26. edentulous cases. Forensic Science International
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denture, J Prosthet Dent. 1999;81;237-9. Lip prints (Cheiloscopy), Ind J Dent Res.
5. Ine’s Morais Caldas. Review Establishing identity 2001;12(4):234-7.
using cheiloscopy and palatoscopy. Forensic Science 11. Thomas CJ, Rossouw RJ, The early development
International. 2007;165:1-9 of palatal rugae in the rat, Aust Dent J
6. Kaur R, Garg RK. Personal identification from lip 1991;36(5):342-8.
prints. Abstracts/Forensic Science International. 12. Thomas CJ, The role of the denture in identification:
2007;169S:S47-S49. a review, J Forensic. Odontostomatol. 1984;2:13-6.
7. Latent Prints Examinations, http://www.fbi.gov/ 13. Thomas CJ, Van Wyk CW The palatal rugae in an
hq/lab/handbook/intro9. html. identification, J Forensic Odontostomatol.
8. Lip prints could help forensic science, The Indian 1988;6:21-7.
Express, http://www. indianexpress.com.
8

Forensic Facial Reconstruction
Nitul Jain, Sohail Lattoo, Vishwas Bhatia
Chapter Overview
 Daubert standard  Technique for creating a three-dimensional clay

 Theoretic foundations reconstruction
 Types of identification  Currently used methods
 Types of reconstructions  Problems with facial reconstruction
 History  Facial reconstruction and the media
INTRODUCTION forensic science, anthropology, osteology, and

anatomy. It is easily the most subjective—as well
Whenever human remains are found, attempts are as one of the most controversial—techniques in
made to assign these to a definite person. Current the field of forensic anthropology. Despite this
methods of identification include odontosto- controversy, facial reconstruction has proved
matology (comparison of teeth), DNA analysis, successful frequently enough that research and
dactyloscopy, and analysis by x-ray comparison. No methodological developments continue to be
method of identification offers 100 percent certainty advanced.
that the parts definitely belong to that person; it All identification methods require comparative
cannot be excluded that somewhere in the world data and materials from the person concerned. For
there is or was another person who has the same DNA analysis and fingerprints, databases exist
features. At the end of the examination the whose data can be compared against the collected
probability that the identity is correct should always data. If a targeted person’s data are, however, not
approach 100 percent. When the probability exceeds in a file or they have not visited a dentist in the
99.8 percent, this is referred to as a “probability preceding years, then inquiry approaches and
bordering on certainty”. morphological investigations have to be used to
Forensic facial reconstruction (or forensic facial identify a comparable person. Depending on the
approximation) is the process of recreating the face extent of decomposition and completeness of the
of an unidentified individual from their skeletal human remains, forensic autopsy or forensic-
remains through an amalgamation of artistry, osteological examination may offer information

regarding sex, age, size, proportions, ethnic origin,
and habits or diseases.
The face, which has an excess of a hundred
individual features, is of great value in recognizing/
identifying a person. In unknown dead bodies, a
facial photograph is taken, which is sometimes
digitally processed, so that it becomes suitable as a
portrait image for witnesses to study or for
newspapers to publish. For the purposes of legal
identification of a dead body—which requires a
person to take a look at it, for example, a family
Fig. 8.1: The famous reconstruction of king Tut’s face from
member—the face is often the only body part to the ancient recovered mummy
be uncovered. In many unidentified dead bodies,
the face has been rendered unrecognizable to the
point of complete skeletization through autolysis,
decay, by animals, or other destruction. If the listed
methods do not succeed in identifying the body,
facial reconstruction may be used as a method of
last resort. Here in this chapter, I have tried out to
sketch out the historic development of forensic
facial reconstruction and critically discuss the
different methods and current developments.
In addition to remains involved in criminal
investigations, facial reconstructions are created for
remains believed to be of historical value and for
remains of prehistoric hominids and humans. For
example, recently all of us had seen recreation of
the face of King Tut’s Mummy, (Fig. 8.1) the
young ruler of Ancient Egypt. Based on an earlier
CT Scan of the boy king’s mummy, Paris-based
forensic sculptor Elisabeth Daynès created a silicon- Fig. 8.2: National Geographic magazine, which had first
reported the existence of king Tut’s mummy
skinned bust using the previously acquired data
and combined it with average traits of today’s
Egyptians. The CT data was then sent to a US
DAUBERT STANDARD
forensic team, who worked to verify the findings, In the US, the Daubert Standard is a legal
without knowledge of who their subject was. The precedent set in 1993 by the Supreme Court
reconstruction was featured in the June, 2005 issue regarding the admissibility of expert witness
of National Geographic magazine (Fig. 8.2), in testimony during legal proceedings. This standard
the touring exhibit Tutankhamun and the Golden was set in place to ensure that expert witness
Age of the Pharaohs, and on the National testimony is based upon sufficient facts or data, is
Geographic Channel’s special documentary named the product of reliable principles and/or methods
King Tut’s Final Secrets. (including peer review), as well as ensuring that
Forensic Facial Reconstruction 171

the witness has applied the principles and methods In living subjects, however, substantial differences
reliably to the facts of the case. in the measurement results were noted depending
When multiple forensic ar tists produce on the bodily position of the subject. Measure-
approximations for the same set of skeletal remains, ments taken in an upright position on the head
no two reconstructions are ever the same and the and in a seated position are most meaningful, (Figs
data from which approximations are created are 8.4 A and B), because they correspond best with
largely incomplete. Because of this, forensic facial the usual position of the head in living persons.
reconstruction does not uphold the Daubert Measurements taken in a seated position are
Standard, is not included as one of the legally possible only by using ultrasonography, whose
recognized techniques for positive identification, resolution, however, is limited.
and is not admissible as expert witness testimony.
Currently, reconstructions are only produced to
aid the process of positive identification in
conjunction with verified methods.
THEORETIC FOUNDATIONS
In forensic facial reconstruction, or rather, forensic
reconstruction of soft facial parts, the basic premise
is that in certain anatomical points of the skull there
are definable soft tissue thicknesses. In several
studies, these were measured, and the mean
thickness for the respective point (so called
landmarks) (Fig. 8.3) was calculated. The
measurements used to be taken on dead bodies,
A
with needles, MRI, or CT.
The imaging methods provided an opportunity
to perform measurements in living subjects, to be
able to exclude postmortem changes and artifacts.
B
Fig. 8.3: Some of the most important anatomic landmarks Figs 8.4 A and B: The various soft tissue thickness at
used on the skull for facial reconstruction specific location used for facial reconstruction

For the training in facial reconstruction, skulls condition. The problem is, on the one hand, that
should be used for whom a portrait photograph is this has not been taken into consideration during
available to enable a comparison after the data collection and therefore, this variable cannot
reconstruction has been completed. But an exact be captured statistically. On the other hand, it is
reconstruction does not necessarily mean that the difficult in a decomposed or skeletized corpse to
model will be recognized as the missing person. If determine the dead person’s nutritional condition
a missing person is identified after the publication before death.
of a police search photograph that is based on a
facial reconstruction, then the question is what has TYPES OF IDENTIFICATION
led to this. If a conspicuous beard or hairstyle,
combined with unusual clothing, have been There are two types of identification in forensic
faithfully reproduced in a police search photograph, anthropology: circumstantial and positive.
then the individual face fades into the background. Circumstantial identification is established when
Conversely, a face that has been reconstructed an individual fits the biological profile of a set of
perfectly, to the last detail, but is surrounded by skeletal remains. This type of identification does
an unsuitable hairstyle, can make recognition not prove or verify identity because any number of
difficult or even impossible. Gerasimov is said to individuals may fit the same biological description.
have solved nearly 100 percent of cases in 140
Positive identification is one of the foremost goals
reconstructions. The Two dimensional reconst-
ruction of the French national police, which was of forensic science, is established when a unique
based on a phantom image, however, did not result set of biological characteristics of an individual are
in a single successful identification in more than matched with a set of skeletal remains. This type
100 cases. In critical consideration of these results, of identification requires the skeletal remains to
then it is impossible in the individual case to correspond with medical or dental records, unique
conclude with any degree of certainty whether the antemortem wounds or pathologies, DNA analysis,
facial reconstruction or other elements of the and still other means.
inquiry have provided the decisive clues for the Facial reconstruction presents investigators and
identification. This poses a fundamental problem family members involved in criminal cases
in the validation of the methods. concerning unidentified remains with a unique
More crucial than technical errors or measure- alternative when all other identification techniques
ment errors related to the positioning of the subject have failed. Facial approximations often provide
during data collection, however, is the extent to the stimuli that eventually lead to the positive
which the actual value in the case at hand deviates identification of remains.
from the mean value for the respective landmark.
Further to a person’s sex, their age is a highly TYPES OF RECONSTRUCTIONS
influential variable. With increasing age, the
Two-dimensional Reconstructions
connective tissues lose their elasticity, the soft facial
parts lose their firmness, and they start hanging Two-dimensional facial reconstructions are hand-
down in folds/wrinkles. The subject’s age is to be drawn facial images based on antemor tem
taken into consideration in most samples to be photographs, and the skull. Occasionally skull
investigated. The largest individual influence for radiographs are used but this is not ideal since many
the thickness of the soft tissues on the landmarks, cranial structures are not visible or at the correct
however, is due to by the individual’s nutritional scale. This method usually requires the

collaboration of an ar tist and a forensic some kind of knowledge about the identity of the
anthropologist. A commonly used method of two- skeletal remains with which they are dealing (as
dimensional facial reconstruction was pioneered by opposed to 2D and 3D reconstructions, when the
Karen T Taylor of Austin, Texas during the 1980s. identity of the skeletal remains is generally
Taylor’s method involves adhering tissue depth completely unknown). Forensic superimpositions
markers on an unidentified skull at various are created by superimposing a photograph of an
anthropological landmarks, then photographing individual suspected of belonging to the
the skull. Life-size or one-to-one frontal and lateral unidentified skeletal remains over an X-ray of the
photographic prints are then used as a foundation unidentified skull. If the skull and the photograph
for facial drawings done on transparent vellum. are of the same individual, then the anatomical
Recently developed, the FACE and CARES features of the face should align accurately.
computer software programs quickly produce two-
dimensional facial approximations that can be HISTORY
edited and manipulated with relative ease. These
programs may help speed the reconstruction It was Mr M Gerasimov (1965), Soviet archeologist
process and allow subtle variations to be applied and anthropologist who developed the first
to the drawing, though they may produce more technique of forensic sculpture.
generic images than hand-drawn artwork. The article by Grüner offers a good historic
overview. Facial reconstruction was preceded by
Three-dimensional Reconstructions the comparison of skulls with portrait images, for
the purposes of identification. In the 19th century,
Three-dimensional facial reconstructions are either: attempts were already made to reconcile found
A. Sculptures (made from casts of cranial remains) skulls with portrait paintings, albeit in an
created with modeling clay and other materials. unsystematic fashion and by using outline sketches.
or Welcker (1883) and His (1895) were the first
B. High-resolution, three-dimensional computer to reproduce three-dimensional facial approxi-
images. mations from cranial remains. Most sources,
Like two-dimensional reconstructions, three- however, acknowledge His as the forerunner in
dimensional reconstructions usually require both advancing the technique. His also produced the
an artist and a forensic anthropologist. Computer first data on average facial tissue thickness
programs create three-dimensional reconstructions followed by Kollmann and Buchly who later
by manipulating scanned photographs of the collected additional data and compiled tables that
unidentified cranial remains, stock photographs of are still referenced in most laboratories working
facial features, and other available reconstructions. on facial r eproductions today. Facial
These computer approximations are usually most reconstruction originated in two of the four
effective in victim identification because they do major subfields of anthropology. In biological
not appear too picturesque or too artificial. anthropology, they were used to approximate the
appearance of early hominid forms, while in
Superimposition
archaeology they were used to validate the
Superimposition is a technique that is sometimes remains of historic figures. In 1964, Gerasimov
included among the methods of forensic facial was pr obably the first to attempt
reconstruction. It is not always included as a paleoanthropological facial reconstruction to
technique because investigators must already have estimate the appearance of ancient peoples.

Initially, forensic reconstruction of soft facial Corbet created the first forensic facial reconstruction
parts aimed to reconstruct a face for historic of an approximate 2,200 year old mummy based
skulls. This was also the case for the work of on CT and laser scans. This reconstruction is known
Gerasimov, who used clay to sculpt his faces. He as the Sulman Mummy project.
was the first to apply his techniques to forensic
investigations. The authorities asked his help in TECHNIQUE FOR CREATING A THREE-
DIMENSIONAL CLAY RECONSTRUCTION
solving the cases of unknown dead bodies whose
aspect had been changed beyond any
recognition. The facial reconstr uctions of Note: Because a standard method for creating
Gerasimov are reputed to have facilitated three-dimensional forensic facial reconstructions
recognition and later identification of many has not been widely agreed upon, multiple methods
victims among the population. and techniques are used. The process detailed
Although students of Gerasimov later used his below reflects the method presented by Taylor and
techniques to aid in criminal investigations, it was Angel from their chapter in Craniofacial
Wilton M Krogman who popularized facial Identification in Forensic Medicine, pages 177-
reconstruction’s application to the forensic field. 185. This method assumes that the sex, age, and
Krogman presented his method for facial race of the remains to undergo facial reconstruction
reconstruction in his 1962 book, detailing his have already been determined through traditional
method for approximation. Others who helped forensic anthropological techniques.
popularize three-dimensional facial reconstruction The skull is the basis of facial reconstruction;
include Cherry (1977), Angel (1977), Gatliff however, other physical remains that are sometimes
(1984), Snow (1979), and Iscan (1986). available often prove to be valuable. Occasionally,
The “super projection procedure” was the first remnants of soft tissue are found on a set of
purely photographic method: the por trait remains. Through close inspection, the forensic
photograph, a pane of acrylic glass, and the skull artist can easily approximate the thickness of the
marked with landmarks were lined up on an optic soft tissue over the remaining areas of the skull
bench. The landmarks from the photograph and based on the presence of these tissues. This
the lines emanating resulting from this were eliminates one of the most difficult aspects of
transferred to the acrylic glass. After removal of reconstruction, the estimation of tissue thickness.
Additionally, any other bodily or physical evidence
the photograph, the skull was adjusted according
to the drawings on the acrylic pane. Finally, skull found in association with remains (e.g. jewelry, hair,
and photograph were photographed in the glasses, etc.) are vital to the final stages of
calculated position on the optic bench. This reconstruction because they directly reflect the
method was simplified with the help of a procedure appearance of the individual in question.
whereby two television cameras recorded photo- Most commonly, however, only the bony skull
graph and skull simultaneously; the images were and minimal or no other soft tissues are present on
then projected with a video image mixer. the remains presented to forensic artists. In this case,
Nowadays, digital image processing is available for a thorough examination of the skull is completed.
the super-projection/superimposition of skulls and This examination focuses on, but is not limited to,
portrait photograph. the identification of any bony pathologies or unusual
In 2004, it was noted by Dr Andrew Nelson of landmarks, ruggedness of muscle attachments,
the University of Western Ontario, Department of profile of the mandible, symmetry of the nasal
Anthropology that noted Canadian artist Christian bones, dentition, and wear of the occlusal surfaces.

