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Journal of Dental & Oro-facial Research Vol 13 Issue 02 Aug 2017 JDOR

CBCT - The Newfangled in Forensic Radiology


Sujatha S.1, *Rizwana Azmi S.2, Yashodha Devi B. K.3,
Shwetha V.4 and Pavan Kumar T.5
*Corresponding Author Email: rizwanaazmi@gmail.com

Contributors: Abstract
1Professor and Head, 2 Post Forensic radiology has a lot of scope in human identification, it acts as vital evidence
Graduate 3Senior Professor, for antemortem and postmortem records and assists in identifying the person, age,
4,5Assistant Professor , Department
gender, race, etc. This paper reviews the different radiological techniques using
of Oral Medicine and Radiology,
Faculty of Dental Sciences, M.S. Cone beam computerized tomography (CBCT) and advances available for
Ramaiah University of Applied successful identification of the deceased.
Sciences, Bengaluru-560054
Keywords: Forensic Odontology, Cone Beam CT, Age Estimation, Sex
Determination, Pre and Post Mortem Data

Introduction
Forensic science deals with the identification of review we have discussed various radiological
the dead which depend largely on the techniques and new developments available for
preservation of soft-tissue components of the successful identification of the dead, cause of
body and cannot be used if the remains are burnt, death, for medico legal purposes and also
decomposed, mutilated, and destroyed. In the anthropological research.
human body, teeth and facial bones are resilient
and withstand the decompositional/destructional Age estimation of living and deceased individuals
forces well even under extreme forces and/or is imperious in both forensic and clinical work.
temperature variations.1 Teeth are particularly There is increase in skeletons and unidentified
useful in determining the gender where there is dead bodies globally due to instances such as fire,
nothing to suggest the individual's identity.2 As air crash, natural calamities, building collapse,
radiographs are able to capture characteristic railway accidents or manmade incidences like
anatomical features, they can be auxiliary tool in murder, bomb blasts or mass firing etc., hence it
identification of the dead and in solving medico- is essential to determine the identity of the dead
legal cases. Radiographic identification person for legal, criminal and ethical
technique is efficient, comparatively easy, perspectives.3 In 1950, Gustafson was first to
records can be obtained in both living and dead, introduce a scientific method for age estimation
and they are economical than DNA technology. using six age-related changes in tooth structure,
Radiographs of skull and teeth have been mostly such as secondary dentine formation, periodontal
used for forensic identification as these structures recession, attrition, apical translucency,
are the strongest and highly resistant to trauma cementum apposition and external root
and decomposition. With the advent of CBCT, resorption3,4. Matsikidis et al. described that the
which shows greater precision to diagnose trauma characteristics of Gustafson method (except
and pathologies of the cranium, the number of apical translucency) using dental radiographs.
image requests by forensic professionals has Subsequently, numerous studies 3,5, 6, 7 have been
increased, making possible the use of this conducted with different dental radiographic
technique to support human identification by techniques employing the characteristics studied
comparing images of significant anatomical by Gustafson to aid in age determination.
structures of the cranium. So, in the present

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Journal of Dental & Oro-facial Research Vol 13 Issue 02 Aug 2017 JDOR

