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Digital photography in dentistry

Article · January 2010

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 Indian J Stomatol 2010;1(2):77-80

Digital photography in dentistry

1 2
Kiran DN , Anupama K

Abstract

Photography has been rightly described as 'painting with light'. Because of the limited or no knowledge in clinical or scientific
photography a lot of 'photographic garbage' is being produced today. A quality photograph involves “making photographs” not
“taking photographs”. As the rest of the world, dentistry has also moved from analog photography to digital. As with any new
technology acceptance is a function of time. So stay tuned ....... and get ready to go digital.

Key Words: Photography, Digital photography, Scientific photography, Clinical photography.

Introduction changes in camera settings are necessary between intra and

“A picture is worth a thousand words”. With the advent of extraoral photography. It was also reasonably priced. The
new generation digital cameras more and more dentists are 'Dental Eye', however, will not be made available in the
using digital images in their regular practice. Like the rest digital format.5
of the world, dentistry has moved from analog
photography to digital. Digital photography has virtually Digital camera systems
replaced conventional film photography as there is By a comparison of their features and capabilities, they can
dramatic reduction of the cost of digital photography as be divided into three groups: amateur, semi-professional
compared to conventional film photography and is one of and professional.6 Semi-professional cameras include
the reasons for the rapid large scale acceptance of digital advanced viewfinders and single lens reflex (SLR) designs
photography as a part of medical imaging as are available without interchangeable lenses. The lower cost and
in seconds and can be displayed on computer screens or simplified controls of semi-professional systems may
large projection screens within minutes. Images can be initially seem appealing, but they often possess several
rotated, enhanced, lightened, darkened, cropped or altered limitations. A few of these inadequacies include
in almost any way. Digital photography has been generally
available since 1981. In 1991 'Autotrader' were the first
mass market publication to move completely to digital
recording of images. Now, many trades and professions,
including estate agents, advertising agencies, police and
the media use digital photography on a routine basis.1 It is
now widely used to document patients, visual documen-
tation makes it significantly easier to demonstrate
problems and thus motivate patients to accept needed
treatment. It improves the dentist's ability to communicate
with peers, patients and the public. Current 'best practice' is
a full set of extra and intraoral photographs, both at the start
and completion of a treatment and ideally, some mid-
treatment photographs showing key-stages in treatment.2
The ideal characteristics for intra and extraoral photo-
graphy for dentistry are reproducible magnification of the
images, good depth of field and consistent, homogeneous
illumination. Ideally, all the above characteristics should
be standardized within one series of images, as well as Figure 1 Digital images made up of Red, Green and
consistent over long periods oftime.3, 4 Blue light at levels between 0 and 255. 167 m colours in all.
In the pre-digital era the 'Yashica Dental Eye'was produced inconsistent image control, flash positions that are not
for intra and extraoral photography. This SLRcamera had a ideal for intraoral photography, distorted images from
100 mm macro-lens, which was permanently fixed to the utilization of an insufficient macro lens in the wide-angle
body with a built-in ring-flash. A macro-lens allows for position lack of control over the position of the focusing
distortion-free imaging at close range with high depth of plane and the effects of a long lag time on focusing, lack of
field. The aperture settings were automatically adjusted manual exposure and flash mode.6 To improve image
when changing the focus from intra to extraoral quality, various modifications in these systems have been
photography and was thereby very user-friendly; no developed (i.e., the use of diffusors, macro lens with
1
Professor, Department of Oral & Maxillofacial Surgery, 2 Assistant Professor, Department of Conservative Dentistry& Endodontics, M.M
.College of Dental Sciences & Research, Mullana, Ambala, India. Correspondence : Dr Kiran DN, email: kdn30673@ gmail.com

