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Forensic odontology with digital technologies: A systematic review

Shinpei Matsuda, Hisato Yoshida, Kiyokadzu Ebata, Ichiroh Shimada, Hitoshi

Yoshimura

PII: S1752-928X(20)30111-6
DOI: https://doi.org/10.1016/j.jflm.2020.102004
Reference: YJFLM 102004

To appear in: Journal of Forensic and Legal Medicine

Received Date: 9 January 2020

Revised Date: 18 June 2020
Accepted Date: 21 June 2020

Please cite this article as: Matsuda S, Yoshida H, Ebata K, Shimada I, Yoshimura H, Forensic
odontology with digital technologies: A systematic review, Journal of Forensic and Legal Medicine
(2020), doi: https://doi.org/10.1016/j.jflm.2020.102004.

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Forensic odontology with digital technologies: A systematic review

Shinpei Matsuda1, Hisato Yoshida1, Kiyokadzu Ebata2, Ichiroh Shimada3, Hitoshi Yoshimura1

1. Department of Dentistry and Oral Surgery, Unit of Sensory and Locomotor Medicine

Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan

2. Department of Radiology, University of Fukui, Fukui, Japan

3. Department of Forensic Medicine and Human Genetics, Faculty of Medical Sciences, University

of Fukui, Fukui, Japan

Address correspondence and requests for offprints to Dr. Shinpei Matsuda

Department of Dentistry and Oral Surgery, Unit of Sensory and Locomotor Medicine Division of

Medicine, Faculty of Medical Sciences, University of Fukui

23-3 Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui 910-1193, Japan

Tel: +81-776-61-8409, Fax: +81-776-61-8128

E-mail: shinpeim@u-fukui.ac.jp

Funding: This work was supported by The Fukui Bank, Ltd. in an industry-university cooperation.

Declaration of interest: The authors declare no conflicts of interest associated with this manuscript.
Abstract

Postmortem dental examinations play an important role in individual

identification. In forensic odontology, individual identification is based on a traditional

visual comparison of the antemortem dental record and dental radiographs with those

obtained by postmortem examinations. Digitization in forensic odontology has recently

started. The aim of this systematic review was to reveal the progress in forensic

odontology by using ante/postmortem information obtained by digital technologies.

Thirty-six eligible studies were included. No methods with digital technology have been

accepted worldwide because of various factors such as expensive special equipment and

the cost of other components. Further research should be conducted and progress should

be made in the field of forensic odontology along with the progression of general digital

technology.

Keywords: forensic odontology; digital technologies; dental imaging examination;

tooth; orofacial soft tissues

Abbreviations

PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses,

PICOS = Population-Interventions-Control-Outcomes-Study design,

AXIS tool = Appraisal tool for Cross-Sectional Studies, CT = computed tomography,

CBCT = cone-beam computed tomography

1. Introduction

Forensic medicine has made an important contribution historically, and

research in this field must continue.1 Recent progress and the popularization of digital

technology, including computers, have played an important role in the development of

medical and dental treatment, and progress has especially been made in the diagnosis

and visualization of treatment targets. These technologies will also contribute to clinical

practice and the development of forensic medicine and forensic dentistry. Postmortem

examinations, including pathological and imaging examinations, can provide important

information for investigations regarding the cause of death of an individual.

Furthermore, postmortem examinations might play an important role in the individual

identification of unidentified bodies. Progress made in the processing technology of

antemortem and/or postmortem imaging will contribute significantly to the

aforementioned issues, especially in cases of disasters, accidents, crimes, and so forth.2

