Journal of Forensic Radiology and Imaging 1 (2013) 5662

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Journal of Forensic Radiology and Imaging

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Review article

Dental and craniofacial imaging in forensics

K.A. Shahin a,n, Laxmikanth Chatra b, Prashanth Shenai a
a
b

Department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Nithyananda Nagar Post, Deralakatte, 575018 Mangalore, Karnataka, India
Department of Oral Medicine and Radiology, AB Shetty Memorial Institute of Dental Sciences, Nitte University, Mangalore, Karnataka, India

art ic l e i nf o

a b s t r a c t

Article history:
Received 27 October 2012
Received in revised form
12 November 2012
Accepted 7 December 2012

The present review article aims at discussing the various trends evolved in forensic dentistry, particularly
referring with the usage of radiographs. Since the radiographs are the quick, easy, simple, economical
and non-destructive method of obtaining information about age, sex, race of the victim, it is an
indispensable aid in identication. With the advancement of newer technologies, more accurate
information is obtained for identication as well as in the facial reconstruction of the unknown deceased
person. This article gives an overview of different radiographic methodology and characteristics for
identication in oral and craniofacial region. To obtain the most reliable outcome in identication it is
necessary that one applies most of these techniques repetitively with appropriate knowledge.
Crown Copyright & 2013 Published by Elsevier Ltd. All rights reserved.

Keywords:
Forensic dentistry
Radiographic identication
Age estimation
Gender estimation
Race estimation

Contents
1.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.1.
Historical review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.2.
Forensic identication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Age estimation through radiographic skeletal changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Gender estimation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Racial estimation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Stature estimation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. Introduction
Forensic is derived from a Latin word forum where legal
matters are discussed. Odontology refers to the study of teeth or
dentistry [1]. Federation dentaire Internationale [FDI] dened
forensic dentistry as the branch of dentistry in the interest of
justice deals with proper handling and examination of dental
evidence with the proper evaluation and presentation of dental
ndings [2].
Human dentition is one of the most reliable means of identication. Its uniqueness has been calculated mathematically and
has been stated that about 1.8  1019 possible combinations of
32 teeth being intact, decayed, lled, missing may be present [3].
n

Corresponding author. Tel.: +91 9845840680, +91 8884835536.

E-mail address: drshahinkauser@gmail.com (K.A. Shahin).

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The enamel is the hardest tissue in the body and the dentition
is well insulated by the supporting alveolar bone and the oral
musculature and thus likely to survive the outward damaging
inuences like re, explosion, and putrefaction in water or soil [4].
Additionally, teeth are also relatively less affected by internal
disturbances like nutritional and endocrinal disorders. When
visual identication becomes impossible in tragic incidents, dental
evaluation sheds light on the age, sex, nationality of the deceased
person.
1.1. Historical review
The rst recorded case of dental ndings for identication was
made of a rich roman women Lollia Paulina, between 49 and
66 AD who was identied after her death through her unique
arrangement of her teeth [5]. In India, 1194 AD, King Jai Chandra of

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K.A. Shahin et al. / Journal of Forensic Radiology and Imaging 1 (2013) 5662

