Digital Photography in Orthodontics

Introduction Photographs are an essential part of clinical documentation. Current best practice is a full set of extra- and intra-oral photographs, both at the start and completion of a course of orthodontic treatment and, ideally, some mid-treatment photographs showing key-stages in treatment (Sandler, 2000).

Photographs are an essential part of clinical records for a number of reasons:

1. Unreliable memories. 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.

2. Medico legal requirements. In our increasingly litigious society, it is critical to have clinical photographs that indicate any preexisting pathology or trauma to the teeth. Close-up photographs are strongly advised for any marked decalcification or enamel fractures that are evident from the outset. The debonding appointment is often the first time patients or parents really focus in on the labial enamel, and it may be the first time

they actually notice surface decalcification, fractures, or other blemishes. Proper records will help avoid any post-treatment disputes.

3. Teaching needs. Slides are probably the most important teaching aids in orthodontics. If cases are to be used in lectures, posters, papers, and presentations, a high standard of clinical photography is required.

4. Treatment evaluations. A quick scan of sequential slides with patients and parents during treatment will save lengthy explanations of biomechanics or tooth movements.

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. Digital images are made up of picture elements (pixels) comprising red, green, and blue light, each set at a level between 0 and 255. If all three colours are set at 255 white is the result, while if all are set at zero, black results (Figure 1 ). 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, determines the quality of the final output.

FIG. 1 Digital images made up of Red, Green and Blue light at levels between 0 and 255. 167 million colors in all.

In the 1990s a typical CCD would comprise 640 x 480 pixels resulting in acceptable images for snapshots, but lacking the quality needed for high quality clinical photographs (Figure 2 ). By 1999 the first mega-pixel cameras (over 1,000,000 pixels per image) were becoming available, but above 15 mega pixels the law of diminishing returns kicked in with a disproportionate price increase for only modest improvements in quality.

FIG.

Low pixel count (left) results in poorer quality image than required for orthodontics(right).

Bearing in mind a conventional 35-mm slide is thought to contain the equivalent of 2530 million pixels of information there was still a long way to go for digital images to be serious competition. In addition, conventional photographic equipment for orthodontic images produced good image quality, was very reliable and user-friendly (Sandler and Murray, 1999 ), and was relatively inexpensive. However, well-recognized problems with conventional photographic techniques are the cost of developing and processing films, the time required for processing and physical storage of all the patients slides or prints. Digital photography offers many advantages including: 1. rapid turn-around; 2. checkable exposure accuracy; 3. no ageing of photos; 4. dust and scratches are irrelevant;

5. built in white balance; 6. immediate viewing; 7. no film or processing costs; 8. inexpensive storage; 9. easy retrieval; 10.duplication easy; 11.Transmission around the world in seconds is entirely feasible.

Prosumer cameras One type of digital camera (prosumer) falls into the mid-range price bracket 5001500 and lies between the consumer camera and the professional models. They usually have a host of useful features including macro-zoom lenses and potentially high image quality. The piece de resistance of digital cameras is undoubtedly the image preview facility in that images can be immediately viewed on the LCD screen and accepted or, if flawed, deleted and retaken. The problems with the prosumer cameras used for orthodontic photography are three-fold. First, the flash provided with most digital cameras is a point flash. Experience has shown that for high quality intra-oral images ring flashes are essential to avoid unacceptable shadowing on most of the images (Figure 3 ). Despite the use of deflectors and diffusers the results with the built-in point flash tend to be disappointing. The point flashes are also not powerful enough to allow the photos to be taken on very small apertures (F32). This is essential

as it greatly increases the depth of field and ensures most of the frame is in focus. In addition, even if it is possible to add a ring flash to the prosumer camera high quality consistently exposed images require through the lens (TTL) metering, which is not available on these lower end systems. After 20 years of ever increasing quality of orthodontic photography using SLR systems, TTL metering, and ring flashes, some of the orthodontic community are accepting mediocre photographs, taken with substandard digital equipment just for the facility of immediate viewing.

FIG. 3 Point flash intra-oral images are invariably inferior to ring flash due to shadowing and variable exposure.

It is possible to overcome some of the shadowing problems of a point flash by modifying the technique used. Taking the occlusal shots from much further away may ensure adequate illumination, but will inevitably waste pixels unnecessarily and focusing will also be problematic (Figure 4 ). Turning the camera around on buccal intra-oral shots may also reduce shadowing to a degree.