Dentition in this domain is unique because it consists of a combination of

decayed, missing, and filled teeth.3 Additionally, teeth are resistant to fire, extreme

temperatures, and decomposition.3 Thus, postmortem dental examinations can play an

important role in individual identification, even under extreme conditions. In forensic

odontology, individual identification has essentially been based on traditional visual

comparisons of antemortem dental records and radiographs with those obtained by

postmortem examinations; this remains the case today.4 Moreover, such traditional

dental comparisons are less useful than other techniques because they lack a standard

number of concordant points of similarity between antemortem records and postmortem

examinations that would aid in individual identification.3

Finally, the development and analysis of traditional written dental records are
subjective.5 As such, these analog methods are vulnerable to oversights and/or mistakes

in the individual identification of unidentified bodies.5 The authors considered that one

means to improve the various analog methods for dental individual identification would

be to digitalize and unify them. With the development of digital and communication

technologies, these methods could become universal through the development of big

databases and, when compiled in this manner, could make a significant social

contribution in preparing for individual identification after mass disasters (e.g., severe

flooding, earthquakes, tsunamis, and volcanic eruptions).6

Although forensic odontology based on digital technologies has progressed, no

review is available. Because digital technologies have made rapid progress, the authors

considered that assessment of the recent progress in this area would be a contribution to

the literature. The aim of this systematic review was to evaluate the progress in forensic

odontology, by using ante/postmortem information obtained by digital technologies in

the past 10 years.

2. Materials and Methods

This systematic review was performed according to the Preferred Reporting

Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.7

2.1. Eligibility criteria and exclusion criteria

Eligibility criteria were established by using the

Population-Interventions-Control-Outcomes-Study design (PICOS) strategy as follows:

P: humans of all ages and any sex; I: ante/postmortem examinations using digital

technologies; C: not applicable, O: individual identification; and S: cross-sectional,

retrospective studies.

The exclusion criteria were as follows: (1) case report, case series, controlled

clinical trial, narrative review, systematic review, and letters to the editor; (2) animal

experiment trial; (3) full text was unavailable; and (4) text in languages other than

English.

2.2. Information sources and search strategy

An electronic systematic literature search was conducted by using PubMed

(National Library of Medicine, National center for Biotechnology Information) and

Scopus. Because digital technologies have made rapid progress, literature published

between 2010 and 2019 was searched to assess the progress in this area. The literature

search strategy is presented in Table 1. The final electronic searches were performed on

February 29, 2020.

2.3. Study selection

S.M. performed the initial literature evaluation and selection. Next, H.Y.

evaluated and approved that literature. The study selection process comprised the

removal of duplicates, screening of titles and abstracts, and reviewing of full texts.

Disagreements between reviewers were resolved through discussion and consensus.

2.4. Risk of bias

Considering the problems of quality and the risk of bias, the authors evaluated

studies based on appraisal tools to assess the quality of cross-sectional studies (AXIS

tool).8 The AXIS tool comprises 20 components and can be used to aid the inclusion of
cross-sectional studies in systematic reviews.8

3. Results

3.1. Study selection

By performing an electronic literature search using PubMed and Scopus, 165

texts were extracted (Figure 1). Forty-one duplicates were removed, and 71 texts were

excluded on the basis of title and abstract. Fifty-three texts were assessed for eligibility,

and 36 eligible texts were included in this study.

These 36 eligible texts were divided on the basis of the analysis target as

follows: (1) studies of dental imaging examination, (2) studies of teeth, and (3) studies

of orofacial soft tissues. Seventeen texts were studies of dental imaging examination,9-25

7 texts were studies of teeth,26-32 and 12 texts were studies of orofacial soft tissues.33-44

The details of these studies are described below.