Fig. 8.5: The sequence of events depicting facial reconstruction using clay technique
All of these features have an effect on the correspond to the reference data. These sites
appearance of an individual’s face. represent the average facial tissue thickness for
Once the examination is complete, the skull is persons of the same sex, race, and age as that of
cleaned and any damaged or fragmented areas are the remains. From this point on, all features are
repaired with wax. The mandible is then reattached, added using modeling clay (Fig. 8.5).
again with wax, according to the alignment of First, the facial muscles are layered onto the cast
teeth, or, if no teeth are present, by averaging the in the following order: temporalis, masseter,
vertical dimensions between the mandible and buccinator and occipitofrontals, and finally the soft
maxilla. Undercuts (like the nasal openings) are tissues of the neck. Next, the nose and lips are
filled in with modeling clay and prosthetic eyes are reconstructed before any of the other muscles are
inserted into the orbits centered between the formed. The lips are approximately as wide as the
superior and inferior orbital rims. At this point, a interpupillary distance. However, this distance
plaster cast of the skull is prepared. Extensive detail varies significantly with age, sex, race, and
of the preparation of such a cast is presented in the occlusion. The nose is one of the most difficult
article from which these methods are presented. facial features to reconstruct because the underlying
After the cast is set, colored plastics or the bone is limited and the possibility of variation is
colored ends of safety matches are attached at expansive. The nasal profile is constructed by first
twenty-one specific “landmark” areas that measuring the width of the nasal aperture and the

nasal spine. Using a calculation of three times the post-cranium are anthropologically investigated
length of the spine plus the depth of tissue marker and measured. It is important to gather as much
number five will yield the approximate nose length. information as possible about the appearance of
Next, the pitch of the nose is determined by the deceased from the available human remains and
examining the direction of the nasal spine—down, artifacts. Of particular relevance are the color,
flat, or up. A block of clay, that is the proper length shape, and length of the hair, beard/facial hair in
is then placed on the nasal spine and the remaining men, skin color, eye color, height and weight, age,
nasal tissue is filled in using tissue markers two and and ethnicity.
three as a guide for the bridge of the nose. The For the later model, traces of clothing or hats are
alae are created by first marking a point, five also useful. They provide vital clues to the person’s
millimeters below the bottom of the nasal aperture. personality. The less is left of the individual the less
After the main part of the nose is constructed the information can be gained. An isolated skeletonized
alae are created as small egg-shaped balls of clay, skull allows conclusions merely about age and sex.
that are five millimeters in diameter at the widest
point, these are positioned on the sides of the nose Classic Manual Methods
corresponding with the mark made previously. The The aim of forensic reconstruction of soft facial
alae are then blended to the nose and the overall parts can be formulated clearly: it is to create a
structure of the nose is rounded out and shaped recognizable image of a missing person. The
appropriately. assessment of a concrete facial reconstruction or a
The muscles of facial expression and the soft tissue whole method is problematic. A seemingly
around the eyes are added next. Additional objective method is the comparison of a
measurements are made according to race (especially photograph of the person with that of the
for those with eye folds characteristic of Asian reconstruction, after successful identification has
descent) during this stage. Next, tissues are built up taken place. For the classic manual techniques,
to within one millimeter of the tissue thickness several studies exist that have shown a good
markers and the ears (noted as being extremely consistency between the reconstruction, their
complicated to reproduce) are added. Finally, the reproduceability, and the actual looks of the person.
face is “fleshed,” meaning clay is added until the Such results are so far lacking for computer aided
tissue thickness markers are covered, and any specific methods. Basically, the classic manual methods
characterization is added (for example, hair, wrinkles allow application of the soft facial parts that are to
in the skin, noted racial traits, glasses, etc.). be reconstructed directly on to the skull in the form
of clay, wax, or synthetic substances. Such an
CURRENTLY USED METHODS approach, however, has to be rejected from an
ethics perspective if a funeral is planned after
Requirements for a Forensic
successful identification. In all cultures and belief
Reconstruction of Soft Facial Parts
systems, the head is a central element of the body.
The prerequisite for every method used for facial The standard procedure is therefore to cast the
reconstruction is a mostly intact skull, preferably skull as a first step. Silicone is most suitable for
with the lower jaw bone present. If bone injuries this. Using the templates produced in this manner,
or destruction are present, then the skull will have the skull is cast in synthetic material or plaster. The
to be reconstructed before the facial reconstruction resulting skull model then forms the basis for the
can take place. Before the reconstruction work can reconstruction of the soft facial parts. The skull
start, the skull and remaining parts of the model is then marked with landmarks and the

distance holders fixed on to these, whose lengths The sculpture-like head model (crude model)
reflect the average soft tissue thickness above the has to be furnished with a skin color and hair, and
respective landmark (Figs 8.4A and B). maybe a beard. The head thus constructed can be
In the so called Manchester method, the face is photographed on its own or on a body model
reconstructed from the musculature step by step wearing the clothes of the deceased. The result: a
with clay (Figs 8.6A to E). The muscular tracks photograph that can be used in the police search.
on the bone indicate whether the musculature was Using the reconstructed head, several variations
more or less strongly developed. Glass eye models
of hair and clothing may be undertaken and
are inserted into the eye sockets. After the
documented by photography.
musculature has been completed, the epidermis,
Classic manual forensic reconstruction of soft
glands, and skin are applied according to their
facial parts is labor intensive and therefore cost
anatomic position. For this step, the nutritional
condition and the biological age of the person are intensive for the client. Even a practiced craftsman
essential for deciding the thickness of the layer. This will take a minimum of 40 hours.
information, combined with the extent to which
Graphic Methods
the facial muscles were developed, helps the person
doing the reconstruction to decide whether to To undertake facial reconstruction in the sense of
intentionally exceed or undercut the soft tissue a phantom drawing, detailed anatomic knowledge
thickness that are indicated on the landmarks with of the head will have to be combined with artistic
distance holders. After subsequent smoothing and skills. The three dimensional reconstruction of the
sculpting of the skin, a sculpture-like face has been soft facial parts occurs in the mind of the
created. investigator, who puts on paper the image of the
In the “American method” the soft parts are person he is reconstructing. This method is fast
applied at first in the shape of ribbons in the area but can hardly be checked and largely depends on
of the spacer device. The spaces in between are the individual skill of the investigator.
filled in subsequently. This method also offers
flexibility with regard to the shaping of the Computer Aided Reconstruction
nutritional condition, but the influences of the of the Soft Facial Parts
facial muscles cannot be taken into consideration With regard to the enormous expenditure in terms
as in the Manchester method. of time for manual forensic reconstruction of the
Fig. 8.6A to E: Pictures showing step-wise process in developing a face from the skull

soft facial parts on the one hand and the ever same landmarks with their respective soft tissue
increasing capabilities of computers on the other thickness are used.
hand, it is understandable that there is a desire to Programs have already been developed that
develop a fast, efficient, and cost effective computer place the landmarks automatically, but this often
aided forensic facial reconstruction tool. Improved leads to gross mistakes. Therefore, such programs
objectivity is another desirable effect that is hoped have the capability to manually correct the
for. landmarks or place them primarily manually. These
The three dimensional digital capture of the steps are much more labor intensive than fixing
skull is the first step. Mostly, a surface scanner or a the spacer to the landmarks of the real skull copy.
CT scan is used for this (Fig. 8.7). This step is After the virtual anchoring of the landmarks and
faster than making a real copy of the skull. The their spacers, the ends of the landmarks are joined
soft facial parts have to be applied to the virtual together and the spaces in the resulting lattice
skull copy. Most methodological approaches are pattern filled in and the edges smoothed over.
based on the experiences of classic forensic Depending on how powerful the computer is,
reconstruction of the soft facial parts. Usually, the digital reconstruction of the soft facial parts can
Fig. 8.7: The computerized technique using MRI, CT Scan and computer database to visualize the face from skull

be achieved in seconds. The problem is that the achieving a result within very few days is quite
resulting faces do not have any individual features understandable.
and are reminiscent of an adversary in a computer
game rather than a real person. On this back- PROBLEMS WITH FACIAL
ground, attempts are currently being made to
establish methods that enable the investigator to
RECONSTRUCTION
use several methods for the reconstruction. For Insufficient Tissue Thickness Data
example, it is being attempted to undertake the
There are multiple outstanding problems
virtual facial reconstruction on screen step by step,
associated with forensic facial reconstruction. The
just as in the classic manual methods. This takes
most pressing issue relates to the data used to
more time, but the advantage is that as many
average facial tissue thickness. The data available
intermediate steps can be saved as desired, and steps
to forensic artists are still very limited in ranges of
can be repeated or used in a different variation.
Another approach that several working groups ages, sexes, and body builds. This disparity greatly
have trialed entails correlating morphometric and affects the accuracy of reconstructions. Until this
morphological skull variables with existing data is expanded, the likelihood of producing the
phantom images (for example, from the German most accurate reconstruction possible is largely
federal criminal office or the French national limited.
police), in order to produce an automatic phantom
image of the unknown skull. Such a file then Lack of Methodological Standardization
contains a certain number of portrait photographs A second problem is the lack of a methodological
(frontal aspect), whose individual facial com- standardization in approximating facial features and
ponents (for example, the nose, ears, or mouth) individuating characteristics. Forensic anthro-
can be used in isolation and combined into new pologists and artists have published individual
faces. This way, phantom images can be put techniques used in their own practices. However,
together according to witness statements. a single, official method for reconstructing the
The use of such phantom image data for facial face has yet to be recognized. This also presents
reconstr uction has, however, fundamental major setback in facial approximation because
weaknesses. A three dimensional structure (face) facial features like the eyes and nose and
based on another three dimensional entity (skull) individuating characteristics like hairstyle—the
is being reconstructed two dimensionally (phantom features most likely to be recalled by witnesses—
image) without an intermediate step. The image lack a standard way of being reconstructed.
data as a basis for the phantom image file are usually Without consistency and a standard method for
(at least at the time of data collection) from living approximating these features, it will remain very
persons, whose skull shape is unknown. difficult for forensic reconstruction to earn wide
Critically, in some cases, the phantom image recognition as a legitimate form of forensic
method is being aggressively promoted with the identification. Recent research on computer-
argument that it is faster and more cost effective assisted methods, which take advantage of digital
than the conventional method. For the prosecution image processing, pattern recognition, promises to
or the police, the lure of having a facial overcome current limitations in facial
reconstruction at a fraction of the usual cost and reconstruction and linkage.

Subjectivity to the subject under investigation as it does upon
the accuracy of the technique.
Reconstructions only reveal the type of face a person
may have exhibited because of artistic subjectivity. FACIAL RECONSTRUCTION
The position and general shape of the main facial
AND THE MEDIA
features are mostly accurate because they are greatly
determined by the skull, but subtle details like certain In historic skulls, the idea of being able to look
wrinkles, birthmarks, skin folds, the shape of the into a face from a long gone past and thus into
nose and ears, etc. are unavoidably speculative (Fig. another world, is particularly attractive. In addition
8.8) because skeletal remains leave no evidence of to the necessary authenticity, the most important
target variable is presumably in the field of esthetics.
their appearance. The success of reconstruction
For example, the facial reconstruction of
depends as much upon the circumstances pertaining
Tutankhamun as shown on the cover of National
Fig. 8.8: The composite picture showing the facial subjectivity in process of facial reconstruction

Geographic in 2005 has gained an excessive media missing face to a skull. For the appearance of the
attention. face, other components play a part in addition to
Due to the recent rise in popularity of television the soft parts: hairstyle and beard, skin color, and
shows (e.g. CSI: Crime Scene Investigation, CSI: clothing. The manual, computer aided methods
Miami, CSI: NY, NCIS, Bones, and the UK provide a chance to alleviate the workload and
programme Meet the Ancestors) and feature films improve speed for the future. However, they need
concerned with criminal investigations, forensics, to be used by morphologically versed investigators
and law enforcement, the presence of forensic facial if not interdisciplinary teams. Practicing the manual
reconstructions in the entertainment industry and methods will be indispensable in learning the
the media has also increased. The way the fictional morphologic fundamentals/basics now and for the
criminal investigators and forensic anthropologists future.
utilize forensics and facial reconstructions are,
however, often misrepresented, an influence known
as the “CSI effect”. For example, the fictional
BIBLIOGRAPHY
forensic investigators will often call for the creation 1. Kreutz K, Marcel A Verhoff. Review article:
of a facial reconstruction as soon as a set of skeletal Forensic facial reconstruction – Identification based
remains is discovered. In reality, facial on skeletal findings. Dtsch Arztebl. 2007;104(17):
reconstructions are widely used as a last resort to A1160-5
stimulate the possibility of identifying a victim. 2. S De Greef, et al. Large-scale in-vivo Caucasian
In conclusion, the classic methods of forensic facial soft tissue thickness database for craniofacial
reconstruction/Forensic Science International.
reconstruction on the facial soft parts—if done
2006;159S:S126-S146
carefully—offer an opportunity to recreate the
9

Mass Disaster Victim Identification
Victim
and Dentist’
Dentist’ss Role
Ajay Telang, Anil Pandey
Chapter Overview
 What is a disaster and a mass fatality incident?  The standard operating procedures
 Kinds of disaster  Chain of custody
 Need for the preparedness  Evidence collection and preservation
 The ways a dentist can be of help in case need  Dental records and mass disasters
arises in disaster management  Man made disasters
 Preparation for unfortunate disasters and protocols  Dental radiography in mass disasters
 Role of dentists in mass disaster forensics
 Phases of response
WHAT IS A DISASTER AND A MASS This chapter particularly draws attention of dentist
to the various events and happening, where they
FATALITY INCIDENT? can provide some sort of help to the various
A disaster is a sudden occurrence that exceeds the authorities in resolution of the aftermath effects.
resources available in a community to deal with it.
A mass fatality incident is an occurrence that causes
loss of life that exceeds death investigation
KINDS OF DISASTER
resources in a community. A disaster contingency Basically they can be divided into three broader
plan identifies and develops plans to use such categories (Figs 9.1 A to E). The initial response
resources should the need arise. as well as the management of each kind of disaster
In India, we come across such kind of disasters is slightly different, in terms of various protocols
very often, which may take any shape and can cause and rules to be followed. These are:
loss of life in any proportion, be it the terrorist
Natural: Tsunami, volcanic eruptions, floods,
evoked bombings, natural flood/earthquakes or
cyclones, earthquakes
train mishaps/accidents. These horrifying incidences
cause a great loss of life leaving behind many of the Accidental: Mine explosion, plane/train crashes,
family members grieving and economically unstable. fires, unusual calamities
Mass Disaster Victim Identification and Dentist’s Role 183

B
C D
E
Figs 9.1A to E: Various kinds of disasters; man made, natural and terrorist evoked

Terrorism and military evoked: Bomb explosions, operate close to capacity on a daily basis. Add the
military attacks, serial killings. generation of mass casualties by a major incident
Teamwork and planning are two overlying or a significant bioterrorism attack into the
principles crucial to disaster management. Dental equation, and a basic life-saving response by the
team preplanning includes training, formal existing medical care system becomes nearly
agreements with medical examiner, supply sources impossible. There is a need to marshal all available
and immunizations. Dental teams are generally resources in response to a disaster of great
included in the operations sections under the magnitude if losses and disruption of everyday life
mortuary services branch in the identification are to be minimized and recovery facilitated.
group in the identification processing unit. Professionals who plan and manage emergency
responses must reach out to groups that have assets
NEED FOR THE PREPAREDNESS to contribute to the response effort but are not
intrinsically tied to the medical response (e.g.
Mass disasters represent a significant challenge for hospital personnel). Dentists and dental staff are
dental personnel who are frequently called upon examples of such groups. For a long time, dentistry
to provide identifications. Recently-published has played a well-acknowledged role in
materials have highlighted the need to prepare such participating in the recovery from mass casualty
groups for the disaster challenge and report events, such as natural disasters, bombings, and
inadequacies in existing preparation methods with transportation accidents, primarily in the forensic
an emphasis on team integration, organization and identification of victims when identities can not
the psychological and emotional effects of such be established by conventional means. Some
work. individual dentists also have participated in victim
In the last few decades, identification by dental rescue and treatment. For the most part, the dental
means has been described as one of the most profession is a loosely organized network of
reliable methods for identification of victims in mass individual practitioners. There are approximately
disasters and when one individual must be 175,000 professionally active dentists in the United
identified. Visual recognition of facial features in States, and they are distributed in a manner much
badly burnt human victims is often impossible and like that of the general population. They own,
identification by fingerprints may not be possible equip, and supply the office facilities in which they
due to the degree of destruction of the bodies.
provide oral health care. Approximately 85 percent
Dental identification may be based on pathological of dental practices in the United States are solo
conditions, disturbances of tooth eruption, practices, and 11 percent are made up of two
malocclusions and on dental treatment. The dentists. The consolidation that has characterized
identity of an individual may be established on the many industries and businesses in the United States,
basis of the uniqueness of concordant ante and including medicine has not occurred in dentistry.
postmortem dental features. A comparison Only a small proportion of dental care is provided
between antemortem records and postmortem in a hospital setting. In contrast to medicine, most
findings may thus often lead to identification or dental care is provided to patients by one primary
provide convincing proof to rule out a particular care dentist in one facility. The average dental office
identity. is essentially a mini-hospital or an outpatient clinic.
Also, it is evident from recent catastrophic events It is equipped with radiographic capability,
that the traditional medical care system may be sterilization equipment, central suction, medical
over whelmed because many medical centers gasses and various anesthesia capabilities, suites with

surgical lighting, some surgical equipment and
supplies, laboratory space, and administrative areas
for records and patient reception. Trained and
experienced office staff are present to operate in
these areas. Dental offices are dispersed throughout
the community.
Dentists are exposed to information in many
general medical areas during their predoctoral
education that can be useful in disaster response
Fig. 9.2A: Postal letters containing anthrax spores which
situations. They also routinely perform many tasks created havoc in United States postal departments
that emergency responders may be required to do,
such as perform minor surgery, dispense drugs, give
injections, and administer anesthesia. It should be
apparent from this description that dentistry has
much to contribute to the response to a major
disaster in terms of personnel and facilities when
the traditional medical care system in an area is
overwhelmed.
After the seminal events that occurred in the
fall 2001, particularly the deliberate attempts to
spread weapons-grade Bacillus anthracis spores
(Figs 9.2A and B) through the US mail system,
the American Dental Association convened two
workshops to determine how dentistry could
contribute to the response to mass casualty disasters
and how dentistry could become better prepared
to respond.
It is generally thought that dentistry can be of
Fig. 9.2B: Microscopic picture of anthrax spores recovered
greatest assistance immediately after the occurrence
from the postal letters in United States
of a mass disaster before the full force of federal
assistance can be mobilized effectively. During The Historical Perspective
recent disasters, this mobilization time varied from Case report 1: “The Alfred P Murrah Federal
a few days to a week. Many victims of disasters Building bomb blast, (Fig. 9.3) Oklahoma City
cannot wait that long for help. When local medical on April 19, 1995”.
resources are unable to cope adequately with a huge It has always been considered as the Gold
number of victims, dentists can be recruited to Standard of disaster response. The forensic teams
provide certain services that will allow physicians worked for 16 days × 12 hours shifts daily, because
to do things only they can do. Dentists can enhance of whom 168 confirmed victims and 168 positive
the surge capacity of the local medical system until identifications were made. Out of these cases, 45
additional physicians arrive or the demand for cases were identified on the basis of Dental
immediate care decreases. identifications, 77 cases by a combined Dental ID

Fig. 9.4: Pictures showing the incidence of bomb
explosions in Bali, Indonesia.
around the world, and victim identification teams

were sent from more than 20 countries,
necessitating the adoption of universal protocols
before evidence collection and analysis.
In another example, the USS Iowa explosion,
Fig. 9.3: The Alfred P Murrah building explosion in City of
45 of 47 victims were identified through dental
IOWA, United States. This mass disaster is referred to Gold
standard in mass disaster management comparison either alone or in conjunction with
fingerprint matching. Because the victims were
and fingerprints identification techniques and active duty military personnel, high quality, up-
Remainders by footprints, palm prints, visual, to-date dental records were easily available,
radiological, and DNA means. providing optimum circumstances for dental
Case report 2: Horrendous bombing incident in comparisons to be completed.
Bali, (Fig. 9.4) Indonesia. The crash of Arrow Airways Flight 950 near
There were 115 people identified by methods Gander Airport in Newfoundland, Canada provides
including DNA, while 12 were identified using a contrast to the ideal operational conditions in
fingerprints. About 100 were identified by methods the USS Iowa investigation. As in the previous case,
including dental records, and 7 identified by forensic odontology contributed to a significant
methods including medical records. Searches were number of the nearly 250 US Army personnel
made, using the DNA profile, for varying levels of identifications; however, unlike in the USS Iowa
kinship such as parents, children or siblings. explosion, the servicemen were carrying their
Case report 3, Asian tsunami December 2004 (Figs medical and dental records during the flight. The
9.5 A and B). Armed Forces Institute of Pathology was charged
In the Asian tsunami of 2004, dental records with the identification of the victims. The team
contributed to nearly 85 percent of the consisted of 23 armed forces dental officers and
identifications. The tsunami provides an example 16 support staff. One subgroup of these personnel,
of the problems that can arise in a forensic response the dental registrar, was charged with the receipt,
to a mass disaster. This case involved over 200,000 inventory, and custody of all obtained medical
dead and injured persons. Nearly 60 nations were records. Because the primary dental records were
represented in the victims, and ten nations were mostly fragmented or destroyed in the crash,
affected by the disaster. Disaster relief came from records were obtained from civilian sources.

