BDJ - I Ahmad - Fotografia Digital

Digital dental photography.
IN BRIEF
• Digital dental photography is useful for
Part 1: an overview every discipline of dentistry, and is an
PRACTICE
essential part of contemporary practice.
• A usable dental image should have
correct colour rendition and sufficient
I. Ahmad1 detail to show the oral clinical scenario.
• The aim of this series is to simplify
technical jargon about digital
photography, and present protocols that
VERIFIABLE CPD PAPER can be readily incorporated into a busy
dental practice.
This paper is the first article in a new ten-part series on digital dental photography. Part 1 previews and outlines the con-
tents of the subsequent papers and in addition, defines the aims and objectives of a digital dental image and the features
that are required for an ideal intra-oral picture.
INFINITE POSSIBILITIES
The possibilities of dental photography,
as with photography for other applica-
tions, are limited only by the imagina-
tion (Fig. 1). As a profession, dentistry
can either be a source of immense satis-
faction or a routine treadmill. One of the
ways to enhance satisfaction is by using
dental photography, which is a wonderful
means to appreciate what can be achieved
with current therapy, gratifying to both
the clinician and patient, and helping to
transform routine practice into a passion-
ate pleasure. However, like any occupa-
tion, it is ultimately the individual’s input
Fig. 1 The possibilities of dental photography are limited only by the imagination
FUNDAMENTALS OF DIGITAL
DENTAL PHOTOGRAPHY
1. Digital dental photography: an overview
2. Purposes and uses
3. Principles of digital photography
4. Choosing a camera and accessories
5. Lighting
6. Camera settings
7. Extra-oral set-ups
8. Intra-oral set-ups
9. Post-image capture processing
10. Printing, publishing and presentations
1
General Dental Practitioner, The Ridgeway Dental
Surgery, 173 The Ridgeway, North Harrow,
Middlesex, HA2 7DF
Correspondence to: Irfan Ahmad
Email: iahmadbds@aol.com
www.IrfanAhmadTRDS.co.uk
Refereed Paper
Accepted 15 November 2008
DOI: 10.1038/sj.bdj.2009.306
© British Dental Journal 2009; 206: 403-407 Fig. 2 Dental photography can be elevated to almost an art form
BRITISH DENTAL JOURNAL VOLUME 206 NO. 8 APR 25 2009 403
© 2009 Macmillan Publishers Limited. All rights reserved.

PRACTICE
and subsequent gains that yield gratifi-

cation. This series will endeavour to ele-
vate dental photography to almost an art
form, especially in the case of aesthetic
dentistry, which is no less than painting
a picture or moulding a sculpture (Fig. 2).
But photography is not just reserved for
aesthetic dentistry; it is also invaluable
in other disciplines such as orthodontics,
periodontics, implantology, dental tech-
nology and oral surgery, to name but a
few examples (Fig. 3).
One of the major reasons dentists shy
away from dental photography is its per-
ceived technical complexity, requiring
laborious efforts to achieve the desired
results. This is analogous to computers. Fig. 3 Dental photography has many applications, eg for assessing shade in a dental
laboratory using a shade guide (Vita Classic)
When computers were fi rst introduced a
few decades ago, they also faced similar
objections. However, with the passage Image quality
of time, computers have become com-
10
monplace and indeed indispensable in State-of-the-art image quality Large format
nearly all walks of life. Another factor 9
which has added to dental photography High-end image quality Medium format
technophobia is the introduction of dig- 8
ital photography, which has alienated
many already reticent practitioners; Professional use, expert dental 7 Professional DSLRs
and quite rightly, there is ample truth
6
to support this reluctance. Firstly, pho-
tography is unnecessarily and perhaps
5
perversely presented as a complex pro- Amateur & enthusiast,
Semi-professional DSLRs
most popular for dental use
cedure; secondly, the technical aspects 4
can be daunting, especially when
choosing a camera and accessories for 3
dental use. Thirdly, technology is per-
petually changing, making purchases 2
Casual, family, festivities Disposable, Polaroid, compact
of even a few years earlier inferior and and holiday snaps & intra-oral (fibre-optic) cameras
1
obsolete. However, these obstacles are
readily overcome and should not be a 0
deterrent, especially when the benefits
outweigh the initial expenditure and Fig. 4 Image quality and equipment represented an a scale from 0 to 10
leaning curve.
To counteract these concerns and equipment. It should be a fact of life that pictures in less than a day, while the afi-
demystify many misconceptions about one accepts, rather than being the decid- cionados will fi nd many helpful hints to
dental photography, consider the following factor for not incorporating dental enhance their productivity and achieve
ing. First, photography is no more com- photography into routine practice. superlative images.
plicated than many of the procedures The aim and objectives of this series is
routinely performed in dental practices. to dispel fallacious misconceptions about A TOY OR A TOOL?
However, similar to learning a new tech- dental photography, simplify techni- At the outset, it is important to decide
nique, a degree of perseverance and cal aspects and concentrate on the bare whether the dental equipment will serve
patience is necessary. Secondly, choosing essentials necessary for dental applica- as a toy or a tool. If it is the former, once
photographic equipment for dental pur- tions. After all, driving a car does not the novelty factor has expired, the equip-
poses depends on the intended use, which require the driver to know the workings ment will be consigned to a corner to
is discussed below. Thirdly, it is true that of an internal combustion engine. After accumulate dust. If the answer is a tool,
technological advances make equip- reading the ensuing chapters, most nov- it should be regarded as an indispensable
ment dated, not unlike computers, cars, ices will be able to purchase the neces- part of the dental armamentarium, simi-
electric consumer goods or even dental sary equipment and start taking dental lar to a dental handpiece. Furthermore,
404 BRITISH DENTAL JOURNAL VOLUME 206 NO. 8 APR 25 2009

PRACTICE
the investment in equipment may be (DSLR). Since their introduction in the expert training and knowledge to exploit
wasteful if the initial enthusiasm turns early 1960s, the basic design of SLRs the format to its maximum potential. If
to frustration. This is a crucial point that has remained almost unchanged. In fact, quality is the ultimate concern, then
is addressed throughout this series by all the features of DSLRs such as lenses, a medium format camera is the ideal
making technical jargon palatable, and aperture and shutters are identical as choice, but perseverance and patience is
techniques easy to follow and incorpo- those for conventional fi lm cameras. the downside. For a dental practice, their
rate into a busy daily schedule. The popularity of SLRs is that they are physical size and a steep learning curve
immune from parallax, since the view- would deter the majority of practitioners
IMAGE QUALITY VS INTENDED USE fi nder, lens and image sensor, or fi lms, from entertaining this format.
Before choosing and purchasing a digital all share the same optical axis. There- Lastly, for superlative quality sur-
camera system, the most important fac- fore, what you see is what you get, which passing even that of a medium format
tor to consider is the quality of an image is crucial when taking macro pictures. system we have the view or large format
required for dental purposes. The market Another advantage of this format is that cameras. These are based on the original
is awash with a myriad of cameras and it offers immense versatility and unlim- camera designs from the genesis of pho-
photographic accessories. For dental use, ited accessories. Camera bodies, viewing tography over a century ago. Their use
the primary factor is deciding which screens, fi lm winders, a massive array of is restricted to still life, product shots,
camera format is suitable for yielding the lenses ranging from ultra-wide angle to fashion iconography and documenting
required image quality. Image quality is super telephotos, auto-focus and manual works of art such as paintings, sculp-
paramount because every dental image lenses are all interchangeable. Further- tures and crafts. Besides prohibitive
is a medico-legal record and therefore more, a DSLR system can be tailored to cost, the sheer size of these contraptions
accurate documentation is essential. To almost any kind of photographic applica- can be overwhelming. Depending on
simplify matters, image quality can be tion. In addition, portability, auto-expo- the modular attachments for a specific
represented on an arbitrary scale from sure, dedicated synchronised flashes and assignment or application, once assem-
0 to 10, with zero representing a poor or studio lighting make the task at hand bled they can have dimensions of four
unacceptable quality and ten represent- easier and more predictable. metres in height and three metres wide.
ing the best possible image reproduction Depending on budget, two types of Hence, their use is obviously contrain-
(Fig. 4). At the bottom of the scale are DSLRs are available, the amateur or dicated for a dental surgery set-up. It is
disposable, instant Polaroid®, compact semi-professional and full professional worthwhile noting that currently, both
and intra-oral cameras. All of these varieties. The former are suitable for the medium and large format cameras use
cameras offer convenience, portability keen enthusiast as well as dental appli- the same size of image sensors, and the
and accessibility at the expense of poor cations. The more expensive, profes- higher image quality yield with large
image quality, and are unsuitable for sional versions have additional features, format systems is primarily due to the
documenting a dento-legal record. Fur- which are often superfluous for dental higher resolution lenses.
ther up the scale are single lens reflex applications and the extra cost is prob- In addition to quality, camera equip-
(SLR) and rangefi nder cameras, which ably unjustifiable for dental use unless ment for dental use must be adaptable
are both capable of delivering better the slightly improved image quality is for a practice environment with regard
image quality. an overriding concern. to accessibility, health and safety com-
However, rangefi nders can be elimi- Travelling further up the image qual- pliance, cross-infection control and
nated for dental use because for macro ity scale, the next encounter is the ease of use. Considering all factors, the
or close-up photography, parallax is an medium format cameras. These have the choices available are either a DSLR or
unacceptable drawback. Parallax is when advantage of a larger sensor than DSLRs, medium format. But if ease of use is the
the lens and viewfi nder do not share the usually with a 50% greater surface area deciding factor, then the only choice is
same optical axis, and what is seen in and a comparable improvement in image a DSLR. Most of the discussion in this
the viewfi nder is not the same as what quality. Before digital sensors, these series on digital dental photography will
is recorded on the fi lm or digital sensor. cameras were the choice for fashion, therefore concentrate on DSLRs, which
While this phenomenon is negligible or portraiture and high-end fi lm photogra- are widely accepted as the most versatile
irrelevant for landscape or family snaps, phy, since they are capable of producing and compatible for dental applications.
it is of paramount concern for taking images that are ten times the size of a
pictures of small objects such as teeth. 35 mm SLR format. The medium format IDEAL FEATURES OF
The SLRs are the most ubiquitous cam- also offers enormous flexibility since
AN INTRA-ORAL IMAGE
eras employed for semi-professional and the camera body, lenses, attachments To simplify matters there are two fea-
professional uses. The template of dig- and accessories are based on a modular tures that are essential for a useful
ital SLRs is based on their analogue pre- concept. Hence, even to a greater degree dental image. The fi rst is correct colour
cursors for fi lm photography. With the than SLRs, a medium format system rendition, which also includes correct
advent of digital photography, they are can be assembled bespoke to a specific exposure, and the second is sufficient
allocated the prefi x ‘digital’ and there- photographic need. However, the entire resolution to record both soft and hard
fore termed digital single lens reflex assembly is cumbersome, requiring tissue details.

PRACTICE
The fi rst item to consider is colour ren- Free gingival margin with gingival groove Stippling of the attached gingiva
dition. It is crucial that a dental image Distinction between inflamed and healthy gingiva
Gingival
precisely records the colour that is per- clefts and
recession
ceived by the eyes. This implies that Composite
filling with
the colour rendition should be as close stain and/or
defective margins
as possible to what is observed dur-
Minimum
ing a dental examination. Eliminating specular
reflections
the influence of different light sources Clearly obscuring
tooth colour or
discernible
or illuminants, the image should faith- enamel cracks characterisations
fully reproduce the colour of both hard

Tooth shade
and soft tissues as they appear in the distinction Clearly visable
from incisal incisal translucency
mouth. There should be no colour casts (translucency), of veneering porcelain
body colour to on an all-ceramic crown
and the gingivae, oral mucosa, teeth cervical
(deep chroma)
and any prostheses should be conveyed
with extreme colour accuracy. The cor-
rect colour rendition of soft tissue is Dense underlying core/deep chroma of Enamel chip
veneering porcelain on an all-ceramic crown
an excellent method for distinguishing
between healthy and diseased tissue and Fig. 5 An intra-oral view showing salient features that should be recorded and discernible on
a dental image
for recording pathological changes such
as white patches, inflammation, ulcera-
Stippled attached gingival with melanin pigmentation
tion, burns, lacerations, carcinoma, Free gingival margin with gingival groove
etc. Similarly, a correct colour rendi-

tion of the teeth reveals enamel trans- Cervical
composite
lucency, decay, erosion and abrasion, filling
as well as cervical dentine exposure

and sclerosis. Correct colour reproduc-
Inter-proximal
tion is also an essential communication and incisal
Superficial
enamel
translucency
tool for shade analysis during compos- staining
ite fi lling placement, bleaching and

for ceramists endeavouring to match
artificial prostheses with surrounding Defective,
ditched
natural dentition. composite
filling Clearly visable
The second item to consider is suf- enamel
translucency
ficient detail. Besides a dento-legal at incisal edge
Clearly defined muco-gingival Stained enamel crack
record of the prevailing clinical situa- Surface enamel loss junction between keratinized
and non-keratinized oral mucosa
tion, recording detail is fundamental
for examination, diagnosis, treatment Fig. 6 A second intra-oral view showing salient features that should be recorded and
discernible on a dental image
planning and assessing outcomes of
therapy. If the resultant image lacks
fi ne detail and resolution, it serves lit- • Shade transition of teeth traversing throughout the remaining chapters, all
tle clinical purpose and is no more from cervical/body/incisal edges these features will be demonstrated with
useful than a poor quality radiograph. • Enamel characterisations, lobes, mot- numerous images. However, to highlight
Although not exhaustive, the list below tling, stains, chips, texture, hypopla- some of the above features, Figures 5-8
gives a few salient items that should sia, cracks, fractures and perikymata show some of the items that should be
be recorded with accuracy for a useful • Incisal, interproximal translucency clearly discernible.
dental image: and mamelons
• Distinction between healthy and dis- • Attrition, abrasion, erosion, abfrac- RESUME OF THE SERIES
eased tissue, especially pathological tion lesions The following list shows the contents of
changes • Hypo-calcification, fluorosis, tetracy- the subsequent chapters in this series.
• Attached gingivae, showing degree cline stains
of stippling (texture) for assessing • Cervical dentine exposure, stains Chapter 2
certain dental biotypes • Defective restorative margins Digital dental photography: purpose
• Transition between keratinised and • Secondary caries, restorative material and uses.
non-keratinised oral mucosa for wear, chips and staining. • Dento-legal documentation
assessing width of keratinised tissue • Communication
(attached gingivae, free gingival mar- Off course it is impossible to show all • Portfolios
gin, gingival groves, clefts, scarring) the above features in a single picture, but • Marketing.
406 BRITISH DENTAL JOURNAL VOLUME 206 NO. 8 APR 25 2009

PRACTICE
Chapter 5
Free gingival margin with gingival groove Stippled attached gingiva
Lighting.
• Characteristics of light
• Types of lighting for dental use
• Electronic flashes for dental
applications
Inter-proximal and
incisal translucency • Manipulating light.
Chapter 6
Camera settings.
• Depth of field
• Exposure
• Colour spaces
• Synopsis of camera settings.
Clearly defined muco-gingival
Clearly visable mamelons
at incisal edge junction between keratinized
Chapter 7
and non-keratinized oral mucosa
Extra-oral set-ups.
Fig. 7 A third intra-oral view showing salient features that should be recorded and • Portraiture
• Dental laboratory set-ups.
Perikymata Chapter 8
Intra-oral set-ups.
• Cross-infection control
• General guidelines
• Full arch
• Quadrants
• Magnification views
• Oral mucosa
Enamel lobe
• Texture, dentine layer, enamel cracks
• Translucency
• Shade analysis
• Posterior teeth.
Chapter 9
Mottled enamel
Post-image capture processing.
Fig. 8 A fourth intra-oral view showing salient features that should be recorded and • Initial processing
• Correcting orientation, exposure,
laterally inverting and cropping
Chapter 3 Chapter 4 • File formats
Principles of digital photography. Choosing a camera and accessories. • Scaling
• The sensors • Digital single lens reflex • Image storage and transfer.
• Technical aspects • Image quality
of digital • Photographic accessories Chapter 10
photography. • Dental armamentarium. Printing, publishing and presentations.

Digital dental photography. IN BRIEF
• Besides dento-legal documentation,
Part 2: purposes and uses dental photography has a host of
PRACTICE
applications for all dental disciplines.
• Communication with patients, technicians
and specialists is enhanced with dental
I. Ahmad1 imagery and photography is a vital tool for
educating patients, staff and colleagues.
• Pictures of treatment carried out at
the practice can be used for compiling
portfolios for marketing, and for
construction of a practice website.
Although the primary purpose of using digital photography in dentistry is for recording various aspects of clinical informa-
tion in the oral cavity, other benefits also accrue. Detailed here are the uses of digital images for dento-legal documenta-
tion, education, communication with patients, dental team members and colleagues and for portfolios, and marketing.
These uses enhance the status of a dental practice and improve delivery of care to patients.
The primary purpose of digital dental confidentiality. Unless the patient has
photography is recording, with fidelity, unusual or defi ning features such as
the clinical manifestations of the oral diastemae, rotations etc, it is difficult
cavity. As a spin-off, secondary uses for a layman to identify an individual
include dento-legal documentation, edu- by most intra-oral images, and hence
cation, communication, portfolios and confidentiality is rarely compromised.
marketing. Each of these uses enhances However, extra-oral images, especially
and elevates the status of a dental prac- full facial shots, can and do compromise
tice as well as improving delivery of confidentiality and unless prior permis-
care to patients. sion is sought, these types of images
Whether the use of dental photog- should not be undertaken. This is also
raphy is solely for documentation or applicable for dento-facial images that Fig. 1 It is imperative to ask patients to sign a
copyright release form before taking pictures
for other purposes, before taking any include the teeth, lips and smiles, which
pictures it is essential to obtain writ- are often unique and reveal the identity
ten consent for permission and retain of patients. A standard release form stat-
ing the intended use of the pictures can
FUNDAMENTALS OF DIGITAL readily be drawn up, and when signed
DENTAL PHOTOGRAPHY by the patient, should be retained in the
dental records (Fig. 1). A crucial point
worth remembering is clearly stating the
‘intended use’ of the images. While most
patients will not object to dental docu-
mentation for the purpose of recording
5. Lighting Fig. 2 Dental images, similarly to radiographs,
pathology and treatment progress, they
6. Camera settings become part of the patient’s dental records
may be more reticent if their images are
used for marketing, such as on practice
brochures or newsletters for distribution
by a mailshot.
DENTAL DOCUMENTATION
1
Dental images, similarly to radiographs
Surgery, 173 The Ridgeway, North Harrow, or other imaging such as CT scans,
Middlesex, HA2 7DF
become part of the dental records and
Email: iahmadbds@aol.com should be respected accordingly (Fig.
2). Nowadays many media are available
Refereed Paper for image display and storage includ-
Accepted 15 November 2008 Fig. 3 Numerous media are available to
DOI: 10.1038/sj.bdj.2009.366
ing prints, computer hard drives, discs
store images, eg CD, DVD or flash drives
© British Dental Journal 2009; 206: 459-464 and memory cards or other back-up
BRITISH DENTAL JOURNAL VOLUME 206 NO. 9 MAY 9 2009 459

PRACTICE
Fig. 5 Facial profile pictures are useful

for analysis during a course of orthodontic
treatment
Fig. 4 A set of pre-operative images is ideal for examination, diagnosis and

treatment planning
devices (Fig. 3). While this plethora of Examination, diagnosis,

methods allows flexibility and conven- treatment planning Fig. 6 Tooth wear requiring replacement of
lost enamel and dentine
ience, it also demands added responsi- The fi rst use of photographic documen-
bility for ensuring that discs or memory tation is examination, diagnosis and
cards do not go astray. Each medium treatment planning, since often during
has its advantages and limitations. A an initial examination, many items are
printed photograph is ideal for educat- missed or overlooked. Therefore, photog-
ing patients about a specific treatment raphy is an ideal method for analysing the
modality, or for showing the current pre-operative dental status at a later date.
state of their dentition and subsequent Dental photography should be regarded as
improvement after therapy. However, a diagnostic tool, similar to radiographs,
prints are not a good method for archiv- study casts or other investigations and
ing. On the other hand, electronic stor- tests. A series of pre-operative images is Fig. 7 Periodontal pocketing
age is preferred for permanent archiving not only helpful for recording a baseline
and retrieval as it is environmentally of oral health, but is invaluable for arriv-
friendlier, but is more cumbersome and ing at a fi rm diagnosis and offering treat-
not readily available to hand compared ment options to restore health, function
to prints. The chosen medium is a per- and aesthetics (Fig. 4).
sonal preference and varies for each Recording pathology is also a valuable
practice. Fully computerised surgeries reason, but a photographic record also
may opt to store patients’ images with serves a constructive purpose for many
their dental treatment details, while other disciplines, for example analys-
paper-based surgeries may prefer pho- ing facial profi les and tooth alignment Fig. 8 Assessing ridge morphology prior to
treatment planning for implants
tographic prints for easier access. for orthodontics, assessing occlusal dis-
Dental documentation can be divided harmonies, deciding methods of pros-
into the following categories: thetic rehabilitation for restoring tooth Progress and monitoring
1. Examination, diagnosis, treatment wear, and observing gingival health The second use of documentation is for
planning and periodontal pocketing or ridge mor- monitoring the progress of pathological
2. Progress and monitoring phology prior to implant placement, to lesions or the stages of prescribed den-
3. Treatment outcomes. name a few (Figs 5-8). In the field of tal treatment. It is obviously essential to
forensic dentistry, photographic docu- monitor progress of soft tissue lesions to
It is worth remembering the proverbial mentation is an essential piece of evi- ensure that healing is progressing accord-
adage, ‘a picture really is worth more dence. Similarly, taking pictures for ing to plan. If a lesion is not responding
than a thousand words’, especially if one suspected cases of child abuse is also with a specific modality, assessment can
has to type them. indispensable proof. be useful for early intervention with
460 BRITISH DENTAL JOURNAL VOLUME 206 NO. 9 MAY 9 2009