1. Age Estimation by three-dimensional evaluation of CBCT


images. There was an inverse and significant
In children, age can be estimated based on the correlation between age and the pulp-to-tooth
tooth eruption sequences and the developmental volume ratios in males and females, with a
stages of teeth, and henceforth it is a relatively stronger correlation in males than females
simple; however, estimation of age in adults after indicating that gender affects the formula used to
maturation of third molars is a matter of estimate age, consistent with the results reported
controversy. To date several techniques have by Tardivo et al 9,10. It was reported that
been explained to determine age in adult simultaneous use of two maxillary canines are
populations based on morphologic and structural better and stronger in estimating age compared to
changes in teeth. the use of four human canine teeth, indicating the
higher capacity of maxillary canines, compared
1.1 Pulp Tooth Ratio to mandibular canines.9
Secondary dentin deposition occurs throughout
life on all the pulpal walls, resulting in a
continuous decrease in the volume of the pulpal
cavity of teeth. Therefore, age estimation in
adults can be carried out by measuring the
amount of decrease in the size of the pulpal cavity
(fig: 1). In 2004, Cameriere et al,8 for the first
time conducted a preliminary study to evaluate Fig. 1 Pulp tooth
the variations in pulp/tooth area ratio (AR) as an
indicator of age estimation. Maxillary canines are 1.2 Spheno-Occipital Synchondrosis
usually chosen as they are the single-rooted teeth Analysis of ossification points plays a
with the largest pulp area, normally the oldest considerable role in forensic age estimation.
teeth and undergo less wear as a result of diet than Spheno-occipital synchondrosis, an important
posterior teeth, and thus the easiest to analyze. growth point on cranial base, provides significant
The smaller size of the other single-rooted teeth information about age estimation through its late
leads to less clear measurement of the pulp/root stage ossification nature. Spheno-occipital
ratio. In multi-rooted teeth, pulp changes are clear synchondrosis is a cartilaginous union between
in the canal but less evident in the root. In the body of the sphenoid and the basilar part of
addition, in adult subjects, molars and premolars the occipital bone. This closure usually occurs
are often missing or damaged as a result of wear. about 2 years earlier in girls than in boys; this
The CBCT imaging technique exhibits proper may be attributable to the early growth process or
accuracy to determine the internal anatomy of maturity of girls 11,12 . Shirley and Jantz13,
teeth.9 Therefore, this technique can estimate age observed the fusion of synchondrosis in females
by measuring the amount of decrease in the occurs 4 years before males, whereas Bassed et
volume of the pulpal cavity of the teeth. al.13(fig:2) in a recent study, found no significant
differences in progress of fusion between males
In a preliminary study with the use of CBCT and females after the age of 16 years. Based on
imaging technique, the pulp-to-tooth volume the direct inspection of the ectocranial site of the
ratios were calculated in single-rooted teeth with synchondrosis the fusion of basilar synchondrosis
the use of primitive custom-made software reflect sexual dimorphism and that complete
program and a formula was designed to estimate fusion at the spheno-occipital synchondrosis
age. It was reported that it is possible to calculate occurs well before 25 years of age corresponding
pulp-to-tooth volume ratios in living individuals closely with the onset of puberty 11.Cranial base

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Journal of Dental & Oro-facial Research Vol 13 Issue 02 Aug 2017 JDOR

synchondroses essentially contribute to the


craniofacial development and more so to dento-
alveolar development and is of significance in
orthodontic practices. Growth at the spheno-
occipital synchondrosis carries the maxilla a) b) c) d)
upward and forward relative to the mandible
resulting in an increased facial height and depth.
Rapid maxillary expansion is recognized to cause Fig. 2 Mid-sagittal CBCT images representing
a minor widening of spheno-occipital the spheno-occipital synchondrosis fusion stages.
synchondrosis in young persons.14 (a) Stage 0, unfused. (b) Stage 1, fusing
endocranially. (c) Stage 2, fusing ectocranially.
Sinanoglu et al 15 in their CBCT study on (d) Stage 3, complete fusion
Spheno-occipital synchondrosis among 7 to 25
year old individuals found the mean ages for
2. Sex Determination
complete fusion (Stage 4) were 18 and 20 for
females and males, respectively. Results showed Sexual dimorphism is one of the integral aspects
that CBCT can be a method of choice for age in personal identification of an unknown cadaver
estimation for above mentioned age group and thus narrowing down the identification heading
can also add the value for determining age of 18 towards the correct possibility. Bones that are
years, which affects the legal decision in most of conventionally used for sex determination e.g.
the counties. In a retrospective CT study on pelvis, skull & long bones etc., are often
spheno-occipital synchondrosis fusion16 among recovered either in a fragmented, incomplete or
the Turkish population of 10 to 25 years, it was commingled state especially in catastrophes like
found to be totally open at the mean (SD) age of explosions, warfare, natural calamities, and other
11.5 (1.5) years in males and 10.7 (0.8) years in mass disasters like aircraft crashes, making
females and it increased with age. Fusion starts identification and sex determination not a easily
achievable task. It has been reported that the
approximately 2 years earlier in women than in
accuracy rate of sex determination is 100% from
men, and the process of fusion completes at the
a skeleton, 98% from both the pelvis and the
age of 17 years in both sexes. Consequently, skull, 95% from the pelvis only or the pelvis and
analysis of spheno-occipital synchondrosis fusion the long bones, 90–95% from both the skull and
degree in use with 1-mm computed tomography the long bones and 80–90% from the long bones
images will be helpful for age estimation between only.
11 and 17 years 5. Suture closure may possibly be
affected by nutritional and health status of the Subsequent to the pelvis, skull is the most easily
deceased, exercise and physical activity of an sexed portion of the skeleton, the craniofacial
individual, allometric growth, general growth and structures being composed largely of hard tissues,
development of the bones, and to some extent by which is relatively indestructible and denser
race. Because of the wide variability in the age of bones like e.g. the maxillary sinus, mandible etc.,
closure as presented in various previous studies it that are often recovered intact can be applied for
sex determination.
just provides a general pattern at various age
levels. Thus, it acts as a guide rather than a Anthropometric measurements of these structures
determining feature in age estimation in the on CBCT images can be used for assessing the
presence of other, more determinate and accurate, sexual dimorphism.17
clues16.

