Clinical

Photography Manual
2
CliniCal photography manual
copyright, Astra Tech AB, Sweden 2008
introduction
Welcome to the Astra Tech guide to clinical photography. At some
time in our lives we have all used a camera, but clinical dental photo-
graphy doesnt lend itself well to the concept of point and shoot.
The nature of the environment, the small sizes and distances involved,
and the difculty of access make dental photography an art as well as
a science. And like science, there are rules that have to be obeyed,
such as focus, exposure and composition. But as with art, results
improve with practice and experience.
As an adjunct to the practice of dentistry, clinical photography brings
rewards such as a sense of satisfaction in a job well done, the ability
to share ones work with colleagues and patients, and a great oppor-
tunity to advance your dental practice.
Good luck with your clinical photography!
Special thanks to Per Rehnberg D.D.S. contributor and photographer
o
CliniCal photography manual
copyright, Astra Tech AB, Sweden 2008
Content
The right equipment for the job 4
Frontal view 6
Occlusal view 7
Lateral views 8
Pre- and post-operative comparisons 9
Full face images 10
Publishing your images 11
^
CliniCal photography manual
copyright, Astra Tech AB, Sweden 2008
The right equipment for the job
By its very nature, this brochure cannot be comprehensive, but good
results are much easier to achieve with the right equipment. Here are our
recommendations.
Optical viewfnder vs. LCD displays (digital cameras)
To guarantee consistent excellent quality, an SLR (single-lens refex camera)
should always be used. With this type of camera, one can see the image
being composed through the optical viewfnder. Other types of viewfnders
may not be so precise when focusing and with reproductions. A digital
camera with an LCD display may seem like a tempting option, but this
type of camera is diffcult to use in a clinical environment when it comes to
accuracy in positioning and focusing. Another important aspect is to choose
a camera where you can set the aperture yourself, as the depth of feld (the
distance in front of and behind the point of maximum clarity that is in focus)
is very limited at the ranges involved when executing macro photography.
Depending on the power of the fash and the distance from the subject, you
should always choose the minimum size aperture possible, such as F22
or F32 (the higher the F-stop number, the smaller the lens opening). This
reduces the risk of distortions and blurred shots.
Flash
Always use a ring or point fash that is intended for close-up photography.
Choose a fash/camera combination that permits TTL (Through The Lens)
control of the fash, which will make perfect exposure easier to achieve. If
you are using automatic focus, the autofocus may not work accurately at
certain light thresholds, especially in low-light situations. Modern close-up
fashes usually have auxiliary lights that simplify focusing. You can also use
the dental operating lights if additional light is required.
Lens
It is a good idea to buy the best lenses available. Choose lenses that are
specially designed for macro photography (close-ups). Macro lenses with a
focal length between 55 and 110 mm are the best and most widely used with
35 mm cameras. Note that the digital system models available today have
smaller image sensors than a camera designed for 35 mm flm. A 60 mm
lens on a 35 mm camera, for example, can often be compared to a 90 mm
lens on a digital camera.