PRACTICE
alternative treatment options rather than

waiting for protracted intervals that could
exacerbate the condition. Other uses
include tooth movement with orthodon-
tic appliances, gingival health after peri-
odontal or prosthetic treatment and soft
tissue healing and integration following
surgery or gingival grafts (Figs 9-10).
Visual documentation also emphasises to
patients the need for compliance to regain Fig. 9 Inflamed free gingival margins around Fig. 10 Healthy free gingival margins after a
defective crowns on central incisors week of temporisation with acrylic crowns
oral health, eg adhering to oral hygiene
regimes or dietary recommendations.
Treatment outcomes
Besides achieving health and function,
which are relatively objective goals,
the outcome of elective treatments such
as cosmetic and aesthetic dentistry is
highly subjective. Aesthetic dentistry is
one of the major branches of dentistry
that can produce ambivalent results. In
these instances, if dental photography is Fig. 11 The benefits of scaling and polishing
for the teeth and gingivae are clearly evident Fig. 12 Refractory periodontitis in a diabetic
not routinely used as part of the course
in this image patient
of treatment, it is a recipe for disaster
and possible future litigation. Accurate
and ongoing documentation is a prereq-
uisite for ensuring that the patient, at
the outset, understands the limitations
of a particular aesthetic procedure. In
addition, if the patient chooses an option
with dubious prognosis, or against clini-
cal advice, photographic documentation
is a convincing defence in court.
Fig. 13 Gross calculus build-up in a patient Fig. 14 The patient in Figure 13 after
COMMUNICATION whose first dental visit was at the age of 40 scaling and polishing teeth
Patient
Most patients are not dentally knowl-
edgeable and will benefit from explana-
tions of various dental diseases, their
aetiology, prevention and ameliora-
tion. A verbal explanation alone may
be confusing or even daunting for a
non-professional, but when a pictorial
representation is included it can be elu- Fig. 15 Hopeless prognosis due to periodontal Fig. 16 Pre-operative: missing right central
destruction caused by calculus build-up incisor
cidating and has a lasting impact. For
example, many individuals suffer from
some form of periodontal disease and
showing pictures ranging from mild gin-
givitis to refractory periodontitis leaves
an ever-lasting impression, informing
the patient of the potential hazards of
this insidious disease (Figs 11-15). In
addition, most patients are oblivious to
advances in dental care, for example Fig. 18 Post-operative: ceramic implant-
all-ceramic life-like crowns or implants Fig. 17 Zirconia abutment screwed supported crown to replace missing right
onto implant central incisor
to replace missing teeth. Once again, a

PRACTICE
visual presentation is invaluable so that

the patient can judge the benefits, as
well as pitfalls of these relatively novel
treatment options (Figs 16-18). Further-
more, before informed consent can be
obtained, the patient needs to be pre-
sented with treatment options, together
with advantages and disadvantages of
each proposed modality.
The presentation of case studies can
be as simple as showing pictures, either
prints or on a computer monitor, or using
advanced methods such as software
manipulation and simulation of what is
achievable with contemporary dental
therapy. If software manipulation is used,
showing virtual changes, say to a smile,
it is important to emphasise to the patient
that the manipulation is only for illus-
trative purposes and what is seen on a
monitor screen may not be possible in the
mouth. Also, giving ‘before’ and ‘after’ Fig. 19 Dental photography is an integral part of academic teaching
software simulations should be resisted,
as these become a legal document that
the recipient may refer to if the outcome
is not as depicted in the images.
Staff
In a similar vein to patients, the entire
dental team can also benefit from see-
ing treatment sequences, and be better
prepared to answer patient queries. Fur-
thermore, new staff can appreciate the
protocols involved in complex restora-
tive procedures, while existing members
can learn about new techniques based on
the latest scientific breakthroughs before
they are incorporated into daily prac-
tice. Dental education is invaluable for
staff members to play their roles within
a team and stresses their responsibili-
ties for effective communication, cross Fig. 20 Articles in a dental journal add kudos to a practice
infection control and keeping abreast of
changing ideas and paradigm shifts. individual is a personal choice, but hav- findings of a visual examination and also
ing a practice or dentist profi led or pub- allows the specialist to prioritise appoint-
Academic lished in the dental literature adds kudos ments, particularly in cases of suspected
Beyond patient and staff education, to a practice (Fig. 20). Also, local news- pre-cancerous or malignant lesions. Alter-
photography is an integral part of lec- paper features are reassuring for exist- nately, the images can also be relayed via
turing for those wishing to pursue the ing patients and promote the surgery to email attachments, a CD or DVD.
path of academia (Fig. 19). In addition, potential new clients.
if a clinician desires to publish post- Dental technician
graduate books or articles, either now or Specialists Communication is also vital between
in the future, meticulous photographic If referral to a specialist is necessary, clinician, patient and dental technician.
documentation is a must. There are either for further treatment or a second This is particularly relevant to aesthetic
innumerable publications ranging from opinion, attaching a picture of the lesion dentistry, which can be trying for all con-
high-level academia to anecdotal den- or pre-operative status is extremely help- cerned. As previously mentioned, aesthet-
tal journal. Whichever appeals to an ful. This saves time trying to articulate ics is not a clear-cut concept. Therefore,

PRACTICE
Fig. 21 The crown on the right central

incisor has a lower value compared to the
natural left central incisor
Fig. 22 Digital picture frames Fig. 23 An automated computer presentation is an excellent internal marketing tool
if patients’ wishes are not effectively dental treatment option and secondly, use the clinical case studies to accom-
conveyed to the ceramicist, who after convincing sceptics about dental care, pany verbal explanations.
all is making the prostheses, disappoint- or ambivalent patients regarding choice The method of presenting photographs
ment is inevitable. The best way to miti- of practices that can deliver a proposed is varied, including using prints or a
gate this eventuality is by forwarding treatment plan. While explanations computer monitor. If prints are chosen,
images of all stages of treatment to the accompanied by pictures and illustra- they should be printed on high quality
ceramicist, together with the patients’ tions from dental journals and books photographic paper, either by a photo-
expectations and wishes. Photographs are satisfactory for educating patients, graphic laboratory or an inkjet colour
can be traced, or marked with indelible they are not convincing evidence as to printer. An album or folder with sepa-
pens to communicate salient features whether or not a clinician can deliver rators, similar to a family album, is
such as shape, alignment, characterisa- what is shown in the textbooks. However, ideal for displaying different treatment
tions, regions of translucency or defi n- pictures taken of patients at the prac- sequences. An album is also an excellent
ing features such as mamelons, banding, tice who have been successfully treated coffee table book, which can be placed in
calcification, etc. Also, taking pictures carry credence and support claims for the waiting room for patients to browse
at the try-in stage allows the ceramist to performing a specific procedure. through. Using the digital option for
visualise the prosthesis in situ in relation A useful starting point is collating presentation is more elaborate and styl-
to soft tissues and neighbouring teeth, as sequences of different dental restora- ish. The simplest is an electronic or dig-
well as to the lips and face. At this stage, tions, eg crowns or implants. Over a ital picture frame (Fig. 22) loaded with a
alterations can change the shape, colour, period of time, examples of every treat- series of repeating pictures, which can
alignment, etc, before fitting the restora- ment carried out at a practice can be be manually advanced while talking
tion (Fig. 21), which obviously avoids the documented and subsequently used through a modality, or set to automatic
post-operative dissatisfaction that can be for educating patients, informing them transitions if placed in a waiting room
embarrassing, frustrating and costly if a of the benefits and pitfalls of a given or reception area. The most sophisticated
remake is the only reparative option. therapy. A verbal explanation, of say option for creating a digital portfolio is
implants, may be inadequate for patients using presentation software, eg Micro-
PORTFOLIOS to fully appreciate the time and effort soft ® PowerPoint™. This software allows
Building a practice portfolio of clini- necessary for achieving successful greater flexibility compared to advanc-
cal case studies is time consuming but results. But a visual clinical sequence ing from one image to the next. As well
well worth the effort. Some uses have explains the complexities of advanced as adding text, visual effects and ani-
already been mentioned, such as educa- treatments, and also helps to justify the mations, sound or music can be included
tion, and others, eg marketing, are dis- expenses involved. After suitable train- to enhance the presentation, making the
cussed below. The purpose of showing ing, educating patients can be delegated whole educational experience memorable
clinical photographs to patients is two- to another member of the dental team, eg and exciting. Once prepared, the presen-
fold: fi rstly, education about a particular a nurse, hygienist or therapist, who can tation can either be manually advanced

PRACTICE
for one-to-one sessions, or set to auto- than an empty room, which is perceived
matic display and placed in a communal as isolated, cold or an advertisement for
area of the practice (Fig. 23). dental surgery equipment or furniture.
Other ideas are showing the entire prac-
MARKETING tice team or faces of individual dental
The last, and an important use of den- personnel. Clinical images of ‘before’
tal photography, is for marketing pur- and ‘after’ pretty smiling faces are also
poses. Before embarking on any form always useful inclusions, or sequences
of advertising it is advisable to consult showing stages of particular treatments
the GDC guidelines, and preferably have such as crowns, fi llings and implants. If
items checked by an indemnity organi- clinical images are included, it is impor-
sation to ensure adherence to ethical tant to avoid imagery that is gruesome Fig. 24 A selection of practice stationery
that can benefit by incorporating dental
and professional standards. Many stock or off-putting to a layman. Images of imagery
images of teeth and dental practise can surgical procedures, inflammation or
be obtained from a dental library or as haemorrhage are a few examples that
Internet downloads. But as previously obviously warrant exclusion.
mentioned, using clinical pictures of Designing a practice brochure can
practice patients enhances confidence either be assigned to a graphics com-
for those who are ambivalent about pany, or done in-house using numerous
which practice to attend. It also elevates drawing software packages. The market
the practice reputation by picturing is awash with drawing and photo-editing
a welcoming dental team, or showing software of varying complexity that can
treatment carried out at the practice. be utilised to create a bespoke brochure
Marketing can be divided into inter- or newsletter. Many software packages
nal and external categories. The former have standard templates for a variety of
includes all forms of stationery, practice stationery, which is relatively easily tai-
brochures and newsletters, while latter lored by adding text and images. Some Fig. 25 Business cards can incorporate
dental images for marketing the practice
includes newspapers, journals, books or popular designing and graphic soft-
web pages. ware are Adobe ® Creative Suite, Corel
Draw ®, Quark ® Xpress, Pages and many
Internal marketing word-processing software packages, eg
A variety of stationery can benefit from Microsoft ® Word. All these applications
depicting beautiful smiles of bright, have ready-made templates and once
clean and healthy teeth. Many dental the designing is fi nished, the fi les can
practices incorporate pictures of teeth be transferred to a printing house via
or smiles in their logos and with artis- email, CD or memory stick for proofi ng
tic creativity these can be unique and and a subsequent print run. Chapter 10
defi ning trademarks. Examples of stain the series details the stages involved
tionery include letterheads, appointment in designing a practice brochure.
cards, estimate forms, post-operative Fig. 26 Practice brochures and newsletters
External marketing with clinical images
instructions and business cards (Figs
24-25). In addition, practice merchan- Before the advent of the Internet, adver-
dising such as customised toothbrushes, tising in telephone directories, local news- However, to construct a web page with
ball point pens, pads, bags or other gift papers, or even radio and television were an impressive design layout with slick
items are another form of marketing that the ideal channels. While these media are transitions and music requires employ-
can incorporate practice logos. not obsolete, probably the most effective ing a professional web designer. In addi-
A major piece of practice literature method today of getting a message across tion, the web page designer can advise
which lends itself to imagery is the prac- to a large audience is by using the Inter- on the best methods for obtaining hits
tice brochure, leaflet or newsletter (Fig. net. More and more households and busi- for the site, plus a host of additional fea-
26). The choice of images is a matter of nesses have access to the Internet, and tures (eg links) that ensures the invest-
personal taste and can include pictures of using search engines such as Yahoo® or ment is productive. Although the initial
the outdoor view of the premises, recep- Google® is quicker than wading through cost may seem excessive, it is well worth
tion area, treatment and sterility rooms, heavy telephone directories. investing in this form of advertising as
gardens or even a patio waiting area for If one is computer literate, it is rela- it is without doubt the future, and the
the summer months. It is always more tively easy to design an in-house web capital outlay can be readily recouped
welcoming if each of the practice views page, using images similar to that on within a short period of time by refer-
includes a smiling staff member, rather the practice brochure or newsletter. rals and/or new patients.

• We live in a digital world, and recent
Part 3: principles of technological advances have offered
PRACTICE
conveniences and facilities that were
once only stuff of dreams
•
digital photography The eyes and digital sensors share
uncanny similarities, unlike film
photography that is rigid and inflexible
• Digital photography can be summarised
1 by the acronym CPD (capture, processing
I. Ahmad and display).
VERIFIABLE CPD PAPER
Although we live in a digital age, our knowledge of the processes and technology involved is often limited. As a foundation
to understanding the subsequent parts of this series, this part describes the fundamental aspects of digital photography,
which includes the sensors, processing and display.
We are currently living in the digital revo- passes continuously, without divisions an electrical current, or charge, which is
lution: digital broadcasting, digital con- or separations. eventually processed into an image. Ocular
sumer goods, digital dental radiography, In a similar vein, digital photography and digital imagery share many similari-
and photography is no exception. Without offers many benefits compared to conven- ties and are both extremely flexible. For
doubt, digital is the future. tional photography including: example, if we see something we do not
However, the natural world is analogue; • Instantaneity and convenience like, we can look away (with digital pho-
everything around us is continuous: col- • Flexibility for editing, copying and tography, unwanted parts of an image
our, space, time and sound are all sinu- disseminating images can be cropped). If something attracts our
ous, without discrete separations. We have • Environmentally greener by attention, the eyes concentrate on that
separated nature, or digitised it, for the eliminating toxic dyes and processing specific part of the object or subject (with
purpose of convenience, utilisation and chemicals digital photography, any point of interest
manipulation. An example is time, which • Long-term economy by reusing storage can be enlarged). Also, if we do not like
we have divided into days, hours, minutes media such as memory cards. what we see, the brain can change the con-
and seconds, but which in reality, similarly text of reality so that we find the apparent
to our surroundings, is not intermittent but As with any new technology, there is, unsightly representation more pleasurable
however, a learning curve to fully utilise (with digital photography, software manip-
the benefits and avoid the pitfalls. This ulation can alter an image to any desired
FUNDAMENTALS OF DIGITAL chapter describes the fundamental aspects parameter). These few examples highlight
DENTAL PHOTOGRAPHY of digital photography, which serve as an the flexibility and uncanny similarities of
essential foundation for subsequent chap- ocular and digital imagery.
ters. The starting point is the quintessential Conversely, chemical or film photogra-
item for digital photography: the sensors. phy is rigid, with little scope for manipula-
tion and therefore requires that all settings
4. Choosing a camera and accessories THE SENSORS be exact if an acceptable image is to be
5. Lighting
Light sensors can be categorised into three produced. The basis of chemical photog-
6. Camera settings
basic types, ocular, digital and chemical. raphy is photosensitive coloured layers
Surprisingly, the fundamental principles of painted onto a film emulsion which, fol-
the three types are very similar. The ocu- lowing development, reveals the registered
lar apparatus consists of the eyes, optic image on a cellulose sheet. To produce a
nerve and the brain, which is the ultimate correctly exposed and high quality image,
arbitrator for assessment irrespective of the every setting needs to be accurate. For
1
method used to create an image. In the example, sharp focusing, correct orienta-
Surgery, 173 The Ridgeway, North Harrow, light sensitive retina of the eyes, coloured tion, proper framing and composition, pre-
Middlesex, HA2 7DF
dyes are stimulated by incoming light, cise aperture opening and shutter speeds.
Email: iahmadbds@aol.com triggering neural responses to the brain, In addition, the colour temperature of the
which subsequently computes the image ambient light must match that of the film
Refereed Paper of the object being viewed. emulsion, and the developing chemicals
DOI: 10.1038/sj.bdj.2009.416
In digital photography, light sensitive need to be precisely diluted and at the
© British Dental Journal 2009; 206: 517-523 diodes act as the sensors, which create correct working temperature. It is obvious

PRACTICE
that with so many variables, the scope

of error is magnified and even if camera Table 1 Comparison of the three types of sensors
settings are correct, incorrect developing
Ocular Digital Chemical
can produce unsatisfactory results. Besides
the obvious convenience and instance of Light sensitive sensor Retina Electrical diodes (pixels) Dyes on film sheets
digital photography, a major advantage is Storage/relay media Nerves Memory cards or disc Film sheet
the ability to correct technical errors at a
Reproduction media Brain Monitor, projector, print Film sheet
later stage using software manipulation for
rectifying exposure, white balance, fram-
ing, orientation, sharpening, etc.
A comparison of the three sensors, ocu-
lar, digital and chemical, is summarised in
Table 1. It is worth noting that for chemical
photography, the film sheet serves as the
light sensitive sensor, storage and repro-
duction media. However, with the ocular Pixel
and digital imagery, each of these three
entities uses different media, which obvi-
ously expands possibilities for manipula-
tion and offers unparalleled flexibility.
TECHNICAL ASPECTS Fig. 1 Full-frame CCD with a large fill factor

OF DIGITAL PHOTOGRAPHY
The easiest way to describe the basic prin-
ciples of digital photography is by divid- Conducting
ing them into three processes, forming the area
acronym CPD:
• C for capture
• P for processing
• D for display. Pixel
Capture
The heart of all products based on sili-
cone technology, such as computers, stor-
age media, scanners and digital cameras, is
a semiconductor. With image sensors, the Fig. 2 Interline CCD with a small fill factor
semiconductors are photosensitive units
composed of tiny light detecting units Micro-lens
called pixels. The latter are a substitute
for emulsion in conventional film cameras.
Conducting
Pixels come in many shapes and qualities,
area
varying in size from 5 μm to 12 μm.
Basically, the image sensor is a col-
lection of silicone photodiodes (pixels),
which register the intensity of brightness
Pixel
and darkness of an object. In effect, they
are only capable of producing a black and
white image of the object being photo-
graphed. To create a colour image requires
using appropriate filters corresponding to
the three additive primary colours red,
green and blue. Fig. 3 Interline CCD with micro-lenses, which increase the fill factor
Currently there are two types of image
sensors competing in the market, the CCD The CCDs can be further divided into full- captured onto the sensor. The pixels are
(charged coupled device) and CMOS (com- frame and interline CCDs (Figs 1-2). The arranged in a line, and once stimulated
plementary metal oxide semiconductors), former, full-frame CCDs, allow the entire by light, convey the electrical charge to
each having advantages and disadvantages. frame viewed in the viewfinder to be the end of the line where it is processed