Canouj, was identied by his articial teeth after his martyrdom in

the battleeld [6]. The rst forensic odontologist was Dr Paul
Revere, who identied Dr Joseph Warren's body in 1775, through a
silver and ivory bridge constructed by him [5]. Saunders in 1837
was rst to publish a pamphlet entitled, Teeth a test of age,
regarding dental implications in age assessment [7]. The rst case
where dental evidence was accepted in the court was of Dr George
Parkman in 1849 [5].
The applications of radiology in forensic science was rst introduced in 1896 by Prof. Arthur Schuster, just a year after the discovery
of X rays, to demonstrate the presence of lead bullets inside the
victim's head [8]. Schuller in 1921 was the rst to propose the
comparative identication of the radiological images of the frontal
sinuses with plates formerly taken [9]. Culbert and Law in 1927 were
the rst to describe the complete radiological identication of the
skull by using pneumatic cells of the sinuses [9].
Since then radiographs has been used widely for identication
in mass disasters as well. In the year 2004, tsunami devastation in
the Indian Ocean, about 54.16% of non-Thai victims were identied
by dental status in Phuket/Thailand. Ante-mortem information,
particularly radiography and treatment charts were collected from
patient's native country. Post-mortem dental investigations comprised of periapical radiographs, two bitewing radiographs and
ve digital photographs [10].
1.2. Forensic identication
Identication corresponds to a group of different procedures
aimed at individualizing a person or an object [9]. It can be
facial features, physical ndings, ngerprinting, dental ndings,
DNA analysis depending on the extent of the damage of the tissues.
Broadly there are three methods of identication, namely
comparative identication, reconstructive identication and DNA
proling [11].
Comparative identication is established on referring the previous or ante-mortem record with that of the obtained evidence or
post-mortem records. Positive identication or exclusion achieved
by techniques of this category present a high degree of reliability
and accuracy [12]. The forensic dentist produces the post-mortem
record by careful charting and written explanations of the dental
structures and radiographs. Post-mortem radiographs should
replicate the type and angle of the ante-mortem radiograph, if
they are available. Ante-mortem radiographs should be labeled
with one hole and post-mortem with two holes utilizing rubberdam punch to prevent any confusion [13].
Reconstructive post-mortem dental identication is used when
no ante-mortem is available or when there is no clue of deceased's
identity. Here, maximum amount of evidence and personnel
features like age, sex, race, stature are identied [12]. If the antemortem digitized conventional radiographs are available, then
multiple radiograph-like images can be reconstructed and
matched from the post-mortem CT data.
Further, with the advent of newer imaging modalities like 3D
volume rendered computed tomography and improved efcacy of
the proposed computer algorithms, reconstruction of the facial
model is also more procient.
The need of identication arises in [2,13]
1. Criminal cases: where the victim has to be positively identied
before the investigation.
2. Civil case: as in mass disasters, where mutilated victims has to
be identied.
3. Monetary issues: pensions, insurance, other settlements
depend upon positive conrmation of death.
4. Remarriages in many religious backgrounds is illegal unless
their spouses are conrmed dead.

57

5. Burial in many religions require a positive identication preceding entombment in geographical sites.
6. Dissolution of cases by identifying the missing persons.
7. Society's duty to preserve human rights and self-respect begins
with the basic ground of an identity.
Radiographic means of identication in forensic dentistry
mainly comprises of structures like teeth, presence of foreign
bodies, alveolar process, anatomical structures and associated
pathologies. Variability in these structures as seen in comparative
dental radiographs aids in the identication of the individual.
Individual radiographic features appreciated in the process of
identication are shown in Table 1 [13,14].
Radiographic identications are advantageous as they are
simple, easy and quick modes of obtaining the information in a
non-destructive manner in both living and deceased. Further, they
are economical compared to DNA techniques [15,16].
Comparative identication of ante-mortem and post-mortem
conventional radiographs allows the observation of anatomical
characteristics such as coronal shape and size, pulp anatomy,
positioning and shape of the alveolar bone crest, in addition to
various dental treatments [9].
Digitized techniques allow a precise analysis of the spatial
relations of teeth roots and supporting structures on ante- and
post-mortem images. They also facilitate the correct alignment
between ante- and post-mortem radiographs without the necessity of new exposures [9].
Computed tomography (CT) helps in image segmentation and
avoids superimposition of anatomical structures beyond the plane
of interest and digitized radiographs and computer assisted image
analysis also avoid the bias inherent in observer subjectivity and
increase reliability, and accuracy [16,17].
An ante-mortem CT image provides evidence of craniometric
points which can be used in the construction of a post-mortem
replica images and a complete description of the radiological
protocol and the demographic data [9].
Additionally, 3D CT images can be applied for facial recreation in
reconstructive identication [18]. Radiological determination of
manner of death in medico-legal cases by using multislicing computed tomography [MSCT] and other advanced imaging modalities
like magnetic resonance imaging [MRI], and ultrasonography [USG]
was dened to be virtopsy (virtual autopsy) technique [19].
Accordingly, radiographs can be utilized for individual identication to determine age, sex, race, stature and the cause of death
due to gunshots or any other foreign bodies. They also help in
correcting the faulty charting of the tooth for instance in the case
of mesial migration of tooth into the extraction space [13].
1. Age
1.a.
1.b.
1.c.

estimation is categorized into three phases [7,20]:

Pre-natal, neonatal and post-natal [7,20]
Children and adolescents [7,20] and
Adults [7,20].

For age determination, two methods are usually used: the

Atlas method in which radiographic dental development is
observed with published standards, and the Scoring method, in
which dental development is divided into different chronological
stages that are then allotted the scores and are assessed through
statistical analysis [7,21].
1. Age estimation in Pre-natal, neonatal and post-natal life is
a) based on jaw bones pre-natally, appearance of tooth germs,
early mineralization in various deciduous teeth during intrauterine life and degree of crown completion [7,22,23]. The
radiographic phases of age estimation in natal life are represented in Table 2 and Fig. 1.

