e-GiGi 2025; Volume 13, Nomor 1: 217-224

DOI: https://doi.org/10.35790/eg.v13i1.54118
URL Homepage: https://ejournal.unsrat.ac.id/index.php/egigi

Clinical Implications of Dental Injury Analysis in Forensic Odontology:

A Review Article

Muhammad S. Khan, Antonius W. Suhartono, Elza I. Auerkari

Division of Forensic Odontology, Department of Oral Biology, Faculty of Dentistry, Universitas

Indonesia, Jakarta, Indonesia
Email: [email protected]
Received: February 16, 2024; Accepted: August 31, 2024; Published online: September 13, 2024

Abstract: Dental trauma is a common occurrence in forensic investigations and may provide
important clues about the amount of damages and when they occurred, both of which are vital in
court cases. Forensic pathologists and dentists work hand in hand to assess and diagnose oral injuries
accurately, which is crucial for those who are alive and those who have passed away. In order to
guarantee accurate forensic results, the need of standardizing procedures used in dental trauma
analysis, such as clinical and radiographic tests, and the need of thorough documentation are very
crucial. The many kinds of dental injuries, their causes, and how forensic applications help to identify
victims and piece together are very important to be discussed. This article provides a comprehensive
overview of the importance of dental injury analysis, procedures and their implications in various
cases within the scope of forensic odontology for efficient practice, highlighting the vital role of
forensic odontology in medico-legal investigations via an in-depth review of the existing literature.
Keywords: dental trauma; forensic odontologist; clinical examination; radiographic assessment;
legal context

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Introduction
Dental injuries resulting from physical trauma are often seen in the area of forensic science.
Their occurrence varies according on characteristics such as the age, gender, place of origin, and
socioeconomic position of the victims.1 The frequency of dental trauma is greatest among school-
age children, however, it starts to grow from the age of one when children begin to walk for the
first time.2 The prevalence of these injuries is rising due to the growing number of individuals
engaging in contact sports.3,4 It is not known how many people really get traumatic dental injuries,
despite the fact that they do occur with a reasonable level of frequency. This is due to the fact that
the person who has been traumatized does not usually seek out the specialized medical treatment
needed. On the other hand, there are certain instances of acute oral damage that are not detected
because they do not exhibit any signs, such as subjective or objective symptoms.5
Mechanical factors induce dental trauma most often followed by physical and chemical
agents. Dental injuries may be caused by trauma, compression, falls, or iatrogenic factors. The
central incisors, located in the anterior maxillary area, are more vulnerable to direct injuries from
impacts. Indirect injuries may occur when the mandible touches the upper arch. Coronal fractures
in the posterior dental arche and coronal-radicular fracture, condyles, and symphysis may ensue.6
Dental trauma may be produced by misalignment, protrusion, degeneration, decay, restorations,
crown-and-root restorations, long-term gum disease, and seizures. Teeth injuries may harm the
tooth's hard structure, pulp cavity, periodontal structures, or soft tissues, leading to tooth loss.
Endodontic therapy may cause vertical fractures. These fractures may be produced by dental hard
tissue loss, enamel degradation, and iatrogenic causes.3 After a thorough investigation of stressed
teeth, developmental abnormalities were found in the permanent teeth that followed the primary
teeth. After the most major event, the teeth were severely damaged.7
Identification of traumatic dental lesions in corpses has great relevance in forensic practice.
Analysis of dental injuries is important in the forensic aspect because this analysis can be one of
the common threads in case identification. The influence of dental injury analysis can be implied
in living and deceased victims, such as identification of estimated age, identification of signs of
abuse in the orofacial area, such as fractures, lacerations, and bruises, and postmortem identification
by comparing antemortem and postmortem dental records in the form of bite mark analysis.

Classification of traumatic dental injuries

Andreasen and Andreasen describe traumatic dental injuries using a WHO-recommended
approach. The WHO's classification of dental injuries is as follows (Figure 1): 1) damage to hard
tooth tissue and pulp; 2) damage to hard tooth tissue, pulp, and alveolar bone; and 3) damage to
the periodontal tissue. Damage to hard tooth tissue and pulp consists of crown fracture (enamel
infraction), an imperfect fracture in the enamel without losing the tooth structure in a horizontal
or vertical direction; uncomplicated crown fracture, a fracture that only affects the enamel layer;
uncomplicated crown fracture, which is a fracture in the tooth crown that only affects the enamel
and dentin without involving the pulp; and complicated crown fracture that affects the enamel,
dentin, and pulp.8
Damage to hard tooth tissue, pulp, and alveolar bone consists of crown-root fracture, which
is a fracture that affects the enamel, dentin, and cementum. Crown-root fractures involving tissue
are also called complicated crown-root fractures, and crown-root fractures that do not include
pulp tissue are called uncomplicated crown-root fractures; root fractures, namely fractures that
affect dentin, cementum, and pulp without involving the enamel layer; tooth socket wall fractures,
namely alveolar bone fractures involving the labial or lingual socket wall, limited by the facial or
lingual part of the socket wall; alveolar process fractures, namely fractures that affect the alveolar
process with or without involving the alveolar socket of the tooth; and mandibular or maxillary
corpus fractures namely fractures in the mandibular or maxillary corpus involving the alveolar
process, with or without involving the tooth socket.8
 Khan et al: Dental injury analysis in forensic odontology 219

