Review Article Role of prosthodontist in forensic odontology. A literature review

Sunil Kumar Mishra, Harsh Mahajan, Rupal Sakorikar, Anoop Jain1 Department of Maxillofacial Abstract and Implantology, Rishiraj College of Dental Dental identification assumes a primary role in the identification of remains when Sciences and Research Centre, postmortem changes, traumatic tissue injury, or lack of a record invalidate Bhopal, Madhya Pradesh, the use of visual or fingerprint methods. The most common role of the forensic is 1HKE’S S Nijalingappa Institute of Dental Sciences and Research, the identification of deceased individuals. based on assessment Gulbarga, Karnataka, India of prosthodontic appliances is assuming greater significance, as labeling of dentures and other prosthetic appliance could provide vital clues for patient identification. Address for correspondence: Dr. Sunil Kumar Mishra, Various recommendations have been made concerning the importance of denture Department of Maxillofacial identification. This paper presents a review of available literature highlighting the fact Prosthodontics and Implantology, that how a prosthodontist can play a key role in identification of a deceased individual Rishiraj College of Dental if trained to do so. Sciences and Research Centre, Bhopal ‑ 462 036, Madhya Pradesh, India. Key words: , denture marking, forensic odontology, palatal rugoscopy, E‑mail: drsunilmishra19@gmail. prosthodontics com

Introduction postmortem influences will survive longer than other body tissues as the materials used to restore damaged teeth are orensic odontology is the that is extremely resistant to physical, chemical, and biological Fconcerned with dental . It is a relatively new destruction.[9] Forensic identification based on assessment of science that utilizes the dentist’s knowledge to serve the prosthodontic appliances is assuming greater significance, judicial system. Human identification relies heavily on the as labeling of dentures and other prosthetic appliance could quality of dental records.[1] Forensic odontology, as a science, provide vital clues for patient identification.[10] did not appear before 1897 when Dr. Oscar Amoedo wrote his doctoral thesis entitled “L’Art Dentaire en Medecine Harvey defined forensic as that branch of forensic Legale” describing the utility of dentistry in forensic medicine, which in the interest of justice, deals with the medicine with particular emphasis on identification.[2] Dental proper handling in examination of dental evidence with the identification plays a key role in natural and man‑made proper evaluation and presentation of dental findings.[11,12] disaster particularly aviation disaster.[3‑6] The most common The professionals and members concerned with forensic role of the forensic dentist is the identification of deceased science are trained at an international level to positively individuals.[7] Dental structures are the hardest and most and accurately identify the individual who has gone resilient tissues of the human body.[8] Teeth on exposure to missing or is lost or deceased or victimized. The digital orthopantomogram of every citizen can be stored in the Access this article online chip of the national identification card of the citizen along Quick Response Code with other information. The same could be retrieved and Website: analyzed when necessary using the required software.[13] www.jfds.org History DOI: 10.4103/0975-1475.137045 There were historical of identification of individuals based on assessment of prosthodontic

