Establishing Protocol in Digital Dental Photography: Essential Communication Tool for Dental Professionals and Patients

Apr 09. 2021

Digital photography provides good clinical evidence and is an essential communication tool for dental professionals and patients. Therefore, capturing correct information is critical when exchanging digital images. The quality of the captured images significantly reflects the quality of the final restorations.

In an ideal scenario, the technician/ceramist should receive the necessary information from the treating clinician to perform to the best of their abilities, and provide the best possible outcome for their patients. The image captured by the treating clinician needs translation into the language/perspectives as the way the technicians/ceramists see and apply within their workflow – i.e., the clinician should be able to explain why they are capturing the specific photos, and the technician/ceramist should be able to understand the reasons and purposes.

Suppose the technicians/ceramists are fortunate enough to see the patients themselves for the consultations and shade taking. In that case, they should highly value it and grab the opportunity. They should invest time to train themselves with the necessary equipment to capture the required information correctly.

Are you taking photos or capturing images with your smartphone (Fig 1)? Congratulations – you are at least attempting and it is undoubtedly better than nothing. The big issue I see is that there is significant distortion in the proportion of the captured images. Thus, it is not suitable when working on something quite precise such as fabrication of dental prosthetics. Those photos/images are not eligible for further editing or verifying the restorations’ accuracy within the software such as Photoshop or eLAB colour matching technique.

As dental professionals, I cannot emphasise enough that we must use a digital SLR camera (Fig 2), preferably invest in high-end equipment. It might initially cost a bit, but it will save a lot more down the track with adequate lighting and correct settings.

My journey and a strong interest in high-end photography started from attending a 2-day advanced photography/shade Taking course presented by Dr Ed McLaren from UCLA more than a decade ago. The amount of information I had to absorb was enormous due to my lack of understanding in the terminology, but it has now become second nature. Practice makes progress, you see.

The recommended camera settings are:

Macro photography aperture setting f32 as f32 gives the best depth or field.
Full face or portraits – f8.
Set ISO to 100
Set the colour gamut to Adobe 98 or Adobe RGB
Set white balance setting in the menu function to “K” then set the colour temperature to 5300 to 5600 degrees Kelvin
Set the metering mode to “SPOT” meter
Set the file size and type to “RAW’ plus “JPEG” fine or large for most images.
Set camera to “Normal” or “Standard” for most.
Set the “Flash Compensation” to +1/3 to +2/3.

Using expensive equipment doesn’t always mean that you can capture the information appropriately. The camera’s position and angle are crucial, not only for the aesthetic evaluation of the object but also to avoid misleading information.

Fig 3 shows a series of close-up smiles of the same patient. The incisal curvature of the smile on the left is accentuated, whereas it looks like the patient has a reverse smile shown on the right. The middle is the ideal smile photo, captured from a good angle to make accurate aesthetic evaluation for the smile design.

Figs 4-6 show the correlation of the angles of the camera shown in Fig 3. As can be seen, when the object is captured from an angle either too high or too low, the aesthetic assessment will be inaccurate. See the angle shown in Fig 5 – image captured slightly above the object, presenting the camera’s correct angle.

It is also important to note that all photographs presented here are with the patient sitting up, not lying down. When the patient is lying down, it limits the movement of the camera and the patient, which makes it difficult to adjust the angles.

Extraoral Photography:

Dental professionals require two essential photos for aesthetic evaluation – a close-up smile photo and a full face smile photo with eyes open. I have explained the reasons in one of my publications – Reproducing Nature: Smile Design, so please click here to read.

The lateral and profile views are optional, but always good to have them. Remember, you cannot provide too much information so when in doubt, always provide more. It takes seconds to delete them, but bring back the patient for another photo session will be a nightmare.

The following images show my established protocol, what I capture for all cases that I treat. The camera I currently use is Nikon D800E (ever since it came out in December 2014), with R1C1 Close-up Speedlight commander Kit with Photomed R2 Dual Point Flash Bracket. My lens is AF-S VR MICRO-NIKKOR 105MM F/2.8G IF-ED.

The numbers shown below indicates my settings.

Fig 7 shows a close-up smile photo – frontal view.

Magnification Ratio – 1:2.5. ISO 100. F-Stop – F25. Shutter speed 1/125. Flash strength: both 1/4.

Fig 8 shows a close-up smile photo – right lateral view.

Magnification Ratio – 1:2.5. ISO 100. F-Stop – F25. Shutter speed 1/125. Flash strength: both 1/4.

Fig 9 shows a close-up smile photo – right profile view.

Magnification Ratio – 1:2.5. ISO 100. F-Stop – F25. Shutter speed 1/125. Flash strength: both 1/4.

Fig 10 shows a close-up smile photo – left lateral view.

Magnification Ratio – 1:2.5. ISO 100. F-Stop – F25. Shutter speed 1/125. Flash strength: both 1/4.

Fig 11 shows a close-up smile photo – left profile view.

Magnification Ratio – 1:2.5. ISO 100. F-Stop – F25. Shutter speed 1/125. Flash strength: both 1/4.

Fig 12 shows a full-face photo.

Magnification Ratio – 1:10. ISO 100. F-Stop – F11. Shutter speed 1/125. Flash strength: both 1/1.

Intraoral Photography:

Intraoral photos are also essential because we can solely focus on the hard-tissue information without soft-tissue interference, such as facial features and lips.

It clearly shows the crown margins and thus, suitable for assessing the gingival condition and tooth proportion. It is also vital for capturing correct information for colour matching and texture/surface anatomy/lustre of the dentition.