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K.A. Shahin et al. / Journal of Forensic Radiology and Imaging 1 (2013) 5662

Table 1
Individual radiographic dental features appreciated in the process of identication.
Teeth
Teeth present
Teeth missing
Tooth type
Tooth position
Crown morphology
Crown pathology
Root morphology
Root pathology
Teeth pathology
Pulp morphology
Pulp pathology
Periapical pathology
Periodontal ligament

Erupted, unerupted, impacted

congenital missing, lost ante-mortem, lost post-mortem
Permanent, deciduous, mixed, retained primary, supernumerary
Malposition
Size and shape, enamel thickness, contact points
Enamel pearls, cervical enamel extensions, dentigerous cyst
Size, shape, structure, number, divergence of roots
Root fracture, dens invaginatus, root resorption, root hemisections, germination, fusion, concrescence, hypercementosis, dilacerations
Amelogenesis & dentinogenesis imperfecta, dentin dysplasias
Size, shape and number, Secondary dentine
Pulp stones, root canal therapy, retrolls, apicectomy
Abscess, granuloma or cysts, Cementomas, Condensing osteitis
Thickness, Widening, Lateral periodontal cysts

Presence of foreign bodies

Dental restorations
Metallic (partial or full coverage), laminates, dental implants, bridges
Others
unretrieved amalgam particles, broken les, bullets, etc.
Alveolar bone
Alveolar process
Lamina dura

Height, contour, density of crestal bone, enostosis, bone loss, trabecular bone pattern, residual root fragments
Pattern of lamina dura

Anatomical structures
Maxillary sinus
Maxilla
Mandibular canal
TMJ joint
Abnormalities
Other pathologies

Size, shape, cysts, foreign bodies, stula, relationship to teeth

Anterior nasal spine, incisive canal (size, shape, cyst), median palatal suture
Mental foramen, diameter, anomalous, relationship to adjacent structures
Condyle, coronoid process-size and shape
Hypertrophy/atrophy, ankylosis, fracture, arthritic changes
Developmental cysts, salivary gland pathology, reactive/neoplastic, metabolic bone disease, focal or diffuse radiopacities, evidence of surgery
Traumawires, surgical pins, etc.

Table 2
Radiographic phases of age estimation in natal life.
Natal life [7,22]
16th week
intrauterine
26th week
intrauterine
30th week
intrauterine
At birth

Radiographic phases for age estimation

Mineralization of incisors
Advanced mineralization of deciduous incisors, two cuspal outline of deciduous rst molar, one cuspal outline of deciduous molar and crypt of rst
permanent molar
Three-fth completion of anteriors, cuspal fusion of deciduous rst molar, ve cusps of deciduous second molar is seen
Completely fused cusp of deciduous molars but no continuity in the occlusal surface of the deciduous second molar and mesial cusp tip
mineralization of permanent rst molar

1. Age estimation in children and adolescents [7,2226]

b) Teeth are less susceptible to nutritional, hormonal and pathological changes, particularly in children [7]. Thus, they are more
denitive for age assessment during developmental stages.
Dental age estimation in children and adolescents is based on
appearance of tooth germs, earliest detectable trace of mineralization or beginning of mineralization, degree of crown completion, time of emergence of the tooth in the oral cavity, degree of
root completion of erupted or unerupted teeth, degree of resorption of deciduous teeth and measurement of open apices in teeth
[7,2226].
Various illustrious methods applied for age estimation in children
and adolescents are as follows:
Schour and Masseler in 1941 described 21 chronological steps
from 4 months to 21 years of age and published the numerical
development charts for both deciduous and permanent teeth. The
American Dental Association (ADA) has periodically updated and
published these charts in 1982 which specically aids in comparing the calcication stages of teeth on radiographs with the
standards Fig. 2 [20,23,27,28].
Moorees, Fanning and Hunt reported 14 stages of mineralization
for developing permanent teeth and determined the mean age for

the corresponding stage was determined. Infants of 6 months

upto the adults with developing third mandibular molar were
included in the data. Remarkably, female development was ahead
of the male and the root formation stages exhibited variation
compared with crown formation stages [23,28].
Demirjian, Goldstein and Tanner considered seven mandibular
permanent teeth of each quadrant excluding the third molars
(Figs. 3 and 4). They determined eight stages of tooth mineralization which were the indicators of dental maturity of each tooth.
Girls and boys had separate formulas and sexual dimorphism was
not usually distinguished until 5 years. Advantage of this method
is that the missing teeth from one quadrant can be replaced by
other. Additionally, if the rst molar is absent, the central incisor
can be substituted for it as their developmental age overlaps. This
method is the utmost developed of all dental age surveys. The
drawbacks of this method are that it does not include the
developing third molar and the mandibular teeth need to be
present for the survey to be applicable [11,23,29].
Willems in 2001 modied Demirjian method and proposed new
tables for the scores that could be directly expressed in years. The
tedious step of conversion of maturity score to dental age was
excluded, thus making it simpler, yet maintaining the advantages