FIG. 4 Slightly different technique used for occlusal shots with point flashshadows less but pixels wasted.

The second problem involves the viewfinders; some digital cameras are available with a Galilean telescope viewfinder that is very suitable for snapshots, but totally unsuitable for high quality intra-oral photography. The problem is that the viewfinder, when close to the subject, doesnt accurately represent what the lens will see. Live display on the LCD screen is also possible, but they are again inaccurate if the refresh rate is slow, and are very power hungry, making it an unsuitable method unless a mains supply is utilized. Thirdly, the focusing system can be problematic as the auto-focus systems on the prosumer cameras are frustrating to work with when capturing intra-oral photographs. They often take three or four attempts to get the system to focus adequately, and all the area of interest is not always as sharp as it might be. The predetermined distance macro settings available on some of the digital cameras also sometimes give disappointing results. Professional cameras

Top end cameras have always been available. Indeed, Kodak teamed up with Nikon in the late 1990s to produce the Digital Camera System (DCS), which was capable of very high quality images. The problem with this system was that the camera body alone was over 10,000.

FIG. 5 Basic price of Nikon/Kodak DCS 10,495

The Nikon Dl is one of the best digital cameras and is the one used by a great many photojournalists worldwide. It has a vast array of features required by professionals, and the body is built out of titanium to an incredibly high specification, for use in sandstorms, typhoons, and war zones throughout the world. The problem with the Dl is that it is a very heavy camera and would be difficult to hold with one hand, a technique essential for high quality intra-oral images (Sandler and Murray, 1999 ). Also The SB29 ring flash does not work as TTL metering with this body. Finally, a price tag for the whole package of close to 5000 makes it unaffordable for many clinicians. Another digital camera recently released is the Fuji FinePix S1 Pro, which may be the perfect digital camera for orthodontics (Figure 6 ).

The body is made by Nikon and is therefore built to a high specification. The lens system required is the Nikon 105 mm/28 AF Macro and the flash system is the Nikon SB29 Speedlight. The flash provides TTL metering and, therefore, the intra-oral photos taken at F32 are invariably perfectly exposed and in focus. The pictures are all taken on manual focus just by setting the lens adjustment for intra-oral shots, then moving backwards and forwards to focus. Using the limit switch on the lens allows the same magnification to be set for all intra-oral photos, thus allowing direct comparability between photos.

FIG.

Fuji

Si

FinePix

Pro

plus

Nikon

SB29

flash.

Images may be stored on a 64 Mb storage card. The capacity of this card means that 330 images can be stored, using the lowest pixel setting (1440) and maximum compression, resulting in images of about 200 Kb. The quality of these images is more than acceptable for most clinical situations (Figure 7 ). The images can still be cropped and enlarged as necessary retaining sufficient detail for most situations.

FIG. 7 Top pictures with point flash and no TTL metering, bottom with FujiS1Pro.

The only adjustment the camera requires is from F32 to F11 for extra-oral shots and to switch off the flash bulb behind the patients head on the three-quarter and profile view to throw the shadow behind the head.

MANIPULATION OF DIGITAL PHOTOGRAPHS

The requirements for successful use of digital images are a high quality digital camera, and a sufficiently powerful computer to allow easy viewing and subsequent manipulation of the images. Most digital images are stored within the camera on either a Compact Flash card (43 x38x3.5mm in hard case) or a Smart Media card (thinner, lighter, and more flimsy). The former storage medium is probably more appropriate for a busy clinical environment, as the latter requires delicate handling. Once the

images have been captured they need to be 'read' by the computer. At present, the most convenient method is use of an adapter to allow the card to be inserted directly into an empty PCM CIA port. On a modem laptop this is the one occupied by the computers removable fax / modem or alternatively by the network card.

PCM CIA card slots into the laptop

I.EXIF VIEWER

Modern digital cameras are often sold with 'bundled' software to allow viewing of images.

Exif viewer is provided with many cameras, and if loaded correctly, the 'thumbnails' (small representations of each picture on the computer screen) are automatically loaded on the computer screen when the memory card is accessed.

Thumbnails automatically appear in the Exif viewer

Exif viewer also allows inspection of individual images, to check entire area of interest is included, as well as confirming sufficient depth of field was available to ensure the whole picture is in focus.

The Instant preview facility, on all but the cheapest digital cameras' LCD screen, certainly gives an overall impression of the image.

