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Dental photography

INTRODUCTION

Why should one understand and use dental digital photography?

The answer to that is actually quite simple.

Because esthetic dentistry is a visual art, form, therefore displaying, communicating,

and educating, about the process accurately, efficiently, and professionally is

essential for success. What better tool to accomplish this than the digital camera?

Patients easily forget what they looked like before they started treatment. When

anything to do with the appearance is affected, not using a camera puts the

practitioner at substantial legal risk.

Unfortunately, human memory is terribly short, and patients’ recollection of how

their teeth appeared before treatment is often quite hazy, which leads to the potential

for dispute. Even for something as straightforward as tooth whitening, patients may

feel that their teeth have not responded to treatment and thus may seek a refund of

fees. If this occurs, showing them pretreatment and post-treatment clinical

photographs of how the teeth responded to the whitening process should clear things

up.

The patient has simply become accustomed to the new appearance of the teeth very

quickly. Thus photography has a role in things as simple as bleaching and as complex

as extensive rehabilitation; this makes the camera as essential an instrument as dental

loupes, handpieces, and other basic tools in performing esthetic dentistry.

In addition, all practitioners learn by seeing clinical photographs in books and

journals. Viewing their own patients in this same way frequently improves their

diagnostic abilities and ensures that potentially important aspects of the treatment

are not overlooked.

Once one has identified the needs and wants for incorporating digital photography

into their practice, there are important questions that must be asked and answered:

*how do we choose the right digital camera?

*how do we take or capture our digital photographs correctly?

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HISTORICAL REVIEW:

Dental photography has always been an important potential adjunct to dental

records. However, before the advent of recent esthetic procedures, the dental camera

could have been considered a dispensable item. With today's technologic advances

and the proliferation of new procedures, yesterday's luxury item, the digital camera,

has become part of today's indispensable armamentarium.

HISTORY OF CONVENTIONAL PHOTOGRAPHY

In the early half of the twentieth century, dental photography was limited to the

professional photographer's studio.

Before the early 1960s, dental photography was impractical because of a lack of

proper through-the-lens viewing, lighting complications, exposure difficulties, and

affordability.

The major advance in dental photography centers on the shift from film-based to

digital imaging. Film was a great step forward when introduced over a century ago.

Clinically, however, it was not a useful or efficient tool, as it was impossible to

analyze the images immediately and check whether the desired views had been

obtained. Pictures were taken as slides because slide films were considered best for

color reproduction. However, the film had to be sent out to commercial laboratories

for processing.

Due to the specialized processing needed, there was always a delay in return of the

photographs, often 1 to 2 weeks. Showing patients their own teeth was inconvenient

owing to the need to project the images. Copying images when required was an

added inconvenience, as it was very difficult to achieve consistent quality and color

accuracy in duplication.

It was very difficult to show the pictures to patients at the chairside; thus, for most

practitioners, excepting those taking post-graduate examinations or clinicians on the

lecture circuit, photography was not considered a routine practice.

Digital photography has been around for some time, but it was only in 2003-2004

that a good-quality digital single-lens reflex (SLR)–type camera become affordable

for most practitioners.These cameras, which incorporate a mirror and a prism, allow

the photographer to see the same image that the lens is "viewing". Non-SLR cameras

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(called rangefinder cameras) use a viewing window located 3 to 4 inches above the

film plane. This means that the image the viewer sees and the image the film exposes

are not identical. This problem is referred to as parallax, and it makes accurate

closeup dental photography impossible.

Figure 1 A single lens reflex (SLR) camera with the mirror in the view-finding position. In this position the mirror and prism mechanism allows the viewer to see the exact same image as the camera lens.

Figure 2 The parallax problem of range finder (any non-SLR) cameras.

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USES OF DIGITAL AND CONVENTIONAL DENTAL

PHOTOGRAPHY

1-Quality Control

Dental photography can be an effective quality control measure. The magnified

image in a dental photograph often highlights imperfections that the clinician may

have overlooked; such feedback is an excellent learning device.

2-Patient Records

Photographs are an effective treatment planning adjunct. With a thorough medical

history, intraoral charting, study models, radiographs, and intraoral and extra oral

photographs, the treatment planning may be accomplished almost as if the patient

were present. In addition, attaching a photograph to the outside of the patient's record

facilitates instant recall of that patient by all staff members.

