Case report

Medicine, Science and the Law

0(0) 1–4
Analysis of dental injuries with clinical ! The Author(s) 2018
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DOI: 10.1177/0025802417750807
journals.sagepub.com/home/msl

Si-lei Tan1,2, Shu-ya Peng1, Lei Wan1, Jie-min Chen1 and

Wen-tao Xia1

Abstract
Dental injuries, especially of the incisors, caused by punches in violent criminal attacks could be seen in daily forensic
casework involving the identification of injuries to a living body. Sometimes, when there is neither circumstantial evi-
dence nor information about the surrounding circumstances, it is difficult to discern the cause of these injuries and the
manner in which they were inflicted. As an example of clinical forensic medicine, we present the case of a 58-year-old
woman whose teeth were injured when fighting with her son-in-law over household affairs with no witnesses present.
The two parties had conflicting stories about the cause of the woman’s injury. The woman claimed that her teeth were
lost while she was being beaten by her son-in-law, and the man argued that the damage to his mother-in-law’s teeth was
self-inflicted when she bit his fingers. The police attending the crime called for a forensic examination. Forensic
practitioners analysed the mechanism of the tooth loss using multi-slice spiral computed tomography (MSCT) and
imaging reconstruction technology. Local alveolar bone (medial alveolar) fracture and a small area of alveolar bone
loss were found on MSCT. Thus, forensic medical experts speculated that the woman’s lower central and lateral incisors
were lost as a result of a violent attack and were not self-inflicted. Finally, forensic practitioners helped police in avoiding
a miscarriage of justice and wrongful conviction.

Keywords
Clinical forensic medicine, criminalistics, human rights, MSCT, traumatic dental injuries