Figure 1. Classification of types of injuries based on the area and cause of injury. Abbott, 20228

Damage to the periodontal tissue consists of concussion, a trauma that affects the supporting
tissues of the teeth which causes the teeth to be more sensitive to pressure and percussion without
any loosening or change in position of the teeth; subluxation, which is tooth loosening without
any change in position of the teeth due to trauma to the supporting tissues of the teeth; extrusion
luxation (partial displacement), which is the release of part of the tooth out of its socket. Extrusion
causes the crown of the tooth to look longer; luxation, which is a change in the position of the
tooth that occurs due to the movement of the tooth towards the labial, palatal, or lateral, this causes
damage or fracture to the alveolar socket of the tooth. Tooth trauma that causes lateral luxation
causes the crown to move toward the palatal; intrusion luxation, which is the movement of the
tooth into the alveolar bone, which can cause damage or fracture of the alveolar socket. Intrusion
luxation causes the crown of the tooth to look shorter; and laceration (lost or extrarticulation)
which is the movement of the entire tooth out of the socket.8

Examination of dento-alveolar cases

Examinations of dento-alveolar cases consist of clinical examination, supporting examination,
and assessment of the severity of trauma occurs in forensic practise. General dentists can establish
a diagnosis through clinical examination based on the etiology and clinical appearance of living
patients. Meanwhile, forensic doctors can handle and perform clinical and supporting examinations
on living and dead patients.

Clinical examination
Dento-alveolar trauma is common and can result in tooth displacement, fractures, bone
crushing, and soft tissue injuries. Current literature provides guidelines, procedures, and
documentation for trauma first aid, patient examination, treatment planning decisions, and
informing traumatized patients of their treatment options and prognosis.9–11 The severity of tooth
damage increases when two types of traumas occur simultaneously, such as developed roots,
subluxation injuries, or concussions, if their crowns break simultaneously, leading to pulp necrosis
and infection.12

Supporting examination
Clinicians can use several supporting examinations in analyzing dental injuries. Supporting
examinations that can be performed are histological examination, clinical photo examination, and
radiographic examination. Histological examination can be performed on deceased victims to
identify the patient's age, cause of trauma, or the patient's peri-mortem condition. Clinical photo
220 e-GiGi, Volume 13 Nomor 1, 2025, hlm. 217-224

examination can be performed on both living and deceased victims. This examination is
performed to identify the victim and match it with the clinical examination. Radiographic
examination is performed on both living and deceased victims. Clinicians should evaluate patients
and determine the necessary two-dimensional radiographs, using standard angulations and
projections. Early radiographs are crucial for comparisons during tests. Film holders should
ensure uniformity and repeatability. A single periapical radiograph should focus on the upper jaw's
central incisors, maxilla's right lateral incisors, and left lateral incisors. A radiation specialist's x-
ray is also recommended. Periapical radiographs should match the mandible's centrals. Further
radiographs may be needed for mandibular tooth destruction.13–15 Cone beam computed
tomography (CBCT) can be used to better understand root fractures, crown/root fractures, and
lateral luxation. The 3D imaging, if accessible, may be helpful in certain injuries. Before
subjecting a patient to ionizing radiations, it is important to determine whether the picture will
alter the injury's treatment.16