Fig. 9.5A: The most devastating Asian Tsunami, in December Fig. 9.5B: The photograph showing the killer waves of
2005, which killed lakhs of people across the world Tsunami
Forensic dentistr y has provided victim dispensing medications or immunizations),

identification in many different scenarios involving whereas others may require additional training or
many different types and numbers of victims. As some supervision (e.g. providing basic medical care
the result of a major highway accident in Spain in in quarantine situations). There are several general
1996, 28 victims were processed, and 16 of the areas of response activity in which dentists can be
victims were identified through dental records. helpful. These are:
The remaining 12 were not owing to extensive 1. Surveillance
destruction of the dentition by fire or a lack of 2. Referral of patients
dental records. 3. Diagnosis and monitoring
4. Triage
THE WAYS A DENTIST CAN BE OF 5. Immunizations
HELP IN CASE NEED ARISES IN 6. Medications
DISASTER MANAGEMENT 7. Infection control
8. Definitive treatment
The prime purpose of recruiting the assistance of 9. Quarantine.
dentists in responding to mass casualty incidents is
to enable crisis managers to use scarce physician Surveillance: Some mass casualty events are distinct
resources in the most effective manner possible by entities easily recognized and of easily defined
having some services they would ordinarily provide duration and effect on a population (e. g. a severe
be successfully provided by dentists where possible. weather event). Other disasters, particularly
Local circumstances (i.e. the medical needs and bioterrorism attacks and pandemics, often have
resources of the community after a disaster and relatively indistinguishable beginnings and ends
the nature of the disaster) determine how dentists and unpredictable effects on a population. Because
can be of assistance. Some assigned duties do not of the variable incubation periods of infectious
tax the dentist’s knowledge or experience (e.g. agents, the time of exposure can be estimated only

after the resultant disease has manifested. It also may yield valuable diagnostic information or
may take up valuable time to determine that a indication of the progress of treatment, including
population-wide problem actually exists. Dentists the status of the patient’s infectiousness.
can be part of an effective surveillance network
Triage: In the effective response to any mass
because they are scattered throughout a community
casualty event a system must be established to
much as the general population is and are visited
prioritize treatment among casualties, because
by patients who are generally medically healthy and
immediate treatment for all casualties is not possible
have not seen a physician. Obser vation of
because of inadequate resources in personnel,
intra-oral or cutaneous lesions or both when they
facilities, and medical supplies. Dentists are able to
are present and the notification of public health
assist in this important function with relatively little
authorities about these observations may facilitate
additional training. This assistance allows physicians
the early detection of a bioterrorism attack or
spread of a pandemic infection. Early detection of to provide definitive care for patients most urgently
an infectious agent in a population may allow for in need rather than screening casualties. Dental
reduction in the number of casualties by prompt offices could serve as triage centers if needed.
initiation of preventive and therapeutic Immunizations: To limit the spread of infectious
intervention. agents, whether from a natural pandemic, a
Sales of over-the-counter medications are often deliberate bioterrorism attack, or contamination
monitored in the epidemiology community as a as a result of a local event, rapid immunization of
potential early warning of community-wide great numbers of individuals may be required in a
infections. Monitoring of unusual and unexplained short amount of time. In major metropolitan areas,
‘‘no show’’ patients in dental offices also may help where the spread of communicable disease is
provide an early warning. facilitated, this effort may involve millions of
Referral of patients: Patients who show early signs people. Physicians and nurses may be unable to
or symptoms of infectious diseases, have suspicious implement such a program in the critical time frame
cutaneous lesions, or are suspected of having such required. Dentists can par ticipate in mass
diseases may be referred to a physician for a immunization programs with a minimum of
definitive diagnosis and appropriate treatment, if additional training and may be the critical factor
necessary. This referral may be important because in the success of urgent programs. Dental offices
early treatment or early initiation of prophylaxis can be used as immunization sites to minimize the
can have a significant influence on the outcome of concentration of potentially infected persons.
the patient’s encounter with the disease. The Medications: In mass casualty situations, particularly
clinical course of smallpox, for example, can be
after a bioterrorism attack or the unfolding of a
ameliorated by vaccination even after the patient
pandemic infection, the population may require
has been infected.
medication to treat or prevent the manifestation
Diagnosis and monitoring: After an infectious of the infection being faced. Physicians, nurses, and
disease that causes mass casualties has been pharmacists may not be able to effectively prescribe
identified, dentists who are able to recognize the or dispense the medications necessary in the critical,
signs and symptoms of that disease may be able to appropriate time required. Dentists can be called
identify afflicted patients. Dentists can collect on to prescribe and dispense the medications
salivary samples, nasal swabs, or other specimens required after that determination has been made
when appropriate for laboratory processing that by the physicians and public health officials

managing the disease outbreak. Dentists also can • Collecting blood and other samples
monitor patients for adverse reactions and side • Providing or assisting with anesthesia
effects and refer patients who experience untoward • Starting intravenous lines
effects from the medications to physicians for • Suturing and performing appropriate surgery
treatment, if necessary. Dentists also can be used • Assisting in patient stabilization
as sources of information for patients concerning • Assisting in shock management.
the medications they are using by communicating
Quarantine: During a pandemic or after a
information on proper use, problems that may
bio-terrorism attack with a communicable agent,
occur and their manifestation, and the need for
strict quarantine restrictions may be imposed on
compliance. Dentists can monitor the effectiveness
the geographic area contaminated and its environs
of the treatment regimen.
to help prevent or control the spread of the disease
Infection control: Dentists and dental auxiliaries to other areas. The duration of the quarantine varies
practice sound infection control procedures in their according to the incubation time of the agent and
offices on a daily basis. They are well versed and other factors. Before the existence of the area-wide
well practiced in infection control and can bring contamination is established, primary care providers
their expertise to mass casualty situations, may become infected directly or through contact
particularly situations that involve infectious agents, with patients seeking care. During the period of
to limit the spread of infection among individuals quarantine they may become disabled by the disease
and between patients and responders who are or even die. Dentists may not be similarly infected
rendering assistance. Decontamination of casualties by patients because ill patients do not seek care
from certain bioterrorism attacks in which contact from dentists and, if sufficiently ill, do not keep
with patient’s clothing or skin surfaces may spread scheduled dental appointments, which minimizes
the agent to caregivers may be accomplished by intimate contact with infected persons. Dentists
dentists with some additional training. Dentists may be called on to provide some primary health
who are familiar with disaster mortuary activities care for people in the quarantined area.
can be useful in managing the remains of victims
whose death is a result of the event, particularly How Dental Auxiliaries can Help
infectious events. These remains most likely will Confusion, disorganization, and lack of control are
be contaminated and require careful management major barriers to an effective response to a mass
to prevent further disease spread. casualty event. Experienced personnel are required
Definitive treatment: In addition to providing to establish and maintain as orderly a process as
services that dentists ordinarily do, they may be possible for the immediate response to avoid public
able to augment or participate in the treatment panic. Dental of fice clerical personnel are
provided by medical and surgical personnel. experienced in administrative functions, managing
Dentists have training and experience in many areas medical records, organizing patient flow, and
that may be a part of casualty care in mass casualty maintaining communications between dentists and
events: other health care providers. They can provide
• Treating oral, facial, and cranial injuries valuable assistance in those areas. Dental assistants
• Providing cardiopulmonary resuscitation can retain their role in assisting dentists, even
• Obtaining medical histories expanding their function under supervision to help
dentists in the new roles they may be asked to fill.

Dental hygienists can provide new clinical services of dentists in the community and their ability to
with additional training, perhaps including abstain from participation. As such, for the near
administering immunizations in mass disaster future, most dentists who may be called on to assist
immunization programs. in disaster response efforts most likely will not have
received formal disaster training. The task of
PREPARATION FOR UNFORTUNATE educating dental students falls primarily on dental
DISASTERS AND PROTOCOLS schools. Educating and training dental practitioners
is not as centralized as for dental students and must
Besides developing a disaster response plan for
be accomplished by various means and from various
dentistry’s response to mass casualty disasters, the
sources, including dental schools, more than likely
profession itself must be made aware of the added
coordinated through the dental societies. There
responsibilities it may be asked to take on if
are opportunities for dentists who are interested
traditional medical resources of the community are in going beyond basic education and training in
swamped by a surge in demand for care in the wake responding to mass casualty events through
of a large-scale disaster. Additional education and participation in various organizations sponsored by
training for dentists in specific areas of emergency state and other government and NGO agencies.
response that build on the basic principles of
medical care with which they are familiar can ROLE OF DENTISTS IN MASS
significantly expand the scope of services that DISASTER FORENSICS
dentists can provide effectively during these
Forensic interest in mass disasters centers on
emergencies. Educational efforts should begin with
determination of the cause of the disaster and
dental students in during their undergraduate
identification of the victims rather than preservation
course curriculum education. The curriculum
of life and limb. Historically, methods have
should be expanded to include more information
included simple recognition, use of fingerprints,
on the management of large numbers of casualties,
dental records, and skeletal identification using
especially casualties generated by the intentional
radiologic or anthropologic means. DNA analysis
or non intentional spread of infectious agents. has become an essential tool in the analysis of
Dental students should understand the public samples in cases in which severe fragmentation of
health and emergency response communities and victims is involved. These methods in concert have
the control functions they provide in the event of led to the successful identification of thousands of
an emergency. This material can be presented in victims of disasters such as earthquakes, floods,
separate dedicated courses or combined with tsunami, or terrorist attacks. Each of these methods
appropriate existing course work. In either case it of identification has strengths and weaknesses that
is advisable to have a separate course in the last must be taken into account when evidence is
year of dental school that pulls together all of the collected. Proper preservation and storage of
information taught during the preceding years as evidence is critical if analysis is to be accomplished
a summary. in a reliable, efficient manner. Coordination of all
In addition to the teaching of dental students, analytical teams is also essential to provide a flow
the existing profession needs similar education and of evidence from section to section; all must work
training, which presents more of an educational in concert to perform a task that can be of
challenge because of the practice responsibilities monumental proportion.

Evidence Protocols
Evidence processing, no matter what the disaster,
is crucial to maintaining integrity of the collected
evidence so that analytical results will stand up to
scrutiny in the courts and provide closure for the
families of the victims. The entire process in
management of mass disaster should always follow
a chain of events which is properly coordinated
and executed in a phased manner so as to help out
the victims and their families and not to
unnecessarily complicate the situation further.
Fig. 9.6B: Arrangements made for the various procedures to
PHASES OF RESPONSE be followed shortly after recovery of the remains of the
(FIGS 9.6 A TO F) disasters
1st Responder
Any disaster whatever kind it may be is always first
attended by Police, firefighter, and emergency
medical services. The aim of all of these is to bring
the situation under control, isolate the area, to
prevent contamination from any hazardous
substance, if located and to provide all feasible
medical help to the survivors.
Fig. 9.6C: Team work showing the platform for collection and
segregation of various records obtained from the family and
relatives
Fig. 9.6A: The various phases of response in events of mass

disasters. Figure (A) shows the first emergency responders Fig. 9.6D: Various medical workers preparing for the
mainly medical and police personals process of postmortem examination and all investigations

is also established to provide all the information
about events and happenings along with the
support services which are provided to the grieved
families.
Resolution
After phase two ends, more complex events begins.
These consists of removal and transport of human
remains, control of environmental hazards and the
morgue services.
Fig. 9.6E: Medical personnel carrying out the process of

Resolution of Site to Normal
autopsy and postmortem examinations
This phase is taken care up by public health or
environmental agencies, and also consists of
resolution of responders to normal through critical
incident stress debriefing counseling.
Identification center processing protocol is a
continuous event of chain which takes place in the
following schematic manner involving forensic
odontologists at particular time. This collection
begins with recovery of the evidence and processing
in the site for analysis; without the time constraints
imposed by the responsibility of patient care,
evidence documentation is more rigorous. Each
item of possible evidentiary value will undergo the
Fig. 9.6F: After collection of all antemortem and postmortem following:
information, doctors compare them for the purpose of 1. Recovery logged into temporary morgue
identification of the deceased
2. In processing to identification center chain of
custody documentation
Stabilization 3. Photography, full body radiology, personal
This phase of management star ts with effects station
transportation of all the survivors to nearby medical 4. Fingerprints
facilities as soon as possible to save life, suppression 5. Medical radiology
of fire created (air crashes, fire disasters etc.). This 6. Pathology, cause and manner of death
is to be followed by removal of any hazardous 7. Medical labs as directed (DNA)
substances like toxic chemicals, unburnt fuels or 8. Dental (AM/PM evidences)
any other such substance to the responders and 9. Physical anthropology (age, sex, race, skeletal
the public. Law enforcement for security is abnormalities)
strengthened further, followed by the crime scene 10. Mortuary science, embalming
management. There should always be good 11. Return to family.
communication to coordinate response, for The medical response to a mass casualty incident
resource management. A public information cell will always be complicated. Providing quality care

while understaffed, undersupplied, and possibly due to the climate and the rapid decomposition of
operating in an unfamiliar or inhospitable the bodies.
environment is not an easy task. The situation is More personnel involved in the process can
further complicated when the mass casualty spread the work and relieve stress. The observed
incident is the result of a terrorist act, which forces effects on health care professionals participating
medical response to occur in conjunction with a in mass disaster work have been documented to
federal criminal investigation. Although medical include distress while participating but also relief
professionals and students commonly receive and satisfaction by making a positive impact in a
training on the recognition of terrorist events and disaster situation. Support gained through the
appropriate inter ventions, legal aspects and other professionals in the work group adds to the
evidence collection are rarely addressed in depth. positive feelings that can be derived through
successful work in a mass disaster. Further
THE STANDARD OPERATING documentation indicates that persons who
PROCEDURE participate in mock disaster drills feel they are better
For all steps of the identification process, including prepared to participate in authentic events.
antemortem record requests, fingerprint identi- Additional personnel in conjunction with increased
fication, forensic pathology and odontology, and training opportunities should help reduce the stress
DNA analysis, had to be agreed upon. Interpol on involved personnel and aid in faster analysis
took the lead in trying to coordinate data and times.
institute standard operating procedures for physical
evidence, but the legalities involved in obtaining CHAIN OF CUSTODY
medical records had to be negotiated. Interpol has
also issued guidelines to help with the ante mortem Once an item of evidence has been seized or is
records collection. The Interpol Victim located on a patient, care must be taken to record
Identification Guide, section 6.3.2.2, required all the whereabouts and access to the item in writing;
nations with possible missing citizens to provide the more susceptible the item is to contamination
all necessary records in an expedient manner; or tampering, the more closely it should be
however, some countries took a conservative monitored. For example, an article of clothing with
approach and gave estimated numbers of missing a distinctive logo would be more readily
recognizable than a small piece of shrapnel removed
citizens, whereas others reported the numbers of
citizens reported missing and presumed dead. This from a wound. Medical records can serve as a chain
response inflated the number of records thought of custody between providers throughout care to
to be necessary in the identification process. The establish the time, location, and status for objects
Interpol Victim Identification Guide also required of interest that are not removed from the patient
original records in section 4.5.2.5; however, on scene but hours or days later. Items that are
worldwide, the records that were sent varied greatly discovered and collected in the field should be
in quality, and many copies were substituted for labeled (name of patient, name of practitioner, date,
original records. Even more crucial were the time) and preferably stored in an area with limited
procedures necessar y for the collection and public access until they are collected and signed
preservation of evidence and the maintenance of for by a law enforcement officer; inconsistencies
the chain of custody of the evidence which would in delivery and receipt conditions could lead to
be used in the identification; speed was necessary the suppression of evidence.