A digital SLR-camera used for extra-
and intra-oral photographs.
Digital images
Digital cameras are improving
continually. We recommend a digital
camera system (one in which the
lenses can be exchanged) with a
macro lens and ring flash (or point
flashes for macro photography).
Digital images have a number of
advantages, such as immediate
access to any shot and the possibility
to re-shoot if necessary. It is also
easier to process digital images (for
example to change color balance,
rotate and crop any images). Today,
more and more administrative clinical
software can process and safely store
images pertaining to patient data.
'
CliniCal photography manual
copyright, Astra Tech AB, Sweden 2008
Under certain conditions, autofocus can simplify photography, but may
cause problems when taking close-up shots. One option is to turn off the
autofocus function and use the fxed focus set-up on the lens for a more
uniform composition, such as 1:2 or 1:1, then move the camera toward or
away from the subject to fnd the right focus and composition.
Transferring images
The ideal solution for maintaining orderly records is to transfer images from
the memory card after each patient. These can be transferred using a card
reader or directly from the camera via a cable (e.g. USB) into the clinics
image storage program that should preferably be connected to the clinics
administrative software. Wireless electronic transmission is another option.
Lip retractors
There are two types of lip retractors commonly in use: the type which has
to be held in place by the subject or an assistant, and the type which has a
spring incorporated to keep it in position. The latter often means that the
lips rest against the buccal surface of the teeth, which is why this type might
not be the optimal choice.
Mouth mirrors
The mouth mirrors that should be used in clinical photography are the
metal flm plated glass mirrors. When purchasing mouth mirrors, buy
the best you can afford to ensure good optical properties and freedom from
distortion. Treat your mouth mirrors as precision optical instruments when
handling them, avoid fnger marks and ensure that your dental surgery
assistant realizes that they need to be handled carefully to avoid scratching.
Remember that cold metal placed in a warm mouth will almost certainly
cause the surface of the mirror to mist up. This can be remedied by warming
the mirror before use. A steady stream of air from the syringe blown gently
across the surface of the mirror can help, but only if it is gentle enough to
avoid the production of excess saliva. Asking the subject to hold his/her
breath just before taking the shot can also help avoid misting.
Most situations that arise in clinical
photography can be handled with
retractors (A). Retractors that are
adjusted and cut down will add
flexibility in photographing occlusal
views (B).
Using mirrors 1 and 2 will cover
most clinical situations.
c
CliniCal photography manual
copyright, Astra Tech AB, Sweden 2008
Frontal view
Lift the soft tissue upwards and outwards from the buccal surface of the
teeth using a lip retractor. Focusing on the lateral incisor helps ensure an
adequate depth of feld that will have all teeth with an acceptable focus range.
Try to keep the occlusal plane horizontal, lined up with the top or bottom
edge of the viewfnder. Remember that with digital images alignment
errors can often be corrected afterwards.
Take one shot of the intercuspal position and complement this with a
second shot with the patient in a resting position showing free space.
Although the subject can be asked
to hold their own lip retractor while
photos are taken, an assistant who
understands the needs of clinical
photography can be a great asset
in positioning the retractors optimally
and in achieving the best results for
publication or education.
Viewed from the front, the assistant
should be asked to pull the retractors
(i.e. retractor A) not only outwards,
but also forwards towards the
camera. This ensures that the buccal
surfaces of the posterior teeth are
not obstructed by the soft tissue of
lips and cheeks.
Remember to use suction and
syringe to dry the teeth and remove
pooled saliva before each shot.
Focus here
.
CliniCal photography manual
copyright, Astra Tech AB, Sweden 2008
occlusal view
The occlusal view requires the use of a mouth mirror. Use lip retractors to
lift the soft tissue away from buccal tooth surfaces and focus on one premolar.
The images below show preparations for photographing the upper and
lower mandibles in which a mirror is positioned at the correct angle.
Establishing a 45 degree angle between the mirror and the camera for
occlusal shots is recommended although this may not always be achievable.
Positioning the mirror far enough back in the mouth to capture the upper
second and third molars can elicit the gag response, so be prepared to use
the same techniques you might use when taking radiographs or impressions.
If this is a problem, the mirror can be positioned to highlight the region of
interest and rest on the occlusal area of, for instance, the frst molar.
When photographing the lower mandible, the patient should be encouraged
to relax the tongue and if possible, to keep it behind the mirror, pressing
upwards toward the palate.
For optimal results with the occlusal
view, the lips should be retracted
before positioning the mirror.
Ordinary lip retractors will put too
much strain on the oral tissue to
allow correct insertion and positio-
ning of the mirror. The best solution
is either to use two mouth mirrors,
held by an assistant, or to use two
specially adapted lip retractors (i.e.
retractor B), cut down and rounded
for safety, as shown here in the
