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IMI NATIONAL GUIDELINES
Photography of Cleft Audit Patients
The IMI National Guidelines have been prepared as
baseline guides on specific aspects of medical illustra-
tion practice, and provide auditable standards for the
future. They can be implemented in full, or may be
amended according to individual requirements. The
following, which is the first in the series to be
published in this journal, is an abridged version of
guidelines prepared by Marie Jones. The full version of
this and the other guidelines can be read or down-
loaded at www.imi.org.uk.
Standards for photography
. Standardization is the key to good medical photogra-
phy. This applies to background, lighting, magnification
and patient positioning.
. If photography is not taking place in a studio, use a
temporary background such as a white sheet or a
plain wall. Avoid cluttered backgrounds as they are
distracting.
. Ensure that the camera lens and the photographer
are aligned and parallel to the subject; this reduces
the possibility of image perspective distortion due to
poor positioning. The camera should be positioned so
that the lens axis is horizontal and the camera back
vertical.
. If the camera viewfinder has a grid, use this to check the
positioning. The mid-vertical gridline should pass
through the mid-sagittal plane or median plane of the
face. The mid-horizontal gridline passes through the
Frankfurt horizontal plane (see diagram below).
. Both the patient and the photographer should have
suitable seating, which must be supportive.
. The patient’s hair should be pulled back off the face.
The ears should be visible so that the tragus may be
aligned with the camera. This is especially important in
the lateral views.
. Adjust the patient’s chin position and head tilt until the
head is correctly aligned. This may need to be checked
several times before the final shot is taken.
. Make a note of the views and magnifications used, so
that they can be repeated.
. The National Cleft Audit Photography Group recom-
mend the use of a black or white background.
. Standardized lighting should be used. Studio lights
should be positioned at 45‡ to the patient and be level to
the patient’s head. To obtain ‘softer’ lighting without
prominent specular highlights, large reflector umbrellas
may be used.
Babies
Magnification ratio 1:8
AP facial view (01)
1. It is easier to photograph young babies lying down, at
least until the age of six months when they begin to sit up
by themselves. Provide a baby changing mat or a gym mat
covered with either a towel or a sheet. The colour of these
should match your normal background colour as closely
as possible. A plain white sheet is preferable as
an alternative. It may be helpful for a parent or a
colleague to hold the baby gently whilst photography is
taking place. Follow the general rules for alignment as
previously stated. The magnification ratio should be 1:8.
Do not try to fill the frame with the image. The
same magnification can then be used for the entire
photographic record of the patient. If possible, ask the
parent to remove the baby’s clothes, especially loose vests
that may obscure part of the face. Ask the parent to lie the
baby on his/her back on the mat. The parent should kneel
to one side of the baby to avoid being in view or
obstructing the lights. The parent should place the flat of
their hands alongside the baby’s arms; this keeps them out
of shot and prevents the baby from wriggling too much. In
general, young babies are quite happy to be in this
position as they feel secure with the support of their
parents’ hands.
Right and left lateral facial views (03 and 04)
2. To photograph the lateral view, ask the parent to turn
the baby onto his/her side. The parent should place the flat
of one hand alongside the baby’s arm, holding the arms
close to the baby’s abdomen. The other hand should beThe correct positioning for facial views.
Journal of Audiovisual Media in Medicine, Vol. 27, No. 4, pp. 170–174
ISSN 0140-511X printed/ISSN 1465-3494 online/04/040170-05 # 2004 Institute of Medical Illustrators
DOI: 10.1080/01405110500035643
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placed along the baby’s back for support. Check that the
background material covers the area being photographed.
Magnification ratio 1:4
AP lips close-up view (05) and AP lips worm’s eye view
(07)
3. Babies are best photographed lying down for these
views. A parent may need to hold the baby’s head, but
must avoid obscuring any part of the face if possible.