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Journal of Dental & Oro-facial Research Vol 13 Issue 02 Aug 2017 JDOR

2.1. Mandibular Measurements had a forward rotation in mandible ,with the


gonial angle values in females higher than in
Mandible plays a vital role in sex determination males. Taleb et al.20
as it is one of the most dimorphic, largest, and
strongest bone of skull. It very resilient due to
presence of a dense layer of compact bone and
hence remains well preserved than many other
bones. In this respect, the availability of plentiful
antemortem orthopantomograms may be of great
value in studying and developing population
specific standards for accurate sex and age
estimation. Dimorphism in mandible is reflected
in its shape and size meanwhile male bones are Gonial Angle and Inter-Gonial
generally bigger and tougher in as compared to Minimum ramus distance
female bones. The relative development (e.g.: breadth
size, strength, and angulation) of the muscles of
mastication is known to influence the expression
of mandibular dimorphism since there is a
difference in the masticatory forces exerted for
males and females.18

A study by Magdy et al17 on Egyptian population


using spiral CT, six mandibular measurements
showed the overall predictive accuracy as good in
both males and females. Mandibular Inter-Condylar Distance
measurements like ramus length, gonion- Fig. 3 Mandibular Measurements
gnathion length, minimum ramus breadth, gonial
angle, bicondylar breadth, and bigonial breadth 2.2 Foramen Magnum (FM)
(fig:3)can be used in sexual dimorphism and have
very good sensitivity which was substantiated by Cranial base is relatively thick/compact and
the study done by Oliveira et al., 19 The success protected due to its anatomical position, thus this
of estimating the sex was 92.96% for females and area of the skull tends to withstand both physical
85.45% for males. Taleb et al.20 in their study insults and inhumation relatively than many other
revealed that males had statistically significant areas of the cranium, thus preserving this area for
higher mean values regarding all the mandibular forensic examination. Various studies have found
ramus linear measurements than females which is statistically significant differences between males
in agreement with Saini et al21 who found and females for foramen length, breadth, and area
22, 23, 24
significant sexual dimorphism with an overall . Raghavendra Babu et al 23in their study
accuracy of 81%. Usually, the overall size and found that predictability of FM in the
bone thickness of the male skeleton is greater determination of sex as 65.4% , whereas Uthman25
than that of the female; which is related to sex, found an overall accuracy of 67% respectively.
nutrition and physical activity .Normally males Higher mean values of length, breadth,
have greater masticatory force than females that circumference (fig. 4) and area of FM was found
influences the bone size. As regards to gonial in males than in females and the most reliable
angle, it was found that females had a downward indicator to predict the gender was FMA
and backward rotation in mandible while males (Foramen Magnum Area). Considering the high

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Journal of Dental & Oro-facial Research Vol 13 Issue 02 Aug 2017 JDOR

sex predictability of FM dimensions, the foramen identification using cone beam computerized
measurements can be used to supplement other tomography and concluded that frontal sinus can
sexing evidence available, so as to precisely be accurate tool for gender determination.
ascertain the sex of the skeleton. Significant differences were observed in the
frontal sinus measurements between males and
females supporting the dimorphic features of
frontal sinus in humans with 67.59% accuracy
rate. Sai Kiran et al.29 Therefore frontal sinus
index can be used as a reliable tool in sex
determination.