PRACTICE
to form an image. This procedure is time

consuming and must be carried out in
darkness, that is, after the camera shut-
ter is closed. To expedite the process, the
interline CCDs have non-light sensitive
rows between the pixels which convey
the electrical charge simultaneously as
the pixels are ‘stimulated’ by the incoming Fig. 4 A small bit depth results in a pronounced jagged edge
light. This accelerates the process of creat-
ing an image, but due to the conducting
row (non-light sensitive areas), the light
sensitive area (fill factor) available is lower
compared to the full-frame CCDs. This is a
major advantage of full-frame CCDs, since
a fill factor of 70% to 90% means that less
image information is lost compared to an
interline CCD, which has a fill factor of Fig. 5 Increasing the bit depth creates a smoother edge
30% to 50%.
The other competitors to CCDs are the
CMOS sensors. These devices register light
similarly to a CCD, but processing is per-
formed on each pixel rather than being
conducted to the end of a line. Due to
the circuit integration within each pixel,
the CMOS sensors have a smaller surface
area with a reduced fill factor of only Fig. 6 To create a seamless transition between black and white and a smooth edge, a minimum
bit depth of 8, or 256 levels, is necessary
30%. Other limitations of CMOS sensors
are a low dynamic range and increased
noise levels, which are both detrimen- software (for example, Adobe® Photoshop). for red, 8 bit for green and 8 bit for blue
tal to image quality. The advantages are Since all digital equipment and software (256 levels for red, 256 levels for green,
lower power consumption and elimination work with a binary code, a transgression and 256 levels for blue), or a total of 24
of booming (overflow of excess electrical about digitisation is essential. bits (224). This is referred to as the bit or
charges to adjacent pixels). To circumvent All computers function with a digital colour depth of an image. The greater the
the low fill factor of both interline CCDs binary code, that is, they can only com- bit depth per primary colour, the greater
and CMOS sensors, either micro-lenses or prehend 0 and 1. These binary digits are the accuracy of recorded detail. The colour
octagonal shaped pixels with larger sur- termed bits, and eight bits are equivalent depth is an important point to consider
face areas arranged diagonally are used to to 1 byte. A byte is the minimum number when purchasing digital equipment or soft-
increase the light-sensitive potential or fill of bits required to make up a single alpha- ware. The stated colour depth can either be
factor (Fig. 3). betic character. The storage and memory for each primary colour (per channel), or
capacities of computers are therefore the total bit depth of the three primary
Processing quoted in megabytes (MB) or gigabytes colours. Many manufacturers quote 8-bit
There is a misconception equating an image (GB). In digital photography the primary depth/channel, indicating 8 bit per primary
sensor with digital images. However, the function of the A/D converter is to repro- colour (that is, 8 for red, 8 for green and
contrary is true. A sensor is only capable of duce the pure analogue signal into a dig- 8 for blue), which equates to a total bit
delivering an analogue signal. This signal ital code that is as close as possible to the depth of 24. However, other manufacturers
is an electrical charge, obtained from the original. Since digital data is composed state the total bit depth of say, 24.
result of exposing the pixels to light. Each of discrete entities, lacking homogeneity Returning to the image sensor, each
pixel creates an electrical charge depending with noticeable banding, in order for the pixel is assigned a binary number accord-
on the intensity of incoming light and the human eye to visualise a continuous tonal ing to the magnitude of its charge. The A/D
duration of exposure. Further technology is range (greyscale), a minimum of 8 bits is converter assigns the level of brightness in
necessary to transform the analogue elec- necessary (28), which equate to 256 levels steps. As mentioned above, the greater the
trical signal into binary (digital) numbers. (Figs 4-6). number of steps the smoother the transi-
This is achieved by an analogue-digital Consequently, for colour images com- tion on a greyscale and the more precise
converter (A/D converter). Once converted, prising the three primary colours red, green rendition of an image. Most cameras use
the digital data is processed by microchips and blue, each colour channel must have an 8 bit per channel A/D converter cod-
either within the camera, or downloaded a minimum of 8 bits so that a continuous ing for 256 different levels of brightness
to a PC and manipulated with appropriate tonal range is perceived. This means 8 bit and darkness, while professional systems

PRACTICE
use 16 bit per channel, which translates

to 65,536 brightness levels. To calculate
the number of colours possible in a given
system, the tonal levels for each colour
are multiplied. For example, for a cam-
era with a total colour depth of 24, the
number of colours coded is 256R × 256G
× 256B, which results in 16.7 million pos-
8 bit (28 = 256)
sible colours (Fig. 7), and for a total 48-bit
system (16 bit/channel) or 248, the number
of colours is 2.8014. In comparison, the dif-
ference threshold for colour of the human
eye is low enough to discriminate 7 mil-
lion colours.
In reality, only 8 bits are necessary for
the eyes to visualise an uninterrupted
smooth greyscale. However, once an 8-bit
image is manipulated using photo editing
Red channel (28 = 256) Green channel (28 = 256) Blue channel (28 = 256)
software, there is degradation of the origi-
nal 8-bit signal resulting in jagged steps
at the periphery of objects. To avoid these
unwanted artefacts, it is therefore wiser
to start with a 16 bit image, allowing for
degradation while still maintaining the
minimum requisite 8 bit colour depth.
Besides colour depth, the other factor
to consider is the dynamic range of the
sensor (to be discussed further in Part 6).
16.7 million colours
This is determined by the amount of charge
that a pixel can accept, or its saturation Fig. 7 Schematic representation of a 24 bit colour depth system (or 8 bit/channel)
level, termed full well capacity. The larger
Bayer pattern
the physical size of a pixel, the greater
the charge it can hold, and the greater the
dynamic range. Therefore, in high-end
digital cameras the sensors have larger
pixels of approximately 12 μm, compared
to the 5 μm pixels that are used in amateur
or compact cameras.
As previously stated, the image captured
by a sensor is in essence black-and-white
(Fig. 8). Colour is achieved by adding three
channels representing the three primary
colours of additive mixing, that is red,
green and blue. A variety of ingenious
methods are utilised for creating coloured
images including rotating colour filters,
beam splitters, or coating each pixel with
filters of the three primary colours. The lat-
ter is the most popular method, creating a Fig. 8 The pixels of an image sensor only Fig. 9 Colour is captured by placing filters of
mosaic of red, green and blue on the image detect the brightness levels of an object, red, green and blue onto the pixels, such as
creating a black and white image this Bayer pattern arrangement
sensor (Fig. 9). When exposed, each pixel
registers the intensity of light for one of the
three colours, and when collated together The rationale is that the red, green and white light, each individual layer registers
this yields a colour image (Fig. 10). The blue components of white light penetrate red, green or blue, and when combined
latest technology is sandwiching three at different depths: red is deepest, green they form a coloured image.
separate pixel layers of red, green, and intermediate and blue superficial. When The actual image capture is performed by
blue, similar to the dye emulsions of film. these multi-layer sensors are exposed to numerous methods, for example scanning,

PRACTICE
Missing inter-pixel information

is interpolated from adjacent pixels
11 12
Fig. 10 The filtered pixels record the amount

of red, green and blue at each site to form a
colour image
3-shot, 1-shot, 4-shot, microscan and

macroscan. The method used depends on
the application in question. For example,
for photographing static still-life compo-
sitions or documenting works of art and
sculptures, the ideal is the scanner system.
However, a scanning system is inappro-
priate for moving objects, and for sports
photography the 1-shot system is the
13 14
ideal choice.
By far the most popular system, and one Figs 11-15 The pixels are only capable of
that is suitable for dental photography, is measuring the dark and bright parts of an
the 1-shot system. As the name implies, a image, and in effect are only capable of
producing a black and white image (Fig. 11).
single exposure is required to capture the
Colour is created by the three channels red
object being photographed. The set-up is (Fig. 12), green (Fig. 13) and blue (Fig. 14),
as follows. The image sensor consists of and combining these channels produces a
pixels with a mosaic of filters, for example colour image (Fig. 15)
in the Bayer pattern arrangement for the
three primary colours, red, green and blue
(Fig. 9). Once exposed, the sensor records
the corresponding amount of red, green
and blue in the prevailing composition.
The entire process is summarised in Figs
11-15. Depending on the proximity of the
pixels, small amounts of detail are lost,
which are interpolated using information
from adjacent pixels. The disadvantages of 15
this system are that the resulting image is
prone to interpolation errors such as col-
our fringes at edges of objects and Moiré errors by using software to suppress these while a lengthy computation time may be
patterns of strongly chequered materials. unwanted artefacts. However, if suppres- unacceptable to expedite workflow. But
The interpolation algorithms mitigate these sion is too great, genuine detail is lost, taking all factors into consideration, the

PRACTICE
Fig. 17 An image with a file size of 30.3 MB

and 2,797 × 1,895 pixels (5.3 megapixels)
Fig. 16 LCD display on camera back
benefits of a 1-shot system, such as the loss, but is easier to store, manipulate and Fig. 18 An image with a file size of
113.4 MB and 5,329 × 3,717 pixels
ability to record moving subjects, com- disseminate. The JPEG format also has a (19.8 megapixels)
pactness, lightweight and reduced cost, range of resolutions from low to high, with
outweigh the minor and perhaps imper- corresponding file sizes, respectively.
ceptible loss in image quality. If a proprietary format is chosen, the file
Before an image can be viewed a certain is in a raw state and requires processing by
amount of processing is necessary. Firstly, specific software before it can be viewed
the captured image must be processed by and stored into a generic format. On the
software in the camera as a digital file. The other hand if a generic format is chosen at
format of the file at this stage can either be the outset, no further processing is neces-
proprietary, that is specific to a particular sary to view or store the file.
camera manufacturer, or in a generic format
such as RAW (PNG), TIFF or JPEG. Secondly, Display
the size of the ensuing file depends on After in-camera processing, the image
the format in which it is saved. The file can be displayed via electronic or printed
size is a crucial determinant of the final media. Electronic media consists of moni- Fig. 19 A 100% enlargement of a section
of the image shown in Figure 17, with a file
image quality. The file size of an image can tors and projectors, and printed media of size of 2.3 MB and 639 × 616 pixels
be calculated according to the formula: photographic paper or printing paper. (0.4 megapixels)
Number of pixels × (total bit depth ÷ The first time that an image is usually
8) = image size in bytes viewed is on the LCD monitor on the cam-
era back (Fig. 16) The size of these moni-
For example, the maximum file size that tors varies from 2 inches to 3.5 inches,
a digital camera with a 10 million pixel with a resolution ranging from ¼ million
image sensor, and a bit depth of 24 (8 bits to 1 million pixels. The monitors allow
per primary colour) is capable of creating instantaneous viewing of the image for
in an uncompressed state is 30 MB: assessing composition, framing, orienta-
[10 × 106 × (24 ÷ 8)] = 30 MB tion and exposure. However, they are of
little use for determining fine detail or
The file format, and hence its size, is pri- sharp focus due to their low resolution,
marily dependant on the intended use of usually no more than 1 megapixels.
the image. This is usually in a RAW or TIFF The second type of electronic viewing
format. If a smaller size file is required, a is with a computer monitor or an LCD Fig. 20 A 100% enlargement of a section
low-resolution file format such as JPEG can projector (beamer). The resolution of both of the image shown in Figure 18, with a
be chosen. The latter format compresses the computer monitors and projectors varies file size of 7.6 MB and 1,140 × 1,153 pixels
(1.3 megapixels)
original digital file at the expense of detail enormously. For the former the resolution

PRACTICE
ranges from as little as 720 × 480 (0.3 meg- The final point worth mentioning about the monitor (1.3 megapixels). However, if
apixels) to 1,440 × 900 (1.3 megapixels). megapixels and monitors or projectors is both images are now enlarged by 100%
Even the state-of-the-art true high defini- as follows. While both have relatively low to concentrate on the lower mandibular
tion projectors are only capable of deliver- pixel counts compared to digital cameras, incisors, the pixel count of the enlarged
ing a resolution of 2 megapixels (1,920 × a difference is noticeable when an image is section of Figure 17 is 639 × 616 (0.4
1,080), far short of what is achievable with enlarged. For example, this is particularly megapixels) – Figure 19, while for Figure
even the most inexpensive digital compact relevant when photographing pathologi- 18 it is 1,140 × 1,153 (1.3 megapixels) –
cameras. This is the reason that an image cal changes to the oral mucosa. If a small Figure 20. With this enlargement, the pixel
taken with a 3 megapixels camera will lesion, in its early stages, is detected it is count of Figure 19 is lower (0.4 megapix-
look the same as that from a camera with useful to magnify the area for detailed els) than the monitor (1.3 megapixels),
a 10 megapixel sensor. If no difference visual assessment. However, if the image and the image appears grainy and is seen
is visually discernable, why bother with deteriorates when enlarged, it is clinically to be breaking down, with loss of detail.
expensive, high megapixels cameras? The useless, giving few clues to the pathologi- However, the enlarged image in Figure 20
reason is as follows: the resultant image cal process. To illustrate this point, con- matches the pixel count of the monitor
quality is not solely dependant on the sider the two images in Figures 17 and (1.3 megapixels) and still appears sharp
number of pixels. Other more important 18, which were taken with identical light- and retains detail. Notice the scratches
factors include resolving power of the lens, ing, lens, etc. but with digital backs of on the enamel surface on the mandibular
tonal range of the entire system such as bit different pixel count image sensors. The right lateral incisor in Figure 20, which are
depth, dynamic range, file format and size, image in Figure 17 is a 30.3 MB file, with indiscernible in Figure 19. This example
camera hardware (A/D converter, cooling), a pixel count of 2,797 × 1,895 (5.3 meg- emphasises the need to use camera equip-
and image processing software (interpola- apixels), while the image in Figure 18 is ment with high specifications, including a
tion and colour reproduction), etc. Hence a 113.4 MB file with a pixel count of high pixel count, to retain quality when an
an elaborate camera system usually offers 5,329 × 3,717 (19.8 megapixels), that is, image is enlarged.
more than just higher megapixels, but also the second image has a nearly four times The final method of viewing an image is
the features cited above to produce high greater pixel count. When both images are printing, which can either be with an office
quality images. This is an important point viewed full-frame on a standard, 1.3 meg- printer or a professional printing press.
to remember before choosing a camera sys- apixel computer monitor, no difference is Both methods are ubiquitously popular,
tem (covered in Part 4), because two cam- visually perceptible. The reason is that the each having their unique benefits and
eras with identical megapixels will produce pixel count of both images (5.3 megapix- drawbacks. Printing is discussed further
drastically different quality images. els and 19.8 megapixels) exceeds that of in Part 10.

• The most convenient, versatile, easy to
Part 4: choosing a camera use camera for dental applications is the
PRACTICE
digital single lens reflex (DSLR) camera.
• A high quality lens is the key factor for
high resolution images.
I. Ahmad1 • The number of pixels is not an indication
of the image quality, but only the size of
a digital image.
• Many photographic accessories and
dental armamentarium expedite a
photographic session.
With so many cameras and systems on the market, making a choice of the right one for your practice needs is a daunting
task. As described in Part 1 of this series, a digital single reflex (DSLR) camera is an ideal choice for dental use in enabling
the taking of portraits, close-up or macro images of the dentition and study casts. However, for the sake of completion,
some other cameras systems that are used in dentistry are also discussed.
The number of cameras on the market is

daunting and their specifications mind-
boggling. The requirements of a camera
for dentistry are two-fold: capable of tak-
ing portraits, as well as close-up or macro
images of the dentition and study casts
(Figs 1-3). These dual requirements limit
the types of cameras meeting these criteria.
Furthermore, a camera system should be
1 2
flexible, allowing adaptation for changing
technology, and versatile for creative pho- Figs 1-3 A camera for dental use should be
tography (Fig. 4). Therefore to simplify the 3 capable of taking portraits as well as close
technical jungle, we only need to consider up or macro images of the dentition and
dental casts
a digital single reflex (DSLR) camera, as
DENTAL PHOTOGRAPHY
5. Lighting
discussed in Part 1, which is an ideal choice
6. Camera settings
for dental use. However, for the sake of
completion, a few other cameras systems
are discussed that are used in dentistry.
CAMERAS FOR
DENTAL PHOTOGRAPHY
1
The first is an intra-oral or fibre optic
Surgery, 173 The Ridgeway, North Harrow, camera. This is an excellent tool for a
Middlesex, HA2 7DF
cursory tour of the oral cavity, showing
Email: iahmadbds@aol.com patients gingival inflammation, decay and
defective restorations. While its quality is
Refereed Paper adequate for displaying on a monitor, it is
Accepted 15 November 2008 Fig. 4 A versatile camera system allows
DOI: 10.1038/sj.bdj.2009.476
insufficient for permanent documentation
flexibility for creative images
© British Dental Journal 2009; 206: 575–581 or for archiving.
BRITISH DENTAL JOURNAL VOLUME 206 NO. 11 JUN 13 2009 575

PRACTICE
Fig. 5 Before digital photography, Polaroid

instant films were the only method of Fig. 7 Compact cameras are unsuitable
previewing an image before making the final for dental use due to the disadvantageous
exposure Fig. 6 The Kodak P712 digital camera system parallax phenomenon
The second is the Polaroid Marco 5 SLR

camera, relatively inexpensive, with auto-
matic exposure, auto-focusing and built-in
flashes. Various pre-set magnifications are
offered ranging from full face to a few
teeth. The ‘trademark’ of Polaroid is self-
developing prints, usually in a few minutes
after taking the picture. The images are
low quality, unable to be electronically
archived, as only one print is produced
for each exposure. The film is expensive
because each print contains the develop-
ing chemicals. Before the advent of digital
photography, Polaroid prints were the only
method of instantly viewing a picture, but
with the arrival of digital technology these
cameras have become obsolete, having
merely a novelty factor (Fig. 5).
The next tailored camera for dental pic-
tures is the Kodak P712 with an EasyShare
docking port printer. This DSLR is adapted Fig. 8 The body of a DSLR houses the CCD sensor and electronics
from the Kodak budget range of digital
cameras, modified specifically for dental
use. Lenses, focusing, framing, exposure
and flash are all pre-set and automatic.
Unlike a Polaroid, images can be stored
on a computer and/or immediately printed
with the accompanying printer (Fig. 6).
The major drawback with this ‘shoot and
go’ camera is the fixed focal length lens,
which limits flexibility and versatility.
Furthermore, for the same price, a semi-
professional DSLR can be purchased, offer-
ing greater possibilities and functionality.
Other cameras are the rangefinder varie-
ties, for example compact ‘point and shoot’
that are unsuitable for dentistry because
they suffer from parallax (Fig. 7). Parallax is
defined as the difference between the image
seen in a viewfinder and that recorded by
a sensor. With macro photography, as the
lens moves closer to the subject the vari- Fig. 9 The LCD viewer on the camera back allows a video display of the intended image,
followed by instant viewing of the image after exposure
ance increases, which means that certain
576 BRITISH DENTAL JOURNAL VOLUME 206 NO. 11 JUN 13 2009

PRACTICE
Canon EOS 450D Canon EOS 50D Canon EOS 5D MKII
Fig. 10 A high quality macro-telephoto is the

ideal lens for dental photography
teeth or parts of individual teeth may be

missing on the resultant image. Some man-
ufacturers have ingeniously overcome par-
allax by viewing and focusing attachments, Nikon D90 Nikon D5000 Nikon D700
all with limited success. This is analogous
to buying a family saloon car and then cus-
tomising it for formula one racing, which
seems a little futile!
DIGITAL SINGLE LENS REFLEX

The most versatile camera for dental pho- Fujifilm FinePix S5Pro Olympus E-520 Sony a350
tography and for achieving the best results
is without doubt a DSLR system. A DSLR
offers TTL (through the lens) viewing and
metering, precise focusing and accurate
framing. The major advantage of DSLRs
is that parallax is eliminated, because the
viewfinder, lens and image sensor all share Pentax K200D
the same optical axis. This means that what
is seen in the viewfinder is identical to that Fig. 11 A selection of semi-professional DSLR cameras, all approximately £500
recorded on the resulting image.
A DSLR consists of a camera body hous- For dental applications, a dual-purpose format, and therefore have a multipli-
ing the sensor, LCD viewer and microproc- lens is necessary, firstly for portraiture and cation factor. For example, attaching a
essor, which is the ‘brain’ of the camera secondly to focus down for close-up pho- 100 mm lens to a 35 mm camera body
(Figs 8-9). At one time it was a luxury to tography. The ideal choice is therefore a will effectively ‘convert’ the focal length
have a live video display on the LCD, but lens that combines both these features, that of the lens to 150 mm, that is, the sen-
nowadays this feature is almost common- is, a macro-telephoto lens. A word of cau- sor has a multiplication factor of 1.5.
place. However, it should be remembered tion about macro lenses. Many lenses have However, some newer high-end cameras
that the video display lags behind what is ‘macro’ etched on their barrels but are not have larger sensors and therefore the
observed in the viewfinder depending on the true macro lenses. Even compact cameras lenses do not require a multiplication fac-
refresh rate of the LCD screen. The second claim macro facilities but this only indi- tor. It is important to purchase the high-
component is the interchangeable lenses, cates close focusing facilities. A true macro est quality lens that you can, preferably a
which are selected according to the type is capable of producing a 1:2 or 1:1 magni- proprietary make rather than a third party
of photographic application, for example fication. A 1:1 magnification is the ideal and analogue. The lens characteristics (resolu-
macro, portrait, landscape, sports, wildlife, means that the image recorded by the sensor tion and superior optics) are essential for
etc. A few DSLRs have fixed zoom lenses, is the same size as the object in real life. For high quality images, and spending a lit-
which are usually incapable of taking macro 35 mm format DSLRs, a 1:1 image usually tle extra money in the beginning will pay
dental images. The standard lens of a DSLR translates to about four maxillary incisors. dividends in the long term. The lens char-
has a focal length of 50 mm; a shorter focal Depending on the manufacturer and acteristics should include high contrast for
length lens, say 28 mm, is classified as wide arrangement of optics within the lens bar- higher resolution, combined with superior
angled (for example, for landscapes), while rel, the focal lengths of macro-telephotos optical quality for minimising chromatic
a longer focal length is a telephoto (for vary from 50 mm to 105 mm. Also, many and spherical distortions. Lenses with the
example, for sports or wildlife). sensors are smaller than the 35 mm film prefix ‘APO’ (Fig. 10) and ‘ASPH’ indicate