K.A. Shahin et al. / Journal of Forensic Radiology and Imaging 1 (2013) 5662

59

values were then substituted in the regression formula for age

estimation [25].
1. Age estimation in adult
c) Eruption of the third molar at the age of 1721 years marks
the cessation of the development of permanent dentition
clinically, subsequently the radiographic age estimation is
the alternative based on criteria of volume assessment of
teeth and the development of the third molar.
Age estimation by volume assessment of teeth is achieved by
radiological determination of the reduction in size of the pulp
cavity resulting from a secondary dentine deposition, which is
proportional to the age of the individual [11,15,41].
Kvaal et al. in their method, calculated pulp-to-tooth ratio for
six mandibular and maxillary teeth using intraoral periapical
radiograph. The age was derived by using the mean values of
pulp-to-tooth ratios in the regression formula for age estimation
[15].
The relationship between the reduction of the coronal pulp
cavity and the chronological age was surveyed using panoramic
radiograph in individuals of known sex and age. Mandibular
premolars and molars with visible pulp chamber from either one
of the side were considered. The toothcoronal index (TCI) was
gured for each tooth and simple linear regression analysis was
carried out by regressing the proportional coronal pulp cavity
length on the actual age for each group of teeth for males and
females and for the collective sample. [42]
Development of the third molar is taken as a guide to
determine the age of the individual after the age of 17. Harris
and Nortje have given ve stages of the root development of the
third molar with parallel mean ages and mean length [41]. Van
Heerden evaluated the development of the mesial root of the third
molar using panoramic radiographs and also described ve stages
[43].
Other norms like enamel attrition level of teeth and level of
alveolar bone resorptions were considered using panoramic views
in adults but was found inadequate method for age estimation
[44].

2. Age estimation through radiographic skeletal changes

Fig. 1. Age estimation in pre-natal, neonatal and post-natal life.

of the Demirjian method. [30] Many comparative studies proved

that Demirijan's method showed overestimation whereas
Willems method was more applicable for estimating dental
age [3139].
Nolla assessed the mineralization pattern of maxillary and mandibular permanent dentition in ten stages. The radiograph of the
patient was compared with the Nolla's gure and every tooth was
assigned a reading. A total is made of the maxillary and
mandibular teeth and then the total is related with the table
given by Nolla. The advantages of this method are that it can be
applied to any individual regardless of the presence of third molar
and the girls and boys are dealt distinctly [40].
Cameriere's evaluated seven left permanent mandibular teeth in
panoramic radiograph. The dental maturity was calculated as the
sum of normalized open apices and the numbers of teeth with
complete root development after nullifying the magnication. The

Age estimation from sutures can be best done by skull radiographs. Neonates will have edentulous jaws with large orbit size.
At 1 year of life there will be fusion of midline symphysis, fusion of
metopic suture. At the third year of life the condylar portion of the
occipital fuses with the squama. At the fth year condylar portion
of the occipital bone fuses with basiocciput. At 25 years the
coronal, saggital and lambdoid sutures start to close. The saggital
suture is rst to close. Initially it closes near parietal foramen and
the last portion to unite is bregma around 3235 years. By 40 years
there is fusion of coronal suture and at 45 years lambdoid suture
fuses. At 60 years squamous portion of the temporal bone fuses
with parietal bone [12,14].
Age estimation from the size of the skull using cephaloometrics
has been studied and proposed corresponding to the age
[12,14,45]. Age estimation from the sinus using posterioanterior
view also has been proposed [19]. Variations in frontal size
patterns such as size, shape, symmetry, anatomical outline and
number and presence of septa and cells are matched on antemortem and post-mortem radiographic images. The frontal
sinuses are absent at birth [46] and start developing at the age
of 2 or 3 years but at a rudimentary level [47]. The development of
the frontal sinuses is more rapid in the puberty, and is completed
by 20 years of age.

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K.A. Shahin et al. / Journal of Forensic Radiology and Imaging 1 (2013) 5662

Fig. 2. Schour and Massler illustrating 21 chronological steps from 4 months to 21 years of dental age.

