Article and Clinical Photos
by James R. Dunn, DDS and Richard A. Young, DDS
Introduction
Part one of "Dental Photography: A New Perspective" (Chairside, Vol. 6,
Issue 3) described two types of photographs used in dentistry. The
traditional "record-keeping" dental photograph, with a prescribed pose,
magnification ratio and lighting, is a factual record of a dental subject.
The second type of dental photograph is used to communicate a dental
message to patients, dental labs or referral doctors, and in presentations
or marketing. The communication dental photograph follows artistic or
general photographic principles of "storytelling" and artistic design. The
subject is the same — teeth, oral and perioral anatomy — however,
the techniques used to take the photographs follow good photographic
guidelines.
A quality single-lens reflex (SLR) digital camera with attached macro
lens and macro flash or a point-and-shoot camera with a close-up attachment*
can be used to take quality dental communication photographs (Figs. 1a, 1b). Remember: Cameras are important, but photographic technique
and photographic style are more important!
Accessory items used to create communication photographs include: cheek
retractors, mirrors, contrasters, and on- and off-camera flashes (Figs. 2, 3a, 3b, 4).
Simplified portraits also use backgrounds* and reflectors* (Figs. 5, 6).
This article will describe "artistic" techniques, which can be used to
enhance the visual quality of dental photographs with minimal interruption
to the dental practice.
Camera Settings
Lens f-stop (which determines how much light enters the camera
through the lens) should be set to as high a number as possible, and
shutter speed (which regulates how long light enters the camera) should
be set above 1/100 to ensure maximum focus sharpness. The ISO setting
should be between 100 and 200 for highest resolution. Suggested settings
are: manual mode, f/29, 1/160 sec, ISO 200 (Fig. 7).
A macro flash adequately lights the dental subject (Fig. 8). Ring lights
de-emphasize detail, while point lights can cause excessive shadows. A
twin-point light can be used to highlight and also reduce shadows. Point
lights also can be rotated to direct light on important subjects.
Proper white balance is the most important camera setting for accurate
color, and custom white balance is the most accurate white balance for
dental photography. With the camera, lens and flash set for optimum
quality, a photo is taken of an 18 percent gray card. The photo is used
as a reference for the custom white balance setting for all dental photos
taken at the same camera setting (Figs. 9a, 9b, 10a, 10b, 10c, 11). (See your camera instructions
for specific steps on how to set a custom white balance.)
It is suggested to purchase your dental camera from a company that
supplies the camera system pre-adjusted for optimum dental use and
includes a quick-start guide* (Fig. 12). The quick-start guide shows you
how to reset your system when camera adjustments are deliberately or
unintentionally changed.
Anterior or Smile Photos
"Record" or factual anterior photographs, with or without cheek retractors,
lack attractive or artistic appeal. An additional off-camera flash wirelessly
synchronized with the macro flash, with the photo taken at an offangle
position, creates attractive lighting and beauty to a common dental
photograph (Figs. 13a, 13b, 14a, 14b, 14c). Contrasters* can be used to hide distracting
oral tissues and emphasize teeth against a black background (Fig. 15).
Occlusal Photos
Maxillary and mandibular occlusal photos are difficult to capture without
excessive lip, nose or vestibular tissue distracting from the image of
the teeth. Occlusal contrasters* hide much of the distracting tissue and
keep lips, nose and hair hidden with a black border (Fig. 16). Using a
combo mirror* or universal mirror handle* allows firm control of the
mirror and keeps fingers out of the photograph. The same technique is
used to capture quadrant or individual occlusal surfaces (Figs. 17a, 17b, 18, 19).
Anterior Profile Photos
The handle of an occlusal contraster can be placed between the teeth and
the cheek to give a black background for anterior profile photos. Lighting
should be directed toward the facial surfaces of the teeth (Fig. 20).
Lateral Photos
With cheek retractors in place and the teeth closed, a buccal mirror is
placed against the cheek parallel to the occlusal plane. All of the teeth
should be visible in the mirror. The flash is directed onto the mirror to
allow the light to illuminate all of the teeth. A combo mirror or mirror
handle is essential to keep fingers out of the photograph (Fig. 21). The
same technique is used to photograph the facial surfaces of one or all of
the posterior teeth (Fig. 22).
Lingual Photos
The lingual surfaces of mandibular teeth are difficult to photograph
without the use of a mirror designed with a deep concavity to allow
placement over the anterior teeth. The PhotoMed Buccal #3 Mirror* gives
visual access to lingual surfaces of mandibular and maxillary posterior
teeth. Place the mirror between the teeth and the tongue and direct the
flash onto the mirror to illuminate the teeth (Fig. 23).