PRACTICE
low chromatic and spherical aberrations,

respectively. Finally, auto-focus lenses
may not operate in some close-up dental
set-ups, and the ability to revert to manual
focusing is a useful option.
Most semi-professional DSLRs offer all
the specifications necessary for dental pho-
tography (Fig. 11). The salient features to
scrutinise before purchasing a camera are:
1. Image sensor: CCD or CMOS
with greater than six megapixels.
However, most current semi-
professional cameras exceed ten Canon EOS 1Ds MKIII Nikon DX3
megapixels as standard (see Part 3)
2. Bit depth: minimum 8 bit/channel
(24 total bit or colour depth), 16 bit/
channel (48 total bit or colour depth)
preferred (see Part 3)
3. Dynamic range of sensor: minimum
6 f stops, more than 6 f stops
preferred (covered further in Part 6)
4. Dust reduction system for sensor:
mitigating unwanted particle
build-up on sensor or access to the
sensor for cleaning Sony a900 Olympus E-3
5. Metering: multi-pattern TTL with
aperture priority mode (to be covered Fig. 12 A selection of professional DSLR cameras, from £800 to £6,000
in Part 6)
6. Flash metering: TTL synchronisation (Fig. 12) with additional features, some gim- people. Summarised succinctly, image
(to be covered in Part 5) mickry and functions that are superfluous quality depends on the following items,
7. White balance: automatic and for dentistry. Unless one is fastidious about which are briefly discussed below:
manual (to be covered in Part 6) image quality, it is pointless spending ten 1. Magnification
8. Full frame capture (not mandatory if times the amount purchasing equipment with 2. Inherent object details
cost is prohibitive) features that one will rarely use. However, 3. Degree of the trained eye
9. ISO range: ability to set a minimum to ensure a prudent long-term investment, 4. Visual acuity and acutance
of 100 for low noise (to be covered in when choosing a lens it is preferable to opt 5. Psychological perception of detail
Part 6) for a proprietary macro-telephoto lens of 6. Circle of confusion
10. Data formats: RAW, PNG, TIFF and the highest optical quality. This ensures that 7. Distance of viewing
JPEG files (to be covered in Part 9) even if the camera body becomes obsolete, 8. Viewing media.
11. Colour domains: Adobe RGB and the lens can still be used with a newer body
sRGB (to be covered in Part 6) purchased in the future. Magnification and inherent object details
12. Storage media: maximum internal (dependant of illumination) are discussed
capacity or memory cards, greater IMAGE QUALITY in Part 3 and Part 5, respectively.
than one gigabyte (see Part 2) A key factor before choosing photo- An individual trained to ‘see’ certain
13. Interface: FireWire or other high graphic equipment is ensuring that the details will perceive them more than an
speed transfer to computer (to be items purchased harmoniously integrate untrained layman. This is clearly evident
covered in Part 9). and ‘communicate’ with each other to yield in dental aesthetic assessment. A clini-
acceptable image quality. The theoretical cian’s eye is trained to scrutinise details
It is difficult to recommend manufactur- aspect of image quality was discussed in pertaining to dental aesthetics far more
ers or models of cameras, since the mar- Part 3, but now requires further elaboration than the average patient. Visual acu-
ket is rapidly changing and new products in relation to the photographic hardware. ity or perception of sharpness is a func-
are introduced annually or even every few Image quality is influenced by perceptual tion of the eyes, which deteriorates with
months. The best way to choose a camera and practical factors. advancing years and is compensated by
is to visit a retail showroom and check that eyeglasses or magnification aids. A phys-
a semi-professional DSLR meets the above Perceptual factors ical measurement of sharpness is per-
criteria and specifications. Of course one Image quality is a subjective and nebulous formed by densitometers and is termed
can purchase high-end professional DSLRs entity meaning different things to different acutance. The latter is an objective

PRACTICE
measure of sharpness, not influenced by

subjective idiosyncrasies.
Psychological perception of detail varies
enormously, not only from individual to
individual, but also intra-individually. An
individual will see what his or her brain
wants to perceive, depending on their
social, academic, religious and intellectual
psychological make-up. Furthermore, an
individual may perceive the same image
differently at different times depending
on his or her state of mind. Factors such
as stress, lethargy, influence of intoxi-
cating substances (alcohol, psychotropic
drugs), insomnia, inactivity and libido
changes all affect an individual’s ability to
discern detail. Poor image quality with inexpensive 10 megapixel camera, there is little detail
The circle of confusion is a phenomenon of the soft tissues texture and poor depiction of tooth characterization
that also affects image quality. Any lens,
no matter how perfect, will always rep-
resent a perfect pinpoint as a tiny blur.
The circle of confusion can be reduced, but
never to the original pinpoint. Therefore,
an acceptable dimension is assigned to
represent the original pinpoint, which var-
ies from 0.1 mm to 0.033 mm, depending
on different authorities and manufactur-
ers. The significance of the circle of con-
fusion is that the nearer the viewer is to
an image, the smaller the circle of con-
fusion necessary to ensure image sharp-
ness. For example, viewing an A4 image
requires a smaller circle of confusion
compared to viewing a 20 × 10 foot bill-
board poster from a distance. The same is
High image quality with expensive 10 megapixel camera, the soft tissue
true for watching a film in a cinema: the
architecture and gingival stippling is clearly visible, as well as tooth stains,
further away from the screen, the sharper and fracture lines
the image.
Additionally, viewing media also alter
image detail. For example, a printed image Fig. 13 The number of pixels alone does not influence image quality. Both images are taken
with 10 megapixel cameras. The top image, using an inexpensive camera, has little detail and a
which is converted from an RGB original to low dynamic range. The bottom image is with an expensive camera, and is rich in detail with a
CMYK separations will have obvious detail high dynamic range
loss compared to the original image.
Finally, appearance is also affected by
the five modalities of colour: white light through a coloured sur- of a digital image: they determine the size
1. Object colour – colour due to white face, for example viewing transpar- of an image.
light reflected off its surface, for encies using a projector The hardware, and subsequent software
example a tomato appears red 5. Illuminant colour – an incandescent processing and manipulation determine
because all colours of the spectrum entity, such as a light bulb, emanat- image quality. Returning to the acro-
are absorbed except the colour red, ing light of a specific hue. nym CPD (capture, processing, display)
which is reflected off its surface discussed in Part 3, how good the image
2. Volume colour – objects such as col- Practical factors looks is determined by method of capture
oured wine bottles, where the colour The single feature about digital cameras (a function of lens quality together with
is related to the volume of the object most frequently quoted by manufacturers the quality and quantity of pixels), method
3. Aperture colour – colour of a space, and retailers is the number of megapixels. of in-camera processing (A/D converter)
for example blue sky But contrary to popular belief, the numbers and the method used to display an image
4. Illumination colour – transmission of of pixels does not determine the quality (monitor, prints).

PRACTICE
Fig. 14 The tripod supports a mechanical

stage, flash brackets and the camera. A
TTL adaptor mounted on top of the camera
controls the bilateral flashes and exposure is
made with cable release
Fig. 16 The dental armamentarium required for dental photography
with 10 megapixels and one which is ten most contemporary digital cameras, the
or twenty times the price, also with 10 corruption is insignificant and rarely per-
megapixels. Both cameras will capture an ceptible. However, the in-camera software,
image that is identical in size. However, which eventually extrapolates a picture
Fig. 15 A selection of coloured cards used the image from the inexpensive camera from the image capture, should be suffi-
as backdrops for photographic set-ups in a
dental laboratory will be poorer in quality compared with ciently sophisticated to minimise flaws. For
that from the expensive camera. Although example, if the initial capture is 24-bit, but
both cameras have the same number of is processed with a 12-bit depth A/D con-
Capture pixels, to ensure high image quality other verter, 12 bits of information or detail are
The predominant factor affecting image factors much be taken into account such lost. Furthermore, if in-camera processing
quality is the optics of the lens, discussed the resolving power of the lens, the A/D is set to translate a RAW image to a low
previously. Furthermore, as the physical converter, pixel quality, pixel size, bit quality JPEG file format, further loss of
pixel size decreases to cram more onto depth, dynamic range, file format, degree information is inevitable.
the limited surface area of a sensor, the of noise and method of display (Fig. 13).
demands on the lens to resolve detail To summarise, the number of pixels Display
increases. For example, purchasing a determines the size, not quality, of an Finally, the method of display has a bear-
digital camera with a 10 megapixel sen- image. However, the numbers of pix- ing on how the final image is perceived.
sor and attaching a lens capable of only els become significant when enlarg- Once again, image quality is affected by
resolving 6 megapixels of detail will do ing an image. For example, for a print the resolving power of the monitor (CRT
little to increase image quality. The quality size of 5 × 7 inches, a camera with a 3 or LCD), the type of file used to display
of the pixels is determined by the type of megapixel sensor is adequate. If larger the image, the quality of paper and the
sensor, either CCD (charge coupled device) images are required, or enlargement of printing equipment, or the calibration [and
or CMOS (complementary metal oxide a part of the image is necessary, more intensity] of a projector. For the untrained
semi-conductor). CCD sensors allow a pixels are necessary to avoid deteriora- eye and for most dental applications, a
larger bit depth (range of colours), higher tion of the image quality. For dental pho- computer monitor, inkjet printer with
dynamic range (increased contrast) and tography, 6 megapixels are more than photographic paper or standard ‘beamer’
greater signal to noise ratios (avoiding sufficient, allowing a high quality A4 projectors are acceptable. It is only the
grainy images). The CMOS are second- print assuming that the image is printed aficionados who will detect nuances
generation sensors with less power con- without magnification. which necessitate calibration of monitors,
sumption, which allow access to individual projectors and printers to optimise the
pixels. Pictures taken with two different Processing final display.
cameras with the same number of pixels The only method of recording a virgin, or
will vary enormously because the quality pure analogue image signal is to record it PHOTOGRAPHIC ACCESSORIES
of pixels is a crucial factor determining on film. All software and hardware used Besides the camera and lens, other photo-
image quality. It is possible to purchase for processing, to a lesser or greater degree graphic adjuncts are useful accessories to
a relatively inexpensive compact camera adulterate the captured image signal. In expedite dental photography.

PRACTICE
Camera supports allow hands-free, no for dental shade analysis and white balance DENTAL ARMAMENTARIUM
touch protocols to be practised. This not calibration, discussed further in Part 6. The main items needed for intra-oral pho-
only offers convenience, but is also con- The purpose of backdrops, or back- tography are cheek retractors, available
ducive to sterility and disinfection proce- grounds, is to isolate and concentrate from dental suppliers in unilateral and
dures in the clinical environment. A tripod attention on the object being photographed. bilateral varieties. Traditionally, metal
is an essential support item to stabilise the The oral environment serves as a natural retractors were universally used for dental
camera, and other mounted accessories backdrop and due to limitations of space photography, but they are more traumatic
and various types are available offering and access, in vivo backgrounds are rarely than the plastic pliable varieties that are
sturdiness on a solid platform. required. On occasions, a black card placed generally preferred. The bilateral variety is
A tripod ensures precise picture framing behind the maxillary anterior teeth may be used for talking pictures of anterior teeth,
and focusing and is conveniently moved useful for highlighting translucency and while the unilateral type is useful for lat-
aside once a photo session is finished. incisal edge characterisations. eral views and pictures of posterior teeth.
Besides tripods, if space is a paramount For portraiture and extra-oral pictures, Intra-oral photographic mirrors are neces-
concern there are numerous ingenious backgrounds are a requisite and add inter- sary for occlusal, lingual (or palatal) and
camera support devices on the market, est to the composition. However, subtlety lateral views of teeth. Dental photographic
which can be tailored to specific surgery is necessary when choosing backgrounds, mirrors should be front-coated to avoid
requirements. A visit to the local camera since flamboyant, ostentatious or lurid double images. Several sizes are avail-
shop or surfing the Internet provides ample backgrounds detract attention from the able to accommodate various degrees of
ideas and choices. main subject. Any medium such as cloth, mouth opening.
As well as securing the camera to a tri- coloured papers, walls or furniture can Other dental items necessary for pho-
pod, flashes can be mounted either lat- effectively be utilised to separate and tography are readily available in a dental
erally or superiorly to the camera body therefore highlight the main object. A surgery. These include cotton wool rolls,
via brackets, for example the macro flash background consisting of a cluster of saliva ejectors and rubber dam for isola-
bracket (Manfrotto, Italy). Finally, the objects causes visual confrontation and is tion and moisture control (Fig. 16). An
camera and flash bracket can be supported distracting, for example photographing a oil-free, 3-in-1, or 6-in-1 syringe deliver-
on the tripod via a graduated mechani- patient seated in a dental chair with the ing warm air ensures that the soft tissues
cal stage (Kaiser Phototechnik, Germany) entire surgery armamentarium serving as and teeth are free of saliva and blood and
as in Figure 14. A stage also facilitates a backdrop. prevents condensation or fogging onto the
precise focusing, especially when a par- For dental laboratory or bench photog- surface of intra-oral mirrors. Another
ticular scale of reproduction is required, raphy, backgrounds are extremely useful approach to preventing condensation on
for example 1:1 or 1:2. Additionally, no for blocking extraneous objects or the mirror surfaces is to pre-soak in warm
contact with the lenses is necessary, which laboratory equipment and clutter. The sim- water before use. Plaque and food par-
also benefits a ‘no touch’ protocol. This plest backdrops are coloured cards, cut to ticles are removed by flossing and pol-
set-up is also useful for extra-oral bench various sizes, illuminated separately from ishing with prophylaxis paste before a
photographs of dental casts in the dental the main subject, giving a sense of sepa- photographic session (unless the inten-
laboratory. For photographing radiographs ration and three dimensionality (Fig. 15). tion is recording biofilm or extrinsic
a copy stand is indispensable, ensuring Another useful medium is cloth such as stains). Gingival bleeding or crevicu-
precise location and uniform illumination black velvet, which absorbs all incident lar exude, for example following crown
(Kaiser Phototechnik, Germany). light, producing a uniform black back- preparation, is arrested with retraction
Another accessory is a remote release ground. Textured or patterned backgrounds cord soaked in a haemostatic agent, for
cable, which can be wireless or foot control- should be avoided unless a special effect example buffered aluminium chloride.
led and is invaluable for taking pictures of is required. Professional still life shoot- Astringent agents containing adrenaline
surgical procedures where cross-infection ing tables and props with custom-made or ferric compound are avoided to prevent
control is essential. Also, an 18% grey card backgrounds are commercially available cardiac stimulation and black gingival
and a photographic colour guide is useful for expediting repetitious set-ups. residue, respectively.

• Choosing the appropriate type of lighting
Part 5: lighting is essential for obtaining a correctly
PRACTICE
exposed, high quality, detailed image.
• The ideal lighting for dental photography
are camera mounted electronic flashes.
I. Ahmad1 • By using reflectors and diffusers, light
can be modified for specific applications,
or for conveying a particular mood or
ambiance.
Effective lighting is the key to success in all photography but particularly in dental photography. This part of the series on
digital dental photography examines the colour/space/time triad which is achieved by the presence and manipulation of
light, be it daylight, flashlight or other forms of illumination. In addition, the effect of reflectors is described as well as their
effects on colour temperature.
It is often stated that photography is the • Space defines depth, transparency, size,
magic by which light is transformed in shape/form and texture
colour, space and time. This description • Time indicates movement, flicker,
is congruous to human visual experience, sparkle (vitality), fluctuation and glitter.
which is also divided into these three cat-
egories. Since light is the protagonist in In dentistry the pink gingival colour
both photography and visual perception, indicates health, correct tooth proportion
it is logical to commence with a discussion (shape) conveys pleasing aesthetics, and a
about its properties. smile infers a pleasurable moment in time.
Dental photography encompasses three Fig. 1 Variation of the Isaac Newton
CHARACTERISTICS OF LIGHT experiment of splitting white light, using a
facets of the visual experience, colour, prism, into the colours of the visible spectrum
space and time: The colour/space/time triad is achieved by
• Colour is a three dimensional entity the presence and manipulation of light.
consisting of hue, value and chroma Radiant energy (light) is a narrow band of
the electromagnetic spectrum, which ranges
from long waves of radio broadcasting to
FUNDAMENTALS OF DIGITAL short waves of gamma radiation.
DENTAL PHOTOGRAPHY
Visual and greyscale
The visual system of the eye is capable of
detecting only wavelengths ranging from
380 nm (violet) to 780 nm (red), where
4. Choosing a camera and accessories Fig. 2 A tomato appears red because it
‘nm’ is a nanometre or one billionth of a
5. Lighting absorbs all colours except red, which is
meter. According to Isaac Newton, light reflected off its surface
6. Camera settings
has no colour, it is only when it interacts
with an object that colour is produced.
This was depicted in his famous experi-
ment by splitting light using a glass prism
into the colours of the visible spectrum
or rainbow, which comprises red, orange,
1
General Dental Practitioner, The Ridgeway Dental yellow, green, blue, indigo and violet
Surgery, 173 The Ridgeway, North Harrow, (Fig. 1). The significance of Newton’s
Middlesex, HA2 7DF
Correspondence to: Irfan Ahmad experiment is that an object’s colour is
Email: iahmadbds@aol.com due to the colours it reflects, not the col-
www.IrfanAhmedTRDS.co.uk
ours it absorbs. For example, a tomato
Refereed Paper appears red because it absorbs all the col- Fig. 3 A tooth appears yellow/red because it
Accepted 15 November 2008 absorbs all colours except those in the yellow/
DOI: 10.1038/sj.bdj.2009.558 ours of the rainbow except red, which is
red wavelengths
© British Dental Journal 2009; 207: 13–18 reflected off its surface (Fig. 2). Similarly,
BRITISH DENTAL JOURNAL VOLUME 207 NO. 1 JUL 11 2009 13

PRACTICE
a tooth appears yellow because it absorbs

all colours except those in the yellow/red
wavelengths (Fig. 3).
Ideally, photography requires a continu-
ous spectrum light source. A continuous
spectrum is when all colours of the visible
spectrum overlap completely, for example,
natural daylight or tungsten lamps (Fig. 4).
Conversely, electronic flash tubes produce
a discontinuous or linear spectrum, where
colours of the spectrum do not merge Fig. 4 Natural daylight produces a continuous, seamless spectrum
seamlessly but are distinct entities (Fig. 5).
However, for practical purposes, this tran-
sition is negligible and can be neglected.
When spectrum transitions are profound,
for example, from lights that utilise gases
and vapours such as fluorescent tubes,
the emitted light is unsuitable for taking
photographs.
Colour is composed of three dimensions,
hue, value and chroma. If hue and chroma
are eliminated the result is a monochro- Fig. 5 Electronic flash produces a discontinuous spectrum with distinct transitions
matic visual experience termed chromi-
nance. This is, of course, the basis of
black and white photography, which sim-
ply records lightness and darkness (values)
or tones and gradations on a greyscale.
The average of the tones on a greyscale
has a value of 18% grey (Fig. 6). The lat-
ter is known as neutral density, which is
used for calibrating light meters, assessing
exposure and setting the white balance of
a digital image.
Colour temperature
As mentioned previously, any light source
with a continuous spectrum can be used Fig. 6 Greyscale and 18% grey or neutral density
for producing photographic images. For
dental photography, the choices avail- colour temperature increases, the colour sunset. Furthermore, even if the time is
able are natural daylight, electronic flash, of the light changes from red (warm) to ideal, due to erratic weather conditions
tungsten incandescent bulbs (domestic or blue (cold). or shadows cast by buildings, foliage and
photoflood lamps), quartz lighting fixtures, animals, daylight is not a predictable light
HMI illumination, LED and UV. Natural daylight source. Finally, if light of an incorrect col-
The quality of a light source depends on Daylight has a colour temperature of our temperature is used, photographs have
its colour temperature, which is measured 6,540 K, which incorporates wavelengths false colour rendition of either a red or
in Kelvin (K). The colour temperature is of the bluish ultraviolet radiation. This blue colour cast.
an indication of the quality of light; a low type of illumination is useful for certain
figure indicates a warm light (red-yellow), clinical applications (eg shade match- Electronic flash
while a higher figure signifies a cool light ing of ceramic restorations), as well as Two types of electronic flashes are avail-
(blue-white) (Fig. 7). For example, the extra-oral photography (eg face, lips). The able, compact (mounted onto the camera)
reddish yellow light emitted by a candle advantages of natural daylight are that it and studio. Both varieties are commonly
matches that of a blackbody at a tempera- is economical (no purchase necessary!), used as illuminations for dental photogra-
ture of 1,800 K. A blackbody is a theoretical readily available and ‘what-you-see-is- phy. The light output of electronic flashes
object capable of reflecting all light falling what-you-get’ (WYSIWYG) in the result- is corrected to ‘photographic daylight’
onto its surface. In reality, most objects do ant image. However, natural daylight is a with a colour temperature of 5,500 K.
not conform to this ideal, but for practical misnomer; the light is warmer at sunrise, Photographic daylight, as opposed to
purposes the definition is acceptable. As gets cooler at noon and warm again at natural daylight, is ideal for photography
14 BRITISH DENTAL JOURNAL VOLUME 207 NO. 1 JUL 11 2009