Assessment of the severity of trauma occurs in forensic practise

The assessment of the severity of trauma can be done by forensic odontology. The duration
of medical treatment for a trauma victim's recovery is determined by factors such as the anatomic
and functional effects of the injuries, the need for specialized care, and the clinical course of the
injury in forensic practice, indicating the total treatment time.17 The Romanian Criminal Code
governs assault and wounding, with Articles 193 and 1941 defining offenses. Courts consider
traumatic mechanisms and recovery time for victims, with severe punishments for violent
criminals. Medical treatment, hospitalization, sick, and complete recovery days are distinct,
determined by individual injury severity. Collaboration between forensic pathologists and dentists
is crucial for accurate assessment of dental injuries.3 The dentist's professional duty involves
conducting an examination, which the forensic pathologist relies on during a criminal
investigation. They estimate the patient's recovery time and address other concerns, while
thoroughly examining and analyzing all dental records within their expertise.18 To evaluate the
severity of dental trauma in living victims, there are several steps, as follows: 1) Assess the extent
of the injuries, documenting them using medical records, photographs, and witness statements; 2)
Determine the necessary treatment, considering the impact of delayed or inadequate treatment; 3)
Calculate losses and expenses, including medical bills, lost wages, travel, prescription costs, and
other related expenses; 4) Assess the psychological impact of the dental injuries, including
trauma, anxiety, or depression; 5) Use case law and judicial guidelines to determine appropriate
compensation; 6) Consult with dental and medical experts for detailed assessments of the injuries
and required treatment; and 7) Negotiate compensation using evidence and expert assessments,
considering the long-term impact on the victim's quality of life and overall well-being.19
Determining the patient's age based on teeth can be done whether the victim is alive or dead.
An integral aspect of the identification procedure should include age estimate, a branch of forensic
science, particularly in cases when details about the dead are lacking.20 The main way to determine
age for younger people is by dental estimation of chronological age, since there are small
differences in tooth formation and eruption across individuals. This can be done because there are
small differences in tooth formation and eruption between individuals. From around four months
after conception until the first few years of adulthood, when all of the permanent teeth have grown
in, there is a regular and predictable pattern to the development of the human dentition.21
Chronological age analysis of teeth from the sequence of tooth eruption can be determined through
radiography examination. Radiography methods assess pulp health by observing mineralization
phases, considering root and crown development, eruption stage, and mixed primary and adult
teeth. Sensitivity tests measure pulp health by measuring brain activity but may be inaccurate due
to temporary neural response or lack of differentiation of A-delta nerve fibers in baby teeth. Pulse
oximetry quantifies real blood flow, confirming pulp vitality. Both tests are essential for assessing
pulp health and ensuring proper functioning so that the age of the victim can be determined.22,23,24,25
 Khan et al: Dental injury analysis in forensic odontology 221

Determination of patient age in adults or deceased victims can use the Gustafon method, which is
a tooth analysis of six stages; degree of attrition, amount of secondary dentin, position of gingival
attachment, degree of root resorption, transparency of root dentin and thickness of cementum. The
Gustafson method can be seen based on histological examination. This method is taken from
incisor teeth, with a standard error of ±4.5 years, but has high accuracy in identifying age.22,24,25
Scale for measuring the severity of traumatic dental injury (TDI) can be done by a forensic
odontologist. Trauma involving the dento-alveolar region is a frequent occurrence which can result
in the fracture and displacement of teeth, crushing, and/or fracturing of bone, and soft tissue injuries
including contusions, abrasions, and lacerations. Available current literature provides protocols,
methods, and documentation for the clinical assessment of TDI, trauma first aid, patient
examination, factors that affect treatment planning decisions, and the importance of communicating
treatment options and prognosis to traumatized patients. The TDIs are utilized in forensics to
estimate hospitalization duration for serious injuries, classifying injuries, determining recovery
days, and detailing any ramifications, including permanent ones like handicap.26 The TDI guidelines
based on International Association of Dental Traumatology (IADT) explain that TDI is carried out
by several examinations, such as clinical examination, pulp sensitivity and vitality examination,
clinical photo examination, and radiographic examination. In living victims, based on these
examinations, clinicians can take treatment measures such as stabilization, repositioning, or
endodontic treatment. In deceased victims, this can be an analysis of the cause of a case.