154 Journal of Forensic Dental Sciences / September-December 2014 / Vol 6 / Issue 3 Mishra, et al.: Prosthodontist in forensic odontology appliances. During the US Revolutionary War in 1775, DNA Identification Paul Revere, a young dentist, identified war casualties by bridgework.[9] In 1835, a gold denture helped in Methods of human identification that are acknowledged identifying the burnt body of Countess of Salisbury. After as scientific are fingerprint, DNA, dental, and medical the Second World War, 819 of the 3000 of the unidentified characteristics.[18] Because of the resistant nature of dental dead soldiers were denture wearers. But unfortunately, tissues to environmental assaults, such as incineration, only nine persons of those who wore dentures could immersion, trauma, mutilation, and decomposition, teeth be identified.[14] Dr. Goerge Parkman, a professor in represent an excellent source of DNA material.[19] When Harvard university, was killed by Dr. J W Webster in conventional dental identification methods fail, this biological November 1849. The body was completely burnt but material can provide the necessary link to prove identity.[20] identified by charred fragment of a tooth fused to gold DNA identification is expensive, technically demanding, and by Dr. N C Keep, who had made a removable partial logistically difficult to implement on large scale.[21] In case of the denture for Dr. Parkman. In April 1968, a badly mutilated tsunami in Thailand, it proved to be a relatively unimportant body was found on the railway line at Mt. Kuringai near method of identification. DNA identification should not be Sydney was identified by upper acrylic denture bearing a considered as a first live method of identification, but rather name inscribed on it.[9] Identification of European tourists should only be implemented when physical, fingerprint, and in tsunami are done by gold inlay, crown, bridge work, dental methods have been unsuccessful.[22] and dental implants.[15] Photographic Superimposition Dental Identification When examining whether a denture left at investigation A prosthodontist can employ various methods and scene belongs to an unknown set of skeletal remains is techniques available in literature; few were enumerated more troublesome. To demonstrate identity between below, and can play an important role in forensic a complete denture and a skull is difficult since the identification. There are various process and system morphological characteristics of the denture base, employed for identification and prosthodontist can including the arrangement of the artificial teeth, have to become part of this team and render there services in a be compared with those of the surfaces of the jawbones, better way. which cannot be observed from the outside. In cases like this, superimposition and X‑ray computed tomography are Comparative Dental Identification effective for establishing proof of identity.[23]

The central dogma of dental identification is that postmortem Palatal Rugae in Identification dental remains can be compared with antemortem dental records to confirm identity.[8] For dental identification Authors have described the use of palatal rugae patterns to be successful, antemortem data need to be available. rendered on dental casts to compare with found This relies heavily on dental professionals recording remains. Positive identifications have resulted from this and keeping dental notes, radiographs, study models, technique.[24] The pattern of these rugae is considered clinical photographs, etc. Postmortem data are recovered unique to an individual and can be used as reliable method characteristics from an unknown body.[1] in postmortem cases. The anatomical position of the rugae inside the mouth surrounded by cheeks, lips, tongue, The Intelligent Dental Identification System buccal pad of fat, teeth, and bone keeps them well‑protected from trauma and high temperatures. Thus, they can be Incorporates the design and development of dental records, used reliably as a reference landmark during forensic dental database, and identification models. From the ability identification.[25] Palatal rugae have been equated with of data structure analysis, Intelligent Dental Identification fingers and are unique to an individual.[26] It can be of special System (IDIS) can integrate all important dental data interest in edentulous cases and also in certain conditions necessary for identification purposes.[16] where finger prints cannot be taken, such as burnt bodies or where bodies have undergone severe decomposition. By Disaster Victim Identification process the identification of the rugal pattern a prosthodontist may identify the bearer of upper denture.[27] This consists of four main steps, that is, body tagging and bagging, finger printing, , and forensic Denture Labeling and its Important in dentistry. Forensic dentistry team was divided into two Forensic Dentistry parts, that is, dental examination and dental radiology. Prosthodontist can play a key role in forensic dentistry Marking dentures has been well documented as a useful team.[17] aid in the identification of the following: Victims of