PRACTICE
Northern light
(blue sky)
10000
9000
8000
7000
Overcast daylight
(6,500 K)
6000 Noon daylight,
direct sun
Electronic flash
5000 (5,500 K)
4000
3000
Household lightbulb
2000
Early sunrise
Tungsten light
Candle light
1000
Fig. 9 A ring-flash for macro photography
Colour temperature (Kelvin) Photographic daylight (5,500 K) Photographic daylight (5,500 K)
contains equal proportions of
red, green and blue
Fig. 7 Colour temperature and photographic daylight
Fig. 10 Image photographed with a ring flash

that is devoid of shadows, flat and bland
Corded bi-lateral marco flash set-up
Fig. 11 Image photographed with uni-

directional flashes mounted in a bi-lateral
configuration. Notice shadows and highlight
creating depth (compare with Figure 10)
available in numerous shapes and sizes,

for example ring-flash or uni-directional
Wireless bi-lateral marco flash set-up (Figs 8-9). Ring-flashes create a uniform
burst of light, useful for taking pictures of
Fig. 8 A selection of uni-directional flashes mounted in a bi-lateral configuration posterior teeth or areas of difficult access.
The major drawback with ring flashes is
because it is only at this colour temperature of electronic flash is that the light output the uniform light output, which creates
that the three additive primary colours red, is predictable, instantaneous and univer- a shadow-less, flat, bland and lacklustre
green and blue (RGB) are present in equal sally adaptable for any type of camera. The image (Fig. 10). While excellent for illu-
proportions (Fig. 7). Since all photography, major disadvantage is that WYSIWYG is minating posterior regions of the mouth,
including digital, uses the RGB model for not possible, and a photograph can only for anterior teeth or for restorations where
image production, it is essential that the be scrutinised on the LCD camera viewer aesthetics are of paramount concern, ring
illumination contains each of these col- after taking the picture. flashes are not recommended since the uni-
ours in equal proportions. The advantage Camera mounted electronic flashes are form burst of light obliterates fine detail,

PRACTICE
translucency and subtle colour transitions interchangeable with cameras of another

within individual teeth. manufacturer. An important feature to
On the other hand, uni-directional look for when purchasing these flashes is
flashes create shadows and highlights to ensure that they are detachable from
and the teeth and gingivae appear more the camera, preferably with wireless con-
three dimensional, with increased contrast nections. This is particularly useful for
and detail (Fig. 11). The usual directional extra-oral images in the dental laboratory
lighting for dental photography is two (discussed further in Part 7). If this facility
bi-lateral flashes mounted on a bracket. is not possible with camera specific flashes,
The bracket allows the flashes to be posi- the other option is to purchase third party Fig. 12 Image photographed with tungsten
light with a colour temperature of around
tioned as desired, depending on the shape electronic flashes such as the range from 3,400 K
of the patient’s arch form and tooth align- Metz (www.metz.de). These flashes, com-
ment. This set-up is the ideal choice when bined with a manufacturer specific adap-
photographing anterior teeth for captur- tor, can be used with any camera and
ing nuances of characterisation and col- offer greater latitude for taking other
our, texture and translucency, which are types of pictures such as bench shots in a
critical for aesthetic anterior prostheses. dental laboratory.
Uni-directional illumination also offers
versatility to highlight specific details Tungsten and quartz lighting
within a tooth, which guides the ceramist Tungsten light is warmer (reddish) with a
to mimic these characterisations in the colour temperature of 3,400 K (Fig. 12).
final prosthesis. Prior to the advent of electronic studio
flashes, tungsten photoflood lamps were Fig. 13 UV light reveals intrinsic fluorescence
Principle of the angle of incidence of natural teeth
the lights of choice for all studio set-ups.
Dental photography presents a unique The advantages are WYSIWYG, they are
photographic scenario: not only does relatively inexpensive, portable, and useful
a photograph need to record the highly for indoor photography since the colour
reflective enamel surface, but also a layer temperature matches most domestic light-
below it (dentine). ing. Tungsten lights are particularly use-
When highly reflective surfaces are ful for photographing plaster casts of teeth
photographed, the lighting set-up should and dental prostheses, but excessive heat
ensure that unwanted halation is avoided. generation from the lamps makes their use
This is achieved by exploiting the princi- for clinical applications impractical.
ple of the angle of incidence. If a single
light source is used to photograph glass, its Continuous photographic daylight
reflection will cause a ‘hot spot’ or specular HMI illumination has a similar output to
reflection termed halation. While this is electronic flashes, but rather than a single Fig. 14 Diffusers help mute the flash output,
giving a softer lighting
useful for capturing surface texture, it can burst, the light is continuous. These lamps
be annoying for visualising objects behind are capable of delivering light at a con-
the glass (analogous to visualising dentine stant 5,500 K colour temperature, and are field. Alternately, rather than compromis-
strata below enamel). mainly used for the motion picture indus- ing the depth of field, the shutter speed can
In order to mitigate unwanted reflections, try. The obvious advantage is WYSIWYG, be prolonged but this produces unwanted
two light sources are used, positioned on but presently their exorbitant cost makes camera shake and blurred images. Another
both sides of the camera at 45° in the hori- them prohibitive for dental use. disadvantage is LED light sources require
zontal plane (bi-lateral set-up). With this a relatively large battery pack, which is
twin light set-up, the angle of incident from LED cumbersome and annoying.
one flash equals the angle of reflectance of LED (light emitting diode) is a relatively
the contra lateral flash. The result is that new type of illumination for dental pho- UV
reflections from the two light sources can- tography. Various models and configura- UV (ultraviolet) illumination is useful for
cel each other out, and hence the camera tions are available which are attached to showing intrinsic fluorescent properties of
does not ‘see’ any reflections. This type of the front of the camera lenses, for example natural teeth (Fig. 13), or for checking imper-
lighting can be used to photograph dentine Optilume (Optident, UK). The advantages fections within ceramic restorations such as
strata below the overlying enamel of natural are WYSIWYG and constant colour tem- fractures or porosity. However, caution is
teeth, or to visualise the dentine porcelain perature of 5,500 K, but the major draw- necessary when using ultraviolet lights to
layer of a ceramic dental restoration. back is the low intensity illumination, photograph restorations in the mouth. Some
Electronic flashes are usually spe- which requires large apertures for correct UV light sources have deleterious effects on
cific to a particular DSLR and are not exposure that severely reduces the depth of the eyes and should never be used. Even

PRACTICE
the light source. Regardless of the colour

temperature, light needs to be modified
depending on the application or assign-
ment. For example, the lighting set-up to
capture margins of a prepared tooth dif-
fers from that needed to reveal dentine
strata beneath the enamel layer. In each
situation a specific lighting set-up is nec-
essary to record the salient information
of an object.
Angle of illumination
Illumination for dental photography
can either be uniform or directional.
Uniform illumination is 360° coverage,
typically produced by an electronic ring-
flash or directional lighting, which are
Fig. 15 Photograph using naked flashes, which capture surface enamel texture. Notice the discussed above.
saliva flowing off the enamel surface
Modifying light
In addition to position, flashes also require
muting or accentuating for recording dif-
ferent aspects of the dentition. For exam-
ple, to show enamel or crown texture, the
lighting set-up is two bi-laterally posi-
tioned naked flashes to create specular
reflections off the surface with enhanced
contrast. A light source can be modified
by a variety of methods, which are cat-
egorised as follows:
1. Naked light – no modification:
harsh output, primarily used for
high contrast images, for capturing
texture and lustre of enamel and
Fig. 16 One flash and a silver reflector set-up allows light to pass through the enamel layer for porcelain surfaces
revealing enamel cracks and dentine strata characterisations
2. Blocking light – for example, by a
card, eliminates the light from the
set-up. This is useful in a bi-lateral
twin flash set-up, where unilateral
illumination is required for creating
shadows on the opposite side of
the main flash. This is also a useful
method for photographing plaster
casts in the dental laboratory (to be
covered in Part 7)
3. Diffusion – by placing materials (cloth
or Perspex) of varying opacities in
front of the light source. This has two
effects (Fig. 14): firstly the output is
reduced, and secondly the emitted
light is softer. The larger the diffuser,
Fig. 17 Custom made reflectors for use in dental photography the softer the output. The softer
emission is ideal for creating subtler
images, but with reduced contrast
with safer varieties of UV lights, the patient MANIPULATING LIGHT 4. Reflection – with a reflective card
and all personnel in the room must wear The next stage after choosing an illumi- placed opposite a naked or diffused
special UV protection glasses. nation is discussing methods to modify light source. The resulting light

PRACTICE
depends on the surface used to in Part 6). Nevertheless, in rare situations

reflect the light. Reflected light is they may be useful for partial elimination
especially useful for eliminating of shadows.
unwanted halation or highlights from
highly reflective surfaces and is an Other factors for modifying light
excellent method for documenting The power output obviously influences
dentine shade and characterisations the intensity of light. Some compact elec-
(Figs 15-16). For dental purposes Fig. 18 An underexposed image with an tronic flashes allow output intensities to be
intra-oral mirror
reflectors are limited to only a few altered. However, greater latitude is pos-
types, usually art card with different sible with studio lights where output can
reflective surfaces which can be cut these types of metallic reflectors. If the be increased or reduced depending on the
to size and disposed of after a single texture of the silver card is increased (ie prevailing set-up.
use. Also, in the dental laboratory, made rougher), the light is diffused fur- Flash-to-subject distance also influ-
custom-made reflectors (Fig. 17) are ther. The effects on the image are softer ences light intensity, which depends on the
invaluable for photographing casts, shadows and reduced contrast. This type inverse square law. Simply stated, illumi-
wax-ups and transparent stents (to be of light is ideal for portraiture to soften nation is less bright the further away from
covered in Part 7). or eliminate unflattering facial blemishes its source because it has a greater area to
and wrinkles (covered in Part 7). The dis- cover. For example, it the distance is dou-
Coloured reflectors advantage is that texture is indiscernible, bled, the light not only has to travel twice
A highly polished glossy surface, irre- yielding a flatter image that is less vibrant the distance, but also has to cover a larger
spective of its colour, produces a specu- compared with a polished reflector. area. The implication of the inverse square
lar (mirror-like) reflection. Conversely, a law is that if the exposure is f22 and the
textured or matt coloured surface creates Gold reflectors distance is doubled, an increase of two,
reflections that correspond to its colour. Gold coloured reflectors are identical to not one f stops is necessary for the new
For example, a glossy green card will pro- silver, their analogues, but the overall exposure, that is, f8. The opposite is true if
duce a reflection that is specular, while a colour temperature is warmer, creating a the distance is halved; the correct exposure
matt green card will produce a reflection subdued romantic ambience. would then decrease by two f stops, that is,
with a greenish hue. The latter type of f64. The inverse square law is applicable
coloured reflection, if judicially exploited, White reflectors when taking intra-oral images using mir-
can be used to shift the colour balance of White surfaces produce the most diffuse rors. In these circumstances the light from
an image. However, caution is necessary: type of reflection. The reflected emissions the flashes has to travel a greater distance
coloured reflections may yield a pseudo- are extremely soft, much more subtle and by being reflected off the mirror surface
colour rendition. For example, a clinician’s less specular compared to mirror, silver or before it can illuminate the teeth. Exposure
green surgical gown can cast an unwanted gold reflectors. The resulting light does compensation is therefore necessary to
greenish tint onto the enamel surfaces not ‘flood’ the image, but subtly reduces avoid under-exposed images (Fig. 18).
of teeth. shadows. Once again the degree of texture Optical supplementary attachments such
influences the extent of diffusion. as magnifying lenses can be attached to
Mirror reflectors studio lights for focusing the light beam
A highly polished mirror or mirror-like Grey reflectors from as small as 1° to about 10°, which
card behaves similarly to a glossy surface While all the above reflectors tend to allows very precise coverage as small as
mentioned above and produces a similar ‘reflect’ the majority of light falling on 1 mm2. Other attachments utilise fibre-
light output. their surfaces, the reverse is true of grey optic cables for ‘bending’ light, thereby
cards. Depending on the intensity of grey, increasing access to unlit recesses in a
Silver reflectors the majority of the light is absorbed and photographic composition. Fibre-optic
A silver card reflector produces a muted a minority reflected. As mentioned pre- cables can also be used to trans-illumi-
output that increases the overall colour viously, grey cards are primarily used to nate all-ceramic dental restorations to
temperature, that is, more blue, and tends ascertain exposure (18% photographic show porcelain layering or for scrutinising
to flood the scene with a burst of bright grey card) and calibration of the white imperfections within the ceramic material
light. Most floodlights in theatres employ balance of digital images (to be covered (to be covered in Part 7).

• Since most camera and equipment set-
Part 6: camera settings ups for dental photography are identical,
PRACTICE
the steps outlined in this article need
only be performed once.
• The main camera settings relate to depth
I. Ahmad1 of field, exposure and white balance
calibration.
• Spending a little time at the beginning
VERIFIABLE CPD PAPER making the necessary setting will avoid
frustration, and pay dividends in the
long-term.
Once the appropriate camera and equipment have been purchased, the next considerations involve setting up and calibrat-
ing the equipment. This article provides details regarding depth of field, exposure, colour spaces and white balance calibra-
tion, concluding with a synopsis of camera settings for a standard dental set-up.
Having chosen a camera, lens, lighting and of and behind the plane of critical focus.
accessories, the next step in preparation The plane of critical focus is the point to
for taking a photograph is setting up and which the lens is focused. For portraiture,
calibrating the equipment. Since most of the depth of field is usually divided into
dental photography uses similar set-ups, one-third in front and two-thirds behind
the settings and calibrations need only to the point of focus, but for close-up pho-
be performed once. The main items to con- tography the division is equal, ie one-half
sider are depth of field, exposure, colour in front and one-half behind. Furthermore,
spaces and white balance calibration. the depth of field for close-up photogra-
phy is usually small (a few millimetres) Fig. 1 Small depth of field: a wide aperture
DEPTH OF FIELD opening will result in only a few items being
and hence the point of focus is crucial for sharply focused, for example the red bead in
Depth of field determines which parts of obtaining sharp images. the centre
an image are in sharp focus. Unlike the Most digital SLRs (DSLRs) have the
human eye where everything is in focus, capability to set auto or manual focusing.
cameras do not share this luxury. Depth of For the majority of situations auto-focus
field determines the extent of focus in front works well, but the dental environment of
bright teeth surrounded by pink gingivae
FUNDAMENTALS OF DIGITAL with a dark oral cavity sometimes causes
DENTAL PHOTOGRAPHY malfunction of the focusing mechanism.
If pictures are constantly out of focus,
switching to manual focusing is a solution.
Some high-end digital cameras can display
3. Principles of digital photography Fig. 2 Large depth of field: a small aperture
a live video image of the subject being
4. Choosing a camera and accessories opening will result in many items being
photographed, either via a monitor on the sharply focused (compare with Fig. 1)
5. Lighting
back of the camera or on a computer lap-
6. Camera settings
top screen via a USB or Firewire cable.
The advantage is that focusing, framing, the patient may have moved before the
composition and exposure can be checked camera has updated the live image.
with a preview shot before the final picture Depth of field varies inversely with the
is taken. Furthermore, with magnification, aperture opening. A wide-open lens with
focusing is possible by viewing individual an aperture of f4 has little depth of field
1
General Dental Practitioner, The Ridgeway Dental pixels. This facility is ideal for still life whereas if stopped down to f22, almost
Surgery, 173 The Ridgeway, North Harrow, photography but of limited use in dental everything from front to back will be
Middlesex, HA2 7DF
Correspondence to: Irfan Ahmad photography. The live image is constantly sharply focused (Figs 1-2). As close-up
Email: iahmadbds@aol.com refreshed to compensate for camera and dental photography has a small depth of
subject movement and is not a true repre- field, it becomes essential to have a small
Refereed Paper sentation in time of what is being viewed. aperture opening, say f22, so that as many
DOI: 10.1038/sj.bdj.2009.607 For example, teeth may appear sharp on teeth as possible or a large area of soft
© British Dental Journal 2009; 207: 63-69
the screen, but when the picture is taken tissue is in focus. In theory, to obtain a

PRACTICE
Fig. 5 When using electronic flash, the

Fig. 3 The aperture on a macro lens should shutter speed must be set to synchronise
not be set smaller than f22 to prevent Fig. 4 The shutter speed should be fast with the flash output, represented by a
diffraction enough to prevent blurring ‘lightning’ symbol
greater depth of field one could consider The scale for the brightest
using even smaller apertures, say f32 or exposure (plus) is further apart
f64, but this practice deteriorates the image

quality due to diffraction. When light rays
are bent around edges of objects they pro-
duce an iridescent or rainbow-like effect
termed diffraction. This is more evident the
smaller the aperture diaphragm, resulting
in decreased resolution. Therefore, set-
ting the aperture to smaller than f22 will
seriously diminish image clarity without
a substantial gain in depth of field. This
is the reason why most macro lenses are
designed with diaphragms that do not
The scale for the darkest
close smaller than f22 (Fig. 3). exposure (minus) is closer together
EXPOSURE Fig. 6 A histogram with a logarithmic scale from the darkest (minus) to the brightest (plus)
exposure
Achieving correct exposure is a quin-
tessential requirement of photography,
the consequences of which are blatantly factor is ensuring that the shutter speed by a ‘lightning’ symbol (Fig. 5).
obvious. Exposure is a combination of is fast enough to prevent image blurring With analogue photography, automatic
two camera settings, the lens aperture and due to patient movements or camera shake exposure with electronic flashes was rela-
the shutter speed. Exposure explains how (if not tripod mounted) – see Figure 4. A tively simple. The TTL (through the lens)
light acts on a photosensitive material, for fast shutter speed (minimum 1/125 s) is metering and OTF (off the film) plane meas-
example a digital sensor. The lens aper- necessary to prevent camera shake and urement of light striking the film emulsion
ture, or opening, controls light intensity, freeze patient movements, even if a tripod allowed the camera to control the dura-
while the duration of light is controlled is used. Blurring is especially a problem tion of the flash output, which was cut-off
by the shutter speed. The aperture size is with a continuous light output such as LED once sufficient light had reached the film
calibrated in f-stop numbers; the larger the illumination, halogen or tungsten lamps. for a correct exposure. However, with dig-
number, the smaller the lens opening. The In these circumstances, it is vital to use fast ital sensors there is no film emulsion for
shutter speed is the length of time the shut- shutter speeds to ‘freeze’ the subject. On light measurements. The sensors are cov-
ter remains open when the shutter release the other hand, when electronic flashes are ered with a protective glass that is highly
is activated, expressed in fractions of sec- used, blurring is less of a concern. This is reflective, making light measurement
onds, for example, 1/125 s is faster than because the duration of the flash light out- impossible. Some DSLRs have overcome
1/60 s. Most contemporary cameras have put is shorter (usually 1/2,000 s) than the this problem with sophisticated electron-
automatic exposure, which calculates the camera shutter speeds, and the subject is ics, but others have yet to reach a practical
shutter speed once the aperture is set (in ‘frozen’ by the sudden burst of light rather solution. If this is the case, two options
aperture priority mode metering). than the opening of the camera shutter. are available to ensure correct exposure.
However, with dental photography Most electronic flashes require that the The first is to set the flashes to automatic
two aspects require attention. The first is shutter speed be set to synchronise with the mode, which calculates the exposure by
ensuring an adequate depth of field, which flash output and depending on the camera emitting an infrared beam directed to the
leaves little latitude but to select a small manufacturer and type of lens, this varies subject to gauge lighting conditions. This
aperture opening, usually f22. The second from 1/60 s to 1/250 s and is represented is satisfactory for photographing distant

