jurnal radiografi

The Journal of Forensic Odonto-Stomatology, Vol.25 No.1, June 2007

K.Nicopoulou-Karayianni,1 A.G.Mitsea,1 K.Horner2

1. Oral Diagnosis and Radiology, Dental School, University of Athens, Greece2. Oral and Maxillofacial Imaging Clinic, School of Dentistry, University of Manchester, UK

ABSTRAABSTRAABSTRAABSTRAABSTRACTCTCTCTCTDentomaxillofacial radiology is a useful tool inforensic science to reveal characteristics of thestructures of the dentomaxillofacial region.Postmortem radiographs are valuable to the forensicodontologist for comparison with antemortemradiographs, which are the most consistent part ofthe antemortem records that can be transmittedduring forensic examination procedures. By usingdentomaxillofacial radiology we can, therefore, giveanswers to problems dealing with identificationcases, mass disasters and dental age estimation.We present the contribution of dentomaxillofacialradiology to the forensic sciences through two casesof deceased persons, where identification was basedon information provided by radiographs. The rightperformance, interpretation and reportage ofdentomaxillofacial radiological examination andprocedures can be extremely valuable in solvingforensic problems.

(J Forensic Odontostomatol 2007;25:12-6)

Key words: forensic odontology, forensic science,radiology, identification

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iNTRODUCTION

Forensic radiology comprises the performance,interpretation and reporting of diagnostic radiologicalprocedures that pertain to the courts and the law.1-4

The use of radiology in forensic sciences is not newand it has now been over a century since aradiograph was first introduced as evidence in a courtof law.

Postmortem radiographs are a valuable tool for theforensic odontologist because they, and antemortemradiographs, provide a source of robust and detailedinformation for comparative purposes. Even ifantemortem radiographs are not available, it is very

helpful to take postmortem radiographs.3,5 It isimportant that the forensic odontologist takesintraoral radiographs of all of the usual tooth bearingsites, including edentulous areas, in order to screenfor the possibility of unerupted teeth and retainedroots and to view the anatomic structures.3 Thecontribution of dentomaxillofacial radiology is veryimportant in:a. identification casesb. mass disasters (radiographic comparison hasincreased the number of positive identifications 6,7)c. age estimation cases

The aim of this report is to illustrate the contributionof dentomaxillofacial radiology to the forensicsciences, using two cases, where identification hasbeen based on the information provided byradiographs.

CASE 1The first case concerns the identification of a youngwoman. Human bones were found on a beach onthe island of Santorini, Greece (Fig.1). There wassome circumstantial evidence to indicate that theybelonged to a young, female, American citizen whohad disappeared on this island almost two yearspreviously. It was impossible to base the identificationprocedure on visual examination or analysis of thefingerprints – in other words, on classical methods -since only bone remains were found. Moreover, DNAanalysis could not be performed since the youngwoman in question was a native Asian who had beenadopted in the USA. The possibility of identificationhad to be based on data provided by antemortemdental records.

Interpol located the missing girl’s dentist who wasable to supply her antemortem dental records. Theonly available data from these were a panoramic

Dental Diagnostic Radiology12


radiograph (Fig.2) and four bitewing radiographs(Fig.3). These had been taken almost ten yearsbefore the remains were found.

The jaws were examined and three periapicalradiographs were taken of the mandibular molar areabilaterally and the right maxillary molar area (Fig.4).A comparison of antemortem (panoramic andbitewing) and postmortem (periapical) radiographswas carried out. Specifically, the root morphology ofthe molars, the morphology of the pulp cavities, themorphology of the right maxillary sinus and itsrelationship to the roots of the upper right molarsand the bone morphology of the mandible wereevaluated.