It is only the top range cameras, such as the Fuji S 1 Pro, that have a sufficiently high quality LCD screen combined with the facility to scan the entire image easily with a powerful optical zoom. This will allow quality verification by viewing on the camera alone.

Images taken with mid-range cameras may need quality confirming, using Exif viewer, before the patients are sent home.

Each image can be checked for quality.

Once all the images are satisfactory, Dento facial Showcase is opened alongside Exif viewer. The 'Restore Down' button is now used (top right of the screen, button next to Close Program button) for both programs, to allow them to be visible on the screen at the same time. All of an individual patient's images are now selected in Exif Viewer (left mouse button, whilst holding down the Ctrl key) and these are dragged and dropped into a previously opened new file in Showcase.

In a busy clinic, particularly where images are not necessarily downloaded from the card after every patient, it is important to write down the patient's name on paper. This name should be photographed to allow subsequent identification of patients. This is essential if many clinicians use the camera, particularly if the cards are filled to capacity before a backup is made.

II. DENTO FACIAL SHOWCASE

Showcase is a popular program for storing, manipulating, and showing orthodontic records of patients, in an informal setting.

Thumb nails are stored under each patient's name, and attributes such as type of photograph and stage of treatment can be easily attached to individual images, or groups of images.

Slides of particular interest can be selected within Showcase to run a slide show to illustrate the features of the patient's malocclusion.

Individual slides can be presented in order to show maximum detail of each view taken. Alternatively a selection of views can be incorporated with in a single 'slide' for a less detailed, but more comprehensive over view of the case

Patients images can be stored within folders in Showcase categorized in many ways e.g. by the type of treatment, the centre at which they are treated, the type of malocclusion or any other category clinician feels is appropriate. There is a limit of 64 to the number of images that can be stored in each patients file within Showcase, which is a distinct advantage over other database programmes.

III. POWER POINT

For more formal verbal presentations and for written case reports, a submission to journals for publications or for transferring patients to colleagues PowerPoint is an excellent programme. Images can be taken from Showcase directly into PowerPoint. To do this, both programs are opened simultaneously on the screen and the images are selected in showcase, copied and the cursor is moved to a PowerPoint slide into which the image is pasted.

The image will probably need to be resized with in PowerPoint and then the process is repeated for further images. The advantage of the PowerPoint slides is that the relative size and position of the individual images is infinitely variable and maximum space can be occupied by material of interest. Intra-oral slides are scanned into PowerPoint and all five views can be incorporated into one slide to give the 'full picture' of the malocclusion and treatment at that point in time. Radiographic information should also be imported in to the computer. The lateral cephalometric radiograph and OPG can either be scanned, if the scanner has a transparency adaptor, or alternatively photographed with the digital camera. The flash is turned off and the camera aperture opened sufficiently wide to reduce the shutter speed to 125 or faster, to eliminate camera shake. The ideal background is an outside window, using daylight to trans-illuminate the film avoiding the greenish hue inevitable when an Xray viewer is used for illumination.

Radiographs captured digitally & converted to gray scale

A cephalometric analysis should be carried out for all case presentations and this information can easily be added to a PowerPoint slide. Written information is also added to the slide of the OPG to further enhance the presentation and areas of particular interest can be easily highlighted.

Digital patient records are revolutionizing record collection, manipulation, and storage. Using the three programs described, it is easy to view and store the images collected, as well as prepare high quality slide shows for written and verbal presentation.

All the information on particular patients can be presented to patients, individual colleagues or a large audience in a clear and concise manner, which can serve as an aid to future diagnosis and treatment planning.

SOURCES OF ERRORS IN CLINICAL PHOTOGRAPHY

Clinical photographs taken before, during and after orthodontic treatment form an essential part of the patients' records. If correctly taken, they offer more useful information about the malocclusion and treatment than any other clinical record. There are, however, many potential sources of errors whilst obtaining these invaluable records. Photographs of inadequate quality may misrepresent the patients starting malocclusion, may inaccurately reflect progress with treatment or may inaccurately record dental anomalies and defects that may be present. With both conventional and digital systems, many of these errors, which involve use of mirrors and retractors and patient positioning issues, are common to both methods. With the recent widespread use of digital equipment a whole new range of possible errors has been introduced and specific problems related to the digital system are discussed in detail. There are a number of errors that are commonly seen and these can be divided into two groups. The first group comprises errors due to inappropriate choice or use of equipment including the camera, lens, flash, retractors, mirrors or suction, or a lack of understanding of the digital technology resulting in inadequate or inappropriate images.