PRACTICE
subjects, but due to the proximity of the

lens to the subject in macro–photography,
the infrared beam misses the intended sub-
ject and the image is often under-exposed.
The other option to consider is increasing
the exposure factor.
As a lens moves closer to the object,
as in close-up photography, the exposure
increases exponentially. For example, for
a 1:1 magnification, the exposure increase
factor is four. Consequently, in order to
obtain a correctly exposed image, one or
more of the following need adjusting:
1. Increase aperture (wider f-stop)
2. Increase time (longer shutter speed)
3. Increase sensor sensitively (higher
ISO number)
4. Increase illumination (brighter Fig. 7 Correctly exposed image
lighting).
Midpoint (zero)
Increasing the first two factors is imprac-

Correct exposure: equal distribution of
tical for the reasons already cited, ie a peaks and troughs either side of the midpoint
wider f-stop would drastically diminish
the depth of field and a longer exposure
time would introduce blurring. The third
factor is increasing the sensor sensitivity,
which reduces image quality by introducing
noise or grain. The only practical solution
is increasing the intensity of the illumina-
tion. This is accomplished by using flashes
with higher guide numbers, or if possible,
increasing the emitted output. A good
method for confirming exposure is taking
test shots for a given set-up, and once expo-
sure is corrected, these settings can be used
Large dynamic range = 10
repeatedly for all subsequent pictures.
Fig. 8 Histogram of correctly exposured image in Figure 7 showing equal distribution of peaks
The histogram and troughs from the midpoint, but a large dynamic range
A histogram is a graphical representa-

tion of the tonal value and exposure of an
image. It shows the tonal or value range
from the brightest to the darkest parts of
a picture. In this respect, it is the digital
photography equivalent of a light exposure
meter. Histograms are part of the menu that
can be displayed on LCD backs of digital
cameras or within photo-editing software.
The two main functions of a histogram
are ascertaining exposure and dynamic
range (DR). Dynamic range is the dif-
ference in brightness between the dark-
est and brightest part of an image. The
significance of the dynamic range is that
fine detail is only discernible within this
range, and is expressed in the number of
f, or aperture stops. Subjects outside the
Fig. 9 Under-exposed image
DR will either be under- or over-exposed

PRACTICE
without discernible detail. The human eye

Midpoint (zero)
has a large DR of 10, a high-end digital Under exposure: distribution of peaks
camera 11, film transparency or high qual- is confined to left side of midpoint
ity photographic print 6 and the printing

press 3 to 5, depending on equipment and
the quality of printing paper. What this
translates to is that a high-end digital cam-
era can record nearly 4 f-stops more detail
than film, and has a DR equal to that of
the human eye. The other factor is that the
human eye does not perceive DR in a linear
manner but in a logarithmic one, ie the
difference in the darkest part of an image
is less than in the brightest parts. This is
depicted in a histogram by exposure stops
being closer together in the dark parts and Dynamic range = 7
wider apart in the bright parts (Fig. 6). This
means that darker areas of an image con- Fig. 10 Histogram of image in Figure 9 showing that the distribution of peaks confined to the
left of the midpoint, with a dynamic range of 7
tain more detail than the brighter ones.
Correct exposure and DR are interlinked,
and the goal of obtaining correct exposure
and an acceptable DR is achieved as follows.
Firstly, to ensure correct exposure, the peaks
and troughs should be evenly distributed
on either side of the midpoint or fulcrum
(Figs 7-8). If the image is underexposed,
the distribution of the peaks is confined to
the negative zone left of the midpoint, and
the opposite is the case for an overexposed
image (Figs 9-12). It is obviously very easy,
and tempting, to correct the exposure by
adjusting the brightness and contrast in a
photo editing software. Although minor
adjustments have little significance, manip-
ulation should be performed judicially, as
gross correction sometimes causes changes
in colour rendition leaving unwanted col- Fig. 11 Over-exposed image
our casts. Also, over-exposed parts of an
image contain little detail and correcting Midpoint (zero)
exposure by reducing brightness will not Over exposure: distribution of peaks
is confined to right side of midpoint
add more detail. A better alternative is con-
sidering exposure increase factors discussed
above, ie altering the intensity and distance
of the illumination.
Secondly, the DR should be created
depending on the intended use of the
image. If the purpose is to print the image,
it is futile to have a DR of 10, since the
printing process will degrade the image to
a value of 4, and six aperture stops of detail
will be lost. However, for projection or
viewing, the DR needs to be greater, up to
the range of the human eye, ie 10. Images
with a large DR have greater detail and are Dynamic range = 7
vibrant, while low DR images are bland and
dull. Practically, it is advisable to achieve Fig. 12 Histogram of image in Figure 11 showing that the distribution of peaks is confined to
the right of the midpoint, with a dynamic range of 7
a mid-range DR in an image, say 6, which

PRACTICE
Fig. 15 The Adobe® RGB colour space has a

large gamut, with many unprintable colours
Fig. 13 Image with a dynamic range of 6
Midpoint (zero)
Correct exposure: distribution of peaks
and troughs either side of midpoint
Fig. 16 The CMYK colour space has a smaller

gamut than the Adobe® RGB and the sRGB
colour spaces
Dynamic range = 6
Fig. 14 Histogram of image in Figure 13 showing correct exposure and a dynamic range of 6
allows acceptable viewing and also reduced standard RGB (sRGB), which is frequently
detail loss when printed (Figs 13-14). used in digital cameras and has a gamut
corresponding to the average computer
COLOUR SPACES monitor (Fig. 17). For dental applications
Colour spaces are illustrations of colour either the Adobe® or sRGB is acceptable.
models and their content is called a gamut, The former has greater latitude, while the
which describes the range of colour that a latter is ideal for viewing on monitors or Fig. 17 The sRGB colour space found in many
digital cameras corresponds to the average
device can output (for example a printer) or for presentations using a projector. computer monitor
record (for example a camera or scanner).
Each space is device specific for a given WHITE BALANCE
piece of equipment with little standardisa- The next setting to consider is white bal- brain’s ability to compensate for different
tion between output and recording devices. ance, which is defined as follows. When a illumination: because short-term memory
Numerous manufacturers have proposed piece of white card is viewed outdoor in ‘remembers’ the card as being white, it
spaces, ranging from large to small. The daylight it appears white. If the same card therefore appears white irrespective of the
most frequently used spaces are the Adobe® is viewed with indoor tungsten lights, it lighting source. As discussed in part 5,1 the
RGB, which has a larger gamut than most still appears white! The reason for this is quality of light depends on its colour tem-
monitors and contains many unprintable that even though the colour temperature of perature; daylight is 6,500 K, while tung-
colours since the CMYK printing space the ambient light has changed, the card still sten is 3,500 K. In the present example, if
is smaller (Figs 15-16). Another colour appears white due to a phenomenon termed colour adaptation were absent the white
space, smaller than the Adobe® RGB is the colour adaptation. Colour adaptation is the card would appear bluish with daylight

PRACTICE
Fig. 18 Incorrect white balance setting at Fig. 19 Correct white balance setting at
5,500 K using 3,000 K illumination, the 5,500 K using 5,500 K illumination, the
result is that the paper appears yellow instead paper now appears white (compare with Fig. 20 WB (white balance) setting dial on a
of white Figure 18) digital camera back
and yellow with a tungsten lamp. 21 22

Unlike the brain, cameras do not pos-
sess colour adaptation and have to be told
about the colour temperature of the illumi-
nation (Figs 18-19). This process is termed
setting or calibrating the white balance.
White balance calibration is set using three
methods: automatic, manual, or with an
18% neutral density grey card.
All cameras have an automatic white Step 1: Open RAW image with 18% grey card in proprietary software. Step 2: Choose ‘Neutral Picker’ tool from toolbar
Note that ‘Gray Balance’ is turned ‘Off’
balance (AWB) setting, where the inter-
nal electronics calculate the white bal-
ance according to the colour temperature 23 24
of ambient light. For most situations this
setting is adequate and functions accu-
rately. However, certain circumstances,
for example daylight entering a window
in a room lit with tungsten lights, may
confuse the camera’s AWB and require
the user to make the setting manually. The
white balance dial on cameras offers vari-
Step 4: Save settings of the grey balance for future recall
ous colour temperature settings to choose Step 3: Click any part on the grey card. Notice that image instantly changes to
the correct grey balance and ‘Gray Balance’ is turned ‘On’
from (Fig. 20). These are either represented
diagrammatically, for example symbols of
Figs 21-25 Steps for grey balance
a candle, light bulb, clouds or sunshine, 25 calibration
or have numerical values. If the latter is
the case and electronic flashes are being
used, the setting to choose is 5,500 K or
photographic daylight.
The most accurate method for setting the
white balance is calibration with an 18%
grey card. The advantage of this method is
that in close-up photography the camera
metering system may not function to its
Step 5: Type name for grey balance setting eg ‘Dental Flash Set-up’
full capacity when the distance from the
subject to the lens is small. In addition, the
oral cavity has a unique range of bright erratic or incorrect. Of course it is easy correctly before taking a picture to limit
and dark areas, ie white teeth, pink soft tis- to subsequently correct a colour cast in post-capture processing to a minimum.
sues and the dark oral cavity background. photo editing software, but the greater The procedure for white balance cali-
This variance of value or brightness the manipulations, the greater the dete- bration with a grey card is as follows. A
often confuses the camera’s electronics rioration in image quality. Consequently piece of 18% neutral density grey card is
and the white balance may therefore be it is crucial that the white balance is set appropriately cut to size and photographed

PRACTICE
Fig. 29 File format set to ‘RAW’
Correcting grey balance: open image and recall setting eg ‘Dental Flash Set-up’ Correcting grey balance: corrected image
Figs 26-27 Single or multiple images are instantly corrected for grey balance by recalling
previous settings
Fig. 30 File format set to ‘TIFF’
Fig. 31 File format set to ‘JPEG’
Fig. 28 Final image after grey balance correction and cropping 8. Colour spaces (domains): Adobe
RGB (larger colour space, ideal
alongside the teeth using a given lighting tweaked, but gross changes will require the for publishing) or sRGB (smaller
set-up. This image serves as a reference calibration procedure to be repeated. colour space, ideal for displaying on
and is opened either in software specific computer monitor or projector)
to the camera manufacturer or in Adobe® SYNOPSIS OF CAMERA SETTINGS 9. Other options: brightness, contrast,
PhotoShop. Next, the ‘Neutral Picker’ tool The camera settings for a standard dental colour saturation and sharpness to
is selected from the toolbar and the mouse set-up are summarised below: zero (can be adjusted later in photo-
cursor is clicked onto the grey card in the 1. Focusing: auto-focus. If pictures are editing software)
picture. The colour rendition instantly blurred, or for greater control for 10. White balance:
changes to the correct white balance. The focusing on specific detail, revert a) Automatic
setting is saved in the Grey Balance menu to manual focusing, for example to b) Manual
tab with a unique name, for example, focus on soft tissue lesions instead of c) Calibration with 18% grey card
Dental Flash Set-up (Figs 21-25). In order the teeth 11. File format (to be covered in detail in
to correct the white balance of subsequent 2. Metering mode: APERTURE part 10):
images with the same lighting set-up, the PRIORITY a) RAW – maximum quality, highest
setting is recalled from the Grey Balance 3. Type of metering (if available): bit depth, greater dynamic range,
menu tab. Furthermore, multiple thumbnails matrix or centre weighted large files, additional processing
can be selected and all images of a photo 4. Aperture: f22 time, requires experience and
session can be simultaneously and instantly 5. With electronic flashes, the shutter training for editing (Fig. 29)
corrected with a single click of the mouse speed is synchronised automatically b) TIFF – good quality, large file,
(Figs 26-28). As previously mentioned, most by the camera (ranging from 1/60 or quicker processing than RAW, ideal
dental photographs are taken with identical 1/250 s) for archiving and printing (Fig. 30)
set-ups. Therefore, the calibration procedure 6. With a continuous light source, ensure c) JPEG – maximum workflow,
need only be performed once unless differ- shutter speed is fast enough to prevent small files, quickest processing,
ent flashes or a different type of illumina- blurring and cameras shake, ie 1/125 reduced quality, ideal for e-mail
tion is used, for example natural daylight. Of s or faster. Alternately, if possible, attachments and printing,
course minor adjustments may be necessary, increase intensity of illumination until unsuitable for archiving (Fig. 31)
such as changing flash positions or cam- a speed of 1/125 s is possible 12. Moiré filter ‘On’ to avoid chequered
era angles, but these alterations have little 7. Set ISO to 100 or lower for maximum patterns (Figs 30-31).
affect on the white balance. Furthermore, signal to noise ratio (ie low noise) to 1. Ahmed I. Digital dental photography. Part 5: light-
if necessary, minor colour shifts can be avoid grainy pictures ing. Br Dent J 2009; 207: 13–18.

• Portrait photography should aim to capture
Part 7: extra-oral set-ups the patient in a relaxed state of mind.
PRACTICE
• The set-up for portraiture can utilise
natural daylight, compact or studio flashes.
• Laboratory or bench images of plaster casts
I. Ahmad1 and prostheses are easily photographed
with studio or compact flashes and a
variety of coloured backgrounds.
• The best approach to achieving unique
and interesting pictures is trial and error.
Experimentation is the key to creativity.
This part of our series specifically addresses extra-oral dental photography consisting of portraiture and dental labora-
tory pictures. Portraiture, which is achieved using three types of illumination, natural daylight, bi-lateral camera mounted
flashes (as for intra-oral images) or studio flashes, can be further divided into full face and dento-facial compositions.
These are necessary for various dental disciples including evaluation of aesthetics, orthodontics and oral surgery facial
profile assessment. Dental laboratory photography includes documentation of plaster casts and indirect prostheses.
Extra-oral dental photography consists of Space Table 1 Categorisation and ranges of

human spaces
portraiture and dental laboratory pictures. The distance between the photographer (cli-
Portraiture can be further divided into full nician) and the subject (patient) is termed Space Distance (m)
face and dento-facial compositions, which the photographic space. However, the latter Intimate 0 to 0.5
are necessary for various dental disciples needs to be in context with other human
including evaluation of aesthetics, ortho- spaces, ensuring that the patient feels com- Personal 0.5 to 1.5
dontics and oral surgery facial profile fortable, relaxed and at no time feels that Social 1.5 to 3.25
assessment. Dental laboratory photog- his or her privacy is being invaded.
Public Beyond 3.25
raphy includes documentation of plaster All animals, including humans, have
casts and indirect prostheses. a predefined territory in which they feel
comfortable and at ease with their environ-
PORTRAITURE ment. This is a primitive survival instinct to Public
Before describing set-ups for facial images, guard against predators and potential dan-
Social
it is necessary to consider a few theoretical ger. In the case of animals, if this space is
Personal
aspects about portraiture photography. violated, the reaction is either an imminent
attack (defence), or fleeing (preservation).
Intimate
FUNDAMENTALS OF DIGITAL For humans, trespassing causes unease,
DENTAL PHOTOGRAPHY tension or even rebuke. Human space is
1. Digital dental photography: an overview categorised into intimate, personal, social
2. Purposes and uses and public. Approximate ranges for these
3. Principles of digital photography spaces are listed in Table 1 and diagram-
4. Choosing a camera and accessories matically shown in Figure 1.
5. Lighting The human spaces vary depending on
personality, culture, context and age. Fig. 1 Schematic diagram of human spaces
6. Camera settings
7. Extra-oral set-ups Timid, shy or introverted individuals usu-
8. Intra-oral set-ups ally have a larger intimate space than causing alarm or unease. Generally, chil-
9. Post-image capture processing the norm, while the opposite is true for dren require greater personal space
10. Printing, publishing and presentations vivacious and gregarious personalities, than adults.
and in Eastern cultures closer proxim- The goal of the clinician is gauging the
1
General Dental Practitioner, The Ridgeway Dental ity is permissible than would be possible patient’s personal space and respecting it
Surgery, 173 The Ridgeway, North Harrow, with Western etiquettes. Also, the context at all times. This creates a relaxed ambi-
Middlesex, HA2 7DF
Correspondence to: Irfan Ahmad in which a photograph is taken alters the ence for both the operator and subject,
Email: iahmadbds@aol.com distance of spaces. People at ceremonial yielding photographs that convey seren-
occasions, such as weddings, allow greater ity rather than tension. A simple way
Refereed Paper approach than in a working or professional to overcome a potential space barrier is
DOI: 10.1038/sj.bdj.2009.667 environment. Finally, age also determines using long focal length portrait lenses
© British Dental Journal 2009; 207: 103–110 how close one can approach without (greater than 100 mm), which allow the
BRITISH DENTAL JOURNAL VOLUME 207 NO. 3 AUG 8 2009 103

PRACTICE
photographer to ‘virtually’ intrude into the

intimate or personal space, without agitat-
ing the subject.
Relating
Photographers relate to a subject in
three ways: projection, introjection and
confluence.
According to the Freudian concept of
psychological defence mechanisms, pro-
jection is a means to alleviate personal
anxieties. In an attempt to resolve per- Fig. 2 A relaxed facial image is ideal for
assessing the inclination of the incisal plane Fig. 3 A dento-facial image shows the teeth
sonal conflicts, an individual attempts to to the inter-pupillary line in relation to the surrounding lips
project his inner feeling onto external enti-
ties such as the environment, people, art,
music, etc. This allows the person to come with staff and the practice environment. product, representing an elusive and desir-
to terms with his or her inner conflicts with A dental example is the classical relaxed able commodity. Introjection images are
the aim of achieving serenity and a paci- smile, with the incisal plane of the maxil- family gatherings and holiday snap shots,
fistic state of mind. Depending on a pho- lary incisor teeth parallel to the curvature when people are relaxed with familiar com-
tographer’s psychological make-up, his or of the lower lip. pany and surroundings. Lastly, confluence
her projection is usually manifested in the Finally, confluence is when, for a fleet- imagery is usually artistic in nature and
photographs they take. A familiar example ing moment, the photographer and subject the photograph becomes more than mere
is the contrived post-operative photograph unite (mentally) and are in unison with one documentation, having a deeper meaning
after restoring the maxillary anterior teeth. another. This requires patience, dedication, than that which is literally depicted.
Many clinicians request a female patient and protracted perseverance. This type of When fabricating aesthetic anterior res-
to apply lurid lipstick to increase the col- image is probably the most challenging, torations, the appearance of which can be
our contrast between the lips and teeth. In and if achieved, conveys a transcendental highly subjective, it is important to ascer-
these circumstances the red lipstick is the quality that appeals to the inner psyche. tain as much information as possible about
operator’s projection onto the patient, con- The photograph elevates to a level that patients’ wishes, desires and their perception
veying the clinician’s sensual emotions. touches our inner subconscious level, hav- of themselves. Therefore, dental portraiture
Introjection is the opposite of projec- ing a profound and lasting impact. should avoid projection and encourage
tion, allowing the subject to reveal their To summarise, projection is ‘going to the introjection imagery, allowing the patient
inner essence and outer presence. In this subject’, introjection is ‘letting the subject to express their personality. For example,
situation the subject is conveying their come to you’ and confluence is ‘achieving a an introvert may be better suited for crowns
personality, rather than having the opera- one-ness’. As a general observation, adver- that blend with the existing dentition, with
tor’s personality imposed on them. This tising companies ubiquitously use projec- cervical stains, cracks and characterisations.
type of photograph requires familiarity tion images to sell products. A beautiful Conversely, the latter would be inappropri-
with the patient, achieving a sense of ease model is often depicted in proximity to the ate for fashion conscious individuals who
Sun
Black background
Patient
Sil
ve
rr
efl
a
er
ec
am
to
lc
r
ta
D igi
Fig. 4 Portrait set-up using natural daylight for illumination Fig. 5 Portrait using the set-up shown in Figure 4
104 BRITISH DENTAL JOURNAL VOLUME 207 NO. 3 AUG 8 2009