More of the baby’s head will fall within the frame than
with an older child or adult, but the magnification should
be 1:4 for continuity. Position the baby on the mat as
before. A towel or other kind of padding may be placed
beneath the background material to fit in the nape of the
baby’s neck. This will allow his/her head to be tilted back
slightly for ease of photography.
This method may also be used for very young toddlers.
However, if a toddler or young child is not comfortable
with this method or with tilting the head back, a parent
may need to stand behind the child so that he/she can rest
their head on the parent. Some children feel safer doing
this. If this method is used, a sheet should be held in front
of the parent to ensure an even background.
Adults and children
Magnification ratio 1:8
AP facial views (01 and 02)
4. When photographing the AP views in young children, a
parent or colleague may need to support the child or sit
close to them. Any loose hair should be tied back from
the face. Collars should not obstruct the view of the neck.
Use the grid screen in the camera to position the face
correctly. Use the Frankfurt horizontal to ensure correct
alignment.
The photographer should be seated correctly and be level
to the patient. It may be necessary for the photographer to
kneel on the floor to be level with a small child.
The patient should be seated with their back and head
held as straight as possible.
Faces are frequently asymmetrical, therefore do not try
to overcorrect the natural asymmetry of the patient.
Right and left lateral facial views (03 and 04)
5. When photographing the lateral views in young
children, a parent or colleague may be able to help by
asking the child to look at them. Babies often respond to
the sound of keys jangling.
Magnification ratio 1:4
Lip views (05–07)
6. These views look at the lips in detail. They should be
taken in portrait format. Observe the general rules for
alignment as before. A magnification ratio of 1:4 is
required for each of these views.
AP lips close-up view (05) and lips blowing view (06)
7. Align the vertical grid through the midline of the face.
8. Ask the patient to purse their lips or whistle. A younger
child will probably understand ‘blowing out a candle’. Try
asking the child to blow a piece of paper first if necessary.
Lips worm’s eye view (07)
9. The patient should tip their head back a little.
The horizontal grid passes along the base of the nose
and the vertical grid through the midline of the face. To
obtain the correct ‘worm’s eye view’, the base of the nasal
alar should be aligned at 90‡ to the camera lens axis. The
lip should not obstruct the base of the nose.
Intra-oral views of teeth in occlusion
Magnification ratio 1:2
Intra-oral views (08–10a)
10. Observe the general rules for alignment. Use a magnifica-
tion ratio of 1:2. A ring-flash is the most suitable form of
lighting for intra-oral views. A Nikon Macro Speedlight ring-
flash attached to a 105-mm lens or a Nikon Medical Nikkor
lens may be used. A handheld or camera-mounted flash may
be used if a ring-flashis not available.Great caremustbe taken
to hold the camera and flash steady. At high magnification it is
easy to get camera shake.
These views illustrate the patient’s ‘bite’. It is not always
possible to show the occlusion of the back teeth effectively.
It can be difficult to obtain the correct oblique teeth
position and show the back teeth at the same time. ‘True
lateral’ mirror views (08a and 10a) may be used as an
alternative to ‘lateral’ teeth views in order to show the
occlusion of the back teeth (see note 18).
The patient will need to have lip retractors in his mouth
to draw the lips sideways and outwards away from the
teeth. Keep tissues handy as the retractors often make the
patient dribble. Most, but not all young children, will
tolerate the retractors. Parents may need to hold the
retractors in the correct position. The parent can stand
behind the child whilst holding these. The child can then
gently rest their head on their parent and they may feel
more secure doing this. It is important to try and keep the
head level once the retractors are in place. Retraction may
be difficult due to lip scarring.
AP teeth view (09)
11. The patient needs to bite on their back teeth. The hori-
zontal gridline should pass through the bite line (occlusal
line). Do not try to overcorrect an asymmetrical bite line.
Focus one third in to achieve the maximum depth of field.