3-Case Presentation

Photographs of the patient's current condition enhance the patient's understanding of

a proposed treatment plan, especially when accompanied by a portfolio of before

and after photographs of similar, successfully treated cases. In addition, the

acceptance of treatment plans may increase through this approach. Digital

photographs combined with the proper software can even be used to predict clinical

results.

4-Treatment Documentation

Before and after photographs provide accurate visual documentation.

Photography also improves the quality of referrals. If a general practitioner sees a

suspicious red lesion under a patient’s tongue, it is quite easy to take a picture of it,

put that into a referral letter or attach it to an email, and send it to the oral medicine

specialist. A complex restorative referral can be made much easier for the

practitioner receiving the referral if photographs can be included along with

radiographs and the referral letter as it allows the treatment planning process to begin

even before the patient visits the prosthodontist’s office. Not only does this allow

the dentist to document what is being done, but it helps in caring for patients more

comprehensively and more efficiently. (11)

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5-Laboratory Communication

A color photograph or slide of the restorative case facilitates communication with

the laboratory. Photographing the shade tab adjacent to the teeth to be restored makes

the chances of success higher.

6-Education

Photography can be used for conferring with a colleague or for lecturing at dental

meetings or study clubs, or in table clinics. It can be used in publications or, as

mentioned above, in patient consultation. Again.

7-Community Service

Presentation to local organizations raises the dental health consciousness of the

community, improves the image of the profession, and expands the dentist's future

patient base by creating a greater awareness of advances in dentistry.

8-Marketing

Photography has a tremendous capacity to help any dental practice grow more

effectively through internal and external marketing.

DIGITAL CAMERAS

2 types available, point and shoot and digital SLR cameras.

The modified point-and-shoot cameras have

an important place in clinical photography.

The early consumer-level digital SLRs were

more expensive than some practitioners

could afford.

The point-and-shoot cameras have the

advantage of being compact, light, and (at

that time) relatively less expensive. Their

disadvantages relate to their distinct

operational and a long learning curve, the

need for a substantial degree of practice and

familiarity with the setup to get the best

images. . Figure 3 Modified point-and-shoot camera

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With digital photography, there is the

advantage of immediately verifying that the

desired image has been captured. It is very easy

to look at the picture on the camera’s screen,

identify what is not right, and retake it

immediately. There is no need for processing,

so images can be viewed immediately, and they

can be shared with patients right away.

Digital photography has both advantages and

disadvantages.

Some of the advantages are:

• Instant photographs are produced.

• The need to develop film is eliminated.

• Images can be previewed before the picture is taken.

• Only desired images are printed.

• Instant image duplication is possible without degradation of images.

• Images can be manipulated by computer.

• Images can be transmitted over telephone lines.

• Images can be placed on the Internet.

• Waste is reduced because poor images can be deleted.

Some of the disadvantages are:

• A significant learning curve is involved.

• Startup costs are higher than conventional photography.

• Additional time is required for the operator to print pictures.

• The risk of data loss is greater because no hard copy exists unless a printed copy is

produced.

• The resolution is lower than with standard film.

Despite its disadvantages, digital photography is increasing in popularity.

Figure 4 DSLR camera

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There are two types of digital cameras available today for taking dental digital

photography:

*single lens reflex SLR digital cameras

*point-and-shoot digital cameras

SLR Point-and-shoot

Actual image viewed is what is captured Image captured is computer generated

Large charge-couple device CCD or

complimentary metal-oxide semiconductor

CMOS chip, resulting in a more true-to-

life-size image therefore you see what you

see

Smaller CCD or CMOS chip, therefore

the image is computer extrapolated

Interchangeable lenses Fixed lens

Automatic and manual control Limited manual control

More expensive Less expensive

Depth of field easily controlled Limited depth of field control

Ideal for all views of dental photography Limited views captured therefore

images must be digitally enhanced

Steeper learning curve Relatively simple to use

Dental photography requires ring/point

flash

Dental photography requires special

modifications like lens adapters and

flash diffusers

SUMMARY

Optimal photographs can be produced if the clinician has a proper understanding of

the equipment and the mechanisms of photography. Correct exposure, depth of field,

and composition are essential.