 The second group of errors relates to any recording medium and involves inappropriate positioning of the subjects.

Technical errors

1. Camera 2. Retractors 3. Mirrors

1. Camera. The correct equipment is required for high quality clinical photographs, which include a camera (either conventional or digital) with a macro-facility (ability to produce I : I images) and, ideally, a ring flash, an appropriate background, suitable lighting and well trained assistants. Correct camera orientation is important, with extra-oral photographs taken in portrait mode and intra-oral photographs taken in landscape mode. To allow direct comparison of photographs taken at different times consistent magnification of images is required. To aid this with conventional equipment a label can be placed on the barrel of the lens indicating the required lens setting (focal length) for each of the standard views .

The magnification will therefore be preset for intra-oral, mirror and extraoral views allowing direct comparison of sequential shots. The lens barrel is set to the predetermined position and the subject brought into focus by moving the camera closer to or further from the patient. With digital images this is not such a critical issue as they can be resized at a later stage to allow comparison with previous or subsequent images providing there is sufficient information on the image to guarantee quality, once cropped and resized. This is determined by the number of picture elements (pixels) on the charge-coupled device within the digital camera and whether the area of interest completely fills the recorded area. Most modern digital cameras record 3 mega pixels or more, which is more than adequate for high quality clinical photography.

2.Retractors. Two sizes of double-ended retractor are prerequisite to obtaining a set of high quality intra-oral photographs.

The large ends of the larger retractor are used to obtain retraction for the anterior intra-oral shot. The assistant should hold both retractors pulling them both laterally and also forwards, which is the opposite to the natural instincts of the assistants when retracting. By pulling the lips forwards towards the photographer it makes it easier for the patient to bite together in occlusion and pulls the soft tissues away from the teeth.

For the buccal shots, one retractor is turned through 180, thus using the smaller end of the larger retractor on the side of interest. The photographer should hold this retractor themselves and, immediately before capturing the image, pull it an extra 4-5 mm both distally and away from the

teeth to ensure at least the distal of the first molars is captured. To allow optimal soft tissue retraction the assistant passively holds the large end of the large retractor on the opposite side

. For both occlusal shots the assistant inserts the small ends of the small retractors under the respective lips and rotates them towards the midline pulling the lips forward, as well as laterally. This is essential to prevent obscuring the teeth with the lips. The direction of pull is away from the teeth, and upwards for maxillary shots and downwards for mandibular shots, thus ensuring a background of reflected mucosa rather than stretched vermillion.

3. Mirrors. Long-handled, front-silvered, glass mirrors are the ideal tool for clinical photography, although they are significantly more expensive than rear-silvered or metal mirrors. Long handles are held by the photographer to allow complete control of the picture and to keeps assistants fingers out of the shot. Glass mirrors produce a far superior photograph compared to polished metal mirrors as there is much greater reflection of the light and they are more resistant to scratching. Silvering on the front side of the mirror prevents double images, which occur due to a second reflection from the glass surface when the silvering is on the back surface.

Ghost image from glass and image from rear silver

Sharp image when front silvered Surface is used

Prior to taking the photograph the mirror should either be warmed to prevent misting of the mirror when it is inserted into the patients' mouth or the patient should be instructed to hold their breath for 10 seconds or so. The occlusal mirrors are available in three different sizes; however, the two smallest sizes are required in less than 10% of patients.

During occlusal photography light is never reflected 100%, and there is a tendency for mirror photographs to be slightly underexposed.

It is therefore worth using an aperture compensation of + 1 F-stop, to ensure good illumination of mirror shots. This adjustment can be usually made on both conventional and modern digital camera systems.

Problems related to Digital Photography 1. Depth of field.* 2. Auto focus.* 3. Shadows.* 4. Constructing symmetrical images. 5. Image storage. 6. Digital image- fit for purpose? *Problems frequently encountered when using midrange 'Prosumer' cameras.

Depth of field problems. The depth of field represents the amount of the image that is in sharp focus, and is dependant upon magnification and the aperture selected. As the magnification increases and as the aperture through which the picture is taken widens the depth of field reduces. Many mid-range digital cameras that bridge the gap between consumer and professional models, (known as 'Prosumer' cameras, e.g. Nikon Cool Pix 990/4500) will only allow the aperture to be reduced to about Fll. When taking intra-oral photographs with these mid-range cameras the depth of field will be relatively small and on the anterior intraoral photograph part of the picture will inevitably be out of focus.