Introduction
According to Chinese criminal law, the severity of
injury is one of the most important factors in convic-
tion and sentences in violent crimes, particularly in
domestic-violence cases. In some cases of unconfirmed
violent attacks, the police may commission a forensic
examination in order to make an assessment of the
cause of the injury and the manner in which it was
inflicted. It is a frequent challenge in forensic medicine
to determine whether an injury was accidental, self-
inflicted or a crime.1 To ensure fair and equitable
administration of justice, it is critical that the details
of the case are clear. In the practice of clinical forensic
medicine, proper examinations are helpful for analy-
sing the manner of injury, especially in complex cases.
Multi-slice spiral computed tomography (MSCT) is
widely used in clinical medicine, as well as in clinical
forensic medicine. MSCT is highly sensitive in detect-
ing fractures, and possesses three-dimensional imaging
reconstruction technologies, such as maximum intensi-
ty projection and volume rendering, which transcend
the limitations of axial imaging. It not only improves
the sensitivity of damage detection, but also provides a
critical view for judging the manner of injury. Here, we
report a case of a woman who suffered traumatic
dental injuries in which the manner of the injury was
determined using MSCT and imaging reconstruction
technology.
Case report
A 58-year-old woman was injured when fighting with
her son-in-law over domestic matters at home on 15
1
Shanghai Key Laboratory of Forensic Medicine, Academy of Forensic
Science, Shanghai Forensic Service Platform, China
2
Department of Forensic Medicine, Medical College of Soochow
University, China
Corresponding authors:
Wen-tao Xia, Institute of Forensic Science, Ministry of Justice, Putuo,
Guangfu Road, Shanghai, 200063, China.
Emails: xiawentao629@163.com
2 Medicine, Science and the Law 0(0)
July 2012. She lost four incisors in the incident, and
was sent with the teeth to the local county hospital
designated by the police for injury assessment.
Clinical medical records documented: ‘42, 41, 31, 32
completely dislocated with a small amount of bleeding
in the gingiva, gingival laceration and pain of 33’. A
diagnosis of complete dislocation of the lower incisors
and concussion of the lower left cuspid was determined.
After 10 days’ treatment, she attended a hospital affil-
iated with a medical college. No fracture was found in
X-rays of her maxilla and mandible. As the dislocated
teeth were not conserved properly, she eventually
underwent alveolar bone repair surgery instead of
tooth replantation. However, the clinician found no
evidence of hard- or soft-tissue injury on the alleged
assailant.
During the police investigation, neither side could
reach a consensus. The woman said that her face was
beaten by the man, resulting in the loss of her teeth,
while the man argued that the dental injury to his
mother-in-law was self-inflicted when she bit his fin-
gers. There were no witnesses to the incident. To clarify
the cause of the woman’s injury, and to deal with this
case fairly, the police assigned us to make a judicial
judgment based on our forensic expertise.
Forensic medical investigations
Examination of clinical and documentary data. Dental X-ray
imaging (Figure 1) performed on 15 July 2012 showed
that the lower incisors were avulsed without obvious
fracture of the alveolar bone. Dental X-rays and CT
imaging of the head on 25 July 2012 showed that both
the maxillary and ethmoidal sinuses were normal with
no fracture of the skull.
Forensic examination
On 27 August 2012, the forensic practitioners investi-
gated the case. The following results were presented.
On physical examination, the woman’s lower central
and lateral incisors were found to be completely
Figure 1. The lower central and lateral incisors are missing, with normal alveolar bone, and clear and complete bone walls. The
alveolar depth is normal, with no apical lesions.
dislocated with normal gingiva. There was no pain in
the temporomandibular joint, and no obvious limita-
tion of mouth-opening. The upper central and lateral
incisors remained normal.
Forensic radiologists examined the woman using a
40-slice MSCT system (Definition AS; Siemens
Medical Solutions, Munich, Germany) on 6 August
2012. Raw data were acquired using the following set-
tings: voltage, 120 kV; current, 240 mA; and slice thick-
ness, 0.75 mm. Image review and three-dimensional
reconstructions were carried out on a MSCT worksta-
tion (Figure 2). The MSCT imaging revealed loss of the
lower central and lateral incisors, accompanied by frac-
ture of the mandibular alveolar process and a loss of a
small piece of medial alveolar bone. The residual alve-
olar bone was of normal depth, and the root tip showed
no lesions.
Conclusion
After comparing the two possible manners claimed to
have caused the traumatic dental injury, the forensic
practitioners determined that the woman’s injury in
this case was caused by external force to her face,
rather than by internal force induced by biting.
Discussion
Violent crime, such as domestic violence and inter-
relationship violence, is listed as the second most
common cause of injury after accidents.2 Research
has shown that aggression in domestic violence often
occurs in the form of blunt trauma and slapping,3 and
the face is the area most predisposed to injury. Among
all facial injuries, dental traumas are common, especial-
ly to the incisors, because of their anatomical location.
According to the statistics, more than 60 cases of tooth
injury were identified in 6000 cases of living injury iden-
tification every year in our institution.
From the standpoint of therapy, anatomy and prog-
nosis, five different types of traumatic dental injuries
Tan et al.
Figure 2. The lower central and lateral incisors are missing, accompanied by fracture of the local alveolar process and loss of alveolar
bone.
Figure 3. Sagittal anatomy cartoon of incisor. The alveolar bone
and ridge are identified.
are recognised: concussion, subluxation, extrusive lux-
ation, lateral luxation and intrusive luxation. The clas-
sification includes injuries to the hard dental tissues and
the pulp, the periodontal tissues, the supporting bone
and the gingiva or oral mucosa (Figure 3).4 The type of
lesion depends on the force and direction of the
impact.5 Intrusive luxation occurs when the force of
the impact causes an axial displacement of the tooth
towards the alveolar bone. The damaged tooth is usu-
ally displaced through the labial bone plate, or can
impinge upon the succedaneous tooth bud.
Radiographically, the apical tip can be visualised and
appears shorter than the contralateral tooth, or cannot
3
be visualised. Extrusive luxation occurs when an
impact in a coronal direction causes axial displacement.
The injured tooth appears elongated and is excessively
loose. This injury could increase the periodontal liga-
ment space apically in the radiographic findings. The
above two kinds of damage are the result of forces from
different directions. Therefore, forensic practitioners
should collect anamnestic data and perform objective
clinical examinations, carry out further instrumental
diagnostic examinations and analyse the manner of
the injury, the severity of the traumatic events and
the extent of the injury.
Fracture or loss of the maxillary or mandibular alve-
olar process is one type of injury to the supporting
bone. These are closed fractures or comminutions
(crushing or compression injuries) that involve the
socket walls in the case of alveolar process fractures.6
The fracture or loss is generally seen in conjunction
with tooth luxation, and usually occurs when an exter-
nal force impacts directly on the face, especially in the
case of forceful blunt trauma and slapping. There is
often gingival laceration in a corresponding position
and lateral alveolar bone fracture when damage
occurs.7 Radiographic findings can show total displace-
ment of the teeth and obvious fracture lines.
However, the health of the teeth can affect the out-
come of the injury. Internationally recognised risk fac-
tors, such as diabetes mellitus and cigarette smoking,
could result in periodontal disease8,9 which would
weaken the defence capacities of the teeth, rendering
them more susceptible to injury. For people suffering
from periodontal disease, traumatic dental injuries can
be caused by slight violence. Therefore, forensic practi-
tioners should also consider the victim’s general health
when analysing the manner and outcome of traumatic
dental injuries. In this case, the woman’s medical his-
tory did not refer to her dental condition before her
traumatic dental injury, so it was difficult to ascertain
whether she had periodontal disease. However, there
4 Medicine, Science and the Law 0(0)
was no radiological evidence of dental, dental pulp or
periodontal disease, or of alveolar bone osteoporosis.
The crux of this case was the detection of alveolar
bone and alveolar process fractures. Currently, the
most common auxiliary examinations used in the
dental department are radiological technologies such
as X-rays, cone beam computed tomography (CBCT)
and MSCT. X-ray imaging, including dental film and
panoramic imaging, is two-dimensional and thus could
not resolve this case because the images overlap.
Limited CBCT scanners have recently become avail-
able in orthodontic practices, and have the advantages
of lower cost, smaller scanner size and lower radiation
dose compared to MSCT.10 However, CBCT is not as
widely used as MSCT in most areas of China. MSCT
has superior advantages in analysing the cause of the
injury by improving the detection of minor fractures
and revealing the bone’s morphological characteristics.
It is effective to use a combination of axial and recon-
structed imaging in the diagnosis of dental trauma.
The woman alleged that she had been beaten, which
led to the loss of teeth. The forensic practitioners
reviewed the images and found fractures of the
medial alveolar process and defects in the alveolar
bone which indicated that the woman’s teeth had
been subjected to external force. Additionally, there
was no loosening of the upper incisors, and she was
in a good oral health. The alleged assailant could not
provide any evidence such as teeth marks on his fingers
that could prove his innocence. Hence, the experts con-
cluded that the dentoalveolar injury in this case was
caused by criminal behaviour rather than being self-
inflicted. The result was finally confirmed by the
police following a confession by the son-in-law.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with
respect to the research, authorship and/or publication of this
article.
Funding
The authors disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: This study was supported by the National Key
Research and Development Program of China (grant
number 2016YFC0800700) and the National Natural
Science Foundation of China (grant number 81401559).
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