When a flash is used as a light source, the process is significantly simplified because

most other variables cannot be altered; exposure is controlled only by the aperture

setting, depth of field is automatically determined by the chosen focus point, and

composition and magnification are determined by personal preference. Attention to

these easily controlled variables makes dental photography simple and satisfying. (12,

14, 15, 20)

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SMILE LITE & SMILE CAPTURE

A revolutionary tool that

boosts the iPhone macro

capabilities to transform it into

a complete dental photography

system. Is not only a cover that

allows the Smile Lite to be

fitted to your iPhone, but as

well a concept of professional

dental photography where the

images are obtained in a very

similar way than is done with

the DSLR cameras. Smile Lite

is a revolutionary tool which

brings you RELIABILITY,

SIMPLICITY and

EFFICIENCY it allows you to

drastically reduce the risk of

mistakes during shade-taking.

Equipped with 5500°K

Figure 5

Figure 6

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(daylight) calibrated L.E.D. (Light Emitting Diodes), Smile Lite provides natural

and neutral light, stable and reliable regardless of the time of the day or the weather

outside (sunny or cloudy). Smile Lite is equipped with a special polarizing filter that

produces near to zero light interference easily adaptable to Smile Lite. This

«magical» filter amazingly annihilates light reflection (specular and diffuse) and

allows the user to observe the teeth in a totally new way: easier appreciation of color,

better understanding of the depth and transparencies, enhancement of the tiniest

details and characterizations.

Smile Lite is selling worldwide because of the versatility between natural light and

polarized light, because of its size, design, long lasting battery and many other

convenient features as the universal USB charger that can be plugged in the

computer, wall plug and any other device with a USB port.

Having a very narrow camera, and thus a very small diaphragm, the depth of field

given by the iSight camera is more than ideal. The lightning given by the 6 LED

form the Smile Lite enhances the texture of teeth, and gives a very accurate color in

every shot. The big display of the iPhone allows the user to capture what they see

through the screen and the ability to perceive many details before the actual pictures

is taken.

Why on iPhone?

It was clear that having

a compact device as the

Smile Lite, it was

necessary to have a

compact device to

capture the digital

media.

The choice of iPhone

was determined in an

early stage for having at

the moment the only

camera that was able to focus from close distances, that is, a true macro mode

without zoom.

Camera definition, processor speed, screen resolution were among other features an

important reason for which iPhone was selected as the ideal device for this goal.

Figure 7

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BASIC ARMAMENTARIUM

The basic equipment required for proper dental photography is digital camera, a

macro lens, a flash unit, and accessories such as mirrors and lip retractors.

1-Digital SLR Camera Body

The camera body's only function is to

hold the sensor and to trip the shutter

for the proper amount of time. Because

the shutter speed for flash photography

is predetermined by the manufacturer,

the camera body's function is greatly

simplified compared with nondental

photography. For these reasons, the

operator need not make a large

expenditure on this part of the system.

The main consideration is that the

camera body must be compatible with

the macro lens chosen. To achieve this compatibility, most manufacturers make

bodies with interchangeable mounts.

2-Macro Lens

Macro refers to the closeup focusing

capability of the macro lenses.

Several reliable macro lenses are on

the market that perform well in

dentistry. They commonly have a

focal length range of 90 to 120 mm.

These lenses produce less distortion

and allow more comfortable working

lengths than lenses with shorter or

longer focal lengths. At least one

manufacturer sells a 55-mm lens.

This focal length works well for

most dental purposes, although the

working distance for closeup views

Figure 8 DSLR camera body

Figure 9 macro lens

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is short and full face views are distorted.

Magnification capability is the second important factor in choosing a lens. Many

good macro lenses achieve a 1:1 magnification without additional converters or

extenders to expand the magnification range. Some older models produce only 1:2

magnification and require extenders to achieve 1:1 magnification.

In dental photography the following reproduction ratios are important

(approximate):

1:10 portrait photography.

1:2 image of a set of teeth.

1:1.2 whole set of anterior teeth.

1:1 anterior teeth with partial canines or premolars and molars filling the format.

2:1 two maxillary anterior teeth.

3-Flash

To obtain proper lighting effects in intraoral photographs, the light must be mounted

on the end of the lens barrel; otherwise the lips will cause harsh shadows. The choice

for proper lighting is either a point or a ring flash, depending on the operator's needs

and preferences.

Figure 10 Flashgun

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Both units can be incorporated into the same system, allowing for personal

preference in each situation; the added expense of having both types of flash units is

minimal.