3.2.1 Studies regarding dental imaging examination

The analyses of information on permanent and primary teeth, such as pulp area

size, tooth length, and root anatomical form, were performed by using digital imaging

and/or data processing software in some studies, and these studies reported that the

results were useful for individual identification and age estimation.9-12 Additionally,

Khalid et al. investigated the dental radiographic image appearances stored in a digital

data bank system of teeth with a single root canal and teeth having received endodontic

treatment; they reported that those images had highly specific morphological features.13

Additionally, some texts reported that the location of the mental foramen, the ramus

height and width, and the angle of the mandible measured in digital panoramic
radiography and lateral cephalography provided useful information that aided in the

estimation of an individual’s gender and age.14-20 Ohtani et al. reported radiographic

imaging examination methods by using portable and rechargeable devices for dental

individual identification and suggested that examination in the prone position was also

acceptable with that method.21

Franco et al. verified the feasibility of dental identification from postmortem

full-body computed tomography (CT) imaging and concluded that postmortem

full-body CT images could be a valuable tool in individual dental identification

procedures.22 By contrast, the examiner would have to consider the lack of ability to

differentiate between dental restorative materials and the presence of significant streak

artifacts in those CT images.22.23 Sakuma et al. applied the fusion function of imaging

analysis software to compare the anatomical relationships of teeth root apexes between

postmortem CT and digital dental radiographs and reported that those methods could

make it possible to compare images taken with different modalities.24 The recent spread

of dental cone-beam computed tomography (CBCT) has likewise led to advances in

forensic dentistry. For example, Trochesset et al. reported that it is possible to construct

intraoral-like images from CBCT images and to have high reproducibility and

superimposition function, which could be useful components of postmortem

examinations, especially when antemortem images and records are not available.23

Finally, Pushparaj et al. reported that image processing algorithms developed

by data processing software using dental radiographs could be useful because this

method is simply constructed by tooth shape extraction and matching techniques.25

3.2.2 Studies regarding teeth

 A study to evaluate the correlation between age and teeth fluorescence, a

phenomenon defined as the absorption of UV light by natural teeth by using digital

software, and reported that it was correlated with age and had a similar and stable

behavior from 7 to 20 years.26 The usefulness of the digital analysis of dentin

translucency, the occlusal groove patterns of the molars, and the superimposition

technique of digital photographs and dental casts were reported.27-29 Johnson et al.

reported that advances in 3D image scanning technology and 3D printers have made it

possible to reconstruct digital teeth.30 Moreover, Franco et al. and Corte-Real et al.

reported that the three-dimensional imaging reconstruction technique was useful for

bitemark analysis.31, 32

3.2.3 Studies regarding orofacial soft tissues

Cheiloscopy, namely, “lip prints,” has been analysed by using digital software,

but the association between the types of lip grooves and the sex of individuals were

controversial.33-35 Loganadan et al. investigated lip prints in Indonesian children and

concluded that further studies should be conducted to reveal the hidden potential of the

method and to create a comprehensive database.36

Although Venkatesh et al. studied ”Tongue Prints,” and this analysis method

requires further research.

Palatoscopy, or palatal rugoscopy, is the study of palatal rugae for individual

identification, and some texts reported the usefulness of palatal rugae analysis that used

digital software, digital scanners, and three-dimensional imaging processing

methods.38-42 Moreover, Mohammed et al. and Syed et al. reported that the

superimposition function and quick response code conversion using a dental cast model
could be applied for palatal rugoscopy.43, 44

4. Discussion

Recent advances in digital medical and dental technology have influenced the

development and application of forensic odontology. In particular, the digitization of

dental imaging examinations has facilitated image analysis, in particular through the use

of computers that enable the measurement of various anatomical structures. It has also

made maintaining information in digital databases and moving images easier. This study

reviewed the literature on the application of such techniques in identification practices

by estimating the age, gender, and height of individuals by using information such as

tooth crown shape and width, size of the pulp cavity, tooth length of the mandibular

third molar, conditions of root canal treatment, shape of the palatal rugae, mandibular

ramus, height, and lip prints. However, according to a review of the literature, no digital

technology is accepted worldwide in forensic odontology.

Notably, the literature reported on the application of digital technology to teeth

and orofacial soft tissue analyses for individual identification, and each study that used

digital technology also used software. Moreover, Pushparaj's text reported on the

development of image matching technology.25 Some texts reported on forensic cases

using those digital examination techniques and usefulness. 45, 46

One necessary component of obtaining useful results is ensuring the

maintenance of adequate posture in examinations for a certain period of time, especially

for panoramic radiograph examinations and cephalometric radiograph examinations.