77

integrated ring flash and close-up lens for improved
magnification with a macroflash). For more predictable
results in dental photography, however, a professional SLR
digital camera is the system of choice.
Basic science of a digital photograph
One of the advantages of digital photography is the
possibility of reviewing the picture immediately to judge
technical aspects such as sharpness, illumination, color
and patient positioning. The immediate availability of
digital images enables the treating dentist to monitor a
selected aspect in successive or serial shots in the presence
of the patient. Fewer appointments with patients may be
necessary, as review of the accomplished or planned
procedures is possible without waiting for photographs to
be processed. Basically a digital camera, just like a
conventional camera, has a series of lenses that focus light
to create an image of an object. But instead of focusing this
light onto a piece of film, it focuses it onto a semiconductor
device that records light electronically. A computer then
breaks this electronic information down into digital data.
In other words instead of film, a digital camera has a sensor
that converts light into electrical charges.8
The image sensor employed by most digital cameras is a
charge-coupled device (CCD). Some cameras use
complementary metal oxide semiconductor (CMOS)
technology instead. Both CCD and CMOS image sensors
convert light into electrons. Both of these have their own
relative advantages and disadvantages. 9
Digital images are made up of picture elements ('pixels')
comprising red, green, and blue light, each set at a level
between0 and 255. If all three colours are set at 255 white is
the result, while if all are set at zero, black results There are
256 grey shades that result from all three colours being set
at the same number. Varying the level of each of the three
colours results in the gamut of 167 million colours.
Numerical values for each of these colours are stored on the
Charged Couple device (CCD). This is made up of pixels,
the number of which, combined with the degree of
compression, determinesthe quality of the final output.1
Light and electronic flash systems
Photography has been described as “painting with light”.6
Proper illumination is one of the most significant factors in
achieving a quality image. Since natural ambient light is
inadequate to illuminate the dark shadows in most intraoral
photographic situations, the most practical light source
comes from a supplemental electronic flash source. An
electronic flash can provide light with neutral color
temperature, short duration of flash and relatively high
light output. These capabilities allow adequate exposure
with low heat generation for patient comfort.6 Modern
camera systems can be set for a white balance that matches
the color quality of the flash.
In flash photography, the lighting effect is dependent upon
the form and arrangement of the flash sources. There are
three types of electronic flash system configurations
available for dental photography10
 Ring flash light source system
 Point flash light source system
 Twin flash light source system
Indian J Stomatol 2010;1(2):77-80
Pixels
Resolution of a photograph is the amount of detail that the
camera can capture and it is measured in pixels. Basically,
the more pixels a camera has, the more detail it can capture.
Also as the pixels increase, larger prints can be made
without losing detail.
Example:
 640x480 - Relatively lower resolution. This resolu-
tion is ideal for e-mailing pictures or posting
pictures on a web site.
 1216x912 - This is a "megapixel" image size -
1,109,000 total pixels - good for printing pictures.
 1600x1200 - This is "high resolution". Good quali-
ty prints of 4 X 5 inches can be obtained
 2240x1680 - Found on 4 megapixel cameras this
allows even larger printed photos, with good qual-
ity for prints up to 16x20 inches. 9
Standardization of facial photography
It is stated that digital image quality is based on 5 factors;
correct color, exposure, depth of field, good tonal range,
and image sharpness.11
A fullface front view, oblique, submental oblique and
lateral views have been described as a useful basic picture
set. Intraoral documentation includes upper and lower
occlusal, buccal left and right and frontal views.12,13
Additional picture sets can be obtained for orthognathic
surgery, skull deformities, synostotic or positional
plagiocephaly, facial palsy, aesthetic surgery, and dental
implantology. In dental implantology, the frontal region of
the upper jaw is particularly and aesthetically important,
and additional close-ups showing neighboring structures
are essential.
One of the fundamental parameters should be the patient's
position with the head at the same level as the camera. For
each picture, the patient's position and distance from the
camera should remain the same and rotation of the head
and tilting must be avoided. The image should be aligned
horizontally and vertically to the middle axis of the
occlusion plane. For facial pictures, the Frankfort
horizontal plane should be parallel to the floor and aligned
vertical to the occlusion plane. The deformity can be
exaggerated or masked if the patient is wrongly positioned
and this is especially likely to happen with orthognatic
patients. The photograph should be adjusted so that the
mid-sagittal plane of the patient is orientated perpendicular
to the optical axis. Interfering cosmetics and jewellery
should be removed as well as blood or saliva in intraoral
views.7
Guidelines for clinical photography14
 Take intraoral photographs in the landscape mode of
camera orientation. For extraoral photographs, use
portrait mode.
 For intraoral photography, use a camera with a macro
lens or facility with the ability to produce 1:1 images.
In general, use the smallest aperture to maximize depth
of field.
 Calibrate the camera system to determine and
become familiar with the optimal settings for
intraoral and extraoral photographs.
78