PRACTICE
Fig. 7 Camera mounted compact flashes

Fig. 6 Sunlight directed into a subject’s face creates unflattering shadows that obscure facial create annoying shadows behind the patient’s
features, especially when wearing spectacles head with coloured or textured backgrounds
desire the ‘bright, white, right look’, and are shot with an 18% grey card as described in vibrant and punchy and gold creates a
ideal candidates for A1, or even B1, mono- Part 6.1 The set-up is very simple, requiring warmer ambience.
chromatic restorations. few items (Figs 4-5):
1. Cloth or card as a background, either Bi-lateral camera
DENTAL PORTRAITURE SET-UPS black or colour of choice
mounted flashes set-up
The set-up for facial or portraits can be 2. Card or cloth reflectors, white, silver The second option is using camera-
achieved using three types of illumination, or gold (purchased from photographic mounted flashes such as ring or bilateral
natural daylight, bi-lateral camera mounted retailer or art card cut to size (1 m2) flashes. The advantages of this set-up
flashes (as for intra-oral images) or stu- 3. Tripod for using slower shutter speeds are convenience and expedience, as well
dio flashes. The types of pictures required or wider apertures if light is low due as being economical and space saving.
depend on the intended facial assessment. to a cloudy day. However, the intensity of ring and bi-
Some suggestions are as follows: On an overcast day, the only item lateral flashes is usually insufficient for
1. Frontal facial at rest (for example, required is a cloth or card for the back- illuminating the face. Using wider aper-
assessing persona of patient) ground, which can be suspended or tures and slower speeds may obtain correct
2. Frontal facial during a relaxed smile hand-held by the dental assistant. If tak- exposure, but the quality of illumination is
(for example, assessing incisal plane ing pictures in sunlight, it is crucial that uniform, which is equivalent to shining car
relationship to the inter-pupillary line) the sun is behind or to the side of the headlights in someone’s face. The resulting
– Figure 2 patient. Pictures taken with the sunlight picture is flat and dull with poor detail and
3. Frontal facial with exaggerated smile directly above, or in front of the patient reduced dynamic range. Furthermore, with
(for example, assessing degree of causes unflattering shadows by the eye- a coloured background, annoying shad-
maxillary gingival exposure) brows, nose and lips that obscure the ows are visible behind the subject’s head
4. Profile at rest (for example, facial features (Fig. 6). This is also true (Fig. 7). This set-up is only recommended
orthodontic assessment, lip positions) for patients who wear spectacles, which for convenience, but is not advisable for
5. Profile during a relaxed smile can hide the eyes and pupils, which are quality facial images.
(assessing inclination of maxillary crucial for aesthetic assessment. The
incisors) simple set-up shown in Figure 4 uses a Studio flash set-ups
6. Profile with exaggerated smile black background and a silver reflector Studio flashes are the ideal, predictable
7. Dento-facial images (framing only lips for bouncing sunlight onto the patient’s and widely used for high quality portraits.
and teeth) with same poses as for full face. This type of set-up is very flattering An area of approximately 4 m2 should be
frontal facial pictures – Figure 3. since it ‘irons out’ wrinkles by soft illumi- allocated for a studio set-up, which can
nation, but care is necessary not to cause either be a separate room or part of the
Natural daylight set-up squinting by inadvertently directing light surgery, waiting room or reception area.
Although unpredictable, if judicially into the eyes from the reflector. Altering The inventory for a simple studio set-up
manipulated, natural daylight can be eco- the angle and type of reflector changes consists of the following:
nomical and a superb illumination for the mood of the picture, for example a 1. Two or three electronic studio flashes
facial images. To ensure correct exposure smooth white reflector produces sub- 2. Flash soft boxes or reflective
and white balance, it is worth taking a test tle illumination, while silver is more umbrellas

PRACTICE
Black background
Patient
r
cto
efle
er r
So
ft
Silv
bo
x
sh
Fla
Digital camera
Fig. 8 Studio set-up 1: black background, one flash and one reflector Fig. 9 Image using set-up shown in Figure 8
3. Light modifying flash attachments,

Studio set-up 2: DENTAL LABORATORY SET-UPS
black background, two flashes
for example barn doors, spot cones, The types of dental laboratory pictures
mesh grids Having two bi-lateral studio flashes totally are limitless, ranging from nuances within
4. Selection of reflectors, for example eliminates shadows rather than softening artificial crowns to showing techniques,
white, silver and gold them as in set-up 1. Both flashes have soft instruments and equipment. Some exam-
5. Coloured fabrics or cards for boxes or reflective umbrellas to mute the ples include documenting pre-operative
backdrops. light output (Figs 10-11). casts, diagnostic wax-up and surgical
stent for guiding implant placement for
The choice of flashes depends on the Studio set-up 3: coloured the patient in Figures 18-20. Similarly,
budget, but relatively inexpensive units are
background, two flashes the patient in Figures 21-23 required
and one reflector
available from numerous manufacturers. veneers for the mandibular teeth. After
Using naked flashes produces harsh light- This set-up uses a coloured instead of a the wax-up, a transparent vacuum stent
ing that usually requires muting, either by black background. If set-up 1 were used based on the wax-up was delivered
using soft boxes, reflective umbrellas or with a coloured background, unwanted as a template for fabricating chairside
attachments such as meshes that fit directly shadows behind the patient would be temporary veneers.
onto the flash heads. In addition, various visible. For this reason a second flash is Is impossible to show every type of pos-
reflectors and backgrounds are necessary used to illuminate the background sepa- sible set-up, and instead a few simple set-
to complete the armamentarium. For con- rately. This also has the effect of creating ups are described which can be adapted
stantly predictable facial shots, the set-ups depth and a three dimensional effect by and tailored to specific needs depending
below should suffice. However, to be more separating the subject from its background on the items to be photographed.
adventurous, experimentation with differ- (Figs 12-13). The most frequently photographed items
ent attachments, reflectors, backgrounds, in the dental laboratory are plaster casts.
etc can yield creative and unique results. Studio set-up 4: These can be of both maxillary and man-
black background, one flash dibular arches, only one arch, a few teeth,
Studio set-up 1: black background, For profile images, a single flash with a soft and with or without artificial prostheses.
one flash and one reflector box or other attachment is used as a uni- Plaster casts are relatively bland, usually
This is the simplest studio set-up, with a directional light to illuminate the face monochromatic and visually boring. One
black background that can be used for (Figs 14-15). method to add interest is incorporating dif-
standard portrait images (Figs 8-9). A black ferent coloured or textured backgrounds,
fabric (eg velvet) background absorbs light Studio set-up 5: or trans-illumination to visualise char-
from the flash and reflector and therefore
coloured background, two flashes acteristics within a ceramic restoration.
conceals all shadows. The choice of reflec- This is identical to set-up 4, except a col- Using different coloured cards enhances
tors depends on the desired mood, and can oured background substitutes the black colour contrast between the plaster cast
be white, silver or gold. The flash is covered backdrop. The arrangement is particularly and coloured background. Two types of
with a soft box, while the reflector softens useful for dento-facial profile and lateral lighting set-up are possible. The first is
shadows on the opposite side, but does not images (Figs 16-17). the studio set-up described for portrai-
eliminate them as in set-up 2 below. ture. The only difference is that a bench or

PRACTICE
Black background
Patient
x
bo
So
ft
ft
bo
So
Fla
x
h sh
Flas
Digital camera
Fig. 10 Studio set-up 2: black background, two flashes Fig. 11 Image using set-up shown in Figure 10
Blue background
Fla
Patient sh
W
hit
er
efl
ec
x
tor
bo
ft
So
Fla
sh
Digital camera
Fig. 12 Studio set-up 3: coloured background, two flashes, one reflector Fig. 13 Image using set-up shown in Figure 12
Black background
h
Flas
x
t bo
Sof
Patient
ra
ca me
ital
Dig
Fig. 14 Studio set-up 4: black background, one flash Fig. 15 Image using set-up shown in Figure 14

PRACTICE
Purple background
h
Flas
x
t bo
sh
Sof
Fla
Patient
a
er
am
lc
ita
g
Di
Fig. 16 Studio set-up 5: coloured background, two flashes Fig. 17 Image using set-up shown in Figure 16
Fig. 20 Surgical stent with drill guides for

Fig. 18 Pre-operative cast Fig. 19 Wax-up of poster quadrants implant location
Fig. 23 Vacuum stent for fabricating

Fig. 21 Pre-operative cast Fig. 22 Wax-up for proposed veneers chairside temporary veneers
Black background
Silver reflector
Fig. 25 Image using set-up shown in

Figure 24
Plaster cast
Silver foil
Compact flash with wireless connection to camera
Fig. 26 Impression photographed using

Fig. 24 Laboratory set-up 1: black background, one flash, one reflector set-up shown in Figure 24

PRACTICE
professional still life table is used for sup-

porting the laboratory items. Beside the
fact that small objects instead of the face
are being photographed, the lighting, back-
grounds, etc are very similar. Once again,
testing with a grey card is recommended
for ascertaining correct exposure and white
balance calibration.
The second option is to use the camera-
mounted flashes that are used for intra-
oral photography. Since the objects to be
photographed are relatively small, the light
intensity from these compact flashes is ade-
quate for illumination. An important point
to remember when purchasing compact
flashes is that they should be detachable
from the camera for ease of manoeuvra- Fig. 27 Laboratory set-up 2: coloured background, two flashes
bility and greater versatility for different
illumination. Another useful facility is
having wireless connection between the
camera and flashes that avoids infuriating
cables. If the flashes are not detachable, a
standard bi-lateral set-up can be used, but Fig. 28 Image using set-up shown in Figure 27
will result in unwanted shadows behind
plaster models with coloured backgrounds
(similar to facial pictures, see Fig. 7). The Fig. 32 Angling the flash behind and above
only way to circumvent this nuisance is the plaster cast highlights preparation
outlines using the set-up shown in Figure 27
using a black background.
The plaster cast is placed onto foil or Fig. 29 Another image using set-up shown in
Figure 27
reflective surface to illuminate the cast
from below and eliminate shadows. If a
coloured background is chosen, one flash
is directed to illuminate the latter and to
optically separate the plaster model from
the background. If a black background
is used, no background illumination is
necessary. For uniform illumination, one
flash is placed 45° to the side while the Fig. 33 Trans-illumination allows
Fig. 30 Clearly visible crown margins of left
visualisation of porcelain layer build-ups
opposite side has a reflector, again at lateral incisor using the set-up shown in
and incisal translucency
Figure 27
45° to bounce light back onto the plaster
model. However, for achieving creative
lighting effects, the flashes are placed and
aligned in different positions. Of course
any of the above flash positions can be
combined with reflectors of different col-
ours and textures to achieve different and
interesting results. A little experimenta-
tion and patience can yield unique and
striking effects. The basic set-ups are Fig. 31 Clearly discernible crown margins of
crown of maxillary canine using the set-up
as follows. shown in Figure 27 (the ceramic crown has Fig. 34 Fibre-optic trans-illumination allows
been superimposed onto the tooth preparation) visualisation of natural enamel opalescence
Laboratory set-up 1: black back-
ground, one flash and one reflector
This is a standard set-up with a black any position to achieve different illu- Laboratory set-up 2: coloured
background, two flashes (top)
background, one flash and a silver mination effects (Figs 24-25). This
reflector on the opposite side. Both the arrangement is also used to photograph If a coloured background is used it must
flash and reflector can be placed in impressions (Fig. 26). be illuminated separately. The first flash is

PRACTICE

Figure 35

Figure 37
Fig. 35 Laboratory set-up 4: placing flash in front of model
Fig. 39 UV illumination allows checking

for porosity or fractures within all-ceramic
restorations
Fig. 40 Photograph with UV illumination

of crown on left lateral incisor (the crown
has been superimposed onto the tooth
preparation)
Fig. 37 Laboratory set-up 5: flash placed to right side of plaster cast
Laboratory set-up 5: coloured

background, two flashes (one side)
aimed at the red card, while the second is fibre-optic light tip is placed behind the
freely moved from above to illuminate the restoration, ensuring that the tip is not vis- Another variation is moving the flash
plaster cast. This arrangement is useful for ible in the viewfinder. Fibre-optic cables of either to the right or the left to illuminate
capturing crown preparation margins and varying diameters and length are available one side while creating shadows on the
varying the angle of the flash illuminat- from most photographic suppliers. Angling other, which conveys depth and dimen-
ing the model will revealed the salient fea- a fibre-optic tip can create striking results sionality (Figs 37-38).
tures (Figs 27-32). Another useful effect is and reveal features such as translucen-
trans-illuminating all-ceramic restorations cies, mamelons, stains and cracks within Ultra-violet illumination
to visualise internal stains and porcelain artificial prostheses. Fibre-optic cables Finally, ultra-violet illumination (UV)
layers (Fig. 33). are also an excellent method of showing shows internal fluorescence of the vari-
opalescence of natural enamel and enamel ous porcelain layers within an all-ceramic
Laboratory Set-up 3: coloured porcelains (Fig. 34). restoration. Photographing with UV light
background, two flashes (behind) is also useful for checking porosity or frac-
The set-up is identical to that described Laboratory set-up 4: coloured tures within all-ceramic units, which can
above, but the ambient light needs to be
background, two flashes (front) be detrimental to the longevity of the res-
reduced or the picture taken in total dark- Placing the second flash in front of toration in the oral cavity (Figs 39-40).
ness. A single flash is placed above and the cast (Fig. 35) produces the lighting 1. Ahmed I. Digital dental photography. Part 6:
behind the ceramic restoration(s), or a effect shown in Figure 36. Camera settings. Br Dent J 2009; 207: 63-69.

• Once an understanding of the basic set-
Part 8: intra-oral set-ups ups is gained, intra-oral photography can
PRACTICE
be expedited in a few minutes.
• Cross-infection control during a
photographic session is mandatory.
I. Ahmad1 • As well as taking ‘stock’ dental images,
one can concentrate on specific points of
interest and analyse them later.
• Intra-oral photography is also an
excellent method of communication with
the patient, ceramist and specialist.
The majority of pictures taken in the dental surgery are intra-oral and this article looks at the practicalities involved in full-
arch, quadrant occlusal, lingual (or palatal) and lateral views, as well as magnified images, oral mucosa, enamel texture,
dentine strata and shade analysis for artificial restorations. Additionally, the issue of cross-infection control is considered.
The majority of pictures taken in the den-

tal surgery are intra-oral, which includes
the following:
1. Full arch – frontal and occlusal
2. Quadrant occlusal, lingual
(or palatal) and lateral
3. Magnification images for detailed
analysis of teeth or soft tissues
4. Oral mucosa
5. Enamel texture, cracks
and dentine strata
6. Translucency: incisal and
interproximal
7. Shade analysis for
artificial restorations
8. Posterior teeth.
Fig. 1 Photographic equipment should be wrapped with disposable cellophane covers

DENTAL PHOTOGRAPHY CROSS INFECTION CONTROL rhodium coating. Finally, all intra-oral
1. Digital dental photography: an overview Unlike other forms of photography, dental photographic reflector and backdrop cards
2. Purposes and uses photography requires strict adherence to should be discarded after use.
3. Principles of digital photography cross-infection control measures. Routine
4. Choosing a camera and accessories cross-infection measures carried out for GENERAL GUIDELINES
5. Lighting dental procedures are also applicable for Most intra-oral images necessitate using
6. Camera settings dental photography. It is recommended cheek retractors and/or intra-oral pho-
7. Extra-oral set-ups that a specific zone be reserved for photographic mirrors. The following general
8. Intra-oral set-ups tographic equipment and accessories. All guidelines are applicable for all types of
9. Post-image capture processing photographic equipment, including the intra-oral photography. The first step is
10. Printing, publishing and presentations camera, lens, tripod (if used) and cable asking the patient to wear safety glasses.
releases should be draped with disposable Unless stains or bio-film are being docu-
1
cellophane covers, similar to that used for mented, the teeth should be flossed and
Surgery, 173 The Ridgeway, North Harrow, chair headrests (Fig. 1). Cheek retractors polished with prophylaxis paste to remove
Middlesex, HA2 7DF
can either be autoclaved or cold sterilised, food debris, plaque and stains which mask
Email: iahmadbds@aol.com depending on the manufacturer’s instruc- intrinsic tooth shade and texture. In order
tions. Intra-oral mirrors should be cleaned to facilitate placement of cheek retractors,
Refereed Paper with cotton gauze soaked in a mild sur- petroleum jelly is copiously applied to the
DOI: 10.1038/sj.bdj.2009.715
face disinfectant, not surgical spirit, which lips, taking care not to smear the teeth.
© British Dental Journal 2009; 207: 151–157 causes smears or irreparable damage of the This lubrication also prevents chapping

PRACTICE
Alternatively the dental nurse can stand

behind the patient to hold two unilat-
eral cheek retractors for full arch images,
but this occupies the nurse who may be
required for subsequent stages of the
photographing procedure. After placing
the cheek retractors, the patient is given
tissues to wipe excess salivary flow. The
teeth and gingivae are gently dried with
a warm stream of air without desiccating
the teeth. Other adjuncts to ensure a dry
environment are saliva ejectors and cotton
wool rolls, discretely placed so that they
are not visible in the photograph.
As mentioned in Part 4,1 it is highly
advisable to mount the camera and flashes
Fig. 2 Patient with bilateral cheek retractors onto a tripod. A tripod not only serves as
for photographing the oral cavity Fig. 5 A maxillary tooth will appear shorter a solid platform, but also frees the opera-
if the patient’s chin is pointing upwards or
the camera axis is inferior to the maxillary tor’s hand to concentrate on taking the
arch. This is a useful set-up for illuminating photograph, reduces fatigue, and prevents
and capturing crown margins potential accidents such as inadvertently
bumping into surgery equipment. To
ensure that a picture is correctly orien-
tated, the camera axis and patient’s head
should be parallel in the horizontal, verti-
cal and sagittal planes. Misalignment of
the horizontal plane can convey incorrect
assumptions, for example a slanted incisal
plane, which is especially critical if anterior
crowns are being planned. In the superior-
inferior plane, incorrect alignment results
Fig. 6 Note the clearly visible crown margins in pseudo-shortening or lengthening of
of the left lateral incisor in this picture
taken using the set-up described in Figure 5 teeth in the inciso-gingival perspective, for
compared to Figure 7, when the patient is example the maxillary teeth appear longer
looking directly into the camera (set-up if the patient’s chin is pointing downwards
Fig. 3 A maxillary tooth will appear longer described in Figure 8)
or the camera axis is superior to the maxil-
if the patient’s chin is pointing downwards
or the camera axis is superior to the lary arch. However, this is a useful set-up
maxillary arch, but this is a useful set-up for for photographing the mandibular ante-
photographing mandibular anterior teeth rior teeth (Figs 3-4). Conversely, shorter
teeth are recorded if the chin is pointing
upwards or the camera axis is inferior to
the maxillary arch. This type of set-up is
very useful for illuminating and capturing
crown margins (Figs 5-7). While an incor-
rect horizontal plane is readily corrected in
photo-editing software, an incorrect tooth
Fig. 7 When the patient is looking directly perspective (superior-inferior plane) is dif-
into the camera the crown margins of the ficult or almost impossible to rectify with-
Fig. 4 Mandibular anterior teeth photographed left lateral incisor are not clearly discernible out introducing further distortions. This is
using the set-up described in Figure 3 (compare with Figure 6)
particularly significant for magnification
or detailed views.
of the lips while they and the cheeks are available on the market and it is useful to Some clinicians prefer to delegate den-
displaced by the retractors. have a selection to hand to cater for dif- tal photography to another member of the
The choice of cheek retractor is a per- ferent eventualities. For full arch images dental team, for example a nurse, hygienist
sonal preference, and also depends on the the bilateral variety is preferred, while or dental technician. While this obviously
extent of mouth opening of the patient the unilateral retractor is more suitable saves time, especially in a busy prac-
(Fig. 2). Many sizes and varieties are for photographing individual quadrants. tice, the resultant images may not yield

PRACTICE
the anticipated information. Ideally, it is

the clinician’s duty to take photographs
since he or she knows what to concen-
trate on. Asking someone else to take
stock, predefined views of each patient
may not reveal clinically relevant infor-
mation. For example, stock images may
not record oral lesions of a patient who
complains of symptoms of oral pathol-
ogy, or document mamelons in a natural
tooth in order that the ceramist can mimic
this in a crown on an adjacent tooth. On
the other hand, standardised views are
indispensable for assessing occlusal rela-
tionships or tooth movement during ortho-
dontic treatment. Furthermore, to achieve
photographically acceptable results, Fig. 8 Full arch frontal set-up Fig. 10 Full maxillary arch occlusal set-up
training and experience in dental pho-
tography is a prerequisite. To summarise,
each patient has different photographic
requirements depending on the proposed
treatment, and therefore the ideal person
to make this judgement is the clinician,
who is also probably more experienced in
dental photography.
The following sections describe the set-
ups necessary for photographing the dif-
Fig. 9 Full arch frontal image Fig. 11 Full maxillary arch occlusal image
ferent types of dental views.
FULL-ARCH mirrors present a potential hazard and it is