4-Proper lip and cheek retractors are made of

clear plastic. The clear plastic allows the tissue

to be seen through the retractor (reducing visual

distraction), and the double end allows

versatility because the two ends can be different

sizes. Plastic retractors can be reshaped with an

acrylic bur to any size the operator finds useful.

Sometimes metal retractors can be used in

combination with buccal mirrors (long slender

mirrors that reflect buccal views and fit between the zygomatic arch and the lower

border of the mandible).

Figure 11 DSLR camera with dual point flash Figure 12 DSLR camera with ring flash

Figure 13 cheek retractor

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Front surface glass mirrors

perform best because they

produce a clearer single image

view, compared with the

double (shadowed) view of

back surface mirrors. Chrome

plated mirrors also perform

well but require a larger

aperture setting for proper

exposure because they do not

reflect light as brightly as glass

mirrors.

Two differently shaped

mirrors are required, one for full occlusal views and one for buccal and lingual

views. The clinician with a practice composed of all age groups probably needs at

least two sizes of each.

5-Film

Digital photography does not use film; "film speed" is a function of the CCD light

sensor or CMOS chip.

SUMMARY

The best combination is therefore an SLR camera, a macro lens, and a ring flash.

The camera sits assembled in the operatory, ready to be picked up and pointed at the

patient. In addition, any practitioner taking photographs will need cheek retractors

and mirrors. The more sophisticated practitioner may prefer visual contrast and can

use black-out sticks in close-up shots to eliminate the out-of-focus background of

the mouth. This is an issue of personal preference but improves the final picture

significantly.

Figure 14 set of mirrors

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BASIC FUNCTIONS CAMERA SETTING

There are four exposure settings or modes in the majority of DSLR cameras and all

employ a through-the-lens-metering system:

Aperture priority

The aperture is the lens opening. So the aperture

control allows the photographer to control how far

the lens is opened when a picture is taken. The

farther the lens is opened, the greater the amount of

light that is allowed into the camera and the lighter

the exposure. Once the aperture value has been

selected, the camera automatically selects the

correct shutter speed to produce an acceptable

exposure. By setting the aperture value, the

photographer decides on the depth of field (the

plane of sharp focus) in the image. One can select

a small aperture value (a high f-number) for a larger

plane of sharp focus and a large aperture value (a

small f-number) for a narrow plane.

A depth of field problem is that the entire dentition can only be photographed

completely in sharp focus if the focal plane is positioned carefully. Therefore, do not

focus on the anterior teeth. For a frontal view, the point of focus should be around

the canines.

Shutter priority

The shutter speed controls the amount of light that enters the lens when the picture

is taken. The more light desired, the slower the photographer should set the shutter

speed. Once the shutter speed has been selected, the camera automatically selects

the correct aperture value to produce an acceptable exposure. This mode is not used

for the purpose of intra-oral photography.

Program

The camera automatically selects both the aperture and shutter speed based on a

built-in-program.

Figure 15

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Manual

The photographer selects both the aperture and shutter speed, but the camera’s built-

in-meter can still be used to calculate the correct exposure.

For dental photography, it is important to be in control of the exposure features.

Therefore, either the aperture priority or manual exposure settings are preferable.

RECOMMENDED DIGITAL SLR CAMERAS AND THEIR

SETTINGS FOR INTRA-ORAL PHOTOGRAPHY:

Camera Nikon DSLR Canon DSLR Nikon DSLR

Flash Nikon R1C1 flash Sigma ring flash or

canon ring flash

Sigma ring flash

Power setting TTL eTTL ¼

Aperture value F22 F25 F25

Shutter speed 1/160 1/125 1/160

INTRAORAL TECHNIQUE

The post treatment photograph can be

repeated at any time, but the

pretreatment photograph can never be

reproduced.

Some photographs may require only the

patient's assistance, whereas others

require assistance from the patient, the

photographer and one or even two staff

members.

Figure 16

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ANTERIOR (FRONTAL) VIEW

Figure 17 anterior view

The anterior or frontal view is the most common view used in dental photography.

It ranges from a single tooth to a full face view.

Clinical Technique

1. Seat the patient semi-upright with the head turned toward the photographer.

2. Place retractors at the corners of the mouth and pull gently outward and forward

so that the buccal tissue is away from the teeth.