upper and lower arch.
Focus here
Upper mandible occlusal image Lower mandible occlusal image
Retractor B positioned for an occlusal
view of the upper mandible.
Retractor B positioned for an occlusal
view of the lower mandible.
o
CliniCal photography manual
copyright, Astra Tech AB, Sweden 2008
lateral views
Lateral images can be taken either with or without a mirror. When taking
images without a mirror, it is better to use a lip retractor with a narrow
(acute) angle between the upper and lower sections (i.e. lip retractor A).
This puts less tension on the lip musculature and helps ensure that the lip
can be drawn backwards as far towards the ear as possible. It will show
buccal surface of the teeth clearly as far back as the second or third molars.
For the best esthetic result, watch for the lower lip escaping back over the
cervical area of the lower incisors, marked with arrows in the frst image
on the left. By asking the patient to relax and at the same time releasing the
pressure on the lip retractors slightly, it is usually possible to prevent this
from happening.
When using a mirror for lateral photos (i.e. mirror no 2), ask the patient
to try to relax once the mirror has been inserted. This creates space for the
cheek to be lifted outwards and permits a better angle between mirror and
camera.
Remember that a lingual positioning of the mirror can trigger the gag refex.
Asking the subject to keep his/her tongue relaxed and in the middle of the
mouth will create more space for the mirror in the sulcus than if the subject,
trying to be helpful, moves his/her tongue from one side to the other and in
doing so raises the foor of the mouth.
Lateral image taken using only a
lip retractor. This often works well
as a standard method as it is quick
and easy. Other variations are pos-
sible, such as with a more anterior
direction when keeping an esthetic
record of the front (with or without
a retractor).
Lateral images taken with a mirror
may sometimes produce better
views, but are more difficult for both
the patient and the photographer.
Note how the flash produces dif-
ferent lighting effects on the two
cropped images above. The mirror
image needs to be rotated horizon-
tally (as in the image below it) in
order to get an accurate view.
'
CliniCal photography manual
copyright, Astra Tech AB, Sweden 2008
pre- and post-operative comparisons
One of the most compelling reasons for taking intra-oral photographs is to
provide a before and after comparison, or to demonstrate the stages in a
surgical or restorative procedure. To make such comparisons effective and
easy to follow, it is important that the viewer can move from one image to
the next in the sequence without having to re-orientate themselves. This
generally means that all images in the series should be taken from the same
angle and with the same exterior limitations.
Look at the sequence of images below, in which perfect continuity is marred
to some extent by the appearance of the lower incisors in the frst photo of
the sequence and their exclusion in the subsequent photos.
A useful technique for emphasizing the foreground in these anterior
shots is to hold an opaque piece of matte (i.e. non-refective) plastic or
oxidized alumina behind the teeth, thereby removing the confusion of the
background.
Images used to illustrate a procedure in progress have the specifc problem
that the act of taking photographs can interfere with or delay the procedure.
However, as with almost all professional photography, it is up to the
photographer to dictate both the composition and angle of the image
required in order to achieve satisfactory results. Taking a little more time to
stage manage each photograph and taking a number of shots of each stage if
necessary is preferable to being rushed and ending up with images that are
of no use for the purpose intended.
The two sets of images below show
how the photographer has success-
fully used the same content and
angle in consecutive shots.
0
CliniCal photography manual
copyright, Astra Tech AB, Sweden 2008
Full face images
Full-face images should be taken against some type of background. A blue
background is very popular, but the results can be that the facial skin tone
takes on a yellowish hue. A grey or black background is more neutral.
Positioning the subject (the patient) against a background and taking a shot
with a fash will give what is called a projected shadow. Projected shadows
can be eliminated by using a darker background (as in the image below).
In the case above, a black matt blind was hung as a backdrop. The ring fash
on a modern camera can be removed so that the camera can be held in one
hand and the fash in the other. By angling the fash so that it casts its light
diagonally from the front of the subject and by taking an image with a lower
aperture (< 18), it is easy to achieve results such as these. The red eyes effect
will be minimized as well.
Ask the patient, for the purpose of variation, to turn sideways or to turn
his/her head in order to give the shot more depth.
If you would like your facial images to be of a more professional standard,
better quality lighting is required, such as for slave fash photography. In
such a case, you should seek the advice of a professional photographer to
make more individual upgrades and adjustments.
Make sure that extra-oral shots are
taken before the intra-oral shots
to avoid the risk of redness and
marking from lip retractors.
To record the subjects resting posi-
tion, ask them to say Emma or
Mississippi just before taking the
picture.
Smiling and laughing views can be
very useful in showing how the lip
line relates to the tips of the teeth
and gingiva (smile line).

