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Examination of Skull and mandibleBy Dr Manoj PatekarJunior residentDept of Forensic medicineGMCH, Aurangabad

HUMAN SKULL

MALEFEMALEGENERAL Large, heavy, rugged, muscular ridges [more prominent]. Smaller, lighter, smoother, muscular ridges [less prominent].FRONTAL SURFACEIrregular and roughSmootherGLABELLA ProminentLess prominentSUPRA ORBITAL RIDGEProminentLess prominentORBITS

Square shaped with round margins, lower on face.Rounded with sharp margins, higher on face.

MALEFEMALENASALAPERATUREHIGHER, NARROWER, MARGINS SHARP LOWER AND BROADER.FRONTO-NASAL JUNDistinct angulationSmoothly curvedFRONTAL EMINENCELess prominentMore prominentTEETHLargerSmallerMALEFEMALECHEEK BONE Heavier, laterally archedLighter, more compressedMASTOID PROCESS Medium to large, round, blunt.Small to medium, smooth, relatively pointedZYGOMATICARCH More prominentLess prominentOCCIPITALAREA Muscular impression and protuberance prominent. Muscular impression and protuberance not prominent .

MALE FEMALEPARIETAL EMINENCELess prominentMore prominentBASESites of muscular insertions well marked.Less markedDIGASTRIC GROOVE DeepShallowPALATELarger U ShapedSmaller parabolicFORAMINALargerSmallerAGEESTIMATIONAge estimation in skull is done by 1>> Fusion of fontanelle 2>> Fusion of sutures 3>> Fusion of bone 4>> Dental examination.

IN NEWBORN

FONTANELLEThe posterior fontanelle closes between birth to one and half months after birth.The two posterolateral fontanelle closes within 2 to 3 months after birth.The two anterolateral fontanelle closes within 6 months after birth.The anterior fontanelle closes and the two halves of the mandible unite at the 2nd year.

SUTURES FUSION OF SUTURES >>>>The union occurs in the inner side of the skull 5 to 10 yrs earlier than on the outer side.Suture closure in skull occurs later in females than in males.METOPIC suture >>> 2 to 4yrs Sagittal suture >>> 30-40 yrsCoronal suture>>> 40-50 yrsLambdoid suture>>>40-50 yrsThe basioccipital fuses with the basiosphenoid at the 18 to 22 years.

Fusion of bone 2nd year Sqaumous part of the occipital bone unites with condylar part6th year- sqaumous part of the occipital bone unites- with basilar part IN ADULTS

SKULL FRACTURESurgical classification Simple fracture Open or compound fracture(1)Simple Fracture It is fracture of bone with intact skin overlying. Compound Fracture It is the fracture with open pathway to the atmosphere or fractured bone penetrating the overlying skin.Fracture of SkullFracture of vaultFissured fractureComminuted fractureDepressed fractureGutter fracturePonds fractureDiastatic/Sutural fracturePerforating fractureCut fractureHeat fractureCrush fractureContre-coup fracture

Fracture of Base

Longitudinal fractureTransverse ( Hinge Fracture)Ring Fracture

Types of hinge fracture- type I, type II, type III

181)Fissured fracture Commonest type of skull fracture.Involving both tables of skull.It may be straight or curved, circular, stellateUsually follows the path of thin & less resistant bones than that of thicker & more resistantbones.

192) Comminuted fracturebreaking of bone into multiple pieces.

203) Depressedcomminuted fracture with depression at that area. This gives clue regarding the striking surface i.e. weapon used. Hence it is also called as Fracture Ala Signature.e.g. blow by hammer over the skull.

214) Gutter fracture If weapon strikes the skull tangentially, outer table of skull gets fractured causing deformity in the form of gutter.e.g. glancing bullet injury. 225) Pond/Indented fracture Here, indentation of skull bone occurs only d/t elasticity of skull bone. Usually seen in infants d/t application of forceps during delivery.

236) Diastatic/Sutural fracture It may be sutural separation (alone) or d/t extension of fissured fracture.

247) Perforating fracture Through & through fracture. e.g. sharp pointed object or bullet injury.8) Cut fracture Usually it results d/t blowing of heavy cutting weapon. e.g. axe

259) Heat fracture Usually it occurs at sutural site d/t production of gases inside the cranial cavity in cases of extensive burns.10) Crush fracture- Here, crushing of skull bone into multiple pieces with distortion of skull & face.11) Contre-coup fracture- Fracture occurs in the direction of force & at the thin & less resistant part of bone

Crush fracture26Fracture of Base of SkullLongitudinal fractureHinge FractureTypes of Hinge FractureType IType IIType III

Type I27

3) Ring fractureCircular fissured fracture surrounding foramen magnum. It results d/t:-Transmission of force through vertebral column in cases of fall over feet or buttock. Transmission of force through mandible in cases of blow over chin.Severe blow over vertex which drives the skull downwards towards vertebral column.Sudden violent twisting of head on the spine.

