FORENSIC SCIENCES RESEARCH

2019, VOL. 4, NO. 4, 316–330

https://doi.org/10.1080/20961790.2019.1678710

REVIEW

Forensic odontology in DVI: current practice and recent advances

a,b,c
Alex Forrest
a
Health Support Queensland Forensic and Scientific Services, Coopers Plains, Queensland, Australia; bSchool of Dentistry, The
University of Queensland, Brisbane, Australia; cSchool of Environment and Science, Griffith University, Nathan, Queensland, Australia

ABSTRACT ARTICLE HISTORY

Forensic odontology frequently plays a significant role in identification of the victims of Received 23 July 2019
multi-fatality disasters, but not in all. It depends on adequate dental remains surviving the Accepted 3 October 2019
disaster and on the availability of dental records to be successful. This paper describes cur-
KEYWORDS
rent practice in the techniques of identification in forensic odontology and outlines recent

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Forensic sciences; forensic
advances that are moving into the mainstream. odontology; disaster victim;
human identification; mass
KEY POINTS fatality; radiology; DVI
 Forensic odontology plays a key role in mass disaster victim identification (DVI) when
good-quality antemortem (AM) dental records are available.
 Images including radiographs, computerized tomography (CT) data and three-dimensional (3D)
scan data are considered more reliable AM records than written dental charts and odontograms.
 Interpretation, transcription and comparison of dental datasets are complex processes
that should be undertaken only by trained dental professionals.
 The future of forensic odontology DVI techniques is likely to include the use of 3D data-
sets for comparison.

Introduction family whose loved one will never be identified or

returned to them. The DVI process aims to provide
Following a mass casualty incident, identification of
a rational, scientific basis for the identification of
the victims may be undertaken in a disaster victim
identification (DVI) operation. Visual identification each victim to ensure that correct identification is
in mass disasters is known to have a high error rate assured. It may also seek to link fragments of vic-
[1] although it is supported by some authors [2]. tims to a previously-identified portion of a body so
However, the International Criminal Police that the most complete set of remains is returned to
Organization (INTERPOL) DVI Guide recommends surviving family and friends.
that all human remains recovered at the scene of a The foremost duty of the forensic odontologist in a
disaster should be stored pending formal identifica- DVI operation is the identification of unknown
tion and release [3]. Early visual identification and deceased individuals. This is achieved by matching
cremation or burial of victims such as happened fol- postmortem (PM) dental features of a victim with the
lowing the South Asian Tsunami in 2004 [4] should dental records of a missing person [6] and may
be resisted in such circumstances. It can lead to require estimation of the age of child victims [7, 8]. It
incorrect identifications that cannot be verified and involves the building of a PM dental profile of a vic-
it can subvert the later application of scientifically- tim by dental examination which may include physical
based identification techniques. The report of the and radiographic examination of the teeth and parad-
INTERPOL Tsunami Evaluation Working Group ental structures, computed tomography (CT) scanning
made an explicit recommendation that its DVI and three-dimensional (3 D) virtual modelling. This
Steering Committee reinforced to DVI Standing PM profile is matched with an antemortem (AM)
Committee members that the use of visual identifi- profile compiled from the dental records of a missing
cation methods in mass fatality incidents is consid- person, which may include written treatment records,
ered unreliable and almost certainly will lead to the images, 3 D datasets, casts of teeth or other dental
incorrect release of bodies [5]. An incorrect forensic items that can help individuate a person [9].
victim identification impacts two parties – those Forensic odontological comparison is one of the
who receive the wrong set of remains, and the three principal identifiers designated by INTERPOL

CONTACT Alex Forrest alex.forrest@health.qld.gov.au

ß 2019 The Author(s). Published by Taylor & Francis Group on behalf of the Academy of Forensic Science.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
 FORENSIC SCIENCES RESEARCH 317

for use in identifying the victims of a multi-casualty tsunami for example) may also impact the availabil-
incident. Its positive outcome is considered suffi- ity of dental records [16].
cient to permit personal identification without fur- It is almost axiomatic that the greatest numbers
ther support from other methods [6, 10]. of deaths from disasters are likely to occur in coun-
tries of low socioeconomic status, possibly due to
The role of forensic odontology in DVI their inability to invest in preparedness or strategies
to mitigate them [17]. In such countries, AM dental
The role played by forensic odontology in mass cas- records may be of limited availability and debatable
ualty situations is always the same: comparison of quality [16], and so the contribution that forensic
AM and PM dental profiles to determine matches odontology can make in DVI operations in those
which support identification [6]. The value of the locations or which involve nationals from such
outcome depends on two underlying assumptions: regions will be heavily influenced by these factors.
that teeth resist decomposition and relatively When good-quality AM data are available, foren-
extreme environmental conditions (which is estab- sic odontology classically identifies approximately
lished from long observation), and that every person