The depth of field is distributed approximately one-third in front and two-thirds behind the focal plane. This disadvantage of small depth of field with pictures taken with larger apertures can be minimized (but not avoided completely) by focusing on the distal surface of the lateral incisors to at least get central incisors to canines in focus.

With professional digital cameras, e.g. Fuji Sl FinePix Pro, combined with the powerful Nikon SB29 flash, which allows through the lens metering a perfect exposure is possible on F32. This tiny aperture allows sufficient depth of field to include both incisor brackets and second premolar brackets in sharp focus provided the focal plane is positioned correctly, i.e. on the mesial of the canines.

With buccal shots and occlusal shots, provided the subject is correctly positioned and retractors are appropriately used, all the area of interest is on one plane; therefore, depth of field should not be an issue.

Auto-focus problems. Digital cameras often allow the choice between auto-focus or manual focus. Manual focus is by far the preferred option for the following reasons. With Prosumer cameras focusing have to be on the lateral incisors and with top end cameras on the canines, whilst still maintaining a centered photograph. Because of the lack of sharply contrasting lines in the area of interest many of these digital cameras have difficulty focusing using the auto-focus setting for intraoral photographs. The result of this is attempt after attempt to get the camera focus light (usually flashing green) to stop flashing, indicating that the shot is in focus. This often proves fruitless despite repeatedly moving the camera slightly between attempts at focusing. All this is occurring whilst the assistant and the clinician are heaving on the retractors to get maximum retraction of the soft tissues and some patients may find this a little uncomfortable.

Frustrating attempts to get auto focus to work.

The solution to this problem is to use the manual focus setting for all clinical photography. With top end cameras with through the lens (TTL) facility focusing is done looking through the viewfinder. With the Prosumer models, the clinician decides the appropriate distance between the patient and the camera that fills the frame with the area of interest, This focusing distance of, for example, 0.2 m, is set manually on the camera, and the camera is then merely moved backwards and forwards until the image on the LCD screen is in sharp focus, and the picture is taken. Twenty centimeters is a good distance to start testing the cameras ability to take sharp anterior intra-oral photographs on manual setting.

For extra-oral photography an attempt should be made to focus on the patients lower eyelid to ensure from the tip of the nose to the ear of the patient falls within the depth of field on the front, three-quarter and profile views.

Using the dental light to illuminate the patient not only helps to reduce red-eye, but also greatly aids focusing in poorly lit surgeries.

Shadows Problems involving shadowing are almost inevitable with Prosumer digital cameras that use a paint flash. If the flash is mounted to one side of the lens this shadowing is particularly noticeable on the lateral shot and on the anterior shot if the flash is above the lens.

Various mirrors, reflectors and diffusers have been suggested in the past to reduce this problem; however, none provide the perfect solution and the additions tend to make the set-up unwieldy to use. The other alternatives are either to use an illuminated screen as the backdrop to the patients when taking the extra-oral photographs, or use a dark non-reflective background (preferably velvet) to maximize the quality of the image. With intra-oral views again the solution with a side mounted point flash is to turn the camera upside down on the buccal view with the very dark buccal corridor. This will ensure the flash illuminates the area that would otherwise be in shadow due to the cheek. This digital photograph can then be rotated 180 before the picture is saved in the patients file.

Dark right buccal corridor as Cheek prevents light from Left Mounted flash.

Shadow overcome by turning Camera through 180 So the flash is now on left.

High quality occlusal photographs are also difficult to obtain using cameras with point flashes with the usual magnification, because of the proximity of the camera to the patient; much of the area of interest is in shadow

. One solution to the problem of inadequate illumination is to focus further away from the patient, which allows more light in and therefore reduces shadowing. In this situation, the area of interest only fills about 20% of the area captured by the camera so the charge couple device must be of high enough quality to produce a good image after 80% of the information captured has been discarded .