Two types of full arch images are required, essential to avoid undue pressure on the soft
frontal and occlusal. tissues or hard tissues to prevent inadvertent
breakage or shattering, with obvious con-
Full arch: frontal view (Figs 8-9) sequences. The set-up is identical to that
1. Ask the patient to bite in centric described previously for full arch pictures,
occlusion with the following differences:
2. Frame picture with as many teeth as 1. Select an appropriate sized occlusal
possible in the composition, ideally mirror depending on the extent of
including the second molars, while mouth opening, and place gently in
ensuring that cheek retractors and the mouth. For the maxillary arch,
cotton wool rolls are not visible place mirror downwards, and for
3. Use the canines as the point of focus mandibular arch upwards, respectively
for ensuring maximum depth of 2. Request the patient to breathe through
field. The point of focus will depend their nose if possible and ask the
on the shape of the upper and lower dental assistant to constantly blow
arches, and if all teeth are not in warm dry air onto the mirror to
Fig. 12 Full mandibular arch occlusal set-up
focus, change the point of focus either prevent condensation
anterior or posterior to the canines 3. Focus onto the reflected image of the
4. Take pictures in various mandibular teeth on the mirror surface, framing as
positions as desired, including many teeth as possible. If mirror edges
centric occlusion, protrusive and or actual teeth are in the frame these
lateral excursions. can be subsequently cropped during
the image processing stage
Full arch: occlusal view 4. Using mirrors means that light
(Figs 10-13) intensity is diminished because it
Occlusal and lateral views require using has to travel a greater distance by
Fig. 13 Full mandibular arch occlusal image
intra-oral photographic mirrors. Intra-orally, being reflected off the mirror surface

PRACTICE
before it reaches and illuminates the

teeth. To compensate for the reduced
illumination, either increase the light
intensity or use a wider aperture, say
f16, to ensure correct exposure.
QUADRANT VIEWS: OCCLUSAL,

LINGUAL AND BUCCAL
The quadrant views record occlusal, lingual
(or palatal) and buccal (lateral) surfaces of
the teeth in an individual quadrant. The
procedure is identical to taking full arch
occlusal pictures, but the only difference
is that narrower lateral mirrors are substi-
tuted for the wider full arch occlusal mir-
rors to concentrate on a specific quadrant
or area. Also, unilateral cheek retractors are Fig. 14 Quadrant occlusal set-up Fig. 18 Quadrant palatal set-up
better suited to photographing quadrants
since they are less cumbersome than the
bilateral variety. As for all images using
mirrors, moisture control is essential and a
warm stream of air prevents condensation
on the mirror surface (Figs 14-15).
Both lingual and buccal images also
require narrower photographic mirrors. For
buccal images, the patient is asked to close Fig. 15 Quadrant occlusal image
their mouth so that the buccinator mus- Fig. 19 Quadrant palatal image
cles are relaxed, allowing room to place
the mirror into the cheeks. Once again,
unilateral cheek retractors may be less
cumbersome than larger bilateral types.
Images can be taken with the teeth fully
occluded or slightly parted to concentrate
on either the maxillary or mandibular
teeth (Figs 16-17).
For palatal images of the maxillary teeth,
the patient is asked to open the mouth and
tilt the head backwards while the mirror is
positioned to reflect the palatal aspects of
the teeth. For improved access, a supine
position is favoured for these types of
images (Figs 18-19).
Lingual surfaces of mandibular teeth
present two unique problems. Firstly, Fig. 16 Quadrant buccal set-up
the sublingual salivary gland openings Fig. 20 Quadrant lingual set-up
present a challenge for moisture control,
and secondly, the proximity of the tongue
causes difficulty for correct positioning of
a mirror. In addition, excessive pressure
may elicit a gagging reflex. Therefore for
these types of views, time, practice and
patience are necessary to achieve satisfac-
tory results (Figs 20-21).
MAGNIFICATION VIEWS
If only particular parts of the oral mucosa
Fig. 17 Quadrant buccal image Fig. 21 Quadrant lingual image
or teeth are of interest, it is best to compose

PRACTICE
the picture concentrating on the desired recommended for safety reasons as well as
areas. As a general rule, excess magnifica- those of limited access. For maximum com-
tion is detrimental to image quality. This is fort and depending on the site of the lesion,
because most macro lenses are incapable of the patient can either be seated or placed in
resolving beyond a 1:1 magnification, and the supine position. If not contra-indicated,
while it is possible to magnify objects to administration of topical or injectible local
greater than life size using various attach- anaesthesia helps alleviate pain and expe-
ments such as extension tubes and bel- dite the photographic session. When com-
lows, the result is a deterioration of image posing the picture, ensure that a healthy
quality. If a magnification greater than 1:1 area beyond or encircling the lesion is vis- Fig. 22 1:1 magnification image
is required it is better to enlarge the image, ible for comparison between healthy and
again within limits, using photo-editing diseased or pathologically altered tissue.
software. This is one of the reasons to start Also, to assess the size of a lesion, placing a
with a high quality image that is capable of periodontal probe or millimetre scale adja-
enlargement without loss of detail. cent to the pathology is helpful. The inten-
The major factor to consider when tak- sity of the photographic light needs to be
ing magnification views is that the depth increased to illuminate poorly lit posterior
of field is substantially reduced, sometimes regions. Finally, colour is important when
as small as 2 mm. This means that fewer photographing soft tissues, as changes from
teeth or parts of teeth are sharply focused, the norm often indicate present or previ-
Fig. 23 1:1 magnification image
not forgetting that the depth of field is in ous pathology. Therefore, calibrating with
front as well as behind the point of focus.
Therefore, to ensure maximum depth of
field it is advantageous to focus on a mid-
point. While framing of a picture is not
critical since the image can be cropped
afterwards, incorrect focusing is difficult
to rectify in photo-editing software. A cer-
tain degree of sharpening can be applied,
but if an image is captured out of focus
it will remain and appear out of focus no
matter the amount of manipulation. A tri-
pod is invaluable for precise focusing and
accurate framing. With a 1:1 magnification
and assuming normal tooth alignment, the
ideal point of focus is the distal aspect of
the maxillary central incisors for maximum
depth of field, which can also be verified
by using the depth of field preview but-
ton. Finally, if no indication is given on the
macro lens regarding the degree of mag-
nification, an easy method for ensuring a
1:1 magnification is when four maxillary Fig. 24 Set-up to capture dentine strata or enamel cracks. A silver reflector is placed on the
contra-lateral side of the flash to bounce light back onto the teeth
incisors occupy the entire viewfinder of a
35 mm DSLR camera (Figs 22-23).
ORAL MUCOSA
Photographing the oral mucosa and gingi-
vae is similar to photographing teeth but
requires minor modifications in technique.
Firstly, disease is painful and therefore
extra care is necessary to avoid trauma
when placing retractors and mirrors if the
tissues are inflamed. Mirrors are essential
if pathological lesions are located in the Fig. 25 Image taken with bilateral flashes Fig. 26 The same image as Figure 25, but
deep recesses of the oral cavity. However, showing the specular reflections that obscure photographed with the set-up described in
dentine strata and enamel cracks Figure 24, which reveals enamel cracks
if trismus is present mirrors are not

PRACTICE
an 18% grey card is advisable for precise

colour rendition.
TEXTURE, DENTINE LAYER

AND ENAMEL CRACKS
Pictures that reveal texture, dentine strata,
enamel cracks and perikymata are invalu-
able for a ceramist for visualising and
subsequently mimicking these characteri-
sations in artificial prostheses. The stand- Fig. 27 Dentine strata and enamel cracks are Fig. 31 A cursory shade analysis is carried
clearly discernible using the set-up described out pre-operatively before bleaching
ard lighting for intra-oral images, ie two in Figure 24
bilateral flashes mounted on either side of
the camera, is the ideal configuration for
capturing texture and lustre by specular
reflection off the enamel surface. However,
specular reflection masks the underlying
dentine colour and characterisations as
well as subtleties such as enamel cracks.
To visualise the latter, a silver or white card
is used to cover one of the bilateral lights,
acting as a reflector to bounce muted light Fig. 32 The patient in Figure 28 two weeks
after bleaching
from the opposite flash onto the teeth with-
out specular reflection. This set-up reveals Fig. 28 The crown on the right central
incisor is devoid of the fracture line that is
the underlying dentine strata or intra- clearly visible in the enamel of the natural
enamel nuances (Figs 24-27). For this type left central incisor
of image, continuous light sources (LED or
dental operatory lights) are advantageous
because the reflector can be angled until
the desired structures, for example den-
tine layer or perikymata, are visible in the
viewfinder before taking the picture. Fig. 33 A detailed shade analysis is
performed pre-operatively with a single shade
Failure to clearly visualise and cap-
tab placed adjacent to a natural tooth
ture cracks or other characterisations
can result in artificial prostheses that
do not mimic adjacent natural teeth. In
Figure 28, the crown on the right central
incisor is devoid of an enamel crack, which
is clearly discernible on the natural left
central incisor.
TRANSLUCENCY –
INCISAL AND INTERPROXIMAL
Enamel translucency is usually located at Fig. 34 A detailed shade analysis performed
Fig. 29 A black card is placed behind the after tooth preparation with a single shade
the incisal edges, cusps and interproximal teeth to highlight enamel translucency tab placed adjacent to the prepared tooth
regions of a tooth. The ability to map the
extent, degree and shape of translucencies
and mamelons is invaluable for communi-
cation between the clinician and ceramist
when fabricating artificial restorations.
The technique is as follows. A black card,
appropriately cut to size, is placed behind
the teeth to obscure the oral cavity and a
1:1 magnification is chosen to concentrate
on the desired teeth (Figs 29-30). Since
black is an optical contrast to the white Fig. 30 Enamel translucency is clearly visible Fig. 35 A detailed shade analysis performed
teeth, the camera’s automatic metering in this image taken with the set-up described at the try-in stage using a single shade tab
in Figure 29 placed adjacent to the ceramic crown
may compensate by overexposing the

PRACTICE
image by ½ or 1 f-stop. This will diminish

the visibility of translucency and it may
be necessary to override the metering by
underexposing to obtain correct exposure.
As for recording texture and lustre, a con-
tinuous lighting source is helpful to visu-
alise translucent areas by angling the light
until the translucent areas or mamelon dis-
tribution are visible in the viewfinder.
Fig. 36 A custom shade tab photographed Fig. 37 The same shade tab as in Figure 36,
SHADE ANALYSIS with electronic flash with a colour photographed in natural daylight with a colour
temperature of 5,500 K appears to match the temperature of 6,500 K, now has a higher
Absolute tooth shade comparisons are surrounding dentition value compared to the surrounding dentition
impossible with photography alone and must
be considered in combination with ocular
or instrumental analysis. However, relative
shade analysis is feasible with photography
and is a useful guide for the dental ceramist
for assessing the progress and extent of
bleaching relative to a shade guide.
Photographs for shade are taken using a
standard bilateral flash lighting set-up. As
for the oral mucosa, calibration with a grey
card is essential. The teeth should be moist
and not unduly desiccated, especially if
using a rubber dam, which causes inac-
curate shade assessment. While moisture
control is still necessary, saliva should be
encouraged to flow over the teeth, simu- Fig. 38 Inlay preparation in mandibular right Fig. 39 Cemented inlay in mandibular right
first molar first molar
lating a natural oral environment. The
patient is asked to hold the entire shade
guide for a cursory analysis, or to hold difficult photographs should be taken or a quadrant, unilateral cheek retrac-
individual tabs adjacent to the concerned with illumination of different colour tem- tors and narrow occlusal mirrors are the
teeth. Shade analysis with shade guides is peratures. This helps to avoid metamer- ideal choice. A rubber dam is an excellent
useful for assessing the extent of bleaching ism and facilities the matching procedure method of isolation, preventing condensa-
(Figs 31-32). For a more precise shade com- (Figs 36-37). tion on the mirrors as well as safeguarding
parison, a shade tab can be placed adjacent against ingestion or inhalation of dental
to a tooth that requires a crown. Ideally, POSTERIOR TEETH instruments. These types of dental images
shade analysis should be performed pre- Photographing posterior teeth is challeng- are ideal for using ring flash illumination,
operatively, after tooth preparation and at ing because of limited access and poor illu- which is intense, uniform and allows ease
the try-in stage, especially if the treatment mination, especially with restricted mouth of manipulation in limited access areas. As
objective is to whiten or brighten the shade opening or excess salivation. The set-up is previously mentioned, a slight overexpo-
of the definitive restorations (Figs 33-35). identical to that for photographing quad- sure may be necessary to compensate for
If the shade of a natural tooth does not rant occlusal images, described above. light being reflected off the mirror surface
match those in a standard shade guide it Therefore, a supine position is preferred, to illuminate the teeth (Figs 38-39).
may be necessary to fabricate a custom allowing better manipulation of intra-
1. Ahmad I. Digital dental photography. Part 4:
shade tab. As with conventional shade oral mirrors and ease of access for saliva Choosing a camera and accessories. Br Dent J 2009;
tabs, if the shade matching is proving ejectors. For photographing a few teeth 206: 575-581.

• Editing an image causes deterioration in
Part 9: post-image quality, is complicated, time consuming,
PRACTICE
onerous and frustrating.
• Ethically acceptable alterations include
capture processing •
correcting exposure, orientation, laterally
inverting and cropping an image.
The most popular file formats to consider
are RAW data, TIFF and JPEG.
I. Ahmad1 • The most expedient and eco-friendly
transfer of images is via the Internet.
Having successfully taken a digital image, the next step is deciding what to do with it. Should it be cropped, correctly
orientated, manipulated, compressed, scaled, sharpened, archived (and if so, which file format is the most suitable),
or even discarded? The premise of this part of our series is to answer these and other questions related to post-production
of a digital image.
With regard to manipulation, it is important orientation or cropping extraneous parts but at present are relatively slow. In some
to remember that dental images are dento- is acceptable, and indeed desirable to visu- instances a print may be immediately
legal documents. Therefore, manipulation alise the clinical situation as it appeared required, and in these circumstances the
should be kept to a minimum, ensuring at the time of taking the picture. Hence, camera or its memory card can be directly
that the original image is not altered to this chapter will only cover manipula- connected via a USB cable, or inserted into
an extent that hides pathology or alters tion that is deemed ethically acceptable an office printer, respectively.
the clinical situation to camouflage what for dentistry. It is debatable whether a Windows™ or
was present in the oral cavity. Current Another important point worth men- Macintosh™ based computer is more appro-
photo-editing software allows an image tioning is that image quality is directly priate for image management and manipu-
to be manipulated beyond recognition, related to the degree of manipulation. The lation. Windows-based PCs have the lion’s
and while this is acceptable for dramatic greater the manipulation, the poorer the share of the market, while Apple® Mac™
or artistic purposes, it is inappropriate image quality. Therefore, it is crucial to machines are more eclectic. Previously,
for dental imagery. Altering exposure, keep alterations to a minimum by ensur- the Windows platform was relatively slow
ing that the original image capture was in handling graphics, being more suited
as perfect as possible regarding exposure, for applications such as word processing,
FUNDAMENTALS OF DIGITAL magnification, orientation and composi- accounting and databases. However, the
DENTAL PHOTOGRAPHY tion. Furthermore, photo-editing software latest version, Windows Vista™, promises
is complicated, applications often requiring to rival the Apple OSX operating system
training and being very time intensive. Snow Leopard with regard to image man-
agement. There is no doubt that profes-
3. Principles of digital photography INITIAL PROCESSING sional photographers, graphic designers
The physical transfer of images from the and printings houses have a penchant for
5. Lighting
camera into computer-based software is by Apple Macs due to their superior capabili-
6. Camera settings
one of the following methods: ties for handling, manipulating and stor-
1. USB-2 cable connection ing image files. For this reason, if budgets
2. FireWire® 400 or FireWire 800® allow and one is taking large volumes of
cable connections dental images, the Apple Mac is the ideal
3. Wireless connection. choice. On the other hand, for small vol-
ume documentation a Windows-based PC
1
The method of transfer depends on the is adequate. Finally, compatibility was
Surgery, 173 The Ridgeway, North Harrow, Middlesex, camera and computer ports. A USB-2 previously an issue between Windows and
HA2 7DF
cable is sufficiently fast for small files, Macintosh platforms, however the newer
Email: iahmadbds@aol.com but extremely slow for larger files. In versions of both operating systems allow
these circumstances, FireWire® 400, or the free exchange of files, without the need for
Refereed Paper faster FireWire 800® cables are the ideal conversion or filters.
DOI: 10.1038/sj.bdj.2009.763
choice. The latest transfer mode is wire- The first thing is to decide whether an
© British Dental Journal 2009; 207: 203–209 less connections, which eliminate cables image is useable or should be discarded.
BRITISH DENTAL JOURNAL VOLUME 207 NO. 5 SEP 12 2009 203

PRACTICE
While image manipulation can correct

many failings in technique, it cannot per-
form miracles. If an image is grossly under-
or over-exposed, it is probably prudent to
delete it and start again. Also, images that
do not reveal items (or details of items)
that were sought should also have a similar
demise. For example, if the purpose of the
intended image was to show translucency
or characterisations within a tooth but it
is over-exposed, no amount of manipula-
tion will reveal the missing translucency
or characterisations. In a similar vein, if
an image is out of focus or lacking detail
in specific areas due to a small dynamic
range, no software can be expected to put
back or replace something that was lacking
or absent in the beginning. Furthermore, Fig. 1 The raw image from the camera without white balance calibration (notice ‘Gray Balance
Off’ on menu tab)
excess manipulation is time consuming
and causes severe deterioration in image
quality. Therefore it may be expedient
and easier to take another picture rather
than labouring with software to achieve
the impossible and ending up with a result
that lacks quality and will ultimately be
of little use.
If not already performed by camera set-
tings, the first item for post-image produc-
tion is to ensure the correct white balance
for the prevailing lighting conditions at the
time of exposure. Setting the white balance
was discussed in Part 61 and can be cal-
culated automatically by camera electron-
ics, manually inputted, or calibrated with
an 18% grey card. If the last option was
chosen, a single image or multiple images
are selected in the chosen software (either Fig. 2 The same image as Figure 1 with white balance corrected by recalling the grey card
proprietary or Adobe® PhotoShop), and the calibration (notice ‘Gray Balance On’ on menu tab)
grey balance settings recalled for calibrat-
ing the new images (Figs 1-2).
Correcting orientation, exposure,

laterally inverting and cropping
A major difficulty with dental photography
is framing the picture with correct orienta-
tion for ensuring extraneous items such as
saliva ejectors, cheek retractors and cot-
ton wool rolls are invisible. This was of
course challenging for film photography,
since little post-production was possible.
However, with digital photography, chang-
ing orientation, cropping or altering the
exposure (within limits) is a relatively sim-
ple task. The latter can either be performed
in-camera, with camera specific software,
or in photo-editing software such as
Fig. 3 Initial image from digital camera
Adobe® PhotoShop.
204 BRITISH DENTAL JOURNAL VOLUME 207 NO. 5 SEP 12 2009

PRACTICE
The order in which correcting exposure,

orientating, laterally inverting or cropping
is performed is irrelevant. Furthermore,
every type of software has its own com-
mands and methods for executing the
above corrections. However, for illustra-
tion purposes, the image in Figure 3 was
edited in Adobe® PhotoShop (Figs 4-7)
and the final result is shown in Figure 8.
Images which are taken using an intra-oral
mirror are laterally inverted and require
subsequent correction, while those with-
out will not require the addition correction
shown in Figure 7.
Scaling Step 1: Select ‘Crop Tool’
Scaling or enlarging an image may often

be necessary, for example after cropping
or for concentrating on specific detail.
Any scaling causes image deterioration
and this is the major reason that high
quality and quantity of pixels is essential
for recording as much detail as possible
at the outset. The mathematical enlarge-
ment of an image is termed interpolation.
The resulting image quality after enlarge-
ment depends on the algorithms used for
interpolation. PhotoShop offers a variety Step 2: Draw marque around desired area
of algorithms for interpolation, includ-
ing nearest neighbour, bi-linear, bicubic,
fractals and reduction. For modest enlarge-
ments, nearest neighbour or bi-linear is
adequate, but for larger scaling bicubic,
fractals and reduction are better choices.
However, scaling is not limitless. If the
original image is enlarged excessively, pix-
elation will occur and the scaling process
for enlarging specific details will obviously
be futile. Therefore, marked enlargement
to the extent where an image breaks
down is pointless, and defaces the image Step 3: Press ‘Enter’ key or click ‘OK’
beyond recognition.
Ideally, an image should require mini- Fig. 4 Cropping: procedure for cropping an image
mal or no sharpening and if blurring is
pronounced, it is better to take another
picture that is sharply focused. An
important point to remember is that if
sharpening is necessary it should always
follow scaling, not precede it. If sharp-
ening is performed