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60% of victims, and contributes to approximately
has a set of teeth (a dentition) which is fundamen- 30% of further identifications in collaboration with
tally and recognisably unique. other identifying methods. The usual pattern in a
The question of whether dentitions are recognis-
“classical” incident is that the early matches are
ably unique has never been answered [11], just as it
made by the fingerprints section, followed by a
has never been answered for fingerprints [12]. The
larger contribution from the dental section, with the
outcome of DNA comparison is also based on the
DNA section providing late results, especially for
probability of encountering random matches. For
children without fingerprint or dental records. The
this reason, distinctive dental restorations (fillings)
DNA section is also able to link fragments to a pre-
increase the opportunities for individuation because
viously-identified body portion. An excellent sys-
they leave artefacts that have unique sizes and
tematic review of the role of forensic odontology
shapes that result from the treatment of disease in
worldwide in major mass disasters is given by
individual teeth and they can be fabricated from dif-
Prajapati et al. [18].
ferent dental filling materials. Such restorations are
radio-opaque when fabricated from metal (dental
amalgam or metal crowns for example). Some tooth AM and PM dental profiles
coloured materials also demonstrate a level of radio-
The accuracy and completeness of the AM and PM
opacity and may fluoresce when exposed to different
dental profiles will obviously affect the outcome of
wavelengths of light [13]. Dental interventions are
any dental comparison. In general, provided suffi-
not limited to fillings alone, but may include dental
extractions, implants, prostheses such as full or par- cient dental remains are present to make construc-
tial dentures, and a range of surgical treatments. tion of a PM profile feasible, its quality is largely a
Teeth may be missing because they have failed to function of the skill, rigour and attention to detail
develop. The presence of disease or pathology of the examining odontologists. This is under the
including periodontal (gum) conditions and dental control of the personnel within the Dental Section
caries (tooth decay), the presence of tooth crowding, and explains why dental data should only ever be
or unusual arrangements of teeth in a dental arch subject to acquisition, data entry and data editing by
and the relationships between teeth in the top and experienced forensic odontologists.
bottom jaws can all add additional features In contrast, members of the Dental Section have
for comparison. comparatively little control over the quality of the
The ability of forensic odontology to add to the AM profile since it is largely reliant on the quality,
forensic identification process in a multi-fatality accuracy and completeness of the AM dental
incident largely depends on the availability and records sourced from hospitals, dental clinics and
quality of AM dental records [14]. Good-quality dental practices. The type and quality of AM
dental records are an essential part of patient dental records from which the AM profile is compiled will
care [15], but not every country has rigorous stand- affect the selection of the comparison process(es) to
ards for the documenting of dental treatment and be used and the level of confidence in the over-
retention of dental records. Particularly in develop- all outcome.
ing countries, the frequent absence of good (or any) All common aspects of the AM and PM profiles
dental records may be an impediment to a dental should be considered in determining if the profiles
comparison [16]. Disasters in which dental surgeries match, so the techniques discussed in this paper are
are destroyed (wildfire, flood, earthquake and rarely applied in isolation without considering the
318 A. FORREST

entire matrix of dental information available the results of their examinations and then transcrib-
for comparison. ing them onto the appropriate forms for quality
assurance [3]. The transcription (or computer
record in case of direct data entry) should also be
The PM dental examination
cross-checked. The outcome should then be subject
It is useful to have access to PM dental radiographs to at least one further quality assurance process
before beginning the physical examination to cross- before being entered into the pool of PM profiles
check observations made in the mouth. INTERPOL available for comparison.
recommends taking bitewing radiographs, periapical The final PM dental profile should contain com-
images of upper and lower molars, premolars and plete written documentation for every tooth whether
incisors on both sides and separate images of teeth it is present in the mouth or not, together with a
with distinctive features such as root canal fillings corresponding completed odontogram as well as
or prosthetic dental crowns [3]. When taking peri- complete radiographic and photographic
apical images, a parallel technique is recommended documentation.
rather than a bisecting-angle technique [19, 20]. If paper forms are used, they will now need to be

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INTERPOL also recommends PM orthopantomo- decontaminated. If a computer is used, the process of
gram (OPG) radiographs [3], but the logistical issue subsequent manual data entry should also be under-
in obtaining these precludes their use in most taken by teams of two forensic odontologists for qual-
instances unless special equipment is available. PM ity assurance because this extra stage provides an
OPG images can be simulated by multiplanar refor- opportunity for further errors to be introduced.
mats of PM CT data if available, and PM CT imag-
ing should be regarded as integral to the PM AM dental records
examination whenever it is available.
The physical dental examination can be very chal- Written dental records
lenging. Rigor mortis may cause difficulty in opening Written dental records are among the least useful of
the jaws, and putrefaction can cause leakage of fluids all dental records and may be described as a surro-
from the soft tissues which can render the teeth diffi- gate record [22]. They are considered a subjective
cult to see. Lighting can also be an issue so headset record because they do not derive directly from a
lighting is very useful as are LED-illuminated dental patient and much of what they record is interpreted
mouth mirrors. Fluids including blood can accumulate by a dentist during examination, treatment, or by a
in the mouth. Water may be used during tooth brush- scribe during transcription.
ing to clean the teeth prior to examination and may Forensic odontologists often receive dental records
also build up. When no suction is available, paper that are poorly documented [23], incomplete, or diffi-
towels may be useful to help absorb fluids. Incinerated cult to understand [24]. They are written accounts of
remains pose particular problems in terms of the fri- observations made on a patient or of treatment car-
ability of remaining teeth and are often best examined ried out on a patient. They may fail to record items
by imaging rather than dissection. Tooth-coloured required by professional record-keeping guidelines
dental restorations may be very difficult to detect in that are of significance to the forensic odontologist
PM circumstances, but may fluoresce when illumi- [14]. The portions recording items of dental treat-
nated by alternate light sources [21]. Trauma can ment and the dates on which they were performed
result in lost teeth lying in a body bag which may not are known as Treatment Notes and may or may not
be noted by the dental team. INTERPOL recommends be accompanied by numerical codes which may differ
that jaws should not be removed unless absolutely from one jurisdiction to another indicating specific
necessary and then only with the approval of the con- treatments. Observations made during a dental exam-
trolling authority with the provision that they are kept ination or following treatment may have been
with the body at all times [3]. Photographs, including recorded by a third party. A dental surgery is a noisy
images of the occlusal surfaces, should be taken to environment, so in this circumstance the recorder
document the teeth thoroughly. INTERPOL provides will write down what they thought they heard the
excellent guidance on PM photographic documenta- dentist say, and what they thought they saw or did
tion [3]. [22]. Errors may therefore occur during the tran-
When performed according to INTERPOL guide- scription and they may also occur through careless-
lines, it is normal for odontologists in the PM team ness or inattention [24]. As both a failsafe and
to work in pairs so that one can record the observa- allowing for rapid assessment of a patient’s status,
tions while the other performs the examination to many written dental records also feature an odonto-
reduce contamination. They should subsequently gram. An odontogram is a stylized diagram of the
rotate positions and repeat the exam, cross-checking teeth on which planned and executed dental
 FORENSIC SCIENCES RESEARCH 319