2.4 Maxillary Sinus (MS)

Maxillary sinuses are air spaces, located in the


maxillary bone and can be in various sizes and
Fig. 4 Foramen Magnum Measurement: shapes. They appear at the end of the second
length, breath and circumference embryonic month and reach their mature sizes at
the age of about 20 years, when the permanent
2.3 Frontal Sinus (FS) teeth fully develop and tend to stabilize after the
second decade of life. MS remains intact even
Frontal sinus is one of the para nasal sinuses of when the skull and other bones may be badly
the skull which is a primary tool for personal disfigured, and hence it can be used in forensic
identification, but the significant dimorphic identification. The radiographic images of
characteristics in its measurements can also be maxillary sinuses provide adequate
used for sex determination as well. The frontal measurements for use in morphometric forensic
sinuses can provide significant evidence for analysis that cannot be approached by other
forensic identification. The irregular forms of the means.
frontal sinuses, initially observed in anterior-
posterior radiographs have been extensively It has been reported in previous studies that the
studied since the first assumption that these are maxillary sinuses are significantly larger in males
found to show an individual pattern like than in females. The computerized tomography
fingerprints. It has been proven that there are not measurements of maxillary sinuses may be useful
two people with the same frontal sinuses, even to support sex determination in forensic
being monozygotic twins.6 The frontal sinus medicine30,31. In a CBCT study, comparison
index (FSI) (height/width ratio) as a maturity between male and female groups showed that the
indicator or tool for sex determination 26. The female group had statistically significant lower
points analyzed on lateral cephalometric values for both the right and left maxillary sinuses
radiographs are the Nasion - Sella (NS) line as regards the width, length and height
horizontally. The studies done by Patil A and dimensions (fig.5).
Ravinkar A V26 using 2 dimensional
Cephalometric radiographs. It was also found that the maxillary sinus height
is the most reliable discriminant parameter that
Benghiac A.G. et al 27 in CBCT study concluded could be used for the purpose of sex
that the FSI can be used as a reliable tool for sex discrimination. S.S. Tambawala et al.32 This
determination. Motawei et al.28 in their study on findings are in consensus with the results of the
frontal sinus as a system for personal CBCT study by Paknahad et al. who found the

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Journal of Dental & Oro-facial Research Vol 13 Issue 02 Aug 2017 JDOR

accuracy rate of sex determination at 78% in 2.5 Mastoid Process


females and 74% in males with overall accuracy
of 76%. In the skull, the mastoid bone is tough and strong,
hence resistant to physical damage. The mastoid
region is favorable for sex determination for two
reasons, the compact structure of the petrous
portion and its protected position at the base of
the skull. So it is commonly found remained
intact in skeletons of very old age. Even though
skull is fragmented, the mastoid stays intact.
From the size of mastoid sex can be presumed i.e.
a larger mastoid suggests male sex and a smaller
mastoid suggests female sex.33 Study done on
human skull by Swati Shah and Pratik Patel 33
showed that mastoid process had significant
craniometric difference between male and female
a) Measurement of width (the greatest mastoid triangles.
distance from the most medial point of the
sinus to the most lateral point of sinus) and Females have smaller mastoids than males,
length (the largest distance from the most greater mean mastoid size values was found
anterior point to the most posterior point of among males (114.5 mm3) than females (89
sinus) of left and right maxillary sinuses in mm3). This finding could be attributed to the fact
axial view of CBCT image that female skulls preserve a juvenile type of
small size mastoid process, whereas, the larger
size mastoid of males could be ascribed to the
attachment of more vigorous musculature, such
as the sternocleidomastoid muscle. This is
confirmed by the relatively rougher and more
irregular surface of the mastoid process observed
in males than in females. Moreover, in male
subjects, the stronger muscles attached to their
mastoids had affected this boney process to
maintain an upright position, i.e., a relatively
more vertical and less medially inclined in
direction which is more significantly manifested
in males than in females as indicated by the
greater intermastoidale distance (IMD) and
b) Measurement of the maximum distance greater distance between the lateral surfaces of
from the lowest point of the maxillary sinus the left and right mastoids (IMLSD) in males than
floor to the upper most point of the roof
in females; and greater mastoid flare (MF) and
defined as the height of left and right
maxillary sinuses in coronal view of CBCT greater mastoid medial convergence angle
image (MMCA) in females than in males. Amin et al 34
Mastoid pnuematization of temporal structures of
the temporomandibular joint (TMJ) and their
Fig. 5(a,b) Gender Determination: Maxillary
relationships with age and sex using CBCT had
sinus Measurements

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Journal of Dental & Oro-facial Research Vol 13 Issue 02 Aug 2017 JDOR

the contradictory result’s, in study done by Methodology and Present Status. Open
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