 Clean the target site of debris, excess saliva, blood, air
bubbles, impression material, excess cement, glove
powder before taking photograph. Target area should
be moist but not dessicated. Change surgical drapes as
needed to avoid blood stained images.
 Isolate the target site (include only what is
necessary in photograph)
 Use clear plastic retractors as appropriate to afford an
unrestricted view of the target area.
 Position the retractors symmetrically to avoid the
appearance of a canted image. Pull the retractors out
and away before taking the picture.
 As needed, use a black spatula to prevent coverage of
the front teeth by the lips.
 Position any contrasting device so that it does not cre-
ate a shadow.
 Use a high-quality mouth mirror as appropriate to
view the target area. Control fogging by dipping
mirror into hot water then drying it with a soft tissue.
Alternatively, use a light stream of air from the air
syringe to keep the mirror from fogging.
 Keep the patient's nose out of a palatal view of maxi-
llary incisors.
 Avoid beard hairs.
 Retract the tongue with a mirror or have the patient
move the tongue to the posterior so as not to obscure
the teeth.
 It is helpful, but not mandatory, to include the laser
handpiece in the intraoral view. The laser need not be
operating when this “During Procedure” picture is
taken.
 Keep fingertips, mirror edges and retractors out of the
picture as much as possible. If patient assists in
holding retractors, have patient wear examination
gloves.
 It is suggested to obtain slightly larger image frames
to allow cropping as necessary.
 Ensure optimum visualization, lighting and exposure.
 As much as possible, keep viewpoint, positioning,
lighting, color, magnification, perspective, contrast
and background the same. Standardize photographic
conditions so that direct comparisons are possible,
even if successive photographs are taken by different
photographers over long time intervals.
 Photograph the teeth in correct axial alignment (for
example, the occlusal plane should be parallel to the
horizontal in the photograph, not canted).
 Align the optical axis perpendicular to the row of teeth
to be photographed to maximize consistency and
depth of field.
 Long-handled, front-silvered, glass mirrors are
preferred.
 When using mirrors, try to photograph the mirror
image only. Frame the image so that lips and mirror
edges are minimized. Do not show unreflected teeth.
Having both the direct and mirror image appear in the
same photograph is confusing.
 Use of manual focus is recommended, as auto-focus is
unreliable in the oral cavity. In general, for anterior
shots, focus on the central and lateral incisors to ensure
79
Indian J Stomatol 2010;1(2):77-80
that the maximum number of teeth are in focus.
 Avoid shadows, as a general rule, when using a single
(not a ring) flash in conjunction with a mouth mirror,
keep the flash on the mirror side.
 Strive for optimum exposure. Keep in mind that
mirrors absorb light and exposures will have to be
adjusted accordingly. Light absorption characteristics
vary from one mirror to another. Generally, use an
aperture compensation of +1 f-stop to help ensure
proper illumination of mirror shots.
 If using a digital camera, check the overall brightness
of the image with the histogram function. The peak
should appear in the middle of the histogram for
extraoral views and slightly to the right side for
intraoral views, consistent with a somewhat brighter
image.
 Unless the clinical condition warrants otherwise, keep
tonal values uniform throughout, especially in pre-
and postoperative images. If using a digital camera,
recalibrate the white balance if the control screen
shows inaccurate color shades.
 Include reference measuring device (as for biopsies).
 Use clean, neutral backgrounds for tabletop
photography (instruments, impressions, materials,
and so on).
 Eliminate poor quality images (over- or underexposed
photos, out of focus images, poor orientation, etc.).
Take full photographic series:
 X-ray
 Before procedure
 During procedure
 Immediately postoperative
 Short postoperative time interval (3-14 days)
 Moderate postoperative time interval (1 month)
 Longer postoperative time intervals (minimum of 3
and 6 months).
Conclusion
Quality photographic results do not just happen, you have
to make them happen. Rapid advances of the last decades
have created an electronic society only dreamed about
in1970. These changes can be expected to continue at an
ever increasing rate, and dentist must prepare themselves
to be in the step with these innovations. Those
professionals who adopt the technology will have some
frustrations because of the learning curves and technology
growing pains. Those who wait however will only fall
further behind and miss out on the incredible benefits of
digital photography.
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Disclosures : The authors report no conflicts of interest.
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