interventions can be recorded in a visual format. clockwise from the backmost tooth on the upper
Obviously, this ought to accord with the information right clockwise around the mouth. In this system
in the treatment notes. Figure 1 shows a portion of a the upper left first molar tooth (14th tooth along
genuine dental record in which the lower right first from the back on the right) would be tooth 14, pro-
molar tooth is shown as extracted in the odontogram nounced “fourteen”. A further system in common
(crossed out), but the lower right second premolar use is the Palmer System in which the adult teeth in
tooth is recorded as extracted in the treatment notes. each quadrant are numbered from 1 to 8 working
This is an example of an error that, without further from the midline backwards and this system uses a
information, renders the written record useless. grid symbol to indicate the relevant quadrant [25].
However, the danger is even more subtle; it is also Confusion could arise in a poorly-handwritten
possible that both the treatment notes and the odon- record. Could what appears to be tooth “47” care-
togram will concur, but both will record that the lessly written in Palmer notation mean the lower
wrong tooth has been treated. This type of error can- right first premolar?
not be detected when using written records alone None of these systems has gained full inter-

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and may result in an inadvertent exclusion of iden- national acceptance and none of them copes with
tity. Experienced forensic odontologists exclude a supernumerary teeth [24]. A forensic odontologist
potential match very sparingly and carefully if only must know which system has been used when inter-
written dental records are available. preting AM dental records received from different
The protocols for specifying teeth also vary. The jurisdictions or countries.
most commonly used system is known as World There is currently no standardised way of
Dental Federation (FDI) notation, and this is recom- expressing dental terminology unambiguously from
mended by INTERPOL for use in national and one country to another. At the time of writing, the
international DVI operations that follow INTERPOL International Standards Organisation (ISO)
DVI Guidelines [3]. In this system, the mouth is Technical Committee 106, the committee which
divided into four quadrants; the upper right quad- deals with dental terminology, has created a working
rant is indicated as quadrant 1, the upper left as group known as “ISO/TC 106/SC 3/WG 5 –
quadrant 2, and so on clockwise around the mouth. Terminology for Forensic Oro-Dental Data”. This
Within each quadrant there are eight teeth in a fully committee comprises members from 24 countries
dentate adult mouth, and they are numbered 1 to 8 and includes official liaison personnel from
from the midline backwards. Thus, the upper left INTERPOL and the North Atlantic Treaty
first molar tooth (tooth 6 in the upper left quadrant Organization (NATO). Its mission is to codify rec-
– quadrant 2 – is numbered 26 (pronounced two- ommended terminology across different countries so
six)). This contrasts with the Universal (or National) that forensic dental data can be communicated in a
System in which the adult teeth are numbered consistent fashion and it expects to report shortly
(Dr. Kenneth Asccheim, personal communication,
unreferenced).

Dental radiographs (X-rays)

Radiographs (X-rays) are a more reliable form of den-
tal record. They record the shadows of objects which
are cast against a special sensor when they are illumi-
nated with X-radiation and are usually shown as a
negative (radiopaque objects shown white). They are
an objective record, which is to say they record exactly
what is present in a visual way [22, 26]. This means
they are immune from the subjective recording and
interpretation issues that plague written dental records
and so they can be used to confirm the information
Figure 1. In the dental record, tooth 45 (lower right second that written records contain. They may also show
premolar, shaded green in the odontogram and treatment tooth-coloured fillings that might not be apparent in
notes) is recorded as having been extracted, but it is tooth the mouth [19]. They are therefore a valuable
46 (shaded in pink) that has been crossed out. We cannot
resource, but they are two-dimensional (2 D) and
resolve this problem without further information or images
such as X-rays. (Image courtesy Health Support Queensland should be used in conjunction with written records
Forensic and Scientific Services (HSQ FSS) and the which may contain additional information about treat-
Queensland State Coroner, with permission) ment performed after the X-ray was taken. The
320 A. FORREST

written record can be used to determine whether a patients with a trigger gag reflex. Recent 3 D intrao-
filling that appears on the side of a tooth in an X-ray ral scanners comprise a wand connected to a com-
is on the side closest to the lips and cheeks or on the puter passed over the teeth (or other item) and it
reverse side. They may reveal information that is not records data which are processed in real time to
visible from a dental examination in the mouth, for produce an accurate 3 D virtual model. This can
instance the presence of root canal fillings or the pres- also be actualised with a 3 D printer. These scans
ence of tooth-coloured restorations [19]. There may are clinically accurate [32, 33], and the process is
be some difficulty in confidently determining the cor- very comfortable for the patient, especially if a pow-
rect orientation (left or right) with some AM digital der-free technique is used. As they become increas-
intraoral images [27]. ingly widespread, 3 D surface scans comprise a new
set of AM data. They do not rely on ionising radi-
CT data ation (unlike X-rays and CT scans) and are not
affected by the presence of prior dental treatments.
AM CT scan data are a very valuable resource. They Unlike CT data, they are equally useful regardless of

