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The use of radiology CBCT in odontology forensic

Conference Paper  in  AIP Conference Proceedings · March 2021

DOI: 10.1063/5.0047278

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The use of radiology CBCT in odontology
forensic
Cite as: AIP Conference Proceedings 2344, 050012 (2021); https://doi.org/10.1063/5.0047278
Published Online: 23 March 2021

Andi Izham, and Elza Ibrahim Auerkari

AIP Conference Proceedings 2344, 050012 (2021); https://doi.org/10.1063/5.0047278 2344, 050012

© 2021 Author(s).
 The Use of Radiology CBCT in Odontology Forensic
Andi Izham, Elza Ibrahim Auerkaria)
Department of Oral Biology, Forensic Odontology Division, Faculty of Dentistry, Universitas Indonesia,
Jl. Salemba Raya No.4, Central Jakarta, DKI Jakarta 10430 Indonesia
a)
Corresponding author: eiauerkari@yahoo.com

Abstract. Forensic radiology exists in a specific field of medical imaging technologies that are utilized to assist doctors.
Radiology technology has increasingly been significantly advanced and developed. Cone Beam Computed Tomography
(CBCT) is one of the forensic odontology for image analysis examinations. Through CBCT radiology, evolutionary
forensic odontology has been developed extensively in many applications, such as the estimation of age through teeth, the
role of dentists in trials or forensic witnesses, analysis of bite marks, investigation of trauma cases, and determination of
sex and race. The advantages of digital CBCT radiographs include the speed at which radiographs are retrieved, radiograph
displays visible directly on a computer screen, and the application of contrast, density, sharpness, image, and color
adjustments available on the CBCT digital radiograph software. These help significantly in identification checks in forensic,
especially in skeletal and odontology cases. This article discusses the use of CBCT in forensic odontology.

Keywords: CBCT, Identification, Odontology forensic

INTRODUCTION

Identification in forensics, especially in the postmortem aspect is crucial for juridical reasons and reconciliation.
However, this process becomes very complex in the event of mass death due to terrorism or natural disasters. The
individual identification is done by comparing the antemortem and postmortem. Forensic odontology is an approach
of identifying teeth since teeth are one of the hardest tissues of humans. One of the important aspects of the
identification in forensic odontology is radiology. Dental radiology produces radiographs of dental anatomy that is
used to compare dental charts or written notes or records so that the victims identification can be easier to proceed
compared with the use of antemortem and postmortem information [1].
The identification process in forensic radiology uses appropriate techniques, which makes the identification easier.
The process can be developed by technicians or professionals with different fields of expertise and with suitable
techniques [2]. The use of radiography in identification can be assessed if antemortem records suffice. Various
morphological and pathological changes can be studied from radiography, one of which can help the identification of
crown and tooth root morphology. The identification was done by comparing the antemortem and postmortem
information obtained from the radiograph. Details of dental anatomy that can be used in identification are tooth shape
and root, number of teeth or abnormalities in the number of teeth, whether or not missing or remaining teeth, tooth
malposition, abrasion conditions, coronal fractures, alveolar bone resorption caused by periodontal disease, bone
pathology, a diastema, presence of dental caries, previous endodontic treatments, interradicular and post-intracoronal
treatment, presence of implants, extraction marks, and dentures [3].
The type of radiology used in the identification of forensic odontology is the conventional radiology, which has
been developed into cone-beam computed tomography (CBCT) technology [4]. The advantages of CBCT digital
radiography such as the processing speed of radiographic results, the appearance of radiographs that can be seen
directly on a computer screen, the repeated use of film, as well as the application of brightness, contrast, density,
sharpness, magnification and color adjustments available in CBCT digital radiograph software are considered very
facilitate the identification process [5].

The 5th Biomedical Engineering’s Recent Progress in Biomaterials, Drugs Development, and Medical Devices
AIP Conf. Proc. 2344, 050012-1–050012-5; https://doi.org/10.1063/5.0047278
Published by AIP Publishing. 978-0-7354-4086-9/$30.00

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 In this article, the author wishes to discuss the use of CBCT in the forensic odontology regarding the digital
radiology benefits of CBCT for the identification of forensic odontology, gender identification, bite marks analysis,
and trauma analysis through CBCT.