Constructing symmetrical images. One major advantage of the very popular Dental Eye 3 camera, over many of its competitors, was the presence of a graticule in the viewfinder. This allowed very well constructed symmetrical and balanced intra- and extra-oral photographs to be taken, even by relatively inexperienced photographers using the occlusal plane the interpupillary line and the Frankfort plane to construct reproducible photographs. Most of the midrange digital cameras do not have the benefit of a graticule to help with construction of the photographs, but some of the top end cameras, e.g. the Fuji FinePix S2 Pro, have 'on-demand' grid lines, which help significantly with construction of the extra-oral and intra-oral images. Card problems. The digital images are often recorded onto PCMCIA cards. These cards have a series of 50 small holes that accept 50 tiny metal pins within the camera. Small imperfections in the PCMCIA card may damage the pins and once damaged will necessitate return of the camera to the manufacturers for repair.

CCD problems. Even when the lenses on the digital cameras are never changed dust may still eventually get onto the CCD of the cameras. This will be seen as tiny 'in focus' black marks, at a specific spot on intraand extra-oral images.

Hairs and dust eventually get onto the CCD

On SLR type cameras it is often possible to get access to the CCD to allow it to be cleaned with optic cleaning liquid on lint-free non-abrasive cloths, but this must be done with extreme care. If in any doubt at all the camera should be returned to the manufacturer for this to be carried out.

Digital image: fit for purpose? Most digital cameras come with a variety of settings and it is sometimes difficult to know which is the best setting to use in any particular situation. The questions that need to be answered are what will the digital image be used for, is memory card space at a premium and will the images ever be used to produce hard copy? When deciding upon the type of image there are choices about the pixel dimensions. These may be 3040, 2048, or 1024 pixels across the wider dimension of the image. (Cheaper cameras have even smaller dimensions of images, but the quality of these is usually unacceptable for clinical

purposes). If the image is only ever to be viewed on a computer screen, there is little point having more information available than can be exhibited on the screen, or displayed using a laptop projector. The average screen has 1024 pixels across, so if a landscape image is going to occupy the whole screen 1000 pixels across will be the setting of choice, reduced proportionally as the area of the slide occupied by the image is reduced.

. Keeping images as small as possible will ensure that the slideshows into which they are imported are a manageable size, and that the computers do not struggle when displaying the slideshow. When creating an orthodontic slideshow an image will often only occupy half of the screen so the image size can be reduced further, to 500 pixels on its horizontal axis, using any of the commonly available image manipulation programmes, prior to insertion into the slide show. This is preferable to grabbing the corners of a grossly oversized image and 'squashing' it to within the dimensions of a PowerPoint slide, as all the superfluous 'memory hungry' information is still within the file making the slideshow unnecessarily large and often unwieldy. On most digital cameras there is also a setting for image quality, as various degrees of

compression are used to reduce memory requirements. A common situation is for the camera to save files at maximum quality with no compression as TIFF files and to have 2 or 3 levels of JPEG compression represented by the 'fine', 'normal' and 'basic' settings. Roughly, the file sizes are reduced to 1/4, 1/8 and 1/16 of the original file size by successive compressions. The 'normal' setting produces images that are adequate for most purposes, and the 'High', and 'Fine' settings are generally required when hard copy prints are required. If there is a possibility that the digital image will need to be printed at some stage then for photographic quality printing a resolution of approximately 300 pixels per inch is required. For a good quality 6 x 4 inch print the image needs to be taken with the 2048 pixel setting across its longer dimension. Images taken for publication purposes, therefore, need to be of a higher size and ideally higher quality (less compression) than those taken for routine patient records. The typical setting for standard digital photographs using a Fuji FinePix S2 Pro is the 1440 setting on 'normal' for the intra-oral photographs and using a + 1 compensation for mirror shots. The aperture of the camera is set at F32 for both types of intra-oral photographs and F5.6 for extra-oral photographs.

Positioning errors Both the patient and the clinician need to be positioned correctly, in a standardized manner, to produce consistent photographs. All features of the malocclusion should be demonstrated, and areas of interest not obscured by clothing, hair, impression material, retractors or saliva. Problems may be encountered where there is a height difference

between the patient and the clinician, and it may not be possible to get a uniform background as the photographs may appear to be taken above or below the patient. This problem can be solved by getting the patient or the clinician, which ever is appropriate, to stand on a platform to raise them to the same height.

The required photographs and the objectives for each shot have been previously outlined.

I. Extra-oral photographs include a full face view, a full face smiling view, a profile view and a three-quarter profile view, and the intra-oral photographs include an anterior view, and right and left buccal views of the teeth in occlusion, and upper and lower occlusal views. With all cameras time must be spent calibrating the system to determine the optimal settings for both intra and extra-oral photographs. Intra-oral photographs should be taken with the smallest aperture possible to maximize the depth of field.