EVIDENCE COLLECTION AND A. Recovery team: If called upon for disaster
protocol.
PRESERVATION B. Antemortem section: As told by the Morlang,
Overall, medical professionals should attempt to this is supposed to be the most difficult section
the best of their ability to store evidence in a for dental teams, involving hardships and a lots
manner that will facilitate future analysis. of communication.
First, one should avoid cutting through holes C. Postmortem section: It consists of examination
in patient clothing that were created before their of all dental structures, photographic docu-
arrival for care. Maintaining holes intact will help mentation of remains, reconstruction and
forensic specialists recreate the scene, corroborate stabilization of fragmented or burned remains,
the size and force of an object that penetrated the excision of jaws—if needed, charting of all
victim, and give guidance for tests to determine injuries, anomalies, restorations.
the presence or absence of trace evidence. Cutting D. Comparison section: After all the neded AM/
through the hole causes permanent distortion to PM information is obtained, the next step is to
the fabric (especially in the case of knitted fabrics) compare the obtained records in the same
and can contaminate the surface of the fabric with manner as that for any other forensic dental
metal or other debris from the scissors that might identification.
not be distinguishable from pertinent evidence.
Second, one should avoid sealing items while DENTAL RECORDS AND MASS
they are still damp. Wet items may grow mold or DISASTERS
mildew that will contaminate the evidence and
make further analysis more difficult. If the In many instances, such as when victims are severely
possibility exists, the item should be allowed to burned, traditional forensic techniques do not
dry before sealing the container. provide conclusive means of identification.
Third, one should avoid the use of plastic bags Pathologic conditions noted in dental records,
when possible. Plastic can cause the degradation treatments, and prosthetic devices may survive fires
of biologic and chemical evidence and can lead to when identifying markings and DNA may not.
a moist environment inside the bag. All evidence, Dental records are among the most readily available
regardless of nature or origin, should be handled ante mortem information that can be accessed by
with gloved hands to protect it from trace damage disaster emergency response teams. As such,
(such as fingerprints) and to protect medical forensic odontology continues to be a crucial
professionals from exposure to toxic chemicals or element in nearly all mass disasters whether natural,
other agents. Although these measures may sound accidental, or intentional. At the onset of a disaster,
tedious, they have been practiced by sexual assault various teams of dentists will be established to start
nurse examiners in hospital settings for over many collecting ante mortem data based on lists of
years. missing persons, a task that relies heavily on the
The forensic odontology team will be highly nature of victims (e.g., military versus civilian).
involved in many of the steps; their work will be Once these records have been compiled, forensic
suspect without proper in-processing and odontologists can begin comparisons between
documentation. Dental ID team can be divided remains and ante mortem records. Traditionally,
into several different sections, based on its overlays have been used in many disaster situations,
mission—Vale and Noguchi. even before the 1980s. These overlay procedures

have been simplified with time and still serve local cosmetically appealing but readily recognizable
coroner or medical examiner offices that may not during radiologic examination.
have the volume or resources to maintain a Radiofrequency identification (RFID) tags have
database; however, the number of victims in a mass been developed that are small enough to be
disaster situation makes simple comparison implanted into a prosthesis or a prepared molar.
unacceptable. This technology originally served the veterinary
Overlays have given way to computerized field but is easily transferred to human use.
matching software. Data comparison systems such Identification would be accomplished through the
as computer-assisted postmortem identification use of an interrogator that triggers a power surge
(CAPMI), WinID, Plass, and DAVID software in the RFID chip which responds by providing
have enabled rapid entry of ante mortem records information to the reader. This method could, if
and post mortem data into a database capable of implemented, ease the work involved in the
completing rapid comparison of huge amounts of identification of victims of a mass disaster; however,
data. Each program has allowed new levels of detail there will be some time lapse before such devices
and greater operator control leading to increased are frequently seen in the overall population.
suggested match accuracy; however, all suggested
matches are verified by members of the mass
disaster team. Other information beyond the MAN MADE DISASTERS
description of dentition can be used in the forensic
odontology field, such as labeled dental prostheses. Forensic Techniques and Evidence Sources
Victims possessing all or most of their dentition in Specific Scenarios
have physical characteristics necessary for their Intentional man-made events are generally broken
identification, whereas those missing all of their down into five major categories: chemical, biologic,
teeth lack such information. nuclear/radiologic, and explosive (CBRNE). Each
Identification from prosthetics has been around of these categories can be divided further into
since the 1800s. Markings on prosthetic devices specific agents or patient characteristics. To best
should be able to establish the identity of the serve medical responders, for each major category,
patient or victim, be easily and quickly applied, and enlisted here in are description of standard analysis,
be fire resistant or placed in such a manner that an overview of emerging detection and forensic
they are protected by the tongue. The marking techniques, possible scenarios in which medical
should not interfere with the function of the device professionals may discover evidence, and measures
and be unobtrusive, and the appearance should be to protect the integrity of the evidence while
acceptable to the patient. Some of the simplest ensuring personal safety. In any investigation, the
marking techniques involve surface marks inscribed bulk of physical evidence is collected by law
by scalpels, pencil marks that are covered by dental enforcement professionals or specially trained
polymer, and inscribing the cast from which the military units. Detailed analysis is performed in a
device was made. More recently, markings have laboratory setting that is determined by the nature
been enclosed in the prosthetic device using of the incident. Nevertheless, there is a chance that
polymethyl methacrylate to ensure permanency. medical responders may discover evidence that will
Metal identification bands have been enclosed in be pertinent to an investigation. Specific items that
compartments within the device, which are may be of interest to investigators are covered in
completely invisible when completed and detail under each scenario.

Chemical Scenario spectrometry and liquid chromatography/mass
The specific forensic techniques use in the spectrometry, have proven sufficient to identify
investigation of a chemical event will vary based most agents, especially when coupled with
pre-concentration techniques and tandem mass
on the nature of the agent; however, certain facts
will require resolution for the state to build a spectrometry.
sufficient case for the prosecution of suspects. The Most chemical agents are either non-persistent
(vapor) or require wet decontamination. Because
verified agent identity, proof of victim exposure to
agents, and the ability of suspects to synthesize and life and limb supersede a forensic investigation,
disseminate the agent will be of particular interest samples will not be taken before decontamination
or medical intervention, even if personnel were able
to those involved in prosecution. Preliminary agent
identification will likely come as victims present to take samples on scene. As an alternative to
with symptoms associated with toxic exposure (e.g. immediate or superficial collection, biophysical
changes specific to agent exposure can be
dyspnea, rhinorhea, ocular pain, dizziness,
vomiting). Intelligence related to possible terrorist determined through blood analysis. Raman
threats in the area might also suppor t the spectroscopy also shows promise as a noninvasive
means to determine exposure to chemical and
preliminary agent identification. The support of
hazardous material (HAZMAT) teams will provide
more information; hand held detectors and manual
testing will confirm the presence of an agent class
(e.g. ner ve agent versus sulfur mustard).
Improvements in the reliability and range of
detectable agents are being explored with the use
of different forms of spectrometry (such as Fourier
transform infrared spectroscopy), photometry, and
chip-based sensors based on carbon nano-tubes.
As part of the detailed analysis, scientists will
also note the impurities and precursors found in
the sample. Few chemical reactions provide 100 Fig. 9.7A: The train in Tokyo subway passage where a
percent yield in every step; in the Tokyo subway chemical attack of Sarin gas was deployed
attack, (Fig 9.7A and B) the liquid sampled on
the train was only 30 percent sarin. The other 70
percent of the substance provided clues as to the
synthetic protocol used, allowing law enforcement
officials to narrow the search to facilities/business
entities that had purchased these chemicals recently.
The sophistication of the synthetic model and the
purity of the product will also indicate the type of
facility and personnel that would likely be associated
with the agent production. Examinations of
organic and aqueous extractions of samples using
instrumentation routinely used in forensic Fig. 9.7B: Picture showing the casualties in
investigations, such as gas chromatography/mass Tokyo train attack

biologic agents. At the time of an attack, it is highly
likely that intelligence gathering will have narrowed
the field of suspects. Through interrogation and
investigative work, it is also possible that a facility
or dissemination device will be located. Chemical
events are particularly dangerous to medical
responders, especially for those operating in the
“cold zone”. Many chemical agents can be
absorbed through the skin (or latex gloves), leaving
responders vulnerable to secondary contamination.
By the time a dental responder is on scene, the
nature of the agent will be at least preliminarily
confirmed, and the manner of decontamination will
have been decided. With this in mind, observing a
patient’s attempt to avoid decontamination (which
will require removal of clothing) should be
Fig. 9.8: Biological attacks, showing the Anthrax spores in
considered highly suspicious, and law enforcement
the US postal departments
officials should be notified of this behavior. If when
monitoring patients triaged as minimally injured,
several patients exhibit a sudden onset of more to minutes or hours in a chemical attack). The core
severe symptoms simultaneously, the medical questions of agent identity, patient exposure, and
responder should notify medical team leaders and agent production require investigation. In the best
law enforcement. The sudden onset may be caused case scenario, agents will be detected before an
by a secondary device or by proximity to the infection occurs. The persistence of biologic agents
dissemination device. In both instances, the and the necessity of relatively high concentrations
authorities should be notified, and all personnel of biologic agents for infection to occur are used
should prepare to undergo decontamination to the advantage of law enforcement and public
measures. If the agent is persistent, the medical health officials. Various federal efforts to create
responder should report any objects found in the sentinel detectors, aim to provide identification of
agents as they are released into the environment
patient’s possession or in the treatment area that
appear oily or greasy but should not attempt to through continuous sampling at a static location;
handle the item, even with gloved hands. however, these technologies rely on the airborne
presence of the agent, which may not occur in cases
of food-borne dissemination.
Biologic Agents
Currently, sentinels are not ubiquitous;
The investigation of a biologic agent is the most therefore, a real possibility remains that the first
challenging CBRNE event. Although an outbreak warning of an attack will occur when citizens
of an unusual nature (such as smallpox) (Fig. 9.8) become infected. Agent identity will initially be
would trigger an immediate response and established through common histologic procedures
investigation, most biologic agents act slowly performed at hospitals, public health laboratories,
within a population, and patients present with or specialized facilities. Analytical techniques are
nondescript ailments in many locations over an being refined to offer faster and more accurate
extended period of time (days or weeks as opposed agent characterization that can be used for any type

of agent and to more readily recognize hoaxes. manner that DNA analysis of bodily fluids can yield
Microchip based technologies allow for a probability of association with an individual.
simultaneous detection of multiple agents in the A medical provider may contribute to an
field and clinical settings The prevalence of genetic investigation in two likely ways:
engineering may also contribute to a delayed 1. By recognizing and reporting a person of
recognition of a biologic attack. interest or
Techniques widely used in academic and 2. By recognizing a device that was part of the
commercial settings allow scientists to control the dissemination of the agent.
genetic properties and abilities of bacterial and viral During any sort of epidemic (natural or
agents, meaning that an agent could ‘‘look’’ like intentional), populations are affected at different
salmonella during screening but actually contain times and at different rates; a patient presenting
the genetic ability to produce a more virulent toxin. with a more developed infection than anyone else
Projects to map bacterial and viral genomes are in the area is a person of interest. This individual
underway to provide baseline information about may have come into contact with the agent before
genetic differences between and among strains that anyone else in the community (perhaps as a result
are currently found in the environment so that the of travel) or may have had involvement in the
future release of a laboratory cultured agent will synthesis or dissemination of the agent. In both
be more readily apparent. Unlike chemical agents, cases, this person will assist public health and law
the production of biologic agents does not require enforcement authorities in pinpointing the origins
regulated chemical precursors. The equipment and of the outbreak and will provide useful information
chemicals necessary to replicate or modify a bacteria in the case of an outbreak.
or virus have many benign uses and are ubiquitous The second possibility is the discovery of a
in biologic and genetic laboratories, enhancing the dissemination device in the possession of a patient.
possibility of ‘‘dual use’’ facilities. Several businesses Items such as vials, medicine droppers, test tubes,
are devoted solely to the creation of DNA and other containers would be of interest to law
sequences to order and do not always screen these enforcement of ficials, par ticularly if these
sequences against the DNA sequences of known containers were concealed but provided easy access,
biologic agents; therefore, the possibility exists that such as being taped to the wrist. Another item of
a major part of production did not even occur interest would be architectural plans, especially if
within a facility. Never theless, intelligence they include details of a heating, ventilating, and
suggesting that this method was used to orchestrate air conditioning system. Handling items potentially
a biologic attack would allow law enforcement to contaminated with biologic agents should be
trace involved parties through billing records of a performed while using the recommended personal
sequencing company. Rather than focusing on the protective equipment associated with the particular
specific location or ability to produce the parent agent.
agent, a link to the equipment used in the
replication of the agent might be established. Nuclear/Radiologic Event (Fig. 9.9)
DNA analysis of samples found in a suspected A radiologic event will require immediate
facility could be compared with the DNA analysis evacuation (much like a chemical event) and the
of samples taken from the scene and from victims, intervention of specially trained teams, in detection,
and statistical models derived from genome characterization, and recovery efforts. If recently
mapping projects could allow probabilities of suggested guidelines are adopted, an area of 500
association to be extrapolated, much in the same m (approximately 0.31 miles) will be evacuated and

forensic scientists will focus on the explosives and
the contaminants to link the device with a facility
and a perpetrator. The most probable circumstance
for medical volunteer involvement would be in
response to a radiologic dispersion device. If a
patient presents with symptoms associated with
high levels of radiation exposure but shows no sign
of trauma or gross external contamination or if he
or she presents with only burns to the hands or
forearms, the patient would be a person of interest
to law enforcement because they may have been
involved in the preparation or transport of the
device. Patients close to the explosion site may
receive penetrating injuries from shrapnel. Facilities
on scene and operating procedures may not allow
for the removal of the foreign body, but a note on
the nature of the shrapnel, patient information, and
destination hospital (if known) would be useful to
Fig. 9.9: The site of nuclear explosion in Japan during the the investigation. If the foreign body is removed
Atomic bombings in Hiroshima and Nagasaki, Japan (if it is blocking the airway), provider information,
the time, date, and patient information should be
considered the ‘‘hot’’ zone where radiation levels
noted on the bag and the item placed away from
are considered too high to operate without
traffic flow until law enforcement officials are able
appropriate protection and medical oversight.
to retrieve it. In the radiologic dispersion device
Information discovered by these teams could be
scenario, the amount of particulate matter on a
used at the launch of a police investigation. For
single piece of shrapnel is not likely to cause a health
example, the specific isotope discovered on scene
risk.
will indicate whether the material was likely to
have been derived from industrial or medical
Explosive Events
instrumentation and will lead to the cross-check
of those facilities for reports of stolen or damaged Bombings are the most common form of terrorist
equipment. Detector technology based on neutron action (Fig. 9.10) to date. Hundreds of events
generation and gamma ray spectra interpretation have occurred internationally causing countless
offers the ability to characterize unexploded fatalities and casualties. As a result, law enforcement
ordnance. agencies are relatively prepared for the necessary
As the threat of radiologic exposure diminishes, analyses following an explosive event; most forensic
information about the device can be sought similar laboratories have sections devoted to arson and
to the investigation of an explosion, especially in explosive investigations. Some police forces cross-
the case of a radiologic dispersion device or ‘‘dirty train officers in urban search and rescue to allow
bomb.’’ Emerging technologies are capable of forensic investigators early access to the crime scene
detecting and classifying explosives from a distance, in the safest manner possible. As is true in the other
making it possible for information to be gathered scenarios, the goal of the forensic investigation is
while minimizing the chance of injury. Again, to characterize the agent (through recreation of

necessary components would confirm the number
of devices used and whether specific design
characteristics were shared among the devices.
Characterization of the actual explosive will begin
with an examination of the physical characteristics
of the device fragments. Low explosives deflagrate,
that is, they propagate energy through thermal
conductivity; therefore, the discovery of fragments
that are warped or charred would be indicative of
a low explosive. High explosives detonate, which
is the propagation of energy through a pressure
wave at supersonic speeds; fragments that have
sharp edges and limited signs of heat exposure
would indicate the possible use of a high explosive.
Fig. 9.10: The picture showing the terrorists evoked explosion If physical components are not immediately
of the Mumbai local trains resulting in hundred of casualties
recovered, surrounding structures and damaged
the device and the chemical composition of the objects can be swabbed and tested for the presence
explosives), link the agent to an individual or group, of explosive residue. Currently, colormetric tests are
and prove that an individual or group planted the employed to determine whether to sample an area
device in a specific location. or object for more specific analysis. Such tests rely
To prove the existence of an explosive device on a chemical reaction between the explosive and
(as opposed to an accidental explosion), an introduced agent that results in a color change.
investigators seek evidence of the four required Studies of the use of photo-luminscent
components of an improvised explosive device: A techniques that use laser excitation to improve
power source, initiators, explosives, and switches. visualization in the field have been developed and
A fifth component, which is not necessary but can are undergoing validation and testing. In
provide useful information, is fragmentation and specialized laborator y settings, explosive
shrapnel such as ball bearings, nuts, and screws identification may also be achieved through re-
included as part of the device to inflict greater crystallization and observation under polarized
damage and increase the likelihood of secondary light. Some of the handheld monitors used for
blast injuries. Bringing these components together chemical detection can also detect the presence of
can give officers an idea of the level of sophistication explosives; however, more sensitive and accurate
of the device and the level of training of the instrumentation based on Raman spectrometry is
offenders and can provide a possible connection emerging that is capable of detecting explosive
between crimes. mixtures at a distance. Neutron interrogation
For example, the use of home-manufactured devices have demonstrated the ability to
rather than commercially machined screws was a characterize explosives (and other substances) by
trademark of explosives in the Unabomber cases, reading the gamma ray signatures released by an
and the use of a Big Ben alarm clock was consistent object following excitation by neutrons released
among all of the devices planted by Eric Rudolph by the detector. This testing is especially useful in
(the Olympic Park bomber). Also, if several devices the determination of the fill of unexploded or
were used in the same attack, evidence of these buried devices. Further confirmation can be

