Clinical photography is a powerful tool in implant dentistry. In these three photos, photography is being used to document the before, during and after stages in removal of a failed implant prosthesis. Clinical photography is also invaluable in communication between all parties to dental treatment including patients, laboratory technicians, and colleagues. Modern digital photography is user-friendly for dentists and allows rapid transfer of information. This Module will outline and explain a suitable camera setup for digital clinical photography on a daily basis and demonstrate its clinical use. The images presented in this module can serve as a baseline for recording patient information and should not be viewed as the only images that should be obtained. Differing views of important aspects of treatment can be vital for good communication.

After completing this ITI Academy Module, you should be able to: discuss the value of digital clinical photography; identify components of an optimal digital clinical photography setup; describe the main settings of a camera and their effects; identify accessories to enhance clinical photographs; evaluate standard views captured for dental team communication; and analyze shade-taking photographs for adequate color information.

The aim of clinical photography is to obtain excellent intraoral and extraoral images of the patient. The images seen here are referred to as standard views. These views represent a comprehensive amount of structured patient information. With the appropriate camera setup and correct application of technique, any clinician should be able to obtain acceptable photographs for communication.

Clinical photography has many applications. These include patient education and communication. This close-up photograph of a fractured maxillary right lateral incisor can help the patient to understand the challenges to be considered in its management caused by the deep bite and lack of interocclusal space. In a similar way, photographs will also assist the clinician with diagnosis and treatment planning as well as legal documentation and even future forensic use. Clinical photography is a valuable tool for communication with a dental technician operating remotely in the laboratory, and it is essential for any clinician considering academic instruction, treatment presentations, or publications.

A key advantage of digital photography - in contrast to images on film - is the immediacy of feedback for the clinician. When images are not as expected, the clinician can immediately make corrections to the camera settings. Equally, there is no time required for film development, so final images can be displayed or transmitted within minutes rather than days, with the images beginning in the camera, automatically transferred to a memory card, then into the computer, and if necessary, printed in the analog world. Due to the speed of feedback, the treatment team can communicate more efficiently, and it is up to the treating clinician to decide how best to get photographic information to relevant parties. Images can be corrected to some degree through the use of computer manipulation; however, this can be minimized through the use of appropriate settings. As an example, contour and position information might be communicated to a surgeon before surgery through electronically transmitted images, and color-critical information may be sent with a corrected print.

Value of Digital Clinical Photography, Key Learning Points: Clinical photography can provide comprehensive and structured information. The information from clinical photography has many uses including patient education, treatment documentation, and team communication. Digital photography allows immediate assessment and correction of images, faster image transmission, and improved communication.

A single lens reflex or SLR camera is currently the most useful camera type for dental photography. An SLR camera has three main parts: camera body, lens, and flash, and these can be interchanged with different types of lenses and flashes. This is important for clinical dental photography, as the flash and lens make the largest contribution to optimal intraoral images. The interchange of parts is also essential in order to be able to record objects that vary in size from the full face down to single central incisors. While other camera accessories such as additional camera flashes and tripods can serve specific functions, with these basic system parts all clinically relevant images may be obtained without significant additional learning.

A digital SLR camera also benefits from high-performance memory cards, which are widely available, as well as advanced rechargeable batteries for optimal operation and longer intervals between recharges.

The SLR digital camera is one of three main types of digital cameras on the market used for dental photography. In the middle is a compact camera, in which the lens and flash are integrated in the camera unit, with no possibility of interchanging. On the right is a compact interchangeable lens camera or ILC. This is a dental-specific camera system, and it can use a variety of lenses and flashes. Currently the ILC is a very new type of camera, and it cannot yet be recommended to replace the gold standard SLR.

In comparison with SLR cameras, preassembled "off-the-shelf" compact camera systems are rarely adequate for clinical photography. This is because they are not optimized for taking photos of small objects such as a single tooth or section of teeth at a close distance. Their flash is small and low in power. In addition, the flash is usually not in line with the lens and therefore not as effective at giving even coverage of light for the image. The lenses on compact cameras tend to produce unacceptable levels of distortion. These drawbacks limit the effectiveness of off-the-shelf compact cameras for clinical photography.