3. If a point light is used, it should be at the 3 o'clock or 9 o'clock position to create

a sense of depth with shadows.

4. Hold the camera so that the occlusal plane is perpendicular and centered

horizontally to the plane of the sensor (CCD or CMOS).

5. Align the patient's midline with the center of the frame. Adjust the magnification

(usually 1:2).Compose the photograph to include all relevant teeth and soft tissue.

6. Focus the camera while correcting the magnification.

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MAXILLARY OCCLUSAL VIEW

The maxillary occlusal view is the most difficult view to obtain and requires

patience. This photograph usually requires assistance from two staff members.

Clinical Technique

1. Seat the patient in a semi-upright position with the head turned toward the

photographer.

2. Instruct one of the assistants to gently rotate the retractors upward and outward.

3. Instruct the other assistant to rest a full-arch mirror on the maxillary tuberosity,

not on the teeth. The mirror should diverge from the occlusal plane as much as

possible so that the camera can be held 90 degrees to the plane of the mirror.

4. If a point light is used, it should be at the 9 o'clock or 3 o'clock position.

5. Hold the camera so that the plane of the sensor (CCD or CMOS) is parallel to the

full arch in view.

6. Align the midline of the palate with the center of the frame and adjust the

magnification (usually 1: 2). Compose the photograph to include all relevant teeth

and soft tissue.

7. Focus on the premolar area while correcting the magnification.

Figure 18 maxillary occlusal view

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MANDIBULAR OCCLUSAL VIEW

Figure 19 mandibular occlusal view

The mandibular occlusal view is the reverse of the maxillary occlusal view.

Clinical Technique

1. Seat the patient in the supine position, parallel to the floor.

2. Tip the patient's head back slightly and turn it toward the photographer so that the

occlusal plane is parallel to the floor.

3. Rotate the retractors gently downward toward the mandible and outward.

4. Rest a full-arch mirror on the retromolar pad not on the teeth.

5. The mirror should diverge from the occlusal plane as much as possible so that the

camera can be held 90 degrees off the plane of the mirror.

6. If a point light is used, it should be at the 9 o'clock or 3 o'clock position.

7. Hold the camera so that the plane of the sensor (CCD or CMOS) is parallel to the

full arch in view.

8. Align the midline of the tongue with the center of the frame and adjust the

magnification (usually 1:2). Compose the photograph to include all relevant teeth

and soft tissues.

9. Focus on the premolar area while correcting the magnification.

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BUCCAL VIEW

Figure 20 buccal view

Buccal views are ideal for photographing the patient's centric occlusion.

Clinical Technique

1. Seat the patient in a semi-upright position with the head facing straight for left

buccal views and toward the photographer for right buccal views (reverse for left-

handed dental units).

2. Place a buccal mirror distal to the last tooth in the arch. Move it as laterally as

possible while at the same time retracting the lip. The mirror also serves as a

retractor.

3. If a mirror is used, passively hold a single retractor on the side opposite the mirror.

4. If no mirror is used, pull the retractor on the side being photographed as distally

as comfortably possible for the patient. Passively hold the retractor on the side that

is not being photographed.

5. If a point source light is used, place it on the same side of the camera as the mirror.

6. Hold the camera so that the plane of the sensor (CCD or CMOS) is as

perpendicular to the mirror as possible.

7. Set the magnification (usually 1:1.5 to 1:2). Compose the photograph to include

from the distal area of the canine to the most posterior tooth, with the plane of

occlusion parallel to the film plane and in the middle of the frame.

8. Focus the camera on the premolar area while correcting the magnification.

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LINGUAL VIEW

Figure 21 lingual view

Lingual views of the maxilla or the mandible are obtained similarly.

1. Position the patient semi-upright with the head facing straight for right views and

toward the photographer for left views (reverse for left-handed dental units).

2. Place retractors at the corners of the mouth, rotated toward the photographed arch

and passive on the opposite side.

3. For a mandibular photograph, place a mirror between the tongue and the quadrant

being photographed, distal to the terminal tooth, parallel to the long axis of the teeth,

and pushed laterally as much as possible. For a maxillary photograph, place the

mirror against the palate in the midline, distal to the terminal tooth, parallel to the

long axis of the teeth, and pushed as laterally as much as possible.