Similarly, dental radiographic examinations require an open mouth for an extended

period of time. Because the setting of the panoramic and dental radiographic
examination position affects imaging findings, there may be cases when the results of

those examinations are not acceptable in forensic analysis. Ohtani et al. suggested that

examination in the prone position is acceptable with digital identification methods.21

Additionally, some studies reported on the assessments of the usefulness of

postmortem full-body CT images and/or CBCT in forensic odontology.22, 23 Eliášová et

al. compared CT and CBCT and reported that CBCT imaging offers fewer image

artifacts, shorter image reconstruction times, and considerably lower equipment costs.47

However, these examinations may be unsuitable for mass disasters because of the

requirement for expensive equipment on a large scale. Further research and case reports

are necessary to demonstrate the importance of forensic odontology in this domain and

to introduce these types of imaging technologies therein.

Chiam reported the possibility of serious mistakes occurring in digital dental

radiography because of the rotation and inversion function of the images by the

software; the report suggested that information for individual dental identification

should be used in combination with other evidence or circumstantial findings.48

Additionally, postmortem examinations must be held in a secure fashion and at a

distance that ensures the protection of researchers from potential hazards, by practicing

in a radio-biologically responsible manner that uses optimum body-substance

precautions.49

Regarding the information on teeth and soft tissues, including lip and palatal

rugae, some studies were conducted using digital technology to assess the usefulness in

individual identification and the estimation of age and sex.26-44, 50

However, what

remains unclear is whether this tooth-related and soft tissue-related information can be

applied in the field of forensic odontology, and whether soft tissues can withstand the
various factors related to death and whether their anatomical information can be

preserved. Trismus due to postmortem stiffness is one of the problems.

Recently, the application of three-dimensional imaging processing technology

in forensic odontology was reported.31, 32, 41, 50 Wright et al. reported the usefulness of

digital photography for recording and preserving evidence, including bitemarks, in

forensic cases.51 The authors expected to make further progress in collaboration with

their digital photography technique and analysis of orofacial tissue information and

three-dimensional dental arch images reconstructed from CBCT.

Routine dental check-ups with appropriate radiography examinations would

afford a reasonable generation of broad-based national antemortem dental records,

which would provide useful information after a mass disaster or other event.6 In the

dental field, a necessary step might be to increase public awareness of these

technologies and their potential pitfalls and possibilities.

5. Conclusions

In forensic odontology, analyses with digital technologies have progressed in

the past 10 years. However, according to this literature review, no digital technology

method that is accepted worldwide in forensic odontology because of various factors,

for example, the cost and availability of special equipment. Digitization in forensic

odontology is new and gradually emerging. Further research is necessary to advance the

domain of digital technology in forensic odontology.

Declaration of interest

The authors declare no conflicts of interest associated with this manuscript.

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Figure caption

Figure 1. Flow diagram based on the PRISMA flowchart template of the search and

selection process.

Table

Table 1. Electronic literature search strategy

Database Search strategy Number of literature
 (((((forensic odontology) OR forensic dentistry) AND
PubMed digital) AND identification) AND English[Language]) 75
AND ("2010"[Date - MeSH] : "2019"[Date - MeSH])

( TITLE-ABS-KEY ( forensic AND odontology )

OR TITLE-ABS-KEY ( forensic AND dentistry )
AND TITLE-ABS-KEY ( digital ) AND
Scopus 90
TITLE-ABS-KEY ( identification ) AND
LANGUAGE ( english ) ) AND PUBYEAR >
2009 AND PUBYEAR < 2020
Highlights

This review reports the progress in forensic odontology with digital technologies.

Analytical methods for teeth and orofacial soft tissues are reviewed.

No method with digital technology is accepted worldwide.