It was found that the morphology of the roots andthe pulp cavities of both the molars of the rightmaxillary region and the molars of the mandible were

consistent in antemortem andpostmortem views. However,the third molars in both jawswere present in the antemortemradiographs but not in thepostmortem radiographs. Thiswas not unusual since theantemortem radiographs hadbeen taken ten years previouslyand it was reasonable toassume that the third molarshad been removed during thisintervening period. The existingfil l ings in the teeth wereevaluated and also found to beconsistent. Careful study of theantemortem panoramic radio-graph and the postmortemperiapical radiograph of the rightmaxillary molar area revealed

that the size of the second molar filling was smallerin the postmortem radiograph. The remains of thecranium were reexamined and it was found that aportion of the filling in the upper right second molarhad broken away and the cavity was partly empty,thus explaining why the filling appeared smaller inthe postmortem radiograph. Reassessment of theradiographs then revealed that the distal part of thefilling, as shown in the antemortem panoramicradiograph, was identical in shape to that presentedin the postmortem radiograph.

The conclusion drawn was that the skeletonbelonged to the young, female, American citizen whohad disappeared.

Fig.1: Case 1 - Postmortem maxillae

Fig.2: Case 1 - Antemortem panoramic radiograph taken almost 10 years earlier

Fig.3: Case 1 - Antemortem bitewing radiographs

Nicopoulou-Karayianni, Mitsea, Horner 13


CASE 2A tourist discovered a skeleton on the island ofKarpathos, Greece. This coincided with a policesearch for a Swedish citizen who had disappearedtwo years previously from the location. Clinical andradiographic examinations of the remains wereundertaken (Fig.5). The Swedish embassy wasasked to locate dental records for the missing person.An Interpol “Victim Identification Form”, a floppy diskcontaining three digitized radiographs (two bitewingsand one periapical) and an intraoral photo wereprovided.

The morphology, size, midline deviation, occlusionand shade of the teeth were evaluated onantemortem and postmortem photographs (Fig.6).The morphology of the fillings, the type of prostheticrestorations (crowns, bridges and inlays), the rootcanal treatments and root fi l l ings and theintraradicular posts were all evaluated from theradiographs (Fig.7).

Twenty-eight concordant findings allowed a positiveidentification of the missing Swede to be made.

DISCUSSIONForensic dentistry for identification purposes is basedon the comparison of antemortem and postmortemfindings with resultant matching or exclusion. 5,8-11 Theidentification procedures are related to the availability,quality and type of antemortem records. The mostaccurate data obtained during the forensic dentistryidentification procedures are those that are derivedfrom postmortem and antemortem radiographs.These are useful even in cases concerning youngindividuals with little or no dental treatmentedentulous individuals. Radiographs areadvantageous in an international context since theyovercome the disadvantages of different languagesand different classification systems and are acceptedin courts of law as legal evidence. Dentistssometimes register only the treatment that they haveperformed, but radiographs reveal all previousrestorations that are present within a particular fieldof view. It is imperative that radiographs are labeledand mounted correctly. Although therapy performedin the time span between antemortem andpostmortem radiographs may change thecharacteristics of even unique restorations, an

Fig.4: Case 1 - Postmortem periapical radiographs

Fig.5: Case 2 - Postmortem remains



explainable difference that would not precludeidentification can be recorded.6,7,10-14

By studying the radiographs it is possible to evaluatedetails that otherwise could have been overlooked.The radiographs could reveal information concerningthe anatomical structures (such as sinuses), thebone patterns (nutrient canals, incisive canal, mediansuture), bone pathology (sclerosis, radiolucencies),teeth and pulp morphology, root number and form,retained roots, impacted teeth, the type, extent andposition of fillings, the type of prosthetic restorations,endodontic treatments, the placement of retentionpins and posts, the placement and type of implantsand the placement of osteosynthesisplates.5,6,8,9,12-14

Due to the fact that at the start of an investigationwe are usually unaware of the status of antemortemradiographs, multiple postmortem images should beobtained.4 Technically, with postmortem changes,

film positioning may be more difficult, particularly incases where it is necessary to dissect jaws in orderto take radiographs.3,5,8,9 In some cases onlyfragments or portions of the jaws or teeth areavailable for examination and should beradiographed in several orientations. In forensicradiography we should also keep in mind thatexposure adjustments may be necessary during theradiographic procedures. Postmortem changes insoft tissues, which may involve complete loss oftissue, mean that the normal exposure settings fora patient may not apply.3,4,8