Extra-oral photographs

Full face and full face smiling views Ideally, this is a 'portrait' view with the face filling the frame extending to just above the top of the head and just below the chin. The photograph should be symmetrical with the interpupillary plane parallel to the floor. If possible, the dental light is directed towards the patient to constrict their pupils to minimize any 'red eye' effect. The first photograph is taken with the lips at rest and the next one with the patient grinning broadly showing their Teeth. Commonly seen features of a poor extra-oral shot include the photograph taken in landscape orientation, at the wrong magnification and too much of the patient's torso in the photograph. An appropriate and consistent background should be selected, such as a blue non-reflective material, or alternatively to eliminate shadows completely a light box. Soap containers, light switches, door handles and edges of notice boards add 'noise' to the view and detract from the overall quality of the final picture.

It is important to give clear and concise instructions to the patient.

Occasionally, when asked to stand in front of the background, patients will take the instructions too literally and turn their back to the photographer, highlighting the need for explicit patient instructions.

Profile and three-quarter profile views Usually only one profile (the patients right profile to match up with the lateral cephalograms and tracing) is taken. However, for patients with facial asymmetries both right and left profiles should be taken. Again, the face should fill the frame extending to above the top of the head, in front of the nose and below the chin. The back of the head is not necessarily required and it reduces the size of the frame occupied by areas of interest. The patient's Frankfort plane should be horizontal. The dental light, if required, should be directed so that the patient's shadow is thrown behind the patient and the camera's flash, where possible, should be adjusted for similar effect. Errors with profile shots include a misrepresentation of the soft tissue morphology or skeletal pattern and this may be due to patient posturing or alternatively excessive tilting of the head forwards or backwards.

Subjects with long hair should always be asked to tuck it behind their ears so that the Frankfort plane may be assessed accurately and the area of interest is fully exposed.

Intra-oral photographs

Anterior views This is taken in 'landscape' view, with the teeth in occlusion filling the frame, with the occlusal plane horizontal and bisecting the picture. Once the correct retractors have been selected all soft tissues should be retracted away from the teeth laterally and anteriorly. The midlines, if they are

correct, should be in the centre of the frame. One possible error, although relatively uncommon, is taking an intra-oral shot in portrait orientation. Common errors include canted occlusal planes, inappropriate selection and use of cheek retractors. Another totally preventable error is saliva not aspirated or the tongue not retracted before the photograph is taken, and bits of alginate left on the teeth. It is therefore worth familiarizing the assistants with the retractors, always having good suction available and taking photos before impressions when collecting records. To aid focusing for intra-oral photographs the dental light should always be shone directly into the patients' mouth. Adequate depth of field is required particularly for the anterior photograph, so it is important to focus on the level on the lateral incisors to ensure that the maximum numbers of teeth are in focus.

Buccal views Again the occlusal plane should be horizontal and bisect the frame. The frame should be filled with teeth extending from the mesial surface of the central incisor to at least the distal surface of the first permanent molars and further posteriorly if possible. It is important to angle the camera so that the lens is perpendicular to a tangent to the buccal surfaces of the posterior teeth to avoid underestimation of the sagittal discrepancy, which occurs through a 'parallax' effect.

Mirror views

The upper and lower mirror shots should ideally be symmetrical views of the occlusal surfaces of the teeth, extending from just in front of the incisors to at least the distal surfaces of the first molars and ideally to include all the erupted teeth. There should be no direct view of the mcisor teeth. Whilst setting up for the mirror shots move the patient by tilting their head back so that the photographer doesn't have to stoop or twist excessively. There is always a tendency for patients not to open their mouth fully for these occlusal shots. To avoid this problem, after placing the mirror and just prior to talking the shot ask the patient to open 'twice as wide', which usually provides significantly better opening for the shot. Remember that whatever is seen through the viewfinder is invariably what will reproduced on the final photograph. Photographs taken with a mirror require the aperture compensation setting on the camera to be changed to + I to allow more light in. The differences between 0 setting and + I are small, but demonstrate slight underexposure of the shot when mirrors are used with no compensation.

The effect aperture compensation for mirror shots.

With conventional slide photography never trust the last slide on the film as, during processing, the ends of the films are joined together and this may result in exposure to light thus spoiling the last frame. Therefore, always settle for 36 shots per film and rewind at that stage, rather than attempting to squeeze another I or 2 prints on the film.