Electronic flash is a key part of an intraoral camera setup. For an optimal result, the flash needs to provide even coverage of light to avoid objectionable shadows. The lens should produce lifelike images with limited distortion. Of these two clinical images, the quality of the image on the left suffers due to the compact camera's flash placement and lens design. These factors result in shadowing of the maxillary right posterior teeth and anterior teeth that appear too wide. The image on the right demonstrates the image achieved with an SLR camera setup. Next, the module will concentrate on an optimal digital SLR camera setup for clinical photography.

The first part of an optimal SLR camera setup that must be considered is the flash type and shape. White reflections, also known as highlights, are shaped according to the position and shape of the flash. The shape and position of the darkest areas of the image, the shadows, are also determined by the flash. The two images shown here were taken using the same camera and lens but the flash type and shape are different. The image on the left was produced with the dual-point flash, while the image on the right was captured using a ring flash. The differences between the flash effects are subtle but obvious when viewed in comparison. The interproximal areas between the teeth are clearer with the dual-point flash. On the other hand, the dual-point flash produces shadowing of the molars because the flash tubes are spaced widely from the lens and are outside of the commissures of the mouth.

The lens that is used affects the perspective of the image. Its quality also affects the quality of detail in the image. Short focal length lenses tend to enlarge near objects and can distort intraoral structures. Longer focal lengths allow more distance between the camera and the subject, which can have positive effects for illumination in the oral cavity. The magnifications required for proper reproduction of dental structures are referred to as "macrophotography". The SLR macro dental setup takes an intraoral image with little distortion, and the posterior dentition is more faithfully reproduced. The recommended lens for a SLR camera is a 100mm macro lens.

Optimal Digital Clinical Photography Setup, Key Learning Points: Digital single lens reflex (SLR) cameras represent the best setup for obtaining adequate intraoral photographs. Other camera options are compact and interchangeable lens cameras. The key parts of a SLR are the body, lens, flash, batteries, and memory. Each part of a camera setup for dental photography plays a role in creating the final image, and the most important parts are the flash and lens.

Cameras, unlike the human eye, must be set to obtain proper exposure. The intraoral images on the left require different camera settings than the extraoral image on the right. Fortunately for clinicians learning to use an SLR camera, it is possible to achieve the quality of images seen here using a standard range of settings.

Appropriate baseline settings for most SLR cameras for intraoral and extraoral views are shown on this slide. The settings to identify on the camera are Av, which is short for aperture value or opening; Aperture; Focus; and Flash setting. For intraoral views, Av is selected for aperture priority, Aperture is set to f/32, Focus to manual, and Flash Setting to TTL or through the lens. For extraoral photos of patients, the only difference is a change of aperture from f/32 to f/9. These settings and their relevance to clinical photography will now be explained in more detail.

The aperture has particular relevance for clinical dental photography. It is generally the only camera setting that is changed in clinical photography. The aperture controls the amount of the image that is in focus from front to back. The smaller the opening, the more of the image that is in focus. This is very convenient for intraoral photography because a small aperture opening can allow the entire dentition to be in focus from the anterior through to most posterior aspects, as seen in this clinical image. With reduction in aperture opening, there will also be a reduction in the light that can enter the lens. To overcome this, the electronic flash must emit high power light. The aperture setting is most commonly a single number on the display of the camera and in this case is set to f/27.

The aperture opening is often referred to as a fraction with the letter f over a number, for example, f over 32. The aperture is the denominator, with the letter f representing the focal length of a given lens. The actual size of the opening is determined by the lens manufacturer but this doesn’t need to be known. The larger the number, the smaller the aperture opening. The images seen here are examples of aperture openings. In the image on the left the aperture has a large opening with a setting of f/5.6 compared to smaller openings at f/8 in the middle image and f/20 in the right image.

"Zone of focus" or "depth of field" are the terms used to describe the part of the image that is in focus from front to back. Comparison between the effect of a larger and a smaller aperture opening on the zone of focus can be seen in the two images shown. Both images were focused on the contact between between the maxillary lateral and canine teeth. The image on the left was obtained with a larger aperture opening. This results in a limited zone of focus with blurring of the incisal edge of the central incisors and the molars. The right image was recorded with a smaller aperture, and the entire dentition is sharper. Hence the goal in intraoral dental photography is to use the smallest aperture available.