Journal of Forensic Dental Sciences / September-December 2014 / Vol 6 / Issue 3 155 Mishra, et al.: Prosthodontist in forensic odontology fatal disasters, misplaced dentures in hospitals, nursing on some occasions. This included 19.9% of general dental homes, and institutions, as well as patients who suffer practitioners, 25% of specialist prosthodontists, 57.1% of from unconsciousness or psychiatric problems such practitioners with training in forensic odontology, and as traumatic or senile loss of memory.[28‑32] More often 43.5% of clinical dental technicians. No practitioner denture may be found close to the scene where body labeled dentures routinely. Reasons cited for not labeling is found and chances of identification of edentulous dentures included cost, lack of awareness of standards, person wearing denture are less difficult in comparison and recommendations and a belief that it was of little to those in a dentate patient. Hence denture labeling is importance.[35] very important.[3,33,34] In Australia, the Nursing Home Standards require that dentures of residents be “discreetly Denture labeling was evaluated in an Indian sample. The labeled” and marking of all dentures is recommended by results are in contrast to European studies wherein the the Australian Dental Association.[35] Denture marking majority of patients agreed to denture marking, indicating is regulated by law only in Sweden and Iceland.[36] In patient background (e.g., education level) may affect US, denture marking is mandatory but in New York perception to denture marking.[42] dentures are marked only if patient requires it. Although no legislation has been approved pertaining to this Methods of Denture Labeling matter, it is a social and an ethical obligation on the part of the practicing dental surgeon to do so. There Regulatory bodies have recommended that all prostheses have been a number of requests from individuals and be marked with an dentification system[40] and several dental organizations over the years to insist that dental techniques have been described to identify dentures.[43‑54] prostheses are labeled with the patient’s name or a unique Few methods enumerated for marking of dentures are number.[32] Unlabeled dentures have been recovered from presented in [Table 1]. patients and then fitted to casts retained by the treating dentist or laboratory, and this has been an accepted Identification of Dental Implants method of identification.[37] Nonvisual identification of victims utilizes DNA, fingerprint, In the recent Highland Towers Condominium disaster at and dental comparison as primary scientific identifiers. In Ulu Kelang, Selangor there were five edentulous victims incidents where a victim has been incinerated, there may be wearing dentures. The investigating forensic odontologist loss of fingerprint detail and denaturing of DNA. Although did not find any of their dentures having any form of extremely durable, tooth loss will also occur with extreme identifying markings, thereby frustrating the dental temperatures and the characteristics of recovered dental victim identification team from making any conclusive implants, if any, may be the only physical identifying data identification.[38] The authors in a study propose that the available.[59] The physical properties of high corrosion denture should be labeled and include the country code resistance, high structural strength, and high melting point, prefixed before the identity card number. In countries suggest the retention of intact implants following most where no identity cards are issued to their citizens, then physical assaults.[60] the driving license number, social security number or the income tax file number is the recommended identifying Berketa et al.[61] done a study to determine what changes number to be employed.[39] It has been observed in occur following cremation to bone‑supported dental numerous incinerated bodies the lower lingual posterior, implants placed within mandibles of sheep. A selection and the upper palatal posterior portions of the dentures of dental implants was photographed and radiographed. are usually spared. These sites become the choice of areas They were then surgically placed in sheep mandibles and for the marking.[38,40,41] Denture marking should also not the entire sheep heads cremated in a commercial cremator. be restricted to acrylic dentures only but also be extended Following retrieval and reirradiating of the implants, image to those made from cobalt‑chromium. Cobalt‑chromium subtraction evaluation of the radiographs was recorded. appliances resist melting even in some cases of incinerated Photography within the retrieved implants revealed remains. Identifying markings can also be incorporated the batch number within the Straumann™ implant was in orthodontic appliances, maxillo‑facial reconstructive still visible, which could significantly add weight to the prostheses, crowns, and bridges.[39] identification of deceased persons.

A survey undertaken to determine the extent of the practice Berketa et al.[60] did a study to ascertain if the batch number of denture marking in South Australia, the methods in was still identifiable following intense heat exposure in use, and the attitudes of , dental technicians, and a furnace. The information regarding batch number was institutions to it. The results indicated that 24.5% of all laser etched within the chamber of their implant. The result practitioners providing removable prostheses to their indicated that there was an intact identifiable batch number patients include an identifying label as part of the service on removal of the abutment.