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may originate from a medical CT scanner or from a whether the teeth contain fillings (of any material)
Cone Beam CT (CBCT) machine which may be
or not.
installed in a dental office or a radiology practice.
CBCT scans usually feature fewer beam hardening
artefacts and less soft tissue information than med- Dental study models
ical CT scans [28, 29]. Beam hardening is caused by Study models are classically poured from dental
high atomic number materials such as metal amal-
impressions in hard gypsum-based materials. They
gam and implants. These materials filter out lower
are 3 D casts representing a dentition, and they are
energy photons in the X-ray beam to “harden” it
extremely valuable because they function as a proxy
and Compton scattering causes streaking which
for the patient. Their surfaces can be recorded using
obscures the surface detail of the material [30].
a 3 D scanner and compared with a similar scan of
However, regardless of the machine used, the data
the teeth of a deceased person.
capture 3 D information about the scanned portion
of a patient and can be viewed in different ways. It
can be used to create a virtual 3 D model of the Dental appliances
teeth and bones (which can be actualised using a
Dental appliances may include such items as full or
3 D printer if necessary [31]), viewed as a simulation
partial dentures, orthodontic appliances, occlusal
of a 3 D X-ray, or sliced in such a way as to simu-
splints, bleaching trays and mouthguards. All of
late various dental X-rays including the OPG – a
these may be useful for comparison with the denti-
view that records the entire dentition on a single
tion or mouth of a deceased person. Not all such
image [19].
appliances need to be made in a dental surgery. For
The CT is one of the most versatile of all imaging
modalities used in forensic odontology. Because of example, mouthguards may be fabricated in schools
its 3 D nature, it can resolve questions about which for students who play contact sports and may also
side of a tooth contains a filling and it can show be specially made for sports teams, and home
distinctive anatomy from many different angles. The mouthguard construction options are available.
3 D reformatted view also respects perspective when Partial dentures are especially valuable as they are
zoomed in and out in some systems, making it a made to fit a single mouth. Sometimes, dentures
valuable tool when attempting to superimpose an may be marked with a unique patient mark or num-
image of the teeth of the deceased person over a ber, particularly in hospices and nursing
photograph of a missing person. homes [34].

3D Surface scan data Clinical photographs

3D scanners are replacing conventional dental Clinical photographs may record teeth of a patient
impression techniques [32]. During the latter, a suit- in some detail. They can be useful for comparison
ably-sized tray containing a thick paste is inserted with similar photographs of the teeth of a deceased
into a patient’s mouth and both the dentist and the person. It should be borne in mind that duplicating
patient must wait for the material to set before it AM photographs in a PM situation can present dif-
can be removed to show a space representing the ficulties, however. Cadavers are not generally
teeth and gums. This can be a traumatic process for cooperative, and decomposition, incineration or
both the dentist and the patient, particularly in rigor mortis can present serious problems.
 FORENSIC SCIENCES RESEARCH 321

Photographs showing smiling faces well as being used in missing persons comparisons
and routine forensic comparison casework.
Recently, it has become common for individuals to
Like all computer programmes that manipulate
post smiling photographs of themselves on social
data, it depends on the quality of information
media, which may therefore represent a source of
entered. Erroneous or poor-quality records, whether
AM dental information. It may be possible to super-
AM or PM, will inevitably result in poor outcomes.
impose a PM photograph of a victim’s teeth over
For this reason, it ranks possible matches for subse-
the teeth shown on a photograph of a missing per-
son. However, images on social media are com- quent human scrutiny. Interpreting the ranked
monly of low resolution. It takes a great deal of skill matches is a role for an experienced forensic odon-
to accurately replicate the camera distance and posi- tologist. Use of a computer programme such as this
tion when securing a PM image for comparison can lead to successful outcomes very rapidly when
although protocols are available [35], but cadavers good quality data are available.
are not cooperative. In the case of an AM profes- There comes a point in any large DVI incident
sional portrait image, the camera may need to be when any programme reaches the limit of its data

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placed as much as 2 m away from the teeth which and can no longer be useful. It is important to recog-
can be difficult in a mortuary situation. It may be nise this point, which indicates either the need for
simpler to use data from a 3 D reconstruction from more (or better) data, or a change of strategy, or
CT or from a 3 D scanner [36] to achieve a result. both. In such a case, it has been recognised that a
Absent from this list at the time of writing is the process involving progressive filtration of cases by
comparison of serial numbers etched into dental successive expert groups may be useful. For example,
implants. They are absent for a good reason; regret- during the DVI operation in Thailand following the
tably dental implants mostly do not yet feature serial 2004 South Asian Tsunami, the DNA group would
numbers. Identifying the type of implant(s) present provide a series of partial PM matches for a given
may help to reduce the number of potential matches, missing person and pass them on to the Dental
and an excellent website (https://whatimplantisthat. group, whose members would attempt to eliminate
com/) provides a comprehensive catalogue of radio- as many as possible on dental grounds. If identifica-
graphic and graphic implant profiles against which tion could not be confirmed at that stage, cases
PM implants can be compared. However, implants remaining were then passed to the Fingerprints team
are subject to counterfeit, so the comparison process for examination. If insufficient data were present for
is still subject to caveats on that basis. any of these teams to make a case, the files were
passed to an Investigative team with targeted requests
for additional information which tightly focused the
Computers as an aid to forensic comparison new investigative efforts [39]. In this sense, DVISys
When substantial numbers of victims are involved, was useful as a filter for cases that could not be
the use of a computer programme to help in the advanced by the computer matching strategy and
comparison process is a very useful (if not vital) therefore required a different approach.
requirement. Many such computer programmes
exist, some of which are dedicated solely to com-
The comparison process
parison of dental data [37]. They may operate on
the basis of simple AM and PM profiles that record The type of comparison performed depends on the
only a subset of possible dental data (such as nature of the DVI incident (closed or open), the type
whether a tooth is decayed, filled, sound or absent) and quality of the AM dental records available, and
or may utilise comprehensive dental information. the facilities available for PM dental examination and
One of the most widely used of these is DVISys imaging. It may also involve the use of a computer
(dvi@plass.dk), developed by Plass Data, a company programme to provide a series of most likely matches
based in Denmark. At the time of writing, 194 for the Forensic Odontologist to consider.
countries are INTERPOL members and therefore
nominally subscribe to INTERPOL protocols in
Written dental records
DVI. DVISys reflects the INTERPOL yellow (miss-
ing person) and pink (unidentified human remains) If dental records are sourced from another location
forms and accords with INTERPOL protocols. For or country, particularly if the language there is dif-
this reason, it is the most widely used system world- ferent from the one in the country in which the
wide and also one of the most comprehensive, with DVI operation is happening, it can be very advanta-
dental comparison comprising only one of several geous to have forensic odontologists from that other
components. It has been proved effective in several country perform transcription of the dental records
major DVI operations at the time of writing [38], as onto the INTERPOL missing persons form. Local
322 A. FORREST