4. If a point source light is used, place it on the same side of the camera as the mirror.

5. Hold the camera so that the plane of the sensor (CCD or CMOS) is as

perpendicular to the mirror as possible.

6. Set the magnification (usually 1:1.5 to 1:1.2). Compose the photograph to include

from the distal area of the canine to the most posterior tooth, with the plane of

occlusion parallel with the film plane and in the middle of the frame.

7. Focus the camera on the distal side of the canine while correcting the

magnification.

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OTHER VIEWS

Any of the above views can be modified to meet the needs of the user. Usually only

changes in magnification and composition are necessary to suit specific needs. For

example, if only an occlusal view of a quadrant is necessary, the buccal or lingual

mirror can be used in a similar manner as that described for the full-arch occlusal

view, along with a modification in the magnification. For a view of only the

premaxilla, only the necessary portion of a full-arch mirror is used and the

magnification is adjusted (1:1.2). The creativity of the photographer can allow for

any other specific views that are needed.

Figure 22 anterior view showing only maxillary teeth

Figure 23 lateral smile view

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EXTRAORAL TECHNIQUE

Good, finished full face and profile photographs require a pleasant colored

background. An art store can furnish art paper in a number of suitable colors. The

best usually is a pastel color that contrasts with normal hair color and skin tones. A

soft blue is the best overall. This paper can be taped to the wall in the operatory and

removed as needed.

FULL FACE VIEW

Clinical Technique

1. Position the patient approximately 18 to 24 inches in front of the background to

help minimize shadows.

2. Position the head such that a line from the ala of the nose to the tragus of the ear

is parallel to the floor.

3. If a point source light is used, place it at the 12 o'clock position.

4. Position the camera vertically at the level of the patient's eyes.

5. Set the magnification (usually 1:10). Compose the photograph to include from the

inferior border of the hyoid to above the top of the head.

6. Focus the camera on the patient's eyes while correcting the magnification.

Figure 24 full face view

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PROFILE VIEW

Clinical Technique

1. Position the patient approximately 18 to 24 inches in front of the background to

help minimize shadows.

2. Position the head such that a line from the ala of the nose to the tragus of the ear

is parallel to the floor. The teeth should be in occlusion.

3. If a point source light is used, place it on the side of the camera that the patient is

facing. The camera should be in a vertical position at the level of the patient's eyes.

4. Set the magnification (usually 1:10). Compose the photograph so that the profile

dominates the center of the frame, with the area just behind the ear visible.

5. Focus the camera on the patient's eyes while correcting the magnification.

Figure 25 profile view

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TREATMENT PLANNING

A number of years ago the American Academy of Cosmetic Dentistry (AACD)

recommended a standard set of 12 pictures for its accreditation examination, which

represented a good starting point for planning and documentation over a wide range

of situations. The views required were reflective of the limitations of film-based

photography, in which it was very difficult to magnify selected parts of an image.

The first picture should be a full-face picture, taken with the patient looking straight

into the camera, with the interpupillary line parallel to the lower border of the frame,

and the facial midline parallel to the vertical border of the fame.

Framing should include from just below the chin to just above the hairline.

All the other photographs are taken at a fixed magnification ratio of 1: 3 (the

equivalent of a 1: 2 on 35-mm film and full frame digital SLR cameras) and an

aperture of f/22 or higher to provide acceptable depth of field.

The next pictures are a series of three pictures of the patient smiling. The frontal

view has the central incisors in the middle of the picture parallel to the lower border

of the frame and the facial midline parallel to the vertical border. It is important to

note that it should be the facial midline, not the dental midline. Any discrepancy

between the dental and the facial midline will be reproduced in the photograph and

noted. After this, right and then left lateral smile views are taken, with the upper

lateral incisor just above the middle of the picture and the occlusal view parallel to

the lower border. The frontal view will allow the dentist to assess the lip line, the

smile line, the midline, the relationship between the incisor levels, and the lips. The

lateral views also show the teeth on their respective side plus the emergence profile

of the teeth on the contralateral side.

