review article

Clinical Photography in Orthodontics - A Diagnostic Aid

Amit Prakash*, O.P.Mehta&, Kshitij Gupta$, Swapnil Pandey%, Deep Kumar Suryawanshi%

Abstract
Clinical photographs are an essential component of orthodontic diagnosis and treatment planning. High-quality
photographs allow the clinician to evaluate both the skeletal tissues and the soft-tissue drape. A photograph provides
important visual reference for monitoring growth and developmental changes, providing the patient with a view of
the changes and providing the therapist with credible visual material for teaching and research. Photographs are an
essential part of clinical records for a number of reasons. Within a matter of months, patients and parents tend to forget
how severe the original malocclusion was. Having slides available at every visit reminds both the orthodontist and the
patient of the original situation, against which all improvements can be judged. Other important aspect is for medico
legal requirements. This paper highlights each aspect of photography in orthodontics.

Key words: Clinical Photography, Standardization, Digital Photography, Errors, Cameras, Diagnosis

Introduction which allows direct comparisons, even if their

P
tacking is separated by long periods of time and
hotography has been in existence for over a
different photographs have been responsible.2
century. It can best be described as an ‘Art’
for various purposes. It can be a hobby, a Important Terms in Photography1, 3, 4
profession or a science as it has developed into in
recent years. The uses of photography are emence.1 1) Angle of view: The particular portion of a
As dentists we live in a time when complete and scene that is covered by a camera lens. The
comprehensive documentation of our therapy area is determined by the focal length of the
is essential. The aim of dental photography lens.
is to record a maximum of information under 2) Aperture: Lens opening. The opening in a
conditions, which should be as reproducible as lens system through which light passes. The
possible. Photographs for comparison over time size of the aperture may be fixed or adjustable.
can be obtained only if the conditions under which Lens openings are usually calibrated in
they are taken are reproducible. The photographic numbers.
equipment used, the framing of the picture, the
scale of reproduction and lighting are constant. If 3) Auto focus camera: Camera which adjusts
all these conditions are standardized it is possible the lens for correct focus on the subject
to take intra oral and extra oral photographs, automatically.
4) Back ground : The part of the scene that
*
Senior lecturer,
appears behind the main subject of the
&
Professor,
$
Reader,
picture
P.G. Student,
5) Blow up: An enlargement; a print that is made
%

Department of Orthodontics and Dentofacial Orthopedics,

Rishi Raj Dental College and Hospital, Bhopal bigger than the negative or slide.
Corresponding author:
6) Camera angles: Various positions of the
Dr. Amit Prakash
E-mail id : drprakash24@yahoo.co.in camera (high, medium or straight) with

Indian Journal of Multidisciplinary Dentistry, Vol. 3, Issue 1, November 2012-January 2013 627
 review article

respect to the subject, each giving a different is viewed through the same lens that takes
view point as effect. pictures thus avoiding parallax, with a twin
7) Candid pictures: Imposed pictures, often lens reflex camera (TLR) the scene is viewed
takes without the subjects knowledge. through the top lens and the picture is taken
through the bottom lens.
8) Contrast: The density range of a negative,
print or slide, the brightness range of a subject 20) Shutter: Some movable cover in a camera
or the scene lighting. which controls the time during which light
reaches the film.
9) Cropping: Using only part of the image that
is in the negative or slide. 21) Zoom lens: A lens in which the focal length
can be adjusted over a wide range.
10) Density: The blackness of an area in a negative
or print which determines the amount of light The recommended principal standard components
that will pass through it as reflected from it. of an outfit suitable for all aspects of dental
photography are; 3, 6
11) Double exposure: Two pictures taken on one
frame of film or two images printed on one 1) 35 mm single lens reflex camera.
piece of photographic paper. 2) Macro lens of 100 – 135 mm focal length,
12) Emulsion: A thin coating of light sensitive allowing reproduction on a scale of 1:1 or
material, usually silver halide in gelatin, preferably 2:1.
in which the image is framed on film and 3) Lateral flash: Single or preferably double,
photographic paper. ring flash can also be used for intra oral
13) Exposure: The quantity of light allowed photography.
acting on a photographic material. Necessary Tools2
14) Film speed: The sensitivity of a given film In addition to photographic equipment, suitable
to light. It is indicated by a number in ASA photographic mirrors as well as lip retractors are
/ ISO rating, the higher the number, the more essential for production of high quality intraoral
sensitive or faster the film. photographs.
15) Over exposure: A condition in which too
much light reaches the film, producing a Intraoral Mirrors
dense negative as a washed out print. For good photographs with out double images,
16) Panorama: A broad view, usually scenic. surface coated glass mirrors are required. The
rhodium – coated photographic mirrors are
17) Range finder: A device included on a camera suitable for intra oral photography. Intra oral
as an aid in focusing. mirrors with long handles are preferable as they
18) Parallax: At close subject distance, the will be easy to handle. 5
difference between the field of view seen
Fogging of intra oral mirror due to patients’ breath
through the view finder and the lens. There
is a problem faced during intra oral photography. It
is no parallax with single lens reflex lens.
can be solved by any of the following methods.
19) Reflex Cameras: A camera in which the scene 1) The patient can be asked to breath through
to be photographed is reflected by a mirror the nose.
onto a glass where it can be focused and
composed. In a reflex movie camera as a 2) Blow air on the mirror using an air way
single lens reflex camera (SLR), the scene syringe.