CliniCal photography manual

copyright, Astra Tech AB, Sweden 2008
publishing your images
The following guidelines will be useful when
submitting your photographs for publication.
Before submitting photographs, contact the publisher
to check their exact requirements, the fnancial
and copyright terms on which they accept images
and, if appropriate, the arrangements for returning
your material after publication. Obtaining a written
statement from the publisher which clarifes these
matters before you submit your work can save a lot
of time and trouble should a dispute arise.
Requirements also differ in terms of the type and
quality of material which publishers will accept.
Digital images
To ensure the highest possible quality of the original
digital image, the camera must be set up for high
resolution (which will reduce the number of images
you can capture in memory).
Remember that an image that looks fne on your PC
screen may not be of high enough quality for print
reproduction. If you are manipulating original digital
images on your computer (e.g. cropping, rotating,
amending color balance), make sure that the image
quality is maintained when you re-save the amended
fle and that you do not overwrite the original fles.
Certain types of fles compress or otherwise degrade
the data to save space, but in doing so sacrifce quality.
Before submitting, check with the publisher what
types of fles they will accept, what size fles they will
allow and what type of image compression they will
be happy with. Also check whether they prefer to
receive your fles by email or CD/DVD.
Transparencies
The rapid evolution of digital photography reduces
the importance of transparencies. When submit
ting transparencies, ensure that they are in glassless
mounts and are well protected. Ensure that your
name and address are marked clearly on the mount
using a small sticky label, and spot the slide
to show which way the image should be viewed
(especially important with some dental subjects shot
using a mirror). To spot a slide, hold it in front of
you the right way round and right side up and apply
a small round sticker or equivalent felt pen mark to
the bottom left corner of the slide mount.
Prints
Improvements in print technology have meant that
an increasing number of publishers accept prints for
publication. Quality of reproduction is not as good
as when starting with a transparency, but could be
acceptable for some purposes.
Remember that not all flm processing laboratories
work to the same high standards, so have the flm
processed by a reputable laboratory. Photography
magazines routinely run laboratory comparisons,
and the difference can be staggering.
A note on copyright
The fact that you have treated and photographed
a patient does not give you the right to use those
photographs. Your patient may be grateful,
impressed and very pleased with the work you have
done for them, but you should respect his/her rights.
To do so, make it a habit to get a model release
signed by each subject, even if you do not think at the
time that those particular images will be published
or shown in public. There are many variations on
the Model Release document, and an Internet search
will reveal many, which you can adapt to your own
requirements, language and local laws.
Astra Tech AB, P.O. Box 14, SE-431 21 Mlndal, Sweden. Tel: +46 31 776 30 00. Fax: +46 31 776 30 10. www.astratechdental.com
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australia
Astra Tech Pty Ltd.
Suite 1, 53 Grandview St, Pymble NSW 2073
Tel: +61 2 9488 3500. Fax: +61 2 9440 0744
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uSa
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www.astratechdental.com
A successful implant system cannot be determined by
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The following combination of key features is unique
to Astra Tech Implant System

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osseoSpeed

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microthread

biomechanical bone stimulation

Conical Seal Design

a strong and stable ft

Connective Contour

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zone and volume
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microthread

Conical Seal Design

Connective Contour

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