At this point a set of cheek retractors is placed into the patient’s mouth, and then

frontal and left and right lateral photos are taken first with the teeth in occlusion and

then slightly parted. As with the frontal smile view, the central incisors are typically

in the middle of the picture and the facial midline is parallel to the vertical border of

the frame. The occlusal plane is parallel to the lower border of the frame. Lateral

views also have the lateral incisor in the middle of the frame and the occlusal plane

parallel to the lower border of the shot. Finally, some occlusal images are taken using

an occlusal mirror. Patients should open very wide so the mirror can be inserted and

the occlusal surface of all the teeth in an arch can be photographed, from second

molars to incisors. The mouth should be opened wide enough that the interproximal

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embrasures of the anterior teeth are visible, but only a small area of the labial

surfaces are shown. This can sometimes be difficult in the lower jaw. The assistant

may need to position the retractors very precisely to allow the dentist to move the

mirror for the perfect picture. For the lower picture it may also be helpful to have

the patient curl their tongue to the back of the mouth.

These 12 images form a set of pictures that can be used almost universally for most

treatment plans. It is wise to take them at an initial consultation; this permits the

dentist to discuss the treatment plan with the patient immediately. Alternatively, if

the treatment plan is complex and requires the dentist to further analyze the dentition

before presenting treatment, the practitioner can see the patient’s entire mouth

without having to schedule an added appointment. 13, 16, 17, 18, 19, 21Additional

photographs, such as close-up views of the anterior teeth or posterior quadrants and

lateral images of the face can be taken if appropriate to the patient’s condition or if

required for examination purposes.

Figure 26

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CLINICAL TIPS

*To determine the type of mirror, place an explorer directly onto the mirror's surface.

On a front surface mirror, the "tips" will meet. On a back surface mirror, a space will

be seen between the tips, which represents the distance between the glass and the

reflecting surface on the back.

*A commonly encountered problem is mirror fogging caused by the patient's breath.

This can be eliminated either by soaking the mirrors in warm water or by having the

assistant gently blow air from the syringe onto the mirror while it is in use.

*If saliva comes in contact with the mirror's surface, the mirror must be removed

and cleaned to avoid a significant distraction on the finished photograph.

*The dental camera should be readily available, stored either in a wall-mounted

bracket or on a counter near the work area. If the camera is not readily available, it

will not be used. It is not advisable for the dental camera to double as a recreational

camera, because it probably will be at home when needed.

*The single most common beginner's error is incorrect choice of magnification. A

typical magnification error involves including the nose and chin in a frontal view of

the oral cavity. This extraneous information is distracting for the viewer. The

photographer must decide what the photograph should contain and choose the

magnification that eliminates everything else.

*Good intraoral photographs should appear as if the camera were aimed directly at

the desired subject regardless of whether mirrors were used. The photographs should

be devoid of mirror edges, fingers or thumbs, fog, saliva, lip retractors, or any

elements other than the desired aspect of the oral cavity.

*Lip retractors are not always easily eliminated, but clear retractors are an excellent

compromise.

*A more relaxed or casual view without lip retractors is useful and appropriate for

esthetic dentistry, especially when designed for patient viewing. Never show patients

with lips retracted when illustrating esthetic dentistry for patient viewing.

*To achieve maximum sharpness of the image, focus the camera on the canines, not

the central incisors while photographing the anterior view of the patient.

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*A standard set of retractors can be modified by removing the flange on one side of

the retractor, such that when the retractor is rotated toward the desired arch, no

interference comes between the mirror and the retractor.

*When photographing the mandibular occlusal view, use the same altered lip

retractors described for the maxillary view.

*Buccal views can be taken without mirrors if a view of the distal end of the terminal

molar is not required.

*The head should be turned slightly toward the photographer so that the off-side

eyelash is just visible. This avoids the appearance of the patient looking away from

the camera.

*Many cameras feature a "red eye" reduction flash. Pulsating the flash before taking

the photograph causes the subject's iris to contract, thus eliminating the reflection of

light off the retina and minimizing the "red eye" effect seen in some photographs.

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REFRENCES

1. George A. Freedman: Contemporary esthetic dentistry, 2012, by Mosby, Inc.

2. Kenneth W Aschheim and Mark P King: esthetic dentistry, a clinical approach

to techniques and materials, Mosby, Inc., 2001.

3. Swift EJ Jr, Quiroz L, Hall SA: An introduction to clinical photography,

Wolfgang Bengel: mastering digital dental photography, Quintessence

Publishing Co, Ltd, 2006.

4. www.styleitaliano.org, smile lite and smile capture, Aesthetic and restorative

dentistry; 2015.