The aperture value is set as follows: First, select the Av setting on the camera. This is also referred to as selecting aperture priority. Next, adjust the aperture opening by selecting the desired f/number. This image shows the area of the camera where the aperture value is set. Often a small wheel is used to change the aperture. Intraoral photos are obtained with the smallest aperture possible; if available, f/32 is preferable.

The portrait images seen here require a different aperture setting than intraoral images. The distance between the subject and camera is much greater, and this automatically ensures that the zone of focus will still be adequate with a wider aperture opening. The aperture is usually best set to approximately f/9. Other settings on the camera remain unchanged when changing from intraoral to extraoral photographs.

The next setting to look at is Focus. The term "focal plane" refers to the plane within the image, parallel to the imaging device in the camera, where the sharpest focus is attained. This plane moves closer to and farther away from the camera when actuating the focus ring on the camera lens. This is set at the time of image capture. Some of the subject both in front of and behind the focal plane will also be in focus.

In this clinical photo, the central incisors are the center of the image; however, the focal plane is moved away from the camera to be centered on the canines, which maximizes the amount of the dentition in focus. With adequate aperture settings and appropriate focusing, the entire dental arch can be rendered clearly. The recommendation is to set the focus to "manual" for both intra- and extraoral clinical dental photography. Examples on how to focus the camera for recording of standard views will be covered in Learning Objective 5.

"Through the lens" or TTL is the recommended flash setting for clinical dental photography. This means that the power output of the flash will be controlled by the camera, which is simpler for the photographer. The middle image shows an example of flash power set to TTL +0, resulting in an ideal image. If necessary, it is possible to adjust and thereby control the flash power more directly. The images on the left and right demonstrate two different flash settings with different flash powers. With a setting of -1 on the left, the flash has less power and therefore emits less light, which results in a darker image. With a +1 flash power setting on the right, the emitted light is significantly increased and the image much lighter. Manual control allows the clinician direct control over flash power, but this technique also requires practice to be used reliably. It is recommended to use a camera with both automated and manual controls.

For the sake of completeness it should be mentioned that SLR cameras also allow settings for a number of other aspects that have an effect on picture quality. However, these settings are mostly used in non-dental situations and do not need to be changed during most clinical photography. Additional camera settings include shutter speed, sensitivity, white balance, and picture quality. Suggested values for these settings to facilitate successful clinical photography are: Shutter speed set to 1/60th of a second. Sensitivity set to ISO 100. White balance set to Flash. Quality set to JPEG or RAW depending on operator preference and available computer software.

Camera Settings, Key Learning Points: SLR cameras can achieve quality images on a range of standard settings. The critical control to understand and to set correctly for dental photography is aperture. For intraoral photography a larger aperture value allows more of the dentition to be in focus from front to back. Flash is also important, and the recommended setting is TTL (or through the lens) in which the camera controls the power. Manual is the recommended focus setting. Additional settings such as shutter speed, sensitivity, white balance, and quality are not normally changed in clinical dental photography.

In addition to an adequate camera setup with correct settings, a critical accessory for dental photography is clean unscratched front surface mirrors. This expanded view demonstrates the correct positioning of an intraoral mirror and retractor for an maxillary arch occlusal view. Intraoral mirrors are specifically designed for intraoral photography. Mirrors with handles are easier for assistants to use and position but have only one reflective side. To avoid fogging of mirrors, warming of the mirrors or having the assistant direct dry air across the mirror surface can be useful techniques. Handles should be sterilized in separate pouches to avoid scratches, which can render these mirrors unusable. Wrapping the mirrors in a microfiber cloth can be a good way to protect them in the sterilization process.

Retractors come in both wire and plastic varieties. Both types have advantages and drawbacks, but either type can be used with success according to clinician preference. Plastic retractors can be more challenging to use with mirrors but are less intimidating, especially for pediatric patients. Outside of their photographic use, retractors can be used during impression-taking procedures with great success to aid in isolation and visualization for the clinician.