29AM fracture detected by e/o blood stain in & around the fractured edges.Base of skull more susceptible to fracture d/t irregular shape & several foramina passing through it.Fracture of cribriform plate of ethmoid -Bleeding through nostrils -CSF rhinorrhoea

30Fracture of petrous part of temporal bone: -Bleeding through ears -CSF otorrhoeaFracture of basi-spenoid: -Bleeding through mouthFracture of posterior cranial fossa: -escape of blood & CSF into tissues of back of nape of neck.

31Puppes ruleWhere two or more separate fractures occur from successive impacts and meet each other, the sequence of injuries may be determined by 'Puppe's rule'. The later fracture will terminate at (that is, not cross) the earlier fracture line.The course of a later fracture will be interrupted by an earlier pre-existing fracture line.

Age of injury of skullHealing of skull fractures occurs without any formation of visible callus externally or internallyWithin 7 days- edges get glued by serous exudateWithin 2 weeks- deposition of calcium salts , edges shows erosionWithin 3-4 weeks- edges smoothened, new osseous tissue depositedWithin 3 months- edges apposed, bony union, but margins not apposed

Complications of fractures of skullInjury of the brain and meninges Intra-cranial infectionInjury of cranial nervesInfection elsewhereAs sequelae

MANDIBLE

MALE FEMALEGENERALLARGER ANDTHICKERSMALLER AND THINNERSHAPEV SHAPEDU SHAPEDCONDYLESLARGERSMALLERMENTAL TUBERCLELARGE ANDPROMINENTINSIGNIFICANTTEETHLARGERSMALLER MALE FEMALECHINSquareRoundedBODY HEIGHTAt SymphysisgreaterAt SymphysissmallerASCENDING RAMUSGreaterbreadthSmaller breathANGLE OF BODYANDRAMUSLess obtuse,Prominent and evertedMore obtuse,Not prominent,invertedAge estimation>>At birth- two halves of mandible unites by fibrous symphysis menti-coronoid process projects above the condyle>> At 1-3 years-two halves joins at symphysis from below upwards with separation at alveolar margins- Chin devlops, body elongates with height increase>> At 6 years-- size increases, remodelling continous with bone added at posterior border at ramus.>> Adults-Alveolar and subalveolar areas equal in depthMental foramen midway between upper and lower border Ramal height increase, condyloid process at a higher level than coronoid process.

Importance of angle of mandibleMedico-legal importance of anatomicalangle : Opinion as to sexMedico-legal importance of medicolegal angle: Opinion for rough estimation of age.

AGE ESTIMATIONby

DENTALEXAMINATION

TOOTHERUPTIONCENTRAL INCISOR ( LOWER) (UPPER )6 TO 8 months7 TO 9 monthsLATERAL INCISOR (UPPER) (LOWER)7 TO 9 months10 TO 12 monthsCANINE18 monthsFIRST MOLAR

12 TO 14 monthsSECOND MOLAR20 TO 30 monthsTEMPORARYTEETHPERMANENT TEETH

7 TO 8YEARS8 TO 9YEARS11 TO 12YEARS9 TO 10YEARS10 TO 11YEARS6 TO 7YEARS12 TO 14YEARS17 TO 25YEARSTEMPORARYTEETHPERMANENTTEETHSIZESmaller, lighter and narrow Heavier, stronger and broaderCOLOURChina-whiteIvory-whiteNECKMore constrictedLess constrictedEDGESSharpSerratedROOTSRoots of molar are smaller and more divergentLarger and less divergentNUMBER2032CHARTING OF TEETHUNIVERSAL SYSTEM R 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 L

PALMERS NOTIFICATIONR 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 L

FDI(permanent teeth) FDI(temporary teeth) R 1 2R 5 6 4 3 L 7 8 Lreferences3rd edition Knights forensic pathology.Forensic medicine and toxicology , 5th edition, By Krishnan Vij.The essentials of Forensic medicine and toxicology , by Dr. K S Narayan Reddy.Human anatomy, volume 3 head neck and brain B D Chaurasia 4th edition

Acknowledgments Dr K.U.Zine Sir, Professor and HeadDr R.N.Wasnik Sir, Associate ProfessorDr Sushim Waghmare Sir, Assistant.ProfessorDr. Sandeep Haridas Sir, Assistant.ProfessorDr. Mandar Sane Sir, Assistant.Professor

Thank you