Evolution of Forensic Odontology

Keizer - Neilson defined forensic dentistry as "the branch of forensic dentistry which for the sake of justice relates
to the proper handling and examination of dental evidence and the evaluation and proper presentation of dental
findings" [6]. Forensic dentistry is a new and growing part of forensic medicine. The journey of forensic dentistry
began with Agrippina, the mother of the Nero. A Roman Emperor, in 49 CE when she recognized the color change of
the front teeth of Lollia-Paulina after her assassination [7].
Forensic odontology is a branch of forensic medicine that has now become independent. Forensic odontology is a
branch of dentistry regarding how to handle, examine through the teeth, and evaluate and expose the results of findings
relating to the oral cavity for the sake of the law and justice. The other definition of forensic odontology is a branch
of justice dentistry that aims to apply dentistry knowledge in solving the crime problem through the legal [8].
There are three important areas of activity which include modern forensic odontology. The first one is the
evaluation and examination of injuries to the jaw, mouth, and tooth tissue due to various causes. The second activity
is by direct examination to identify victims and criminals. The last one is by examining the complete tooth fragments
or remnants (including all types of dental restorations) for the last possible identification. So there are simply three
goals in forensic dentistry. One of the developments in dentistry is the use of CBCT radiology that can be applied in
forensic odontology. The evolutionary forensic odontology is developed in broad applications, such as age estimation
through teeth, the role of dentists in trials or forensic witnesses, analysis of bite marks or bite marks, investigations in
mass accidents, species determination, sex and race determination, facial reconstruction, matching dental data through
CBCT radiology [9, 10].

Cone-Beam Computed Tomography (CBCT)

The radiological images analysis using Cone Beam Computed Tomography (CBCT) is a method that is now being
increasingly used in postmortem images in forensic examinations, such as age and age examination, virtopsy
examination (non-invasive postmortem examination), and detecting the location of foreign bodies. The advantages of
CBCT compared to projection images are the excellent in a more detailed anatomical description, objects, and also
the paths that look good without being affected by the projection angle. Most of this analyzes are carried out in
morgues or laboratories, but they are increasingly being used in the field analysis. There has been an increase in the
use of CBCT for postmortem examinations in recent years with decreased costs. However, the disadvantage of medical
CBCT is the difficulty in accessing its use because CBCT is not the most practical option that can be used in all
forensic cases [2, 11].

Dental Radiology in Odontological Forensic Identification

Since the discovery of X-ray by Wilhelm Conrad Röntgen, the technology was further developed to digital
orthopantomography, which modern radiology allows visualization of the jaw and related structures as a single
radiograph for identification. Furthermore, dental radiographic panoramas provide the only regularly updated and
"truly reliable identity card" for radiographic comparisons. A comparison of teeth using radiographs for identification
purposes is considered to be accurate and reliable. Dental radiographs for identification purposes were discovered in
1943. Since then dental radiographs have been widely used in the identification process. Periapical intraoral
radiographs with parallel and bisection and bitewing techniques are two of the most commonly used intraoral
radiographic techniques in the identification process to produce postmortem radiographs [12].
In the identification of conventional dentistry, the use of radiology has been widely used due to the anatomical
details as well as comparisons of skeletal landmarks in the antemortem and postmortem records. Concerning the
antemortem and postmortem records, forensic odontologists can identify and determine the ethnic groups, the type of
skin color, and the oral cavity for human identification based on the characteristics obtained. Forensic odontologists
need to take radiographs of bearing teeth in the area to facilitate identification, especially in the event of a mass disaster
[13].
Dental radiography plays an important role as a source of information in collecting victim data and as forensic
evidence. These notes are very important during the individual identification, postmortem profiles, and the estimated

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age of the victim. Currently, dental radiographs are very important to help comparing the antemortem and postmortem.
Radiographic data is very helpful in providing objective evidence of an individual about anatomic conditions and
dental care. Most individual identification cases use radiographic evidence from dental data such as restoration,
endodontic treatment, crowns, extraction marks, and others. Through these comparisons, it can be seen that dental
radiographs can distinguish individuals [14].

CBCT Radiology in Forensic Examination

The CBCT radiography has been widely used in dentistry for clinical purposes. The application of CBCT for hard
and soft tissues in the body, especially facial bones and teeth, allows for detailed 3-dimensional images. In a corpse
identification, the benefits of post-mortem computed tomography (PMCT) are for triage of corpse bags by allowing
examination of corpses without the need to open corpse bags and will later produce an overview of the condition of
the teeth in the corpse [15].
Another advantage of the CBCT machine is that they are easy to operate and the placement of the machine only
requires a small space. The protection needed in using CBCT is not that much compared to others. The installation of
CBCT does not require specific infrastructure accommodation, and at the initial installation is very minimal and easy,
especially in units that can be removed and reassembled. In the operating room the unit can be stored and placed
according to conditions. It only takes a little training to operate this tool as it is designed for specific purposes. In
almost all clinical conditions, to avoid or minimize the use of specialized radiology operators, an assistant or a doctor
is the operator of the device. This is also a consideration in reducing funding at the clinic. [16, 17].