Contrastors isolate an area and give a clean, professional-looking background to images. They are particularly useful in the esthetic zone where they can obtain clear images to demonstrate and to explain, for example, incisal wear to patients. Contrastors are available in metal and black plastic. They are used as an adjunct to retractors and are positioned behind the teeth to be recorded as far posterior in the mouth as possible.

Accessories for Clinical Photography, Key Learning Points: Key accessories for dental photography include mirrors, retractors, and contrastors. Front surface mirrors specifically made for dental intraoral photography are helpful and come with or without handles for aiding assistants. Both metal wire and plastic retractors can be used with success. Black plastic or metal contrastors can be very helpful to isolate the anterior dentition.

Extraoral standard photographs should include frontal resting, frontal smiling, and lateral views. For frontal views, the patient should be relaxed and facing directly toward the camera. The camera should be at eye level, and the view should include the crown of head to the clavicles as seen in these three images; the hair can be pulled back behind the ears if necessary as seen here. For the lateral view on the right, the patient should face toward their left to allow alignment with lateral cephalometric radiographs. Aperture should be set to f/9 as previously recommended, and the flash should be positioned above the patient for frontal views and in front of the patient for lateral views to make shadows more natural and less distracting in the resulting image.

Intraoral views should be taken with the lips fully retracted. The five standard intraoral views demonstrated here provide comprehensive information for discussion and communication among the dental team but additional views may be necessary to communicate specific aspects of each patient treatment. The intraoral views from the top down are frontal view with teeth in maximum intercuspation, occlusal views of both maxillary and mandibular arches, and lateral views of the buccal aspects of the posterior teeth.

Intraoral mirrors are used to obtain the occlusal and buccal views seen here. The angle of the camera to the teeth should be as close to 90 degrees as possible. The mirror has been carefully positioned to bisect the angle of the camera to the teeth being photographed. Having the patient tilt the head to facilitate operator position is a useful technique to aid proper positioning. The patient should at the same time keep their head against the headrest to keep movement to a minimum. Note that images may be captured with the patient reclined or seated upright depending on operator preference. Additional views may be added as necessary by the clinician to communicate specific aspects of each patient treatment.

Here is an example of taking a frontal retracted view photograph. The camera is held in a position parallel to the occlusal plane, and both arms should be held close to the body to keep the camera steady. The framing of the view is defined by the width of the dentition and by positioning the embrasure between maxillary central incisors in the middle of the image. The focus is on the canines. By focusing on the canine cusp tips, the zone of focus is maximized.

Occlusal views are aided by having the patient retract the lips away from the dentition and having the assistant hold the mirror. Some useful advice for the patient is to tell him or her to "Pull your lips toward the tip of your nose" for the maxillary view and to "Pull your lip away from the teeth and toward your chin" for the mandibular view. Both maxillary and mandibular arches use a similar technique, with operator and mirror changing position. The patient can also be sitting upright or reclined, depending on operator preference.

The framing of the view should include the full dental arch, and the midline of palate or lingual frenum should be at the center of the image. The focus is on the occlusal surfaces.

For lateral photographs, the patient retracts the cheek contralateral to the mirror. The patient should use far less tension during cheek retraction than with the other views to maximize flexibility on the side being photographed. The mirror is held by the assistant. The mirror should be held as far distally as possible, using care not to impinge on the buccal mucosa. The mirror should be as close to a 45-degree angle to the posterior teeth as possible. The tongue should be placed toward the opposite side from that being photographed in the case of edentulous areas.

The framing of the view should include as much of the posterior dentition as possible, and the occlusal plane of the dentition should coincide with the horizontal midline of the image. The focus is on the second premolar to maximize the zone of focus.

Additional views can be added to supplement the standard views. Examples of additional photos are shown here. These include an extraoral close-up view of the smile as seen on the left. Views of the patient smiling and in repose with no retractors can give the treatment team significant information about esthetic risks and aid the patient's understanding of esthetic compromises that may be unavoidable. Frontal retracted views, as seen in the middle image, can give an indication of anterior overlap and occlusal plane discrepancies. Oblique views, seen in the right image, can be useful in showing the angle of the anterior teeth relative to the occlusal plane.