628 Indian Journal of Multidisciplinary Dentistry, Vol. 3, Issue 1, November 2012-January 2013
 review article

3) Application of anti-efflorescence. Position of the Mandible

4) Immersion of the mirror in warm water for The six standard views are all taken with the
few minutes prior to insertion. mandible in the rest position i.e. the patient
is relaxed with the lips resting and in normal
A variety of lip and cheek retractors are needed
relation. In certain clinical situations photograph
to project the best possible light on teeth and
may have to be taken with teeth closed or in lateral
to isolate relevant objects. Retractors made
excursion to the left or right. Thus for each of the
of clear plastic are most suitable as they can be
six standard views, there are four variations in the
easily modified and are most comfortable for the
position of the mandible.8
patient.
1) In the rest position
Photographic methods
2) In occlusion
Extra Oral Photography (Portraits and Profile
Photographs): 3) In lateral excursion to the left
Generally 6 views are included in E.O. photography. 4) In lateral excursion to the right
They are: Left and right lateral views, the frontal
view, the frontal view with head inclined back wards Extra oral photographs9,11 (Figure 1)
and two fronto-lateral views. All pictures are taken Lateral views are necessary to assess the profile.
with the camera in the vertical position and at the The top edge of the frame should be just above
patients’ eye level. Particular importance attaches the crown of the head and the bottom edge in
to the choice and positioning of the background the region of the larynx. The empty area of the
and of the lighting.7 frame should be positioned in the front of the
profile. The camera should be focused on the
Background patients’ eye. The head should be aligned so
The background should be such that it does that the Frankfort plane is parallel to the top /
not interfere with assessment of the profile. It bottom edge of the picture. The ear should not
should be unstructured and non-reflective. Felt be covered by hair. For correct reproduction
or cardboard are very suitable materials. Dental of the profile, the force should be turned 3-5o
instruments or other materials should not be towards the camera. This position compensates
included in the picture. A grey background is best for the illusion in a straight profile that the head
for general purposes. It does not cause exposure is turned away from the lens. As a rule of thumb
problems or influence the colour rendering. the mesial outline of the eyebrow turned towards
Coloured backgrounds may also be suitable.8 the camera should be visible. When consistent
head position is not reproduced, distortion of
Illumination appearance is likely. A backward head tilt will
Photofloods or electronic flash illumination may give a prognathic appearance, particularly in
be used. The arrangement of the lighting should the profile view. A forward head tilt will give a
be as simple as possible. A single light source is retrognathic appearance. Head rotation alters the
sufficient for all portraits and profile views. The appearance of symmetry in frontal view.
lighting direction and the distance of its source
from the background must be chosen so that the Frontal view This view of the face can reveal
shadow of the head falls outside the field of view and record asymmetries. Frontal light should be
of the camera. The light should always come avoided as this gives flat illumination and may
from the profile side. This gives good modeling result in ugly ‘red eye’. Lateral light from one
of the angle of the mandible and the ramus.5 side casts a shadow on the side away from the

Indian Journal of Multidisciplinary Dentistry, Vol. 3, Issue 1, November 2012-January 2013 629
 review article