achieved with laboratory-based analysis, which is The nature of an explosive event provides the
made necessary by the fact that most improvised greatest opportunity for a medical responder to
explosives are derived from commonly used, recover evidence or identify persons of interest. The
commercially available products with benign uses. most dangerous situation would be the discovery
For example, a nitrate-based fertilizer mixed of an undetonated device on the body of a patient.
with diesel fuel creates an explosive material This situation might occur in a suicide bombing
(ammonium nitrate fuel oil). The presence of in which multiple bombers planned to attack a site,
nitrates or the presence of diesel fuel is insufficient one or more perpetrators carried devices that did
to definitively characterize the nature of the not detonate, and the suspects sustained injury as
explosive; both substances could be detected by a result of the proximate blast, or if the device was
chance in a given area. Analytical techniques that intended to detonate upon removal from the
reveal more information about the specific patient by medical personnel. In the event of such
structure or molecule complex are more useful in a discovery, one should notify law enforcement
characterizing explosives. Sensitivity is further immediately. Do not attempt to remove the device
improved with concentration techniques such as or move the patient any more than absolutely
solid phase extraction before analysis, as well as necessary. Evacuate the surrounding area rather
the use of artificial neuronal networks, a form of than attempting to move the device (or the patient
enhanced software to modulate the separation it is attached to). Other persons of interest may be
conditions according to the specific needs of the less severely wounded patients who act nervous
sample. Recently, success has been reported in rather than panicked, particularly if the individual
extracting DNA from skin cells left on the surface seems focused on police activities. Law
of exploded pipe bombs; therefore, genetic analysis enforcement officials may not be readily available
could also prove that an individual handled a for interrogation, but a detailed description of the
specific device. individual including identifying characteristics and
The aim of the primary investigation of a suspect contact information should be provided to
is to connect the individual or a group with the investigators, along with any transport information.
explosives used in an event. Police officers will likely Penetrative injuries of varying severity are
use preliminary techniques on scene, such as common in bombings; recorded injuries range
colormetric tests, to determine the presence of from hardware to bone fragments from a suicide
explosives and will use the results as probable cause bomber. Because fragmentation evidence can be
to detain a suspect pending further investigation. useful in device reconstruction or trace analysis,
Explosive residues are readily collected from police knowledge of the removal of such fragments
nonporous surfaces, skin, and fabric. Studies have from patients is useful. Fragments associated
shown that hair has the ability to concentrate directly with the device are important; objects
vapors from some military explosives and that that resemble batteries, springs, electronics (e.g.
concentrations can be linked to exposure time and wires, transistors, microchips, cellular phone
still be traced after washing or environmental components), or plastic tubing should be noted.
exposure. In the laboratory setting, characteristics If the items are removed in the field, one should
of trace elements associated with the explosive, such package and store shrapnel following the guidelines
as sulfur, can be analyzed to associate the explosive presented previously, making sure to wear gloves
material with a suspect or may be found in the and a mask to prevent DNA contamination. In the
suspect’s possession (even in trace form) with more likely circumstance that the patient is
explosive material recovered from the scene. transported with the shrapnel still embedded, the

medical responder should make note of the film, an 8 × 10 inches film with self-contained
patient’s name, identifying characteristics, the chemistry for instant processing.
nature of the shrapnel, and the transport hospital X-ray film mounts, folders, and labels must be
(if known) and should provide this information to on hand to keep radiographs separate and
law enforcement officials. In an explosive event that identifiable back to their source. A computer at
creates extreme structural damage, clothing the mass disaster site can electronically digitize and
removed from patients evacuated from the scene export radiographic images for rapid com-parison.
could be of use. Evidence collection will always
run secondary to engineering concerns such as Commingled, Skeletonized, Carbonized,
structure stability. The ability to start the and Mutilated Remains
investigation by conducting an initial analysis on
When human remains appear to be missing jaws
articles of clothing will save a great deal of time,
or teeth or when scattering and displacement has
because safety concerns may disallow evidence
occurred, it is worthwhile to make flat plate
collection from the explosion site for hours or days.
radiographs with location grids of the entire body
One should store items of clothing as described
or recovered rubble in search of teeth or surviving
earlier.
prostheses. Such dispersion and destruction occurs
in some house fires, skeletonized remains, and in
DENTAL RADIOGRAPHY IN MASS mass disasters when bodies are mutilated or
DISASTERS commingled. Skeletonized teeth are fragile and
brittle. They tend to fracture, usually at right angles
Field Equipment for Mass Disasters and with smooth cleavage through both enamel
In mass disasters involving multiple bodies in and dentin. These wedges of fractured tooth
remote sites or under compromised conditions, structure can be glued in place with Duco® cement
radiographs are often made on location. A tripod- or cyanoacr ylate cement. Specimens can be
mounted portable dental X-ray unit such as the preserved so as to prevent fracture by boiling,
Min-X-ray is used. A power source is provided by bleaching in Clorox, then dipping in a solution of
a generator. Proper shielding is needed. polyvinyl acetate resin. The bones and teeth are
Considering the workload and urgency in a mass then coated and permeated with a clear, thin,
disaster, one does not have the luxury of waiting invisible preservative. The effect of intense flash
for ante-mortem radiographs. All bodies and fires upon teeth is to cause boiling of the pulp and
recovered dental fragments should be X-rayed. explosion of the crowns which then break off at
Full-mouth radiographs are preferred but when the gumline, leaving roots within their sockets.
individual periapical views are too time-consuming Heat which develops more slowly causes exfoliation
and jaw removal is permitted, occlusal-sized film of enamel, leaving dome-shaped mounds of charred
can include the entire posterior dentition in two coronal dentin. These teeth are easily lost from their
to four exposures. Double film packets should be sockets. Recovered conical roots should not be
used. The films can be processed with an automatic forced back into sockets because of their fragility.
dental X-ray film processor equipped with a Rather, they should be guided in and checked
daylight loading hood. If incoming antemortem radiographically. Generally, if a charred root has a
films are being duplicated, a second processor gray (ashed) surface and a black (carbonized)
should be used to avoid mix ups. If a processor is surface, the gray side is labial (indicating higher
not practical, there is Polaroid TPX radiographic heat and more complete combustion) and the black

side is lingual. Carbonized and ashed teeth and BIBLIOGRAPHY
bone are friable and can crumble with the slightest
touch or movement. Teeth might disintegrate 1. Albert H Guay. The role dentists can play in mass
casualty and disaster events. Dent Clin N Am.
when the jaws are removed. These teeth can be
2007;51:767-778.
stabilized with spray acr ylic, cyanoacr ylate, 2. Alfano MC. Bioterrorism response. J Am Dent
polyvinyl acetate, or Duco® cement. Spray acrylic Assoc. 2003;134(3):278-80.
is easiest to apply in situ. Polyvinyl acetate is 3. Assael LA. Readiness and response: the oral and
acceptable, but most time-consuming. maxillofacial surgeon's role in disaster. J Oral
Despite its delicateness, conflagrated Maxillofac Surg. 2005;63(11):1565-6.
mineralized tissue retains its radiographic 4. Beveridge AD, Payton SF, Audette RJ, et al.
characteristics although some shrinkage occurs. Systematic analysis of explosive residues. J Forensic
Sci. 1975;20(3):431-54.
Lowered kVp is recom-mended as the specimens
5. Brannon RB, Connick CM. The role of the dental
require less X-ray penetrating ability. In remains
hygienist in mass disasters. J Forensic Sci.
where teeth have been lost postmortem, the shape 2000;45(2):381-3.
of the roots can be reconstructed by filling the 6. Brannon RB, Morlang WM. The USS Iowa disaster:
empty sockets with radiopaque material (dental success of the forensic dental team. Journal of
alginate impression material mixed with barium Forensic Sciences. 2004;49(5):1067-8.
sulfate) before making postmortem radiographs. 7. Colvard MD, Lampiris LN, Cordell GA, et al. The
dental emergency responder: expanding the scope
of dental practice. J Am Dent Assoc.
SUMMARY 2006;137(4):468-73.
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medical responder becomes more widely accepted
2006;159(1):S15-9.
throughout the country, the probability of a dental
9. Flores S, Mills SE, Shackelford L. Dentistry and
emergency responder responding to a terrorist bioterrorism. Dent Clin North Am. 2003;47:733-
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interested in pursuing a role in disaster response report of a consensus workshop. J Am Dent Assoc.
should seek out opportunities to enhance their 2002;133(9):1181-7.
knowledge of rules of evidence in the states in 11. Valenzuela A, Martin-de las Heras S, Marques T,
which they practice and obtain knowledge of et al. The application of dental methods of
identification to human burn victims in a mass
operating procedures and technical capacities
disaster. Int J Legal Med. 2000;113:236-9.
specific to their city, county, and state. This 12. Valenzuela A, Martin-de las Heras S, Marques T.
knowledge will help the dental emergency The application of dental methods of identification
responder distinguish physical evidence that is most to human burn victims in a mass disaster. Int J Legal
likely to be of analytical value. Med. 2000;113:236-9.
10

Child Abuse, Neglect and Domestic
Violence: Role of a Dentist
Abhishek Singhania, Shikha Atreja
Chapter Overview
 Definitions  Recognizing child abuse/neglect

 Child abuse in India and Indian statistics  Reporting child abuse or neglect
 Bruises  Critical steps in investigating and interviewing the
 Pathogenesis of contusions and factors affecting possible victim
the development and appearance of a bruise  Photo documentation
 Characteristic bruises  Techniques to help visualize bruising
 Conditions that may be confused with abusive  Dating bruises and associated misconceptions
bruising and limitations
 Legal matters regarding child abuse and neglect  Domestic violence and battered women
INTRODUCTION many other countries, there has been no

understanding of the extent, magnitude and trends
Before 1950, it was thought that the incidents of of the problem. The growing complexities of life
family violence were isolated. This idea arose in and the dramatic changes brought about by
part because of the prevailing attitude that men socio-economic transitions in India have played a
had right to discipline their wives and to use major role in increasing the vulnerability of children
corporal punishment on their children i.e. “spare to various and newer forms of abuse.
the rod and spoil the child” attitude. Child abuse has serious physical and psycho-
In the 1960s, movements began that increased social consequences which adversely affect the
awareness of child abuse and in 1970s, activities health and overall well-being of a child. According
followed that were aimed at preventing abuse of to WHO: “Child abuse or maltreatment constitutes
women and elderly person. all forms of physical and/or emotional ill-
Child abuse is a state of emotional, physical, treatment, sexual abuse, neglect or negligent
economic and sexual maltreatment meted out to a treatment or commercial or other exploitation,
person below the age of eighteen and is a globally resulting in actual or potential harm to the child’s
prevalent phenomenon. However, in India, as in health, survival, development or dignity in the
Child Abuse, Neglect and Domestic Violence: Role of a Dentist 205

context of a relationship of responsibility, trust or but no less damaging, are belittling or rejecting
power.’’ treatment, using derogatory terms to describe the
child, habitual tendency to blame the child or
DEFINITIONS make him/her a scapegoat.
The term ‘Child Abuse’ may have different Neglect: It is the failure to provide for the child’s
connotations in different cultural milieu and basic needs. Neglect can be physical, educational,
socioeconomic situations. A universal definition of or emotional. Physical neglect can include not
child abuse in the Indian context does not exist providing adequate food or clothing, appropriate
and has yet to be defined. According to WHO: medical care, supervision, or proper weather
protection (heat or cold). It may include
Physical Abuse: Physical abuse is the inflicting of
abandonment. Educational neglect includes failure
physical injury upon a child. This may include
to provide appropriate schooling or
burning, hitting, punching, shaking, kicking,
special educational needs, allowing excessive
beating or otherwise harming a child. The parent
or caretaker may not have intended to hurt the truancies. Psychological neglect includes the lack
child. It may, however, be the result of over- of any emotional support and love, never attending
discipline or physical punishment that is to the child, substance abuse including allowing
inappropriate to the child’s age. the child to participate in drug and alcohol use.
Sexual Abuse: Sexual abuse is inappropriate sexual

behavior with a child. It includes fondling a child’s CHILD ABUSE IN INDIA AND
genitals, making the child fondle the adult’s genitals, INDIAN STATISTICS
intercourse, incest, rape, sodomy, exhibitionism and Nineteen percent of the world’s children live in
sexual exploitation. To be considered ‘child abuse’, India. According to the 2001 Census, some
these acts have to be committed by a person 440 million people in the country today are aged
responsible for the care of a child (for example a below eighteen years and constitute 42 percent of
baby-sitter, a parent, or a daycare provider), or India’s total population i.e. four out of every ten
related to the child. If a stranger commits these acts, persons. This is an enormous number of children
it would be considered sexual assault and handled that the countr y has to take care of. While
solely by the police and criminal courts. articulating its vision of progress, development and
Emotional Abuse: Emotional abuse is also equity, India has expressed its recognition of the
known as verbal abuse, mental abuse, and fact that when its children are educated, healthy,
psychological maltreatment. It includes acts or the happy and have access to opportunities, they are
failures to act by parents or caretakers that have the country’s greatest human resource. A recent
caused or could cause, serious behavioral, study in India revealed that more than 50 percent
cognitive, emotional, or mental trauma. This can children suffer from one or another kind of child
include parents/caretakers using extreme and/ abuse. Seeing that 40 percent of our population
or bizarre forms of punishment, such as comprises children/adolescents, the number of
confinement in a closet or dark room or being victims can be over 20 millions.
tied to a chair for long periods of time or It is young children, in the 5 to 12 years group,
threatening or terrorizing a child. Less severe acts, who are most at risk of abuse and exploitation.

The State of Andhra Pradesh, Assam, Bihar and 2. Out of 69 percent children physically abused in
Delhi have almost consistently reported higher rates 13 sample states, 54.68 percent were boys.
of abuse in all forms physical and sexual as 3. Over 50 percent children in all the 13 sample
compared to other states. states were being subjected to one or the other
Following are the statistics as determined in the form of physical abuse.
207 page studies on Indian children from various 4. Out of those children physically abused in family
states titled “Study on Child Abuse India 2007” situations, 88.6 percent were physically abused
by ministry of health and family welfare (Fig. by parents.
10.1), government of India, regarding incidence 5. 65 percent of school going children reported
of various kinds of child abuse in rural and urban facing corporal punishment i.e. two out of three
India. It has very clearly emerged that across children were victims of corporal punishment.
different kinds of abuse, it is young children, in 6. 62 percent of the corporal punishment was in
the 5 to 12 years group, who are most at risk of goverment and municipal school.
abuse and exploitation. 7. The State of Andhra Pradesh, Assam, Bihar and
Delhi have almost consistently reported higher
rates of abuse in all forms as compared to other
Physical Abuse
states.
1. Two out of every three children were physically 8. Most children did not report the matter to
abused. anyone.
9. 50.2 percent children worked seven days a week.
Sexual Abuse
1. 53.22 percent children reported having faced

one or more forms of sexual abuse.
2. Andhra Pradesh, Assam, Bihar and Delhi
reported the highest percentage of sexual abuse
among both boys and girls.
3. 21.90 percent child respondents reported
facing severe forms of sexual abuse and 50.76
percent other forms of sexual abuse.
4. Out of the child respondents, 5.69 percent
reported being sexually assaulted.
5. Children in Assam, Andhra Pradesh, Bihar and
Delhi reported the highest incidence of sexual
assault.
6. Children on street, children at work and children
in institutional care reported the highest
incidence of sexual assault.
7. 50 percent of abusers are persons known to the
child or in a position of trust and responsibility.
Fig. 10.1: Picture showing the cover page of the the project
work “study on child abuse- INDIA 2007”, by Ministry of Health 8. Most children did not report the matter to
and Family Welfare, Government of India anyone.
PATHOGENESIS OF CONTUSIONS AND

Emotional Abuse and Girl Child Neglect
1. Every second child reported facing emotional FACTORS AFFECTING THE DEVELOPMENT
abuse. AND APPEARANCE OF A BRUISE
2. Equal percentage of both girls and boys reported
facing emotional abuse. A contusion, or bruise, may be defined as bleeding
3. In 83 percent of the cases parents were the beneath the intact skin at the site of blunt impact
abusers. trauma. The use of the term contusion should be
4. 48.4 percent of girls wished they were boys limited to those circumstances in which an
examiner has concluded that blunt impact occurred
BRUISES at the site of discoloration. A contusion differs from
an ecchymosis in pathogenesis, and these terms
Bruises are a very much neglected branch of should not be used interchangeably. An ecchymosis
injuries. These words were originally delivered in may be defined as blood that has dissected through
a 1938 address to the Medico-Legal Society of tissue planes to become visible externally. An
Great Britain by Sir Bernard Spilsbury. More than ecchymosis may be visible in an area that was never
half a century later in 1991, Langlois and Gresham subjected to trauma. A classic example of an
quoted these same words and observed that “little ecchymosis that becomes visible in an area free of
has changed since then”. Remarkably, in 2006, the blunt trauma is the Battle sign (Fig. 10.2). The
words of Sir Spilsbury continue to be true; bruises area of discoloration over the mastoid process that
remain a very much neglected branch of injuries. is associated with basilar skull fractures involving
Bruising is one of the earliest, most common, the middle fossae. Another example of ecchymosis
and easily recognizable signs of physical child abuse is the development of bilateral periorbital
and can signal escalating interpersonal violence ecchymoses (Fig. 10.3) (often referred to as
within a household. Early detection of abuse “raccoon eyes”). A contusion is a form of hematoma,
through recognition of bruising coupled with but not all hematomas are contusions. A hematoma
appropriate intervention can help to prevent future may be defined as blood that has extravasated from
and potentially more severe physical assaults. the vascular system into the body. A hematoma
Bruising is also an occurrence of accidental injury
and results from normal childhood activity. It is
important to note that bleeding beneath an intact
skin surface can occur from medical conditions and
an absence of bruising does not mean that an
abusive injury did not occur.
Differentiating between inflicted and non-
inflicted injury mechanisms can be complex and
challenging, especially in cases of mobile children.
The age and developmental status of a child in
combination with the number and the location of
bruises are important factors in determining whether
a bruise resulted from an accidental or inflicted
mechanism. Appropriate identification of injury Fig. 10.2: Battle sign, typically present
etiology is critical to ensure the safety of the child. behind the pinna of the ear