Fig. 3. Demirijan's method showing eight stages of incisor, canines, premolars and molars development.

Fig. 4. Radiographic representation of molar assessment through Demirijan's method.

K.A. Shahin et al. / Journal of Forensic Radiology and Imaging 1 (2013) 5662

Further, angle of the mandible and its skeletal changes also

gives an apparent clue of the age of the victim as mentioned in
Tables 3 and 4 respectively [14].

61

dental caries is less in Eskimos [14]. Other characteristic traits

which differentiate races are given in Table 6 [14].

5. Stature estimation

3. Gender estimation
Gender determination is usually done from cephalometric and
posterioanterior views The frontal sinuses are larger in men and
the superior borders of the frontal sinuses are deeper in women
[9]. Signicant sexual dimorphism was seen in the south Indian
population in the head circumference using cephalometrics [45].
Some other prominent features distinguishing males and females
are mentioned in Table 5.

The appraisal of living stature from long bones may also hold
true to other bones as craniofacial bones but may not correlate as
decidedly.
Regression equations were obtained in relation to height to
head circumference and skull diameter (P o0.0001 for both). The
highest correlation was found when individual measurements of
combined data were plotted against height [45]. The location of
mandibular canal showed positive correlation with the stature in
linear tomograms [48].

4. Racial estimation
Similar to age and gender differences certain racial differences
also have been noted. Long pointed canine root, enamel pearls,
taurodontism (bull tooth), congenital lack of third upper molar is
seen in mongoloids [14].
Australian aborigines have larger teeth, Indians have smaller
teeth, Whites have intermediate sized teeth and the incidence of
Table 3
Apparent angle of the mandible aiding to determine the age.
Angle of the mandible in degrees

Age

160175
150160
125140
120130
90125
95115
Obtuse angle o infants

Infancy
13 years
612 years
1517 years
1821 years
3040 years
More than 40 years

6. Conclusion
Radiographs are one of the excellent tools in the eld of
forensic dentistry. Forensic odontologist can rely on radiographs
for age estimation with the various time tested methods, though
multiple methodologies should be applied before arriving at a
conclusive identication such as probable identication, possible
identication, insufcient information or exclusion. Though dental
and craniofacial radiographs are important assessment tools in
race, gender and stature estimation, due to diversity in human
physical constitutional makeup, should also be supported by other
forensic methodology and radiographs of other parts of the body.
Recognizing its importance, the radiographic storing and
record keeping should be upheld in all the dental clinics and
institutions as per the rules of the land. Further the forensic team
should always be well acknowledged with the dental and craniofacial radiography and its forensic signicance and thus include it
in its normal protocol.

Table 4
Skeletal changes seen in the growth and development of an individual.
Area

Infancy

Adult

Old age

Ramus
Mental foramen
Condyle

Short & oblique, forms an obtuse angle with the body

Near the alveolus
Lower level than coronoid

Less obtuse angle

Midway between upper and lower margins
Above the coronoid

Obtuse angle 1401

Near the alveolus
Neck bent backwards

Table 5
Sexual dimorphism.
Characteristics

Male

Female

Skull size
Supraorbital ridge
Orbits
Forehead
Fronto nasal junction
Condyles
Cheek bone
Zygomatic arch
Gonial angle
Palate
Frontal sinus
Nasal aperture
Mandible size
Chin
Body height
Ascending ramus

Larger
More pronounced
Square, lower, smaller with rounded margins
Steeper, less rounded
Distinct angulation
Larger
Heavily, laterally arched
More pronounced
Less obtuse, prominent
Larger, broader, U shaped,
More developed
High & narrow margins
Larger
square
Greater at symphysis
Greater breadth

Smaller
Less pronounced
Round, higher, larger, sharp margins
Vertical, round
Smoothly curved
Smaller
Lighter, more pronounced
Less pronounced
More obtuse
Smaller, parabola shaped
Less developed
Lower & broader
Smaller
rounded
Smaller at symphysis
Smaller breadth

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K.A. Shahin et al. / Journal of Forensic Radiology and Imaging 1 (2013) 5662

Table 6
Characteristic traits in different races.
Traits

Whites

Asians

Negroid

Skull
Prole
Orbit
Nasal aperture
Palate
Face
Inter orbital distance

Rounded
Straight
Triangular
Narrow & elongated
Triangular
Small
Narrow

Square
Intermediate
Higher & rounded
Rounded
Large& rounded & horse shoe
Large & attened
Intermediate

Narrow & elongated

Prognathic
Lower, wider & square
Broader
Long & rectangular
Maxilla & mandible prognathic
Wide

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