Shade Photos
Recording tooth shades with photographs is not 100 percent accurate.
However, several techniques are used to maximize accuracy using your
dental camera. Set custom white balance and use optimum camera settings
for macro photography. Place cheek retractors, but do not allow
the teeth to dehydrate. Position an anterior contraster behind the teeth,
place an 18 percent gray card or neutral color tab** behind the teeth, and
hold one or more shade tabs close to and parallel to the teeth with the
tab identification visible (Figs. 24a, 24b). Take a photograph and evaluate
that neither white highlights nor shadows obscure the teeth or tabs.
One alternative is to use a Rite-lite™ L.E.D. Shade Matching Light**
(AdDent Inc.; Danbury, Conn.) as the light source (Fig. 25). You must
change the settings on your camera before proceeding. Turn off the macro
flash, change the white balance to "K" and dial to 5500K (Fig. 26). The
5500K setting matches the light color of the Rite-lite. Reset your camera
mode to "P" and the ISO to 1000. Take the photograph through the Ritelite
(Fig. 27). Your depth of focus will be short, and the photograph may
not be completely in focus, but the white balance of the camera and the light source will be the same. I know of several laboratories that own
Rite-lites and use this method with good results. Remember to reset your
camera back to your optimum dental photography settings.
Annotating Photographs
Writing on dental photos enhances their communication value. Laboratories
are given a clear direction to follow, and specialists have a clear
idea of what you are requesting or want for your patients. When you
send annotated photographs to patients, you increase the opportunity
to communicate clearly about their dental condition, their needs or the
type of care you have provided. Even with our best intention to make
our photographs tell our story, written words on the photographs enhance
our message (Figs. 28, 29, 30, 31).
Annotations on photographs require either a tablet PC with built-in
graphic functions, or the use of a graphics tablet (www.wacom.com)
attached to your computer. Annotation software is included in a tablet
PC and Windows 7, and included with graphic tablets for other computer
operating systems. After writing on the photos using the enabling
software, the annotated photo is saved as a new file. This file can then
be shared with the person you want to receive the message. Writing on
photos is one of the most powerful communication tools we have in
dentistry.
Portrait Photos
Dental and medical portraits are not attractive. If you use portraits as
communication photographs, they must portray the person as attractively
as possible. Too often after treatment we only show teeth to the patient,
forgetting that the patient sees teeth framed with the face. Dr. Norman
Huefner has described portrait techniques that rival any professional
studio portraits. Huefner's techniques, however, require adequate space
for full professional lighting and backgrounds. It is suggested to use a
simplified technique that can be applied in any dental office using a
dental chair, a wall or a hallway location (Fig. 32).
The simplified portrait technique requires a dental camera that has a
mounted flash* with an attached diffuser*, a non-reflecting backdrop*,
a 21-inch folding white reflector* and a white ceiling. If a white ceiling
is not available, a larger white reflector can be used as a false ceiling
(Fig. 33).
Camera settings are reset to f/5.6-f/8, the lens set to auto focus, and
either a new custom white balance set or the white balance set to flash
(Fig. 34). If your photographic space is small, you may need to use a
lens with a zoom range between 20 to 105 mm. If possible, position the
patient approximately one foot from the backdrop. The black backdrop
fabric is a special theatrical cloth designed to minimize shadows.
The flash with attached diffuser is aimed at the ceiling. The main light
is from the side of the diffuser, while the light bounced from the ceiling
acts as a hair light and a fill light off the reflector held by the patient. The
reflected light fills in shadows on the patient's face. This portrait setup
gives near-similar results to a traditional three-light effect. The results
are very attractive and the pictures are simple for the dentist or staff to
take (Fig. 35).
Posing the patient is a difficult challenge for anyone taking portraits.
Be creative. Try to never take a typical "mug shot" pose. Take a "Wow!"
portrait, so the patient is excited to show others what great treatment
you have given them. Sources for posing suggestions are listed at the
end of this article.
Always have the patient sign a photo release. The best photo release for
your location can be obtained from your dental liability carrier.
Dental Photos as Art
Dental photos can be effective when taken as "snapshots," but become
attractive communication tools when taken following established
guidelines of general photography and art. Little effort is required to make your dental photos attractive to patients, laboratories, referrals and
prospective patients. The payback to you is in the perception of quality
and skill. Make all of your after-treatment photographs art quality. The
"Wow!" response of a patient seeing a photograph of their teeth or
portrait makes the extra effort worthwhile.