Fig. 10.3: Raccoon eyes presenting as periorbital Fig. 10.4: Histological picture showing the three prominent
ecchymosis and edema layers of the skin viz. epidermis, dermis and hypodermis
may or may not be associated with trauma. threshold of the vessel wall. This extravasation
Hematomas may develop in the presence of natural without the loss of the integrity of the skin surface
disease processes in the absence of trauma. is known as bruising or contusion and may be
Physicians working in the field of child physical evident as discoloration.
abuse must remember that each and every word Petechiae represent blood that has extravasated
within a medical record may become part of a from the tiniest branches of the vascular system;
criminal court proceeding. These physicians are they are characterized by pinpoint or pinhead-size
cautioned to be precise and accurate in hemorrhages beneath intact overlying skin or
terminology; loose use of terms and medical slang mucous membranes. Petechiae may range up to
should be avoided. two mm in diameter. The color, shape, and location
The skin is generally composed of three main of a bruise changes as hemoglobin is broken down
layers (Fig. 10.4) epidermis, dermis, and and resorbed. The time that it takes for a bruise to
subcutaneous tissues. The epidermis is a compact appear is dependent on many factors, including:
and firm outer layer that is not easily damaged by type of injuring force, depth of the injury, diffusion
crushing forces. The dermis is the middle layer of the blood through the damaged tissue, and the
composed of a superficial capillary network and a type(s) of tissue injured. The skin varies in relative
fibrous structure that is capable of stretching under tissue composition and thickness throughout the
force and returning to its original form without body to meet the functional requirements of the
damage. The subcutaneous tissues comprise the different body parts. As a consequence of the skin’s
innermost layer, which is rich in capillaries and fat structural differences, some body regions bruise
and may be easily deformed. The capillary networks more readily, whereas others require the application
of the two inner layers of the skin are the structures of greater force for bruising to result. The extent
most affected during injury with the majority of of injury associated with a bruise may not be
hemorrhage occurring in the subcutaneous tissue. apparent from the appearance of the overlying skin.
Blood leaks into the perivascular tissues when A superficial bruise may discolor the skin
damage occurs to blood vessels either through immediately, whereas deep bruising may take days
impact or a pressure increase that exceeds the injury to appear or may never become apparent externally.

The biochemical processes that occur in the skin The presence or absence of multiple tissue planes
and underlying tissue during the stages of repair may influence the area and size of bruising as the
result in changes in the appearance of the injury, tissue planes may allow the blood to track to sites
which is the reason photographic documentation remote from the initial impact.
is critical. Bruising may be caused by brief sudden In addition, there will be differences in the
contact with a blunt object or continually applied development of a bruise depending upon the
pressure. Direct blunt impact injuries may result duration of impact. If there is a rapid application
from the body moving toward the blunt object of force, then the applied pressure is brief allowing
(e. g. a fall into a piece of furniture) or the blunt immediate extravasation of blood, which may be
object moving toward the body (e.g. being struck evident externally in the form of a bruise. If there
with an object). Pinching or gripping at the body is an application of pressure without forceful
with the hand or an implement is an example of impact—If the same amount of force is applied
applications of continual pressure that may also more slowly, then there may be no rupture of blood
result in characteristic bruising. vessels, and thus an absence of bruising.
FACTORS AFFECTING THE CHARACTERISTIC BRUISES

Distinctive bruising patterns result from different
DEVELOPMENT OF A BRUISE injury mechanisms.
Factors affecting the development of a bruise
Grip/Grabmarks: Bruises from a continually or
include properties of:
forcefully applied grip are often relatively round and
1. The impacting object (or surface),
may coincide with 2 to 4 fingertips. Frequently, a
2. Force of impact, and thumb bruise may also be noted on the opposite side.
3. Properties of the body region impacted,
including Closed-fisted Punch: Punches generally result a
a. Vascularization of the tissue bed at the impact series of 2 to 3 bruises that are relatively round, with
site, each bruise corresponding to a knuckle on the hand
b. Tightness of the skin, of the assailant. This bruising pattern is sometimes
c. Presence or absence of tissue planes, observed on the abdomen of children who have
d. Presence of underlying bone such as in the suffered physical abuse. However, it should be
area of the iliac crest and the zygomatic arch, remembered that more than 40 percent of children
e. The state of the coagulation system of the dying from abusive blunt abdominal trauma have no
patient (e.g. has disseminated intravascular contusions visible on the external abdominal wall.
coagulation developed?), and Slap or Impact with Solid Cylindrical Object:
f. Medications that may affect the patient’s Tramline bruising is a common pattern charac-
clotting cascade and ability to form a clot. terized by parallel linear bruises with regions of
A severe bruising force may crush and tear sparing between them. This specific bruising
subcutaneous fat, fascia, muscle, blood vessels, pattern is created when a relatively light object
nerves, and periosteum, or these tissues may be impacts the skin surface rapidly. A classic example
gradually compressed as local swelling occurs. is the pattern left on a cheek from an open-handed
Bruising may be more readily apparent in regions slap mark. The pattern often consists of 3 parallel
in which there is greater vascularization and linear contusions with central sparing. The width
locations where the tissue is loose compared to of the central sparing roughly corresponds to the
areas where the skin is more strongly supported. width of the fingers. This pattern of linear

contusions with central sparing develops as the and bleeding disorders may be confused with
tissues along the edge of the impact site undergo contusions in children. These conditions do not
the greatest deformation. The impacts from the preclude abuse, but should be considered in
individual fingers are of insufficient force to cause children presenting with areas of discoloration and
an underlying crushing injury. no other injuries on physical exam or imaging.
Mongolian spots are areas of blue or blue-black
Other Objects or Household Implements: Often
discoloration usually located on the lower back
during an assault, the pattern of either the
or buttocks. They are also common in the more
impacting object or something lying between the
superior midline of the back, sometimes noted
impacting object and the skin, such as the textile
over the thoracic or cervical region, and may be
pattern of the clothing, is imprinted into the skin
present just about anywhere on the body. They
resulting in a pattern bruise. Such patterned
are seen more commonly in African-American and
bruising may also occur intradermally. Patterned
Asian children, and usually fade by 5 years of age.
bruises in the shape of instruments may be
If an examiner is unsure whether a particular area
diagnostic of physical abuse. Belts and electrical
of coloration is a Mongolian spot versus a
cords are common examples of household
contusion, re-examination after 10 days or so will
instruments that leave distinctive patterns.
resolve the issue. A bruise will show fading in 1
Bites: The typical bite mark is a series of aligned to 2 weeks time, whereas Mongolian spots remain
contusions in a round or oval ring-shape consisting relatively unchanged in the short term. Indeed,
of 2 arches (Figs 10.5 A and B). For more details some people retain them into adulthood.
on bite marks and their appearences, readers are Coining and cupping are folk remedies using coins
advised to please see the chapter on the Bite Marks. with oil or a heated cup applied to the skin for
The various types of abuses maybe categorized healing purposes. Although these are usually
as follows (Table 10. 1). painless procedures, they can cause extravasations
of blood into the perivascular tissues that appear
CONDITIONS THAT MAY BE CONFUSED as bruises.
WITH ABUSIVE BRUISING
Some common conditions including Mongolian
spots, cultural remedies, phyto-photo-dermatitis,
A B
Figs 10.5A and B: Typical bite mark on the arm of a child presenting as ring, shaped of two ovals representing two arches

Phytophotodermatitis occurs after contact of the
skin with certain vegetables or fruit (e.g. celery, limes)
and then sunlight (Fig. 10.6). The skin becomes
hyperpigmented, which can mimic a bruise. Often, a
caretaker will have the agent on his/her hands and
touch the child. The resulting lesion will appear as a
finger or handprint. A thorough history of contact
with these agents is necessary.
Henoch-Schonlein purpura is a form of vasculitis
that involves the small blood vessels and commonly
occurs in children after an upper-respiratory tract
infection or other illness. The purpuric skin rash may
appear as bruising (Figs 10.7A and B) and most
generally affects the buttocks and lower extremities.
Bleeding disorders such as platelet disorders,
idiopathic thrombocytopenic purpura (Fig. 10.8),
Von Willebrand disease, or leukemia can cause easy
bruising. Consequently, children will present with Fig. 10.6: A case of photodermatitis of the forearm, which
unusual or numerous bruises and little history to may be mistaken for any abusive phenomenon
Table 10.1: Showing the summary of various types of abuse
Physical Abuse Sexual Abuse Emotional Abuse Gild Child

Neglect
• Slapping/kicking Severe forms: • Humiliation is the • Lack of attention to
• Beating with • Sexual assault lowering of the self esteem girls as compared
stave/stick • Making the child fondle of the child by harsh treatment, to brothers
• Pushing private parts ignoring, shouting or speaking • Less share of food
• Shaking • Making the child exhibit rudely, name calling and use of in the family
private body parts abusive language • Sibling care by the
• Exhibiting private body • Comparison in between siblings girl child
parts to a child and with other children • Gender
• Photographing a child discrimination
in the nude
Other forms:
• Forcible kissing
• Sexual advances during
travel situations
• Sexual advances during
marriage situations
• Exposure: Children forced
to view private body parts
• Exposure: Children forced to
view pornographic materials

account for the bruising. If a bleeding disorder is protection. Following the doctrine of protective
suspected, laboratory testing including a complete discrimination, it guarantees in Article 15 special
blood count, activated partial thromboplastin time, attention to children through necessary and special
and prothrombin time should be obtained; laws and policies that safeguard their rights. The
consultation with a hematology specialist should right to equality, protection of life and personal
also be considered. liberty and the right against exploitation are
enshrined in Articles 14, 15, 15(3), 19(1) (a), 21,
LEGAL MATTERS REGARDING CHILD 21(A), 23, 24, 39(e) 39(f) and reiterate India’s
ABUSE AND NEGLECT commitment to the protection, safety, security and
well-being of all it’s people, including children.
The Constitution of India
Article 14: The State shall not deny to any person
The Constitution of India recognizes the
equality before the law or the equal protection of
vulnerable position of children and their right to
the laws within the territory of India.
Article 15: The State shall not discriminate against
any citizen on grounds only of religion, race, caste,
sex, place of birth or any of them.
Article 15 (3): Nothing in this article shall prevent
the State from making any special provision for
women and children.
Article 19(1) (a): All citizens shall have the right
to freedom of speech and expression.
A
B
Fig. 10.8: An yet another disease, Idiopathic Thrombocytic
Figs 10.7A and B: Henoch-Schonlein Purpura on the legs Purpura (ITP), which may also be mistaken for an abusive
of a child patient, mimicking an abusive inflicted injury injury

Article 21: Protection of life and personal liberty— Government of India accepted the two optional
No person shall be deprived of his life or personal protocols to the UN CRC, addressing the
liberty except according to procedure established involvement of children in armed conflict and the
by law. sale of children, child prostitution and child
Article 21A: Free and compulsory education for pornography. India is strengthening its national
all children of the age of 6 to 14 years. policy and measures to protect children from these
dangerous forms of violence and exploitation. India
Article 23: Prohibition of traffic in human beings is also a signatory to the International Conventions
and forced labor (1) Traffic in human beings and on civil and political rights, and on economic, social
beggars and other similar forms of forced labour and cultural rights which apply to the human rights
are prohibited and any contravention of this
of children as much as adults. Three important
provision shall be an offence punishable in
international instruments for the protection of child
accordance with law.
rights that India is signatory to, are:
Article 24: Prohibition of employment of children Convention on the Rights of the Child (CRC)
in factories, etc. No child below the age of fourteen adopted by the UN General Assembly in 1989, is
years shall be employed to work in any factory or the widely accepted UN instrument ratified by
mine or engaged in any other hazardous most of the developed as well as developing
employment. countries, including India. The Convention
Article 39: The state shall, in particular, direct its prescribes standards to be adhered to by all State
policy towards securing: parties in securing the best interest of the child
a. That the health and strength of workers, men and outlines the fundamental rights of children,
and women, and the tender age of children are including the right to be protected from economic
not abused and that citizens are not forced by exploitation and harmful work, from all forms of
economic necessity to enter vocations unsuited sexual exploitation and abuse and from physical or
to their age or strength. mental violence, as well as ensuring that children
b. That children are given opportunities and will not be separated from their families against
facilities to develop in a healthy manner and in their will.
conditions of freedom and dignity and that Convention on the Elimination of All Forms of
childhood and youth are protected against Discrimination against Women (CEDAW) is also
exploitation and against moral and material applicable to girls under 18 years of age. Article
abandonment. 16.2 of the Convention lays special emphasis on
the prevention of child marriages and states that
International Conventions and Declarations the betrothal and marriage of a child shall have no
India is signatory to a number of international legal effect and that legislative action shall be taken
instruments and declarations pertaining to the by States to specify a minimum age for marriage.
rights of children to protection, security and SAARC Convention on Prevention and
dignity. It acceded to the United Nations Combating Trafficking in Women and Children
Convention on the Rights of the Child (UN CRC) for Prostitution emphasizes that the evil of
in 1992, reaffirming its earlier acceptance of the trafficking in women and children for the purpose
1959 UN declaration on the Rights of the Child, of prostitution is incompatible with the dignity and
and is fully committed to implementation of all honour of human beings and is a violation of basic
provisions of the UN CRC. In 2005, the human rights of women and children.
RECOGNIZING CHILD ABUSE/NEGLECT

proceedings could follow, the history should be
Dentists are positioned uniquely to detect signs of recorded in detail. While one should always realize
child abuse. According to statistics, 50 percent to that there are other possible explanations, the
65 percent of all physical trauma associated with possibility of child abuse or neglect should be
abuse occurs in head, face or neck. Following is a considered whenever the history reveals the
list of head, face and neck injuries that should alert following:
dentists to possibility of abuse and neglect. Besides 1. The present injury is one of a series of injuries
the list, any injury to the head, face, neck or mouth that the child has experienced.
that is burns caused by specific objects, such as an 2. The family offers an explanation that is not
iron, curling iron, kitchen implement or cigarette, compatible with the nature of the injury. For
patterned injuries recognizable as caused by an
object, such as belt buckle and adult human bites,
may be added to the list.
The common sites that are frequently seen as a
result of abuse are (Figs 10.9A and B):
Head: Skull injuries, bald spots (traumatic
alopecia), bruises behind ears (Battle’s sign)
Eyes: Retinal hemorrhage, blackened eyes (raccoon
eyes)
Nose: Fractures, displacement
Lips: Bruises, Lacerations, angular abrasions (gag
marks)
Intra-oral: Frenum tears, palatal bruising, residual
tooth roots
Maxilla/Mandible: Fractures/improperly healed
fractures, Malocclusion from previous fractures
Teeth: Fractured, mobile, avulsed or discolored
teeth, untreated rampant caries, untreated, obvious
infections or bleeding.
DETECTING CHILD ABUSE IN THE

DENTAL OFFICE
Case History
When a child presents for examination, particularly
if there is an injury involved, the history may alert A
the dental team to the possibility of child abuse.
Indeed, the history may be the single most
important source of information. Because legal Fig. 10.9A:

B
Figs 10.9A and B: The graphical diagrams showing the most common site of the injuries in case of the child abuse
example, one notable author recalls a case in 4. The family does not want to discuss the
which an effort was made to explain away a circumstances of the injury. While the above
clearly identifiable human bite mark as a scrape findings are by no means conclusive, they should
caused by the edge of a diving board. cause the examiner to look further for possible
3. There has been an extraordinary delay in seeking signs of abuse, and to consider this among the
care for the injury. possibilities to be confirmed or eliminated.
General Physical Findings

blunt force trauma. For example, the labial frenum
may be torn when a hand or other blunt object is
Before examining the mouth, alert members of the
forcibly applied to the upper lip to silence the child.
dental team may note general physical findings that
Injuries of this type may also occur in forced
are consistent with child abuse or neglect:
feeding, as a result of the bottle being forced into
1. The child’s nutritional state is poor and growth
the mouth.
is subnormal.
2. Extraoral injuries are noted: They may be in Oral Mucosa Torn from Gingival: Blunt force
various stages of healing, indicating the trauma to the lower face may also cause the mucosal
possibility of repeated trauma. There may be lining of the inner surface of the lip to be torn
bruises or abrasions that reflect the shape of the away from the gingiva. A forceful slap, for example,
offending object, e.g. belt buckle, strap, hand. may have this effect. The location and extent of
3. Cigarette burns or friction burns may be noted, the injury will depend on the magnitude of force
e.g. from ligatures on wrists, gag on mouth. and the location and direction of the blow.
4. There may be bite marks, bald patches (where Trauma to the teeth: Severe trauma to the lower
hair has been pulled out), injuries on extremities face may loosen teeth, completely displace them
or on the face, eyes, ears, or around the mouth. from their alveolar sockets, and/or cause dental
As always, the examiner must remember that fractures (Fig. 10.11). It is not uncommon for
there may be explanations other than child abuse
for some of these findings.
Findings on Dental Examination

Examination of dental injuries includes thorough
visual observation, radiographic studies, mani-
pulation of the jaws, pulp vitality tests, and
percussion. Transillumination may also be helpful.
Typical Oral Lesions