Assessing Victim's Dental Trauma

Assessing victim's dental trauma can be done by a forensic odontologist. The identification
of traumatic dental lesions on both living and dead victims is of great relevance within the area of
forensic practice. This is because it plays a critical role in determining both the mode of trauma
and the cause of death.27,28 In living victims, clinicians can determine the type of trauma that
occurred to the victim, the cause of the trauma, and the time of the trauma. Trauma that can occur
in living victims is physical abuse, non-abusive dental trauma, child abuse, rape, bitemarks in
some cases. In deceased victims, clinicians can determine the time of trauma, the mechanism of
trauma, and the victim's skeletal analysis. Concerning timing of trauma, an accurate trauma
analysis is essential to ascertain whether injuries are related to the individual's life or the
circumstances surrounding their death. Antemortem trauma can indicate past injuries, while
perimortem trauma may relate to the cause of death. Postmortem damage, on the other hand, is
not associated with the death event. In mechanism of trauma, understanding the biomechanical
principles behind the observed trauma can help forensic experts diagnose the type of injury and
its potential cause. This involves analyzing the characteristics of the skeletal damage, which can
vary based on the type of trauma inflicted. The mechanism of trauma can estimate whether the
victim died from sharp objects, blunt objects, high velocity projectile trauma, or thermal trauma.
Related to skeletal analysis, the examination of skeletal remains can yield valuable information
for coroners or medical examiners, aiding in the determination of the manner and cause of death.
Forensic anthropologists and odontologists play a critical role in this analysis, as they can provide
insights into the nature of the injuries and their implications for the investigation.27,28
The methodology for analyzing dental injuries has several stages, as follows; 1) Visual
examination: observing and documenting the condition of the teeth and associated structures,
including the presence of cracks, fractures, or other damage; 2) Imaging: using imaging
techniques such as X-rays to obtain a clearer picture of the injuries within the teeth and jaw; 3)
Histological analysis: in some cases, analysis of dental tissue can be performed to assess signs of
healing or infection.29 The challenge in analyzing dental injuries is that distinguishing between
perimortem, and postmortem injuries can be difficult, especially if the damage occurs in teeth that
have already undergone decomposition. Therefore, the analysis must be carried out carefully and
in the right context to avoid misdiagnosis.30
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Role of Forensic Odontologist

A forensic odontologist is involved in every step of identifying deceased victims as well as
identifying violence against living victims, to determine the nature of the crime.31 Forensic science
and the legal system generally agree that teeth may be used for positive identification purposes.
A forensic odontology expertise and team-based approach are crucial for successful forensic
investigations. They assist law enforcement by analyzing dental evidence in various scenarios,
including dental forensic examination, forensic analysis, and dental remains analysis.32
Dental forensic examination involves assessing and analyzing damage to teeth, jaws, and oral
tissues from abuse, assault, mass disasters, and crime-related incidents. Forensic analysis
scrutinizes markings to potentially identify the offender, while dental remains analysis helps
identify unknown individuals or corpses.33 Forensic odontologists are professionals who use
dental evidence to identify signs of abuse, identify deceased individuals, estimate their age,
analyze bite marks, and respond to mass disasters. They identify signs of abuse in the oro-facial
region, such as fractures, lacerations, and bruises, and report findings to authorities. They also
perform postmortem identification by comparing ante-mortem and post-mortem dental records.
Age estimation is crucial, as they can estimate a deceased individual's age based on dental
development and eruption patterns. Bite mark analysis helps identify perpetrators of violent
crimes by comparing victim's bite marks with suspects' dental structures. They also assist in
disaster response efforts, providing expertise in diagnosis, monitoring, referral, decontamination,
infection control, surveillance, and notification.19 Forensic odontology is a crucial method for
identifying human remains based on dental trauma. It involves examining teeth to assess the
nature and extent of trauma, using unique tooth class characteristics, identifying dental pathology
and anomalies, and comparing the recovered evidence with ante-mortem records. The forensic
odontologist can also determine the victim's biological profile, such as age, sex, race/ethnicity,
occupation, and habits. However, limitations and challenges exist, such as the difficulty in
identifying victims without ante-mortem records and the inability to confirm identity in all cases.34
Forensic odontologists identify nameless cadavers, providing families with evidence for
court use. This process ensures access to the deceased person's body in time for funerals and
provides insight into their death. This helps replace uncertainty with more accurate information,
despite potential distress. The identification process ensures that families have access to the
deceased person's body, allowing for a more accurate understanding of their death.35

Significance of identification
Dental hard tissues are resistant to decay, fire, and natural disasters, making them often the
only remnants after burial. Forensic dentistry has become crucial in medicolegal matters since the
late 1890s, focusing on forensic analysis of human remains, legal proceedings concerning
professional error, and bite-mark assessment in cases of abuse, particularly child abuse. Human
dentition is often compared to a fingerprint due to its unique characteristics, and the physiological
variation of teeth and treatment effects are recorded throughout their lifetime.36

Conclusion
Dental injury analysis helps to determine the cause and mechanism of injury, estimate when
the injury occurred, pattern of injury, and type and intensity of the trauma. This is important in
criminal investigations to match the time of the incident with other evidence. There are several
challenges in dental injury analysis, including soft tissue degradation, tooth fragmentation, and
limited dental records. Overall, dental injury analysis in forensic odontology is an important tool
that helps in the process of forensic identification and criminal investigation. A systematic and
detailed approach can provide valuable information to solve forensic cases.

Conflict of Interest
The authors declare no conflict of interest in this study.
 Khan et al: Dental injury analysis in forensic odontology 223

Authors' contributions
All authors made equal contributions to the writing of the manuscript.

Acknowledgements
The acknowledgement is extended to Universitas Indonesia for the facilities provided, from
the library to collecting data.

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