Many of the aforementioned errors can be overcome with meticulous attention to technique and the use of digital photography. Positioning errors and camera errors are noticed immediately on the LCD screen, which is a major advantage of digital photography. Other errors can sometimes be compensated for by image

manipulation at a later date, but this is not without its disadvantages. Rotation of images for example will lead to distortion of straight lines and thus 'steps' in arch wires. Resizing digital images is of course possible, but information is unnecessarily sacrificed if the frame area is 'wasted' by filling it with areas of no interest. Some programmes such as Dolphin TM allow guide lines to be used when resizing images so consistent magnification is almost guaranteed. The principles of use of retractors, mirrors and suction are identical whether using conventional or digital equipment.

Conclusions

Good quality accurate clinical photographs can easily be obtained using the correct equipment and appropriately trained staff. An awareness of all the possible errors in extra- and intra-oral clinical photography will increase the chances of obtaining high quality images.

References

1. SandlerJ,MurrayA. Digital photography in orthodontics. JOrthod.2001Sep;28(3):197-201. 2. Palomo JM, Wolf GR, Hans MG. Use of digital photography in the Case orthodontic clinic.Am J Orthod Dentofacial Orthop. 2004 Sep;126(3):381-5. 3.Sandler J. Digital records in orthodontics.Pa Dent J (Harrisb). 2001 Nov-Dec;68(6):29-33. 4.McKeown HF, Murray AM, Sandler PJ. How to avoid common errors in clinical photography.J Orthod. 2005 Mar;32(1):43-54. 5.Coimbra O, Lomheim C. Digital imaging and orthodontics. Am J Orthod Dentofacial Orthop. 1999 Jan;115(1):103-5. 6.Fiorelli G, Pupilli E, Patane B. Digital photography in the orthodontic practice.J Clin Orthod. 1998 Nov;32(11):651-6. 7.Sandler J, Murray A. Recent developments in clinical photography.Br J Orthod. 1999 Dec;26(4):269-72. 8.Abelson M. Digital imaging update. Am J Orthod Dentofacial Orthop. 1999 Nov;116(5):587-90. 9.Mah J, Ritto AK. Imaging in othodontics: present and future. J Clin Orthod. 2002 Nov;36(11):619-25. 10.Swartz ML. Digital photographs and powerpoint. Am J Orthod Dentofacial Orthop. 2004 Nov;126(5):639 11.Halazonetis DJ. Making slides for orthodontic presentations. Am J Orthod Dentofacial Orthop. 1998 May;113(5):586-9.

12.Burke JF. Video printing in orthodontic photography. J Clin Orthod. 1987 Feb;21(2):118-22. 13.Juggins KJ. The bigger the better: can magnification aid orthodontic clinical practice? J Orthod. 2006 Mar;33(1):62-6.

14.Meredith G. Facial photography for the orthodontic office. Am J Orthod Dentofacial Orthop. 1997 May;111(5):463-70. 15.Scholz RP. Imaging in the orthodontic office (and beyond). Am J Orthod Dentofacial Orthop. 1998 Oct;114(4):464-6. 16.Pappel JE. Lip retractor for occlusal photography. J Clin Orthod. 1996 Nov;30(11):639. 17.Sandler J, Murray A. Clinical photography in orthodontics. J Clin Orthod. 1997 Nov;31(11):729-39. 18.Redmond WR, Redmond WJ, Redmond MJ. Clinical implications of digital orthodontics. Am J Orthod Dentofacial Orthop. 2000 Feb;117(2):240-1 19.Ackerman MB, Ackerman JL. Smile analysis and design in the digital era. J Clin Orthod. 2002 Apr;36(4):221-36. 20.Scholz RP. Considerations in selecting a digital camera for orthodontic records. Am J Orthod Dentofacial Orthop. 1998 Nov;114(5):603-5. 21.Abelson MN. Parameters for digital imaging: Part 1. Am J Orthod Dentofacial Orthop. 2000 Nov;118(5):580-2.

22.Hatcher DC, Aboudara CL. Diagnosis goes digital. Am J Orthod Dentofacial Orthop. 2004 Apr;125(4):512-5.

23.Sandler J, Murray A. Manipulation of digital photographs. J Orthod. 2002 Sep;29(3):189-94.

24.Sandler J, Murray A. Clinical photographs--the gold standard. J Orthod. 2002 Jun;29(2):158-61.