Both oral and facial injuries of child abuse may
occur alone or in conjunction with injuries to other Fig. 10.10: Torn maxillary labial frenum
parts of the body. The oral lesions associated with
child abuse are usually bruises, lacerations,
abrasions, or fractures. Suspicion of child abuse
should be particularly strong when new injuries
are present along with older injuries. Thus scars,
particularly on the lips, are evidence of previous
trauma and should alert the investigator to the
possibility of child abuse. As noted earlier, further
investigation is required when the explanation for
the injuries does not justify the clinical findings.
Torn Frenums: Tears of the frenula, particularly
the labial frenum, are frequently seen in child abuse Fig. 10.11: Fractured maxillary central incisor in case of
cases (Fig. 10.10). These injuries may result from child patient reflecting some sort of traumatic injury

root fractures to occur, but this finding may be Lateral luxation: Tooth displaced in a direction
missed unless the radiographs are examined other than axially, with comminution or fracture
carefully. These injuries, as well as most other of alveolar socket.
traumatic injuries, may be accidental rather than Exarticulation (complete avulsion): Tooth
abusive. Therefore, one must always determine completely avulsed from socket. Comminution of
whether the injur y is compatible with the alveolar socket: crushing and compression of
explanation given. If the dental injuries resulted alveolar socket, found with intrusive and lateral
from a fall, for example, one would usually expect luxation.
to also find bruised or abraded knees, hands, or
elbows. When these additional injuries are not Fracture of alveolar socket wall: Fracture
present, further inquiry is appropriate. confined to the labial or lingual socket wall.
In evaluating and reporting dental injuries, it Fracture of mandible or maxilla: Involves the
may be helpful to use Andreasen’s classification, base of mandible or maxilla and often the alveolar
based on a system adopted by the World Health process, may or may not involve alveolar socket.
Organization. It is summarized below:
Laceration of gingiva or oral mucosa: Shallow
Crown Infraction: Incomplete fracture (crack) of or deep wound in mucosa resulting from tear, and
enamel with loss of tooth substance. normally produced by sharp object.
Uncomplicated Crown Fracture: Confined to Contusion of gingiva or oral mucosa: Bruise
enamel or enamel and dentin, pulp not exposed. usually caused by blunt object, no break in mucosa,
usually causes small submucosal hemorrhage.
Complicated Crown Fracture: Involves enamel
and dentin, pulp is exposed. Abrasion of gingiva or oral mucosa: Superficial
wound produced by rubbing or scraping mucosa,
Uncomplicated Crown-root Fracture: Involves
leaving raw, bleeding surface.
enamel, dentin, and cementum, but does not
expose pulp. Discolored Teeth: The tissues of the dental pulp
receive their primary blood supply through the
Complicated Crown-root Fracture: Involves apical foramen. When the tooth receives a
enamel, dentin, cementum, and exposes pulp. concussion, the apical blood vessels may be severed,
Concussion: Injury to supporting structures or hematoma or edema may occlude the blood
without abnormal loosening or displacement of vessels as they enter the tooth. As a consequence,
the tooth, but with marked r eaction to the pulp may become necrotic and nonvital.
percussion. Necrosis of the previously pink pulp tissues will
usually cause a noticeable darkening of the tooth
Subluxation (loosening): Injury to supporting (Fig. 10.12). In some cases of dental trauma, the
structures with abnormal loosening, but without dental pulp’s response to the injury may be to
displacement of the tooth. deposit additional secondary dentin in the pulp
Intrusive luxation: Tooth displaced into alveolar chamber. This may continue until the entire pulp
bone, injury accompanied by comminution or chamber is filled in, or obtunded. Again, the loss
fracture of alveolar socket. of the hollow pulp chamber with its normally
pinkish contents is likely to cause a change in the
Extrusive luxation: Tooth partially displaced out color of the tooth.
of its socket.

It is important to remember that both of the due to scarring. This may result from a burn or
processes described above occur over a period of other trauma.
weeks, or even months. Consequently, when a child Other Soft Tissue Injuries: Trauma to the mouth
presents with current dental trauma and also has may also cause ulceration of the palate or uvula.
one or more dark teeth unrelated to caries, it is Additionally, lacerations are sometimes found in
probable that the child has experienced previous the floor of the mouth, which may be caused by
trauma. Further inquiry to determine the nature forced bottle feeding.
of the trauma should be undertaken. Severe Injury to Jaws and Associated Structures:
Previously Missing Teeth: In examining a child Fractures of the maxilla, mandible, (Fig. 10.13)
who has experienced recent trauma, it may be noted and other cranial bones may be found in cases of
that one or more teeth has been lost prior to the child abuse. If the radiologic study shows signs of
present incident. The etiology of this earlier tooth old as well as new fractures, a pattern of repeated
loss should be investigated. If it was due to “an trauma has been found, and needs to be
accident”, a pattern of repeated trauma has been investigated with reference to possible child abuse.
established. This pattern needs to be evaluated, and The examination for maxillofacial fractures is
child abuse is one of the possibilities to be performed within the concept of overall patient
considered. care, including airway maintenance, control of
Trauma to the Lip: It is not uncommon to find hemorrhage, and neurologic examination. In a
contusions, lacerations, burns, or scars on the lips significant number of jaw fractures there is also
of abused children. Bruises to the lip may result from damage to associated structures, including the
forced feeding. Burns on the lip, as well as burns on cribriform plate, nasal, and zygomatic bones.
the face or tongue, may be signs of physical Intracranial lesions and skull fractures may also be
punishment. Bruises at the angles of the mouth may present. The diagnosis of fractures of the jaws is
result from efforts to gag or silence a child. made primarily on the basis of clinical and
Trauma to the Tongue: The tongue of an abused radiographic findings.
child may exhibit abnormal anatomy or function
Fig. 10.12: Discolored mandibular anterior teeth, reflecting Fig. 10.13: Severely fractured jaws in a case of child
a previous episode of trauma to the area in question patient

The clinical examination includes both extraoral (Fig. 10.14) or body surfaces (e.g. left and right
and intraoral palpation. Bilateral palpation is helpful side), without plausible explanation, should be
to detect asymmetry. Swelling or ecchymosis in the concerning for abuse. This distribution indicates
lower face is suggestive of fractures of the mandible. that the body has sustained forces severe enough
Fractures should also be suspected if there is an to cause bruising from multiple directions.
abrupt change in the occlusal level of the teeth. This pattern of injury does not typically result
This may be associated with open bite, difficulty from minor household accidents. Pierce et al
in opening the mouth, and facial asymmetry. Other observed that stair falls involving multiple contacts
signs and symptoms include abnormal mobility of between the body and the stair surface resulted in
bony structures, or the ability to move the two or fewer bruises. If bruises are present on
mandible beyond its normal excursion in any multiple planes, typically, the injuries on one plane
direction. Dingman and Natvig suggested result from an initial impact between the body and
supporting the angle of the mandible and pressing an object or hand, and the injuries on the opposite
the anterior mandibular region up and down to plane result from a secondary impact between the
detect fractures of the body of the mandible. body and another object. For example, if a child is
Crepitation and deviation of the midline on struck by an assailant and the force of the strike
closing may be diagnostic signs, as well. Pain in causes the child to impact with a piece of furniture,
the area of the temporomandibular joints may then bruises may appear on the plane of the body
suggest fractures in this region. The medical on which the child was initially struck and on the
practitioner who observes dental trauma is well plane of the body that impacted the furniture.
advised to seek consultation with a dentist
experienced in dental injuries to children. This
might be a pediatric dentist, oral and maxillofacial
surgeon, or general dentist. This added expertise
is important, not only to care for the present injury,
but also to help evaluate previous trauma.
Bruises Resulting from Physical

Child Abuse
An absent, vague, or implausible history is often
associated with cutaneous injuries resulting from
physical abuse. Frequently, bruising is an incidental
finding, unrelated to the reason why the patient
presents for medical care. All children, especially
infants and young children, who present to the
emergency department for any symptom, should
be undressed, and the skin should be carefully
examined. All cutaneous injuries should be
documented for location, size, pattern, and color,
as well as the presence of pain and swelling. A child
Fig. 10.14: A severely injured kid with multiple marks of
presenting with bruising to multiple planes assaults over his body

Subtle differences in bruising location within a to the anatomic lines of stress rather than the shape
given body region may raise concerns and affect of the injuring object.
the plausibility of the stated injury mechanism. In When a young child presents with bruising to
addition, studies indicate that the distribution of the head or face without a documented and
bruises may be indicative of injury etiology. plausible trauma history, head imaging should be
In infants and young children, bruises to the strongly considered. Ear bruising may be an
head (with the exception of the forehead), neck, indication of increased morbidity and mortality.
ears, and torso including chest, abdomen, Tin ear syndrome, characterized by distinct
genitourinary region, back, and buttocks rarely unilateral ear bruising, radiographic evidence of
result from accidental injur y mechanisms. ipsilateral cerebral edema with obliteration of the
Therefore, bruising on infants or young children basilar cisterns, and hemorrhagic retinopathy,
in these regions, without an appropriate history, results from rotational acceleration produced by
should be concerning for abuse and appropriate blunt trauma to the ear. This triad of injuries is
medical evaluation and testing should follow. concerning for child abuse. Genitourinary bruising
Bruising to the pinna and helix is rarely accidental may occur from straddle injuries as a result of
and is concerning for inflicted injury, especially if bicycle and playground accidents or falls. In such
present bilaterally. Unilateral, non-accidental ear situations, the highly vascularized tissue is
injury is predominantly left-sided resulting from compressed against the underlying osseous tissue,
blows by a right-handed assailant. Ear bruising and the majority of wounds are superficial. Non-
(Fig. 10.15) may be subtle and children should penetrating straddle injury mechanisms typically
be examined carefully for such injuries. Feldman result in minor trauma to the external genitalia;
described four pediatric cases, each with petechial this includes superficial lacerations to the scrotum
hemorrhages on the top of the pinnae resulting or penis in boys and lacerations or abrasions of the
from abuse. It is believed that the apex of the ear is labia in girls, with the labia minora being the most
folded on itself and crimped against the head by a frequently injured structure. Accidental straddle
blow resulting in capillary injury. The auricular injuries may occur either anterior or posterior to
injuries in each case exemplify bruising conforming the posterior hymenal border. However, more
injuries occur anteriorly because the tissues are
more likely to be compressed by the bony
prominence. Minor injuries to the posterior
fourchette have been documented in children
presenting with a history of non-penetrating
straddle injury. Hymenal trauma is associated with
a history of penetrating injury and is concerning
for abuse. Bruising to the penis can be seen in cases
of physical abuse, especially in situations
surrounding toilet training.
The caregiver may inflict injuries as a result of
unrealistic expectations. If bruising to the penis
occurs from an accidental situation such as
becoming caught in a zipper or slammed in the
Fig. 10.15: A child with abusive injuries on the toilet seat, the appropriate history should be
pinna of the ear available. Genital bruising accompanied by a vague

or absent history is concerning for an abusive injury. To illustrate the reporting requirement,
Strangulation may cause petechiae or bruising California law requires that any child-care custodian,
along the neck and/or cephalad petechiae health practitioner, nonmedical practitioner, or
including the mucous membranes and the employee of a child protective agency who has
periorbital regions. Subconjunctival hemorrhages knowledge of, or who observes a child whom he or
may also be seen. Ligatures may cause linear she suspects has been the victim of child abuse,
bruising over the wrists and lower extremities. report to a child protective agency immediately or
These marks may not be bilateral or completely as soon as possible and send a written report within
circumferential. Forceful hair pulling results in the 36 hours of learning of the incident. The definition
scalp being lifted off of the calvarium. When this of health practitioner includes dentist resident, dental
occurs, a large hemorrhage can result which tracks hygienist, and other licensed individuals, which
down over the forehead and face, and appears as includes the registered dental assistant. The report
widespread bruising over these areas. The can be made to the local police agency or welfare
discoloration often evolves over a few days. In department.
addition, loss of clumps of hair is often seen and
may be mistaken for tinia capitis. CRITICAL STEPS IN INVESTIGATING AND
INTERVIEWING THE POSSIBLE VICTIM
REPORTING CHILD ABUSE OR NEGLECT Investigators must overcome the unfortunately
It is absolutely vital that photographs of the child frequent social attitude that “babies are less
be taken as soon as possible after the child has been important than adult victims of homicide and that
brought to the doctor. Any person may report natural parent would never intentionally harm their
abuse/neglect. Reporting is not accusation; it is a own children”. When battered child syndrome is
request for assistance, investigation and protection. suspected, investigators should always express
If it seems child is in immediate danger, police concern towards type and severity of injuries. Ask
should be called. Before reporting, one should have child if he feels safe at home and whether injuries
all records of suspicion along with patient’s full were intentional and given by whom. Collect
detail. Prevent abuse and neglect through dental information about the “acute” injury that led the
awareness coalition. person or agency to make the report. Conduct
When one suspects child abuse, it is important interviews with the medical personnel who are
to document the findings thoroughly. This record attending the child and review medical records.
of the evidence is crucial for whatever legal Interview all persons who had access to or custody
proceedings may follow. Documentation may of the child during the time in which the injury or
involve written notes, photographs, and radio- injuries allegedly occurred.
graphs. In some cases videotapes or audiotapes may Always interview the caretakers separately as
be helpful. If the child requires medical attention, joint interviews can only hurt the investigation.
referral should be made to the proper resource. Do not be surprised if parents deny or frame
Even if immediate medical care is not required, if situations to explain, particularly when they change
a pediatrician is readily available the dentist may explanation to match questions. Parent/caretaker
wish to consult regarding the suspected child abuse should be reassured about confidentiality of talks.
prior to reporting. However, the absence of If only one caretaker is suspected of abuse, the non-
consultation does not relieve the dentist from the abusive caretaker may need to sign for release of
responsibility to promptly report suspected abuse. the records. If both are suspected, then there are

provisions that override normal confidentiality rules receipt. If possible, a forensic dentist should be
in the search for evidence of child abuse. consulted at the earliest stages of the evaluation.
Caretaker’s changes in explanations often mean The forensic dentist can help with identification
investigators must visit the home or the scene of of the bite type, pattern variations, identification
the injury more than once. of the biter, and may perform additional types of
The ideal time to obtain such evidence is photographic documentation.
immediately after the child’s injury is reported,
before caretakers have an opportunity to tamper PHOTO DOCUMENTATION
with the scene. If the child apparently suffered It is impor tant that skin findings are well
cigarette burns, collecting cigarette butts found in documented from the earliest stages of medical
the home may facilitate analysis of the burn care, especially if there is concern for abuse. Quality
patterns. If the case involves a combination of photographs provide critical documentation and
sexual and physical abuse, collecting the child’s may be helpful later for legal purposes. A 35-mm
clothing and bedding may allow identification of or high-resolution digital camera may be used.
what happened and who was involved. Photographs taken in either format will become
If the child shows evidence of bite marks, saliva part of the patient’s permanent medical and legal
swabbing should be done to allow positive record. Images must be stored in a secured medium
identification of the biter. If the child has suffered and certified as being the original image. When
a depressed skull fracture, any objects the non-genital injuries are photographed, the first
approximate size of the fracture should be seized picture should be of the victim’s face (an
for appropriate analysis. identification label with patient number may be
If a bite mark is present or suspected, it is included) and other photographs should follow in
important to collect trace evidence as well as a systematic order. A minimum of two photographs
photographic documentation; it is often possible of each cutaneous finding are recommended. The
for an expert to determine the identity of the first photograph should be an orientation
specific biter. Procedures for collection of trace photograph that shows the injury in the context
evidence should be developed after consultation of the body region involved as well as the
with the local crime laboratory for advice based anatomical orientation of the injury. The second
on methods and services available at that particular photograph should be a close-up of the injury with
laboratory. Some investigators suggest the “double a scale in the picture. In some jurisdictions, it may
swab” technique in which the skin surface is first be standard practice to take a third photograph.
swabbed with a sterile cotton tipped applicator This third photograph is a close-up image taken
moistened with sterile saline. This first swab is without a scale to show that nothing is being
followed by a dry swab. Both swabs should be concealed. Many forensic examiners use a standard
allowed to completely air-dry before being placed L-shaped scale recommended by the American
in individual envelopes that are then sealed with Board of Forensic Odontology. The scale should
tape. Chain of custody, with written documentation be placed in close proximity to and in the same
thereof, must be maintained for all evidence plane as the injury being photographed to avoid
collected. Information necessary for the chain of perspective distortion, which may alter the size or
custody form includes the names of persons contour of the wound pattern relative to the scale.
collecting or receiving evidence, the type of If an American Board of Forensic Odontology ruler
evidence collected or received, and the date of is not used, a circular scale, such as a coin, may be

used to document size. Photographs should be biologic components in the illuminated region.
taken in the film plane meaning the camera is Wavelengths from 10 to 400 nm are defined as
positioned parallel to the injury, with the lens at a ultraviolet (UV) and those greater than 700 nm
90° angle relative to the injury. If the injury is a are defined as infrared (IR). Ultraviolet radiation
bite mark, the documentation sequence is modified penetrates human skin only a few microns into the
as follows for the preservation and collection of epidermal tissue. This shallow penetration results
genetic evidence on the wound: initial photograph in less scatter of the reflected rays and a great degree
(to demonstrate the untampered appearance, of definition of surface detail; the shorter the
location, and orientation), salivary trace evidence wavelength, the greater the resolution. Infrared
collection, and comprehensive photo light has deeper penetration of up to 3 mm and
documentation. All photographs should be taken allows injuries below the surface of the skin to be
with the bite mark parallel to the film plane and in visualized. Because UV and IR wavelengths are
the orientation in which the bite was inflicted. If outside the visible spectrum, it is impossible to see
the bite marks are located on curved surfaces of the details of an injury as they appear in UV or IR
the body, each arch may have to be photographed radiation with the unaided eye. Photographic
separately to keep the wound parallel to the film techniques with specialized film and filters sensitive
plane and prevent distortion. Adequate lighting to the UV and IR wavelengths may be used to
should be used for all photographs. A ring flash capture an image of the injury, which can then be
may help to decrease washout that occurs with a seen with the unaided eye. However, these
regular electronic flash. reflective UV and IR photography techniques have
limitations in emergency department settings and
TECHNIQUES TO HELP VISUALIZE for use with children; specifically, high cost,
BRUISING specialized and fragile equipment for multiple users,
When light strikes human skin, it is either reflected, and requiring children to hold still due to long
transmitted to deeper layers, scattered, or absorbed. exposure times.
Different wavelengths of light vary in ability to Ultraviolet illumination is another technique
penetrate human skin, and the various biologic that may help to visualize regions of abnormality
components that comprise the skin have varying on the skin and may be better suited for pediatric
absorptive and fluorescent properties. The emergency care. With this technique, a source of
spectrum of normal skin is dominated by the incident radiation stimulates electrons to higher
summed absorbances of hemoglobin and melanin, energy levels. As the electrons return to stable orbit,
with small contributions from fibrous protein, energy is released, often in the form of light, which
collagen, and fat. When a bruise is present, there is known as fluorescence. When induced with
are increased amounts of hemoglobin at the injury incident radiation, many biologic compounds
site followed by bio-compositional changes exhibit fluorescence and have characteristic
resulting from the healing process. These changes absorption spectra. Vogeley et al used a Wood’s
affect the absorbance and fluorescence curves of lamp as a source of UV illumination and a digital
the skin. Using alternative light sources, which camera to improve bruise detection. With the
deliver wavelengths of light outside of the visible accessibility of a Wood’s lamp in most pediatric
spectrum of 400 to 700 nm, can aid in better facilities, and the elimination of the specialized
visualizing trauma, patterned injury, and disease. filters, lenses, and films required by reflective
This is due, in part, to differences in the degrees photography, UV illumination is a more pragmatic
of absorption and fluorescence by the different and less expensive technique for the clinical setting.