odontologists are more likely to be familiar with methods including comparison of AM and PM
local charting conventions, and this can resolve con- dental X-rays demonstrates that the technique
fusion during the transcription process. The tran- is reliable.
scription should be in the language currently being This comparison process can be taken to another
used in the DVI operation and it should be cross- level by superimposing the two images [26] as in
checked by at least one additional local odontologist Figure 3.
for quality assurance purposes. Finally, subtraction imaging can be used to prove
AM dental records are not always recent or com- that the two images originated from the same source
plete (the patient may have visited multiple dentists [22] as shown in Figure 4.
but records from only some of them may be avail- The level of skill required in taking PM X-rays
able) and therefore forensic odontologists do not that are sufficiently similar to their AM counterparts
always seek a perfect match between the AM and to allow for the possibility of superimposition and
PM dental profiles. Instead, they ask if the PM pro- subtraction images is considerable. It will usually
file could have evolved from the AM profile because require the taking of subsequent PM X-rays after

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further dental treatment may have been provided by the AM images have been received.
different dentists since the last available treatment These techniques are useful to apply in small
record. Generally, there should be no unexplainable closed disasters but may be logistically complex in
discrepancies between the AM and PM dental pro- larger incidents.
files before a case is made for identification on den-
tal grounds [9]. CT and CBCT images
CT images are extremely useful. They can be
2D Images acquired using a mobile scanner, and without open-
Comparison of AM and PM 2 D images such as ing a body bag or disturbing the remains [41] which
X-rays (Figure 2) provides a level of confidence may be critical following incineration [29, 42]. They
that cannot usually be achieved by using written can reveal the state and morphology of the dental
dental records alone unless there are multiple remains prior to the actual viewing of the deceased
highly-probative concordant features in them with and help determine if and where loose teeth may be
no unexplainable contradictions [19]. Because the scattered inside a body bag. Critically, they can
images are objective records of the dentition at the reduce the incidence of removal of lower jaws as
time they were made, their comparison is rarely part of the PM dental examination process since
ambiguous if dental restorations are present but details of the teeth from both jaws can be viewed
may present difficulties if no radio-opaque restora- without the remains being disturbed [43]. The data
tions or individuating features are visible [26]. can be segmented and reformatted in different ways
Several studies have attempted to validate the pro- to produce different views of the scanned dentition
cess, but the absence of a consistent methodology including 3 D visualizations of hard tissues, simula-
between them makes it difficult to draw meaningful tions of 3 D X-ray images, or various dental 2 D
overall conclusions [40]. Experience in DVI inci- images [20, 28].
Unfortunately, high attenuation objects such as
dents where identification is established by multiple
amalgam restorations produce beam-hardening and
photon starvation which result in images that show
characteristic streaking artefacts [44]. Numerous
methods and algorithms have been implemented to
reduce these [45]. The detailed morphology of such
metal items is generally not as well demonstrated in
CT images as it is in plain film X-rays, so when
comparison or superimposition of AM and PM
images is to be performed, it is often better to
Figure 2. X-ray image comparison. The bright white areas in secure plain film images of a deceased person for
the tooth crowns represent the unique shapes of metal the purpose. The CT data can be used to inform the
amalgam fillings. The chances of getting such a level of forensic odontologist about the state of the teeth of
similarity between the teeth, filling shapes and bone levels the deceased so as to secure the most useful images.
in two individuals chosen at random would be exceedingly The irony is that the scans which demonstrate the
small, so it is reasonable to state that these images originate
from the same person. (Image courtesy Health Support best morphology are usually those without metallic
Queensland Forensic and Scientific Services (HSQ FSS) and fillings, but the most useful are those with metallic
the Queensland State Coroner, with permission) fillings which are most affected by artefacts. There
 FORENSIC SCIENCES RESEARCH 323

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Figure 3. X-ray superimposition. Superimposing the images demonstrates the similarities between the dental features in an
intuitive way. (Image courtesy Health Support Queensland Forensic and Scientific Services (HSQ FSS) and the Queensland
State Coroner, with permission)