Fig 13 shows a retracted frontal view in occlusion. I ask the patient to bite together. You can have extra sets of hands having an assistant to hold the cheek retractors or ask the patient to hold them.

Magnification Ratio – 1:2.5. ISO 100. F-Stop – F25. Shutter speed 1/125. Flash strength: both 1/4.

Fig 14 shows a retracted frontal view in edge-to-edge position. I ask the patient to move the bottom jaw forward (while I’m doing it myself to show them).

Magnification Ratio – 1:2.5. ISO 100. F-Stop – F25. Shutter speed 1/125. Flash strength: both 1/4.

Fig 15 shows a retracted frontal view with a black contraster. Note that the patient is now holding the cheek retractors herself. The assistant can hold the contraster or it is relatively stable enough in the mouth without holding it. Make sure that the patient is not biting down the contraster – we need some space between the incisal edge and the contraster to avoid unnecessary reflections.

Magnification Ratio – 1:2.5. ISO 100. F-Stop – F25. Shutter speed 1/125. Flash strength: both 1/4.

Fig 16 shows the retracted lateral view with contraster on the right-hand side.

Magnification Ratio – 1:2.5. ISO 100. F-Stop – F25. Shutter speed 1/125. Flash strength: both 1/4.

Fig 17 shows the retracted lateral view with contraster on the left-hand side.

Magnification Ratio – 1:2.5. ISO 100. F-Stop – F25. Shutter speed 1/125. Flash strength: both 1/4.

Fig 18 shows the retracted lower frontal view with contraster. I ask the patient to look up a bit and bring the cheek retractors down at the same time.

Magnification Ratio – 1:2.5. ISO 100. F-Stop – F25. Shutter speed 1/125. Flash strength: both 1/4.

Use of Cross-Polarisation Filter:

Today, capturing intraoral photos with a cross-polarization filter is a must. It eliminates unwanted light reflection and defines the internal tooth structure so that the technicians/ceramists can match and mimic the characteristics in detail. I use polar_eyes from PhotoMed.

Fig 19 shows a retracted frontal view with contraster, and the polar_eyes are attached to the lens and twin flash units. The camera’s angle should be the same as Fig 15, but with different settings.

Magnification Ratio – 1:2.5. ISO 100. F-Stop – F22. Shutter speed 1/125. Flash strength: both 1/1.

Fig 20 shows a retracted lateral view with contraster on the right hand side, and the polar_eyes are attached to the lens and twin flash units. The camera’s angle should be the same as Fig 16, but with different settings.

Magnification Ratio – 1:2.5. ISO 100. F-Stop – F22. Shutter speed 1/125. Flash strength: both 1/1.

Fig 21 shows a retracted lateral view with contraster on the left hand side, and the polar_eyes are attached to the lens and twin flash units. The camera’s angle should be the same as Fig 17, but with different settings.

Magnification Ratio – 1:2.5. ISO 100. F-Stop – F22. Shutter speed 1/125. Flash strength: both 1/1.

Fig 22 shows a retracted lower frontal view with contraster, and the polar_eyes are attached to the lens and twin flash units. The camera’s angle should be the same as Fig 18, but with different settings.

Magnification Ratio – 1:2.5. ISO 100. F-Stop – F22. Shutter speed 1/125. Flash strength: both 1/1.

Use of Fluorescent Filter:

Unless taking dental photography is your hobby or obsessed with teeth, there is no need to capture images with a fluorescent filter. I bought the filter called fluor_eyes from PhotoMed years ago, but it seems that they no longer sell it.

If you are keen to learn more, please visit here, which shows a novel method of capturing fluorescence in clinical dentistry.

Also, I don’t take the photos with fluor_eyes regularly, it is still good to know how and below is my settings.

Fig 23 shows a retracted frontal view with contraster, and the fluor_eyes are attached to the lens and twin flash units. The camera’s angle should be the same as Fig 15 (or Fig 19), but with different settings.

Magnification Ratio – 1:2.5. ISO 500. F-Stop – F18. Shutter speed 1/125. Flash strength: both 1/1.

Fig 24 shows a retracted lateral view with contraster on the right-hand side, and the fluor_eyes are attached to the lens and twin flash units. The camera’s angle should be the same as Fig 16 (or Fig 20), but with different settings.

Magnification Ratio – 1:2.5. ISO 500. F-Stop – F18. Shutter speed 1/125. Flash strength: both 1/1.

Fig 25 shows a retracted lateral view with contraster on the left hand-side, and the fluor_eyes are attached to the lens and twin flash units. The camera’s angle should be exactly the same as Fig 17 (or Fig 21), but with different settings.

Magnification Ratio – 1:2.5. ISO 500. F-Stop – F18. Shutter speed 1/125. Flash strength: both 1/1.

Looking back on these images captured initially back in 2015, it has brought back many good memories. 6 years on, I still take the photos almost the same way presented here. Consistency provides coherence in my presentations, and dental professionals can easily follow my established protocol if they are willing to do so.

I will still need to work on the clinical intraoral photos with occlusal and palatal/lingual mirrors. Once I get access to a dental chair, will share the protocol upon being presentable.

References:

Advanced Photography/Shade Taking Course by Dr Ed McLaren. www.edmclaren.com

Brokos. Y, et al. A Novel Method of Capturing Fluorescence in Clinical Dentistry. Compendium. Vol 39, Issue 1; 2018. https://www.aegisdentalnetwork.com/cced/2018/01/a-novel-method-of-capturing-fluorescence-in-clinical-dentistry

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