Nowadays, dental records are often electronic,including digital or digitized radiographs and intraoralphotographs. The use of electronic dental recordslead to improvement in the accuracy and quality ofantemortem dental information.9-11 Digitalradiographs and intraoral pictures have the mainadvantage that they can be easily transferred andevaluated. Moreover, they can be computerprocessed and enhanced to generate more usefulinformation for the identification procedures. Thereare documented cases that would have beenunresolved without the use of digital enhancementtechniques.9,10,15-16 Forensic odontologists shouldalso be aware of the limitations of electronic dentalrecords. The transfer of such information, includingradiographs or intraoral photographs, may raiseethical issues concerning the patient’s privacy.Moreover, the probity of the data included inelectronic dental records has yet to be evaluated.9,10,14,15

In conclusion, radiographs are a paramount tool inforensic dentistry because they reveal uniqueinformation about anatomy and previous dentaltreatment.6,7,16 The cases discussed in this reportare examples of the essential role of bothantemortem and postmortem dental images inidentification.

Fig.6: Case 2 - Photographic comparison of morphology, size and shade of teeth, occlusion and midline deviation

Fig.7: Case 2 - Radiographic comparison of restorativeendodontic treatment morphology in (A) postmortem and(B) antemortem

A

B

Nicopoulou-Karayianni, Mitsea, Horner 15


REFERENCES1. Brogdon BG. Forensic Radiology. Boca Raton

Florida: CRC Press LLC, 1998:27-32,55-60,98-132.

2. Bowers MC. Digital analysis of bite marks and humanidentification. Dent Clin North Am 2001;45:327-39.

3. Rothwell BR. Principles of dental identification. DentClin North Am 2001;45:253-70.

4. Bell GL. Dentistry’s role in the resolution of missingand unidentified person’s cases. Dent Clin North Am2001;45:293-308.

5. Keiser-Nielsen S. Person Identification by means ofthe teeth. A practical guide. John Wright & Sons Ltd,Bristol 1980:37-8.

6. Borrman H, Grondahl HG. Accuracy in establishingidentity in edentulous individuals by means ofintraoral radiographs. J Forensic Odontostomatol1992;10:1-6.

7. Stene-Johansen W, Solheim T, Sakshaug O. Dentalidentification after the dash 7 aircraft accident atTorghatten, Northern Norway, May 6th 1988. JForensic Odontostomatol 1992;10:15-24.

8. Whittaker DK, MacDonald DC. A color atlas ofForensic Dentistry. Wolf Medical Publications Ltd.,Glasgow, 1989:5-15.

9. Avon SL. Forensic Odontology: The roles andresponsibilities of the dentist. J Can Dent Assoc 2004;70:453-8.

10. Fitzpatrick JJ, Shook DR, Kaufman BL, Wu SJ,Kirschner RJ, MacMahon H, Levine LJ, Maples W,Charletta D. Optical and digital techniques forenhancing radiographic anatomy for identification ofhuman remains. J Forensic Sci 1996;41:947-59.

11. Borrman H, Dahlbom U, Loyola E, René N. Qualityevaluation of 10 years patient records in forensicodontology. Int J Legal Med 1995;108:100-4.

12. Ekstrom G, Johnsson T, Borrman H. Accuracy amongdentists experienced in forensic odontology inestablishing identity. J Forensic Odontostomatol1993;11:45-52.

13. Borrman H, Gröndahl HG. Accuracy in establishingidentity by means of intraoral radiographs. J ForensicOdontostomatol 1990;8:31-6.

14. Wood RE, Kirk NJ, Sweet D. Digital dentalradiographic identification in the Pediatric, Mixed andPermanent Dentitions. J Forensic Sci 1999;44:901-16.

15. Tsang A, Sweet D, Wood R. Potential for fraudulentuse of digital radiography. J Am Dent Assoc1999;130:1325-9.

16. Wood RE. Forensic aspects of maxillofacialradiology. Forensic Sci Int 2006;159S:S47-S55.

Address for correspondence:Anastasia Mitsea18 Ellis str.121-37 PeristeriAthensGREECETel: + 30 21057 52433e-mail: [email protected]


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