Figure 4. Subtraction imaging. The postmortem (PM) image is superimposed on the antemortem (AM) image and turned into
a negative. When its opacity is reduced, the AM image becomes progressively more visible until all the overlying negative
and underlying positive colours cancel to resolve to grey wherever the images are similar. Changed features now become
clear. The suggestion of a white margin around the amalgam fillings indicates a slight mismatch in the sensor or beam align-
ment or both between the two images, demonstrating that they are the same object. (Image courtesy Health Support
Queensland Forensic and Scientific Services (HSQ FSS) and the Queensland State Coroner, with permission)

are many other morphological details that can be CT images may be used in several ways by foren-
compared with OPG X-rays including tooth root sic odontologists. These include direct comparison
and pulp shape, sinus morphology, patterns of tooth of CT slices, which is especially useful in comparing
crowding, missing teeth and periodontal bone levels the morphology of pneumatic sinuses including the
as well as bony pathology. This is fortunate since maxillary sinuses, ethmoid air cells and frontal
decreasing numbers of young people feature metal sinuses. It is important to ensure that the PM and
restoration. Victims with large numbers of metallic AM slices are taken with precisely the same plane
restorations can be also subjected to 3 D surface orientation, and this requires experience, but may
scanning which operates equally well regardless of be aided by using multiplanar reconstructions
the presence or absence of metal. (MPR) to determine slice orientation [46]. The aid
324 A. FORREST

of a radiographer or radiologist is very helpful when validated [48]), or they may be used to guide the
using this technique. CT images have also been used forensic odontologist as to which PM plain film
to differentiate between dental materials used in images should be captured for later definitive com-
tooth-coloured fillings [47] although this is only parison with AM X-rays. Direct comparison
useful if the material has been recorded in the AM between AM OPG and PM reconstructed images is
dental record. most useful when many distinctive dental interven-
Another technique is to perform MPR of the CT tions are present as shown in Figure 5.
or CBCT data to simulate common dental X-ray Where children are among the victims of a small
images [28]. They can be used to simulate dental DVI operation, it may be useful to use the CT
periapical images and OPG X-rays. The thickness of images to rank them according to increasing age on
the plane to be reconstructed is an important con- receipt of the CT data rather than performing for-
sideration. Once the path of the reconstruction has mal age estimation which can be undertaken later.
been determined, it is useful to increase the thick- This may help in targeting the identification effort
and providing information about whether useful
ness of the slice on either side of the central plane
AM dental records might be available. While CT

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or path. While thicker slices allow the capture of
and MRI images may be useful for age estimation,
more information, they are also affected by poorer
more research needs to be devoted to this
image sharpness. The optimum slice thickness is
topic [49].
case-dependent and relates to the data that need to
be visualised. A slice thickness of 10 mm – 15 mm
seems to return the optimum balance between infor- 3D Surface scan data
mation and image sharpness in most cases. Because 3D dental impression techniques are beginning to
the orientation of the jaws may be different follow- make inroads into dental practice. While they are
ing death due to trauma or displacement, it is often appearing in the general dental practices in devel-
necessary to perform separate MPR for upper and oped countries, orthodontic and prosthodontic spe-
lower jaws as they may not remain in the same rela- cialist practices have been among the early adopters,
tive positions as they occupied during life. so it is important to consider such specialist practi-
Fragmentation may also require different fragments ces when seeking AM dental records. Information
to be reconstructed separately. about specialist referrals should always be sought as
The images resulting from reconstruction can be part of the AM record investigation. Dental labora-
directly compared with AM intraoral or OPG tories are increasingly becoming equipped to handle
images (a technique that has been previously digital workflows in developed countries, which in

Figure 5. Comparison between antemortem (AM) orthopantomogram (OPG) X-ray of a missing person and multiplanar recon-
structions (MPR) of CT data of the upper and lower jaws of a victim. Corresponding features are indicated by yellow arrows.
The red arrow in the upper jaw indicates a tooth that was extracted before death and the orange arrow in the lower jaw indi-
cates a filling that was replaced. Both are accounted for in the written dental record. (Image courtesy Health Support
Queensland Forensic and Scientific Services (HSQ FSS) and the Queensland State Coroner, with permission)
 FORENSIC SCIENCES RESEARCH 325

turn encourages general dental practitioners to The feasibility of using these scans of smaller seg-
adopt digital impression techniques. The equipment ments to compare with PM data is still not known,
required is improving rapidly and it is becoming particularly after the dental intervention is com-
more affordable and better supported. Practices are pleted. To what extent does major dental restorative
also finding that they no longer need storage space work affect the outcome? Data are not yet available
for large numbers of physical dental models when on the results of comparing orthodontic scans (a
virtual models can be stored digitally. specialty that routinely scans entire dental arches)
When AM 3 D surface scan data are available, when the teeth are moved during treatment. The
they can be compared roughly with reformatted sur- smallest fragment size that can be used to confi-
face data from CT or CBCT PM scans (Figure 6), or dently identify an individual using this technique is
more accurately with PM data from a comparable not known, and since some disasters involve frag-
3 D scanner. It is likely that the technique of 3 D mentation of the jaws, this is an important question
comparison will become increasingly important for to answer. A great deal of research needs to be
use in single-case identifications and this process undertaken to answer these questions, but it seems