light, which hampers assessment of symmetry. It away from the camera just sufficiently for the
is therefore necessary to brighten the side of the lateral contour of the orbit on the non camera side
face away from the light with a reflector. This will to be still completely visible i.e. not masked by
give an even illumination with good modeling. the eye ball.
This can be done using two lateral light sources.
The top edge of the frame should be just above
the crown of the head and the bottom edge in the
region of the larynx. The camera is again focused
on the patient’s eye. The head should be aligned
so that the bipupillary line is parallel to the upper
Figure 1 : Clinical Photographs –Extraoral
/ lower edge of the frame. The distance from the
outer canthus of the eye to the hairline should Intra oral photographs1,2,9-11 (Figure 2)
be equal on each side. The line from the outer Five standard intra-oral views together provide
canthus of the eye to the superior attachment of the complete oral photographic record. (Fig 2)
the ear should also be parallel. This line parallels
the F.H. is a consistent, practical and clinical They are; Frontal views, the left and right lateral
anatomic reference. views of the teeth and the two occlusal views.
Some of these views are taken directly and some
Inclined Frontal View A frontal view with the through photographic mirrors.
head inclined backwards by 45o is commonly
used in orthognathic cases and in plastic surgery, The Frontal View
particularly in patients with clefts of lips or palate
For frontal view the following arrangements are
or deformities of nasal septum. A lateral light
appropriate.
source with reflector or two light sources to the
left and right of the patient should be used. The 1) The center of frame should be at the point of
top edge of the frame is above the forehead and contact between the upper central incisors.
the bottom edge below the larynx. The camera
should be focused on the nasal entrance of the 2) Centre of focus should be between canine
patient. The head should be aligned so that the and first premolar.
bipupillary line is parallel to the top or bottom 3) Edge of frame should be at the lateral edges
edge of the frame. beside the last molars.
Front Lateral Views In these views the sagittal 4) The occlusal plane should be parallel to the
plane is oriented about 45o to the optical axis. upper or lower edge of the frame.
This type of photograph is necessary in cases
before and after surgery. Illumination is by a The illumination used is provided by a lateral
lateral light source, which must always come flash unit in the 12 O’clock position, a double
from the side of the face to which the tip of the lateral flash combination or a ring flash.
nose points. This ensures that the patients shadow
The Lateral Views
falls outside the field of view of the camera. The
edges of the frame should be just above the crown The lateral view is ideally taken as follows;
of the head and in the region of the larynx. The
1) The centre of frame should be at the tip of the
camera should be focused on the mesial contour
second premolar.
of the eye turned towards the camera. The F.H.
plane should be parallel to the upper and lower 2) Centre of focus should be also at the tip of the
edges of the frame. The head should be turned second premolar.

630 Indian Journal of Multidisciplinary Dentistry, Vol. 3, Issue 1, November 2012-January 2013
 review article

3) The edge of the frame should be beside the last open his mouth as wide as possible. The patient
molar or at the side of the central incisor. is asked to shift the tongue upto the palate, prior
4) Occlusal plane should be parallel to the upper to insertion of the occlusal mirror. The tongue
or lower edge of the frame. should be shifted to prevent the tongue resting on
the teeth. The mirror should be held at a distance
The lateral view can be also taken with the help from the mandibular teeth, to make as full a view
of a mirror. A standard lip and cheek retractor as possible.
and a narrow, elongated mirror are needed. The
dental assistant should place the mouth angle The occlusal view of the maxilla

Figure 2 : Clinical Photographs –Intraoral

retractor into the mouth opposite the side to be This view should be taken as follows;
photographed with the mouth open, the narrow
mirror should then be inserted into the vestibulum, 1) The centre of frame should be at the
and the patient should be asked to carefully close intersection of the sagittal plane with the line
the jaws. The mirror has to be held at an adequate joining the second premolars.
distance from the buccal surface to enable all teeth 2) The centre of focus should be in the sulcus or
from the molars to the canine to be viewed. on the marginal gingiva of the premolars.
The occlusal view of the mandible 3) The edge of the frame should be behind the
molars and in front of the incisors.
This view should be taken as follows:
These five pictures provide an overall view of
1) The centre of frame should be at the the dental arches. The scale of reproduction used
intersection of the sagittal plane with the line should be between 1:1.5 and 1:1.8. If more details
joining the second premolars. are required, pictures of groups of teeth can be
2) Centre of focus should be in the sulcus or taken. Here again, the use of fixed conditions will
in the region of the marginal gingiva of the provide comparable pictures. For groups of teeth
premolars it is not possible to stipulate precise conditions, for
3) Edge of frame should be distal to the last the requirements to be satisfied by such pictures
molars and in front of the incisors. are too variable. However a few general rules
The retractors should be placed and occlusal should be observed if uniform photographs are to
mirror is inserted and the patient is requested to be obtained.

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1) Photograph the teeth in correct axial • Photographs helps to record white-spot

alignment. This means that the occlusal lesions of enamel, hyperplastic areas and
plane should be parallel to the horizontal in gingival clefts to document that such
the picture. preexisting condition are not caused by
2) Try to align the optical axis perpendicular to orthodontic treatment.
the row of teeth to be photographed. This will Conclusion
give consistent views and reduce the depth of In photography we should be clear with our basic
field problem. fundamentals and should know how to apply them
3) When mirrors are used photograph only in a given situation. Good quality accurate clinical
mirror images. photographs can easily be obtained using the
correct equipment and appropriately trained staff.
4) Every unwanted thing that might distract the
attention of the observer should be avoided References
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632 Indian Journal of Multidisciplinary Dentistry, Vol. 3, Issue 1, November 2012-January 2013
Reproduced with permission of the copyright owner. Further reproduction prohibited without
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