In addition, use of a digital camera eliminated the children. Some of the inherent difficulties in dating
need for low lighting conditions, long exposure bruises include the amount of bleeding, depth of
times associated with the 35 mm format, and, injury, bruise location, skin color, ambient light at
ultimately, the requirement for children to be still the time of examination, and chronicity of bruising.
for extended periods. The UV illumination has Stephenson and Bialas photographed accidental
allowed enhanced visualization of faint bruises and bruises of known ages in children. The photographs
those that were not otherwise visible. Further work were reviewed by a blinded observer asked to
and studies with children are needed in this area. describe the colors present in the bruise and
Ultraviolet and IR lighting techniques are not estimate the age of injury. Age estimations were
used routinely in the documentation of contusions incorrect in 20 of 44 cases, and accuracy was
in most medical examiner offices. Evidence unrelated to the age of the child, presence of a
visualized via these methods may not be admissible fracture, or bruising site. The study showed that
in court unless it has been shown to be scientifically multiple colors can be present within a single bruise
recognized and clinically accepted by the scientific/ and bruises can change color at very different rates.
medical community. Acceptance may include The study concluded that aging bruises from
publication in a peer-reviewed journal. To date, photographic evidence is imprecise. Bariciak et al
the best technique for documentation of investigated whether it was possible to accurately
estimate the age of a bruise on direct clinical
contusions remains the complete and accurate
examination and found physician estimates, despite
examination and documentation of findings using
level of clinical training or experience, to be highly
good light in a controlled environment such as the
inaccurate within 24 hours of actual age of injury
medical examiner office or the hospital exam room.
and not much better than chance alone.
All findings should be documented in multiple
Munang et al found the practice of relying on
formats, including photographic, diagrammatic,
color, including yellow, to age bruises to be
and written forms.
imprecise and flawed because of inter-and intra-
DATING BRUISES AND ASSOCIATED observer variations in describing color.
MISCONCEPTIONS AND LIMITATIONS Hughes et al conducted a study to understand
the perception threshold for the color yellow and
Often, there is a need to date when a bruise determine how consistently observers perceived the
occurred for child protective or legal purposes. presence of yellow. They found variability in the
Consequently, various techniques have been used
threshold for the perception of yellow color among
in attempts to assess the age of bruises; these are the general population and a declining ability to
described in an article by Langlois and Gresham. perceive yellow coloration as the observer’s age
Among these techniques, visual assessment has increased.
been a commonly used method to age bruises; These studies demonstrate that caution must
however, it is a process that remains notoriously be used when offering opinions on the age of a
inexact. Forensic pathology textbooks and texts bruise. The estimated age (and presence) of a bruise
focused on physical abuse of children have should never be the sole criteria for a diagnosis of
attempted to describe changes in bruise color over child abuse. Instead, the diagnosis should be
time, and although there does appear to be some determined by incorporating the findings of a
evolution of color, there is no clearly predictable careful history of the injury, past medical history,
order. In addition, most research related to the family history, associated risk factors, physical
color evolution of bruises is based on adult cadavers examination, and appropriate laboratory testing
and these findings may not be translatable to living and imaging.

children should have a careful skin examination
when presenting for medical care. Multiple factors
must be taken into account to distinguish
accidental and inflicted etiologies, including bruise
location and pattern, additional injuries or medical
findings, developmental capabilities of the child,
and the plausibility of the stated injury mechanism.
Bruises resulting from normal activity generally
occur over bony prominences on the front of the
body, most commonly on the lower leg and
forehead. Bruising is rare in preambulatory infants.
Bruises to the torso, head (with the exception of
the forehead), neck, ears, and multiple planes of
the body are concerning for abuse. Children with
disabilities or significant motor delay may have
different bruising patterns because of their unsteady
gait or assistive devices. Proper written and
Fig. 10.16: Women patient with injuries on her face and
lips, pointing towards some sort of abusive trauma
photographic documentation of cutaneous injuries
is critical.
BIBLIOGRAPHY
DOMESTIC VIOLENCE AND BATTERED 1. K Kaczor et al. Bruising and physical child abuse,
WOMEN Clin Ped Emerg Med. 7:153-60.
Battered Women Syndrome: It has been defined 2. Kacker L, Kumar SVD. Study on Child Abuse:
as a symptom complex occurring as a result of INDIA 2007 Ministry of Women and Child
abusive actions directed against a woman by her Development Government of India.
male partner. It has been reported in approximately 3. Kenney JP. Short communication, Domestic
15 percent of male-female relationships. Because violence: A complex health care issue for dentistry
today. Forensic Science International. 2006;159S
of injuries to the head/neck, (Fig. 10.16) dentists
S121-S125.
treating injuries of head and neck might be 1st to
4. Langlois NE, Gresham GA. The ageing of bruises:
examine and treat such patients.
a review and study of the colour changes with time.
Laskin counseled oral surgeons to be aware of
Forensic Sci Int. 1991;50:227-38.
non-accidental trauma. These injuries may 5. Roberton DM, Barbor P, Hull D. Unusual injury?
include—fractures of nasal bones, jaws, orbital Recent injury in normal children and children with
complex, fractured, avulsed, subluxated teeth or suspected non-accidental injury. BMJ. 1982;285:
lacerations/contusions. Muelleman et al indicated 1399-1401.
that facial abrasions and contusions were most 6. West MH, Barsley RE, Hall JE, et al. The detection
common form of injury patterns. and documentation of trace wound patterns by use
of an alternate light source. J Forensic Sci.
SUMMARY 1992;37:1480-8.
7. Wright F. Photography in bite mark and patterned
Bruising is one of the earliest and most common injury documentation-part 1. J Forensic Sci.
signs of physical child abuse. All infants and young 1998;43:881-7.
Annexure I
Forensic Dentistr
Forensic Dentistryy Kit
Various instruments required for a preliminary forensic investigation must include the following.
List of Various Materials and Instruments
Various
• Reference material • 35 mm camera
• Tape recorder • 35 mm film
• Paper pads • Modeling clay
• Manilla envelopes for case records • Boxing wax
• Identification forms • Fiberoptic lights or flashlights
• Tags with string or wire • Striker saw or hand saw
• Masking tape • Straight and curved retractors
• Staplers with staples • Scalpel handles
• Felt tip pens • Scalpel blades
• Large felt tip markers • Large scissors
• Plastic denture bags • Large hemostats
• Pencils • Mouth props
• Clip boards • Tongue blades
• Plastic cups • Cotton applicators
• Fatigues/work clothes • Mouth mirrors (front surface)
• Boots • Explorers
• Work gloves • Periodontal scalers
• Scrub suits • Cutting pliers
• Rubber aprons or surgical gowns • Stratight pliers
• Surgical gloves • Mallet
• Surgical masks • Millimeter rule
• Portable dental X-ray • Disclosing solution
• Dental X-ray • Hydrogen peroxide solution
• Film badge monitor system • Sodium hypochlorite solution
• Automatic film processor with daylight • 4 × 4 sponges
loading hood • Toothbrushes
• Dental X-ray film mounts • Computer/equipment
• Dental X-ray film envelopes • Computer paper
• X-ray light view boxes • Computer forms
• Processor chemicals • File cabinet
• Lead shielding • Batteries
Annexure II
The upper (Maxilla) and lower jaw (Mandible), with the teeth
The universal numbering system for both deciduous and permanent teeth
Annexure III
The dental age depending upon the eruption status of the teeth in the oral cavity
Index

Page numbers followed by f refer to figure and t refer to table
A Bite 11, 110, 115 Comparison techniques 136

ABFO scoring criterion 143, 145 mark Complicated crown
Abrasion of gingiva or oral mucosa pattern in 3-dimensional fracture 217
217 settings 141 root fracture 217
Advanced methods 21, 24 recognition 120 Computer aided reconstruction of
Afchar-Bayat sample 126, 132 soft facial parts 177
classification 156 Bruises 207 Contusion of gingiva 217
Lip Prints Classification 157, 158t Cormoy system 165
Age estimation and dental C Correia Classification 165
methodology 78 Criminal litigation 67
Calculation of maturity score 104
radiology 74 Crown 29
Cameron and Sims Classification
Alternate light imaging 56, 59 infraction 217
116
American morphology 71
Cannibalistic biting 153
Board of Forensic Odontology Cryogenic grinding 39
Carrea
125 Cusp of carabelli 27
Classification 163
method 177 Cyanoacrylate dye 159
Palatal Rugae Classification
Amorous bite mark 115 163, 163t
Analysis of length of long bones Cementum apposition 88 D
83 Chain of custody 193 DaSilva
Analyzing and recording Cheiloscopy 155 Classification 163
lip prints 158 Child abuse 118 Palatal Rugae Classification
palatal rugae 166 in India and Indian statistics 205 164, 164t
Animal bites 118, 144, 145 Chronology of human dentition 83 Daubert standard 170
Antemortem Dental Record Civil litigation 68 Demirijian seven-tooth system for
performa 45f Classic manual methods 176 age estimation 99, 104
Appropriate Dental Development Classification of Dental
Survey 99 facial bite injuries 150t changes 80
Arthritic changes in TMJ 81 various bite mark systems 115 charting of restorations 132
Articular eminence flattens 81 Closed fisted punch 209 comparisons 2
Attrition reflecting aging Closure of DNA evidences 38
phenomenon 19f frontanelle 83 identification 10
Attritional wear of teeth 81 skull sutures and palatine sutures index 22
83 radiography in mass disasters 202
B Coalescence of cusps 103 radiology and forensic sciences
Basauri Classification 163, 165, Combination fluorescent 61 65
165t Comparative dental identification records and
Battle sign 207f 11 forensic photography 43
Bilious personality rugae 164 Comparing meaningful features 68 mass disasters 194

Deposition of secondary dentine 90f First aid 126 Infrared
Detecting child abuse in dental Fluorescent cameras 62f
office 214 techniques 59 photography 56, 62
Development of incisor 104f tubes 61 Initial
Differences in bite patterns of child Forensic cusp formation 103
and adults 143 dentistry kit 227 root formation 103
Digital facial reconstruction 169 Intercanine distance 135
dental radiographic identification odontology 10 Intrusive luxation 217
71 sciences 1 Iodine spray reagent 159
photography 56, 57 techniques 195
Discolored Fracture of J
mandibular anterior teeth 218 alveolar socket wall 217 Jose Maria Dominguez
teeth 217 mandible or maxilla 217 Classification 156, 157
Distortion in human bite marks Fractured maxillary central incisor
121 216f K
DNA Function of masticatory muscles Killer waves of tsunami 187f
molecule 33 132 Krause and Jorden Charts 85
polymorphisms 35
typing methods 36 G L
Double swab method 129 Genomic DNA 34 Light spectrum 53f
Gingival recession 81 Limitations of dental radiography
E Glenoid fossa 81 77
Emotional abuse 205 Graphic methods 177 Liquid nitrogen 39
and girl child neglect 207 Gustafson’s Lo’Pez De Le’on Classification
Epiphyseal union 83 chart of formation and eruption 163, 164
Erupting third permanent molars of deciduous and Locard exchange principle 7f
87f permanent teeth 108 Location of bite marks 118
Eruption 108 grading and scoring 90f Lymphatic personality rugae 164
Evaluation of method 91, 99, 107 Lysis buffers 39
cranial trauma using radiological
methods 75 H M
injury and death 67 Haase’s rule 85 MacBeth color charts 58f
Evidence collection Hard tissue changes 80, 81 MacDonald's classification 116
and preservation 194 Henoch-Schonlein purpura 212f Manchester method 177
from bite Highlights of Moorees method Mandible bone 69f
suspect 131 103 Mandibular
victim 126 Hitler's corpse 66f angle 81
Extrusive luxation 217
landmarks 69
I Manmade disasters 195
F Idiopathic thrombocytic purpura Martin Santos Classification 156
Facial bites 150 212f Mass disaster victim identification
FDI System of Nomenclature for Impressions 126, 130, 132 and dentist's role 182
Permanent Dentition 17f Impulsive biting 152 Maxillary
Field equipment for mass disasters Indian Scenario and Lacunae in incisor 19f
202 System 51 landmarks 70
Index 233

Maximum mouth opening 132 Photodermatitis of forearm 211f charts 99f, 100f
Medium lips 156 Photographic documentation of method 99
Mental foramen 81 bite site 128 Scope of forensic radiology 67
Mercury vapor lights 61 Physical abuse 205, 206 Score of Gustafson’s scheme 90f
Methods of dental identification Plumb carbonate 159 Secondary
30 Postmortem dental record dentine 88
Microscopic methods 21, 23 performa 46f distortion 123
Missiles and foreign bodies 67 Pulpal morphology 71 Severely
Mitochondrial DNA 34, 35f fractured jaws 218f
Moorees method 99, 100
Q injured kid 219
Morphogenesis of deciduous Quartz-halogen lamps 61 Sex
dentitions 99f determination
R
in bite marks 151
N Raccoon eyes 208f using canine dimorphism 21
Racemization of aspartic acid in using PCR 24
Nature of bites 145 human teeth 95
Nervous personality rugae 164 differences in tooth size 21
Radiographic anatomic landmarks Sexual
Non-accidental injury 143, 146 of jaws 68
Non-perishable substances 142 abuse 205, 206
Radiography in mass disaster victim crimes 118
Non-visible light photography 56, identification 73
60, 129 dimorphism in human canines
Radiology in reconstructive dental 23f
identification 72 Silver nitrate 159
O Reconstructive postmortem 18 Size of bones for age estimation
Obtaining dental DNA 39 Renaud Classification 156, 157, 85
Oral 158t Skin pigmentation 120
cavity 80 RFLP methods 36 Skull of Hitler 66f
mucosa torn from gingival 216 Role of Soft tissue
Orthodontic models 48 dentists in mass disaster forensics changes 80
Ossification of hand and wrist 190 injuries 218
bones 83 DNA molecule in identification Sort of traumatic injury 216f
31 Specialized techniques 138, 140
P skull and mandible 20 Stability of DNA 35
Palatal rugae 162f, 167 Root Stages of
Classifications 163 dentine transparency 81 development of
Palatine rugae 162f length multi-rooted tooth 103f
Palatoscopy 155, 161, 165 and crown diameter 22 single rooted tooth 103f
Palmar System for Nomenclature of complete 103 tooth development 105f
Permanent Dentition 17f resorption 88 Standard operating procedure
Paranasal sinuses 165f shape, size and curvatures 71 193
PCR Steps of age estimation 97
machine 37f S Suzuki and Tsuchihashi
methods 36 Sadistic biting 152 Classification 156, 157t,
Periodontal pocketing 132 Saliva swabs 126, 129 158f
Periodontitis 88 Sanguinary personality rugae 164
Periorbital ecchymosis 208f Scanning electron microscope 138 T
Permanent maxillary molars 27f Schour and Massler Theoretic foundations 171

Three-dimensional reconstructions Trobo Classification 163, 164,
173 164t Visible
Tightness of skin 209 Tungsten lamps 61 light color photography 56, 57
Tokyo train attack 196f Types of light photography 56
Tongue pressure marks 116 digital and SLR cameras 57f
Tooth tooth structure 30
mobility 132 Typical oral lesions 216 W
pressure marks 116 Wax seal 112
scrape marks 116 Webster’s classification 116
Torn U
Well-mounted and articulated casts
frenums 216 Uncomplicated crown 48f
maxillary labial frenum 216f fracture 217
Trabecular pattern of mandibular root fracture 217
bone 71f Universal system for nomenclature
X
Transparency of root 88 of permanent dentition 17f Xeroradiography 140

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