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potentially can be automated for use in DVI opera- clear that this third dimension will be a major focus
tions. In the future, 3 D intraoral scanners will of forensic odontology in the future, especially if the
become a routine tool in the forensic odontologist’s comparison process can be automated and incorpo-
armamentarium as high-resolution 3 D AM data rated into a programme such as DVISys.
become increasingly available.
Comparison of 3 D scans of palatal rugae for
Removable dental appliances
identification has been suggested [50, 51], including
for differentiating between monozygotic twins [52]. Of all the removable dental appliances, metal-framed
There are conflicting views as to whether orthodon- partial dentures provide the most distinctive informa-
tic treatment changes the morphology of palatal tion. They are precision-made to fit a single mouth
rugae sufficiently to compromise their use for iden- and may provide a compelling method of identifica-
tification [53, 54]. tion if their AM provenance can be demonstrated. If
Questions still remain to be answered. The utility there is no information about the identity of the per-
of full-arch 3 D scans is obvious, especially if both son to whom they belonged in life, their presence is
upper and lower AM arch scans are available. Scans not helpful. Mercifully, they are occasionally found in
of smaller sections of a dental arch are likely to be the home of a missing person in which case the iden-
performed by dentists using the data for the con- tity of the owner may be inferred. Acrylic partial den-
struction of dental restorations such as crowns or tures are also very useful if they can be fitted to a
implants, both of which involve changing the shapes victim’s teeth, but do not generally fit with the same
of teeth or replacing missing teeth during treatment. precision as those made with metal frames.

Figure 6. Three-dimensional (3 D) superimposition. The postmortem (PM) surface is superimposed on the antemortem (AM)
surface. In this case, scans were secured by a low-resolution medical CT scanner with an approximately 0.3 slice thickness.
Surfaces matching within a region of 0.5 mm are coloured grey, while those that fall outside this range (mainly soft tissues)
are coloured according to the degree of mismatch. With modern intraoral scanners, the resolution and scan precision are
much higher, so the width of the grey zone can be reduced to a level measured in tens of microns, providing excellent indi-
viduation. (Image courtesy Ms Donna MacGregor and Mr Mark Barry, with permission)
326 A. FORREST

Full dentures are less useful. In the event of Advantages of digital technologies in
decomposition or fragmentation, an opinion as to forensic odontology
their fit is more likely to be exclusionary than
AM digital dental records may include computerised
inclusionary.
dental record systems which record both dental treat-
Dentures may be marked with identifying infor-
ment and an odontogram for a patient, replacing the
mation, and this is most often the case if victims
physical record. Plain film X-rays including OPG
have been living in a nursing home or similar estab-
images are routinely captured as digital images in
lishment. Numerous methods have been proposed
developed countries, and CT, CBCT and 3 D surface
for marking dentures over the years, but it is still
data are digital by their nature. Corresponding PM
far less common than forensic odontologists would
data can and should be digital in nature whenever
wish [55]. possible, and chemical X-ray film processing should
Mouthguards may be available for younger victims. be avoided as it must subsequently be digitised for
While these are made of pliable material and are not storage in a computer which introduces possible qual-
precision appliances in the sense that metal-based par- ity issues. The requirement for a dentist to label phys-

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tial dentures commonly are, they may be useful ical X-ray film with the identity of a patient or a
because they represent a reverse model of the teeth forensic odontologist to label a film with the identifi-
they are designed to fit. While they can be fitted dir- cation number of a victim after processing are two
ectly to the teeth of a victim, a better demonstration further potential sources of error.
is to use them as moulds to create a low-resolution The major advantages of digital data are that they
physical model of the teeth they were made from, and can be stored for very long periods of time on
such a model can in turn be compared with the denti- increasingly capacious storage technologies. They
tion of a deceased person by making a further mould can (and should) be routinely backed up, including
from it, observing its fit on the teeth of the victim, to secure cloud-based facilities, to ensure their con-
and slicing it with a scalpel if necessary to demon- tinued integrity and permanence. Off-site backup
strate its adaptation to the tooth surfaces. This method also ensures that they are less likely to be lost if a
was used at least once in the identification of a victim dental practice or facility (or mortuary) is destroyed.
of the 1st Bali Terrorist Bombing in 2002. Digital data can be transmitted very rapidly and
More recently, mandibular advancement splints are received with identical characteristics as when they
have become increasingly common in the treatment were transmitted; there is no loss of resolution or
of sleep apnoea, and may serve a similar purpose to quality. They are immediately useful upon receipt;
mouthguards, usually with slightly better precision images do not require further scanning or imaging as
since they are rigid structures. They are fabricated do physical X-ray films, and because original films or
to cover teeth of both jaws and may therefore pro- dental models are not being sent, identical copies
vide more individuating information than mouth- remain at source so that records are less likely to be
guards unless they, too are designed to stabilize lost during the DVI procedure (which should also
both jaws (bi-maxillary mouthguards). include a data backup strategy). Image data can be
Orthodontic appliances can also be compared to directly imported into a computer programme such as
the teeth of a victim to determine their fit. DVISys, reducing one possible source of error. The
use of digital dental PM data recording is a further
Radio-frequency identification (RFID) tags opportunity to ensure data are entered directly into a
computer programme such as DVISys, eliminating a
RFID tags have been proposed as aids to personal source of transcription error.
identification and were trialled in some victims in Extensive use of digital data and data transmis-
the South Asian Tsunami DVI operation in 2005 to sion requires robust access to the Internet at the
supplement printed identification labels [56] and DVI Victim Identification Centre, and this may not
following Hurricane Katrina in the US [57]. They be easily available in developing countries or in
may be implanted into teeth [58] or into removable remote locations. DVI planning needs to take this
appliances such as dentures [59]. Because their into account when formulating their strategy for
implantation into teeth is an invasive procedure and handling AM data.
requires the preparation of a cavity in healthy tooth
structure with a subsequent dental restoration, it has
not gained widespread acceptance. Using filling
When is forensic odontology useful in
materials of a different colour to signal their pres-
DVI incidents?
ence has also been proposed. RFID technology was Dental identification techniques are dependent on
also used for body tracking in the Hurricane the presence of adequate dental remains, and on the
Katrina DVI operation [15]. availability and quality of dental records.
 FORENSIC SCIENCES RESEARCH 327