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Table 1: Methods of denture labeling Method Procedure Advantage/disadvantage Engraving A label‑maker is used to prepare an embossed plastic The technique is simple and facilitates This system involves marking pattern, which in turn is used to insert a marked metal incorporation of a stable and fireproof label in the models during fabrication, so plate in to a denture framework. The use of small tape the denture base material that denture carries the marked makes it possible to include more than 6 letters on one information.[53,54] lingual flange.[52] Scribing/disking Personal identification details were input into a The advantages of this method are large This method involves marking of the computer where using an image editing software numbers of letters could be included in the denture after it has been fabricated. program the letters were reversed and printed on paper. personal identification label without space One method is to write one’s name Then, methyl methacrylate monomer was applied on constraint; and mechanical strength of on the base of the denture with a the area of the specimen plate where the mark would denture would not be adversely affected waterproof marker or a graphite pencil be located. The paper with the mark was pressed on after abrading the denture surface. the specimen plate and the binder resin that adhered to [14] Other method is printing personal the paper melted in the methyl methacrylate monomer identification labels directly on the on the denture surface. In this manner, identification surfaces of dentures without any details borne by the toner on the paper were removal of the denture base resin.[10] transcribed to the surface of the denture.[10] Inclusion Computer‑printer denture microlabeling system Placement of metallic, nonmetallic A micro label procedure uses a transparency film Advantages of this method are it is easy to labels or microchips upon which with name and other information of the patient use, cost‑effective, the background of the the name and service number is incorporated onto it. Chemically treat printed label is clear and only the black images of the inscribed on to the denture. Various transparency film with 100% cyanoacrylic acid esters characters of the label can be clearly seen. It methods of inclusion are present in adhesive solution before incorporating into a denture. has minimal esthetic impact on the patient literature Incorporate the label into the denture during the Disadvantage is it cannot withstand fire packing stage. The label can then be coated with a thin layer of autopolymerized clear acrylic resin.[49] Stainless steel tape method This method is quick and reliable over a long period. Advantages of this method are it uses Patient’s identification details are inscribed on to equipment readily available in any dental the plate. Stainless steel tape is to be position laboratory, not a time consuming process posteriolaterally in the maxillary denture and at lingual and easy to use. This technique can be used flange in the mandibular denture. After inserting the for both complete and removable partial stainless steel tape it is covered with clear acrylic.[50] dentures. Disadvantage of this technique arise when relining becomes necessary Lenticular card It is a technology in which the lenticular lens is used to Advantage of this technique is, it is durable produce images with an illusion of depth, morphology or and waterproof. It also does not interfere with the ability to change or move as the image is viewed the oral function, because of its small size from different angles. Lenticular printing is a multistep The disadvantage of this technique is that process consisting of creating a lenticular image from the information can never been changed., The at least two or more existing images, and combining it procedure can be used only after the denture with a lenticular lens. Each image is sliced into strips, is processed, as covering the lens surface which are than interlaced with one or more of the other with acrylic resin during denture processing images. These are printed on the back of a synthetic will not allow the information to be seen paper and laminated on the lens.[55] clearly. It may not withstand a fire Bar coding Automatic identification using barcodes incorporated into The advantages of this method are large dentures has been developed. Barcode systems can numbers of data can be stored contain large amounts of data. However, the scanning Disadvantage of this method is the curvature of barcodes may be difficult due to the opacity of the of the denture may cause distortion of the acrylic resin, and for this reason the use of clear acrylic barcode, making it unreadable. Also, barcode resin is recommended with this system.[56,57] technology may present practical obstacles for denture prostheses Incorporation of microchips Radio Frequency Identification (RFID) is a method of Advantages are it is esthetically acceptable, identifying by using radio waves. It consists of a data it does not interfere with oral function carrier, referred to as tag and a reader with an antenna. and its data can be modified at any time. Tag consists of a microchip with patient’s information. Disadvantages are the tag is not fireproof Reader reads the information contained in the tag. First, and it is an expensive technique program the tag by connecting to the computer then incorporate the programmed tag into the channel on the external posterior buccal surface of the denture. Place clear acrylic resin over the tag to recountour the denture.[58]

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