Right and left lateral teeth views (08 and 10)
12. Ask the patient to turn at an oblique angle to the
photographer, until the farther incisors and part of the
canine are visible. To obtain the most efficient lip
retraction, pull upwards and backwards on the retractor
nearest to the photographer. Release the other retractor
(furthest from the photographer) a little, this will make
IMI National Guidelines 171
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it more comfortable for the patient and allow more
retraction on the nearer retractor.
Palate views
Magnification ratio 1:2 (or 1:2.5)
Palate views (11–14)
13. Lighting as for teeth views, with a magnification ratio
of 1:2 (or 1:2.5), all landscape format.
Hard palate view (11)
14. Ask the patient to tilt their head back a little. A parent
may need to stand behind the young child, so that the
child may rest their head on the parent. Ask the patient to
open their mouth as wide as possible. Adjust camera angle
until a good view of the hard palate is obtained. Focus on
the hard palate. The vertical midline in the camera should
line up with the midline of the palate.
Babies hard palate view (11)
15. It is preferable to photograph the palate in theatre, as
it is difficult to obtain a good view of the palate without
making the baby cry; this can be distressing for the parent.
Mirror palate view to show upper dentition (12)
16. If the standard magnification of 1:2 appears too tight,
then use 1:2.5. A dental mirror is required. To prevent the
AP facial views (01–02) and right and left lateral facial views (03–04).
AP lips close-up view (05), AP lips blowing view (06), and AP lips worm’s eye view (07).
Right lateral teeth view (08), AP teeth view (09) and left lateral teeth views (10).
172 IMI National Guidelines
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Hard palate view (11), mirror palate view (12), soft palate at rest view (13) and soft palate lifting view (14).
Optional facial views (15–18).
Right and left true lateral mirror views (08a and 10a).
IMI National Guidelines 173
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mirror from misting up, it should be warmed slightly, by
using warm water. Care should be taken not to burn the
patient. Ensure that the mirror is completely dry before
photography. The mirror should be pushed back into the
mouth until the back teeth are visible. This is best done
very slowly as it may make the patient gag, or the patient
can be asked to insert the mirror themselves. The patient
will need to hold the mirror in place. A parent may need to
do this for a young child. The top lip needs to be pulled
back away from the teeth. This can be achieved by asking
the patient to grin, or by using a small lip retractor if
necessary. If there is lip scarring the top lip may be tight
and it may be difficult to pull back. Focus on the occlusal
surface, and when ready, ask the patient to hold their
breath and take the shot as quickly as possible before the
mirror starts to mist up. If a second shot is needed, the
mirror may need to be warmed again.
Soft palate at rest view (13)
17. Ask the patient to open their mouth as wide as
possible. Adjust the camera angle until a good view is
obtained. Focus on the soft palate. This view is fairly
straightforward but it is often difficult to keep the tongue
from obscuring the palate. Using a tongue depressor does
not generally help as patients tend to gag.
Soft palate lifting view (14)
18. Photography as for view 13. To obtain a view of the
palate lifting up, ask the patient to say a long ‘aargh’.
Alternatively a deep gasp in causes the palate to be lifted.
As with view 13, it is often difficult to keep the tongue out
of the way. However, it is important to see the uvula, so
several attempts should be made until a satisfactory result
is obtained.
Optional views
Magnification ratio 1:8
Facial views (15 and 16)
19. These views demonstrate an uneven bite. Align the face
as for AP views.
Facial views (17 and 18)
20. Align the face as for AP views. For correct positioning
of oblique facial views, the tip of the nose should be
aligned to the cheek, or a 45‡ angle can be measured and
marked on the floor of the studio.
Magnification ratio 1:4
Lip view (05a)
21. Align the face as for view 05.
Magnification ratio 1:2
Right and left true lateral mirror views (08a and 10a)
22. True lateral views may be required when it is difficult
to show the occlusion of the back teeth. A small mirror
will need to be placed adjacent to the back teeth and
moved outwards (approximately 80‡). The mirror is then
photographed. Ensure the mirror is warmed first, to
prevent it misting. Take care that the mirror is not too hot.
174 IMI National Guidelines
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