It is notable that in some developing countries, Conclusion

dental records may not be routinely completed for
The purpose of the DVI process is to provide a
dental treatment [16]. As dentists move into the
rational, scientific basis for the determination of the
forensic arena in those countries (a process which is
identity of victims in a mass-casualty incident.
now becoming widespread and accelerating thanks
Each disaster is unique, so no universal state-
to conferences, meetings and ease of consultation
ments can be made about the routine usefulness of
with fellow specialists through restricted social
any of the principal identifiers. Fires, trauma or
media threads), recognition among dental practi- environmental factors may destroy limbs and digits,
tioners, local dental associations and government compromising the contribution of ridgeology. DNA
bodies to ensure that dental records are recorded, profiling may be affected by incineration or envir-
maintained and kept is being promoted in the litera- onmental factors and is time-consuming and expen-
ture [18]. sive. It depends on the availability of AM profiles
Unfortunately, even in some major developed with which to compare that of a deceased person
countries, legislation or by-laws only mandate the but may also be able to link fragments to a previ-

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retention of dental records for a limited number of ously-identified body portion. Forensic odontology
years [60, 61]. Since dental records (including may be affected if dental remains are destroyed or
images) are increasingly digital in nature, and since not found, or when dental records are inadequate or
storage capacities are increasing at a very rapid rate, not available.
it is not clear why this cannot be addressed to Where dental remains and adequate AM dental
increase retention times indefinitely. The issue of records are available, forensic odontology can be
storing physical records and dental study models is expected to make a large contribution to the identi-
a vanishing problem for those who have migrated to fication effort. Excellent techniques and technologies
digital technologies, and this is a trend that can only are currently available to the forensic odontologist
continue. Further, digital records can easily be to ensure accurate outcomes and to demonstrate the
backed-up offsite, rendering them less susceptible to basis of their conclusions to an Identification Board.
destruction if a dental practice is physically New technologies and tools are rapidly develop-
destroyed during a disaster. ing. A decade ago, CT was a new technology being
applied in this field, and 3D surface comparison was
Future directions an emerging method not yet used routinely. Both
technologies depend on the increasing adoption of
It seems that the future of comparison technologies 3 D imaging in routine dental and medical practice
in forensic odontology is firmly based in the third to ensure that objective AM data are available for
dimension. As CT and possibly CBCT become more comparison with the dental features of victims. CT
tightly integrated into PM examination, 3 D datasets scanning is now a routine medical procedure, and
of teeth, tooth-bearing fragments and dental arches 3 D surface scanning of teeth to create digital dental
will become available even before a body bag is impressions is becoming more widely adopted, par-
opened. As digital impressions begin to move into ticularly in orthodontic and prosthodontic practices
the mainstream of modern dental practice, AM 3 D and in maxillofacial surgery. This emphasizes the
datasets will be increasingly part of the AM dental importance of seeking dental records from special-
profile, and 3 D intraoral scanners will become ists as well as from general dental practitioners.
indispensable parts of the forensic odontologists Digital data can be easily and rapidly transmitted
toolset. All of these converge at a point where AM with no loss of accuracy or detail, and this can
and PM 3 D virtual models of a dentition will greatly speed a response in a DVI operation.
become available. The future of forensic odontology in DVI will
At present, there is a dearth of affordable easy- increasingly depend on 3 D datasets including CT
to-use public-domain software running on multiple and 3 D surface scan data, and current forensic
platforms to permit easy and quick 3 D object com- odontology practitioners will become progressively
parisons from multiple different imaging modalities, more experienced in the utilisation of these technol-
although programmes like MeshLab [62] offer ogies as they become more tightly integrated into
opportunities for comparison of point clouds as well daily practice.
as meshes. It is to be hoped that such simple soft- Developing countries are increasingly recognising
ware emerges. the importance of forensic odontology in routine
It is possible that in the future, the process of 3 D casework as well as in DVI, and practitioners in
comparison could be automated, providing opportu- many of those countries are attending forensic
nities for very rapid and reliable AM and PM odontology conferences and meetings and acquiring
model matching. the skills and equipment needed to provide a
328 A. FORREST

forensic odontology service. Their activities should [11] Franco A, Willems G, Souza PH, et al. The
be promoted and supported by the forensic odontol- uniqueness of the human dentition as forensic evi-
dence: a systematic review on the technological
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ensure that capacity for a scientific response is built 1277–1283.
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8555–8560.
Author’s contribution [13] Kiran R, Chapman J, Tennant M, et al. Detection
of tooth-colored restorative materials for forensic
The author was the sole contributor to this paper. purposes based on their optical properties: an
in vitro comparative study. J Forensic Sci. 2019;64:
254–259.
Compliance with ethical standard
[14] Stow L, James H, Richards L. Australian oral
This article does not contain any studies with health case notes: assessment of forensic relevance
human participants or animals performed by and adherence to recording guidelines. Aust Dent
J. 2016;61:236–243.
the author.

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[15] Hinchliffe J. Forensic odontology, Part 2. Major
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[16] Acharya J, Shrestha R, Shrestha PK, et al. When
Disclosure statement protocols become fairy tales and gods remain
No potential conflict of interest was reported by buried under: excerpts from the diary of forensic
the author. experts at ground zero during the mega quake that
hit Nepal. Am J Forensic Med Pathol. 2017;38:5–8.
[17] Cordner S, Ellingham STD. Two halves make a
ORCID whole: both first responders and experts are
needed for the management and identification of
Alex Forrest http://orcid.org/0000-0002-3370-670X the dead in large disasters. Forensic Sci Int. 2017;
279:60–64.
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