More examples of additional images are shown here. Documentation and demonstration shots of treatment stages and procedures can also relay critical details to the laboratory during fabrication of prostheses. Views taken while accomplishing specific procedures can be useful when describing them for other clinicians or to prepare patients for following treatment steps. The examples here show a seated abutment, a seated impression component, and the mucosal shape and health of an implant transition zone. Specifically for intraoral views and as a matter of routine, the clinical area of photographic interest should be cleaned up before images are captured. This is to ensure that excess of saliva and or blood do not obscure the images.

Standard Clinical Views, Key Learning Points: Standard views include both extraoral and intraoral photographs. The extraoral photos include frontal views and a lateral view with the patient turned to the left. The five intraoral standard views are: frontal retracted, maxillary and mandibular occlusal, and right and left lateral. The operator, patient, camera, and flash positions are all important for the quality outcome of the photographs. Use and careful positioning of photographic accessories are also important for the photographic outcome. Additional photographic views can be obtained to suit specific patient and treatment circumstances and procedures.

Shade photographs are a specific form of intraoral photography. Standard camera settings and retractors are used as previously described. Shade tabs are used for reference for the ceramist. It is essential that the shade tabs receive the same lighting as the teeth to which they are being compared.

This is usually achieved by holding the shade tab or tabs in the same spatial plane as the tooth or teeth of interest so as to be at the same distance from the flash. It is sensible, however, to consult the ceramist as to the desired angulation of the tabs for color reproduction. In this series of shade photographs, the tooth to be matched is the maxillary left lateral incisor. The tooth has a provisional prosthesis, so the shade tabs are positioned to compare with the adjacent teeth. In this series of clinical images, the left photograph shows the body of the tab held to the tooth edge, and the middle image shows edge-to-edge positioning. In the right image, the tab positions are the same as the left image, but the flash is positioned so that the image is lit from the anterior to highlight and thereby demonstrate different optical details to the laboratory.

It is always sensible to provide the ceramist with as much information as possible. Shades can vary within a tooth and also between different teeth in a dentition. Use of different shade tabs in a series of photographs can convey these variations to the ceramist. In the four images shown here, a different shade tab is used in each and compared with the tooth on either side of the treatment site as appropriate.

Specific photographic shade communication can also give visual information about unique details and other internal structures of teeth. This is achieved by using different angulations of the flash. The flash can be held apart from the lens by the clinician or assistant. For comparison, a standard shade image is seen on the right. In the left image, the flash is positioned to the patient's left, perpendicular to the plane of the anterior teeth. This allows the image to demonstrate the enamel depth as well as enamel fracture lines. In the middle image, the color has been removed and the ceramist can assess value changes in the facial surface and body of the tooth. This image was obtained with the flash positioned directly below the incisal edge and aimed upward. When recording internal structures of teeth, shade tabs may or may not be of use in the image.

Shade tabs that are positioned outside of the plane of the teeth receive different light levels from the flash. This results in a poor reference and increases the chances of shade mismatch and errors.

Shade Communication Photographs, Key Learning Points: Shade communication photographs can be an invaluable aid to the ceramist. Shade tabs should be included in photographs as a reference but should always be placed in the same plane and at an equal distance from the flash as the teeth referenced. The flash can be moved to alternate positions to communicate unique details and internal structures of a patient's teeth.

Digital Clinical Photography, Module Summary: The information from clinical photography has many uses including patient education, treatment documentation, and team communication. Digital single lens reflex (SLR) cameras are the best setup for intraoral photographs, and the most important camera parts are the flash and lens. The critical control in dental photography is aperture, and for intraoral photography a larger aperture value allows more of the dentition to be in focus from front to back. Flash is also important, and the recommended setting is TTL (through the lens).

Key accessories for dental photography include mirrors, retractors, and contrastors. The five intraoral standard views are: frontal retracted, maxillary and mandibular occlusal, and right and left lateral. Shade communication photographs can be an invaluable aid to the ceramist, and shade tabs should be placed in the same plane as the teeth referenced.