Use of CBCT Radiology in Sex Identification

The maxillofacial forensic radiology is a very important area in identifying individuals, especially in natural
disasters, criminal case investigations, burnt bodies, aircraft accidents where victims are difficult to identify. In
humans, there are various structures in the maxillofacial skull that can the support identification primarily of the
identification of individual gender, such as the sinus and nasal septum. The use of CBCT radiology in sex identification
by looking at the sinuses and nasal septum can be more beneficial because the images seen can be constructed 3-
dimensionally [18].
Bangi et al. compared the size of male and female sinuses using CBCT, and reported that the maxillary sinus is
significantly larger in men than women. This research measured the dimensions of mediolateral (ML), superoinferior
(SI), and anteroposterior (AP) of the maxillary sinus on CT in 100 patients [19]. Shahnaz S. et al. also reinforced the
idea, mentioning that the overall value of the parameter was significantly greater in males compared to females with
right height (90.0%) and left height (83.3%) being the best predictors [20]
Akhlaghi et al. in anthropometric studies also used the CT scan radiology for the diagnostic value of the maxillary
sinus for sex determination in adults in Iran. The sinuses distinguished between men and women regarding the
maximum height, maximum width, maximum diameter of the anterior-posterior sinus and the maximum distance
between the right and left maxillary sinuses. The result is a greater value obtained by the male maxillary sinus
compared to women, while the age group of 50 years is not recommended since it is not enough to consider sinus
parameters for sex identification [21]. Meanwhile Tejavathni Nagaraj et al. they identified individuals using the size
of the frontal sinus and nasal septum pattern. The results were similar to studies using the maxillary sinus, namely the
frontal sinus and nasal septum, which are larger in size than men [18].
Amin, on osteometric assessment of the various morphological properties of the mandible for sexual dimorphism
in Jordan used CBCT radiology to see in the 3D view for each mandible, where measurements were made of nine
parameters (ramus height, right and left coronoid height, lower jaw length, gonial angle, intergonial width,
intercondylar width, mental and mandibular foramen) the results were male gender had a higher score and a lower
score for the female gender [22].

Bite Mark Analysis via CBCT

The bite mark analysis plays an important role in forensic investigation and identification. Bitemarks are signs
created by teeth, either from oneself or from other people's bites. Bite marks and patterns are characteristics of each
individual and mostly seen in the context of sexual violence, murders, and child abuses. The evidence of bitemarks is
often found on the bodies of living people, dead people, and objects surrounding the crime scene. Victims often notice

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bite marks on the face, neck, arms, breasts, legs, waist, genitals in women, and other objects such as apple food,
chocolate, and cheese so that they can be more easily analyzed when identified [23].
Sachidanand et al. analyzed bite marks in students using 3D CBCT for reconstructions, the bite patterns of the
students were made on apples. A very significant analysis was better using CBCT radiology in the identification of
bite patterns than in the usual analysis [23]. Marques J et al. also support the prior results, using CBCT for the analysis
of the relative density of bite marks on food ingredients such as chocolate, cheese, apples, gum, pizza, and tarts. Using
CBCT pictures, the analysis can be very accurate, especially for the pattern of bitemarks, and matched to the previously
obtained dental model [24].

Trauma $nalysis through CBCT

Over the past 10 years, the post-mortem computed tomography (PMCT) has developed into a tool for routine work
at more and more forensic medical institutes throughout Europe and the world. The PMCT analysis for postmortem
autopsy is very useful when identifying trauma cases in the skeleton. Furthermore, the analysis has the potential to be
a valuable tool in postmortem individual data. Helemann et al. the use of CT in malpractice investigations, which
found that some cases were judged to have suspected errors during treatments. This proved the role of CT in an
investigation, which is very helpful in solving a case [25]. In a review by Giorgetti et al. the role of radiology in the
investigation of gunshot wounds using PMCT can provide an overview of the results of changes in tissue structures
in gunshot wounds in homicides. The role of the forensic pathologist is included in the investigation so that
observations are better and more accurate [26].

CONCLUSION

Forensic radiology requires enhanced radiographic features to describe lesion details or unique anatomy on
postmortem radiographs. The current use of digital radiology such as CBCT provides a widely used means of assisting
postmortem images in forensic examinations, including determining and identifying biological aspects (i.e. age and
sex examination). The advantages of CBCT digital radiography include imaging directly on the computer screen and
customization applications such as contrast, brightness, density, sharpness, magnification and colors. The increased
spatial resolution in skeletal and dental features is also one area of strength for CBCT within the scope of forensic
odontology.

ACKNOWLEDGEMENT

Financial support from the University of Indonesia to EIA is gratefully appreciated. The authors would like to
express sincere thanks to Muhammad Garry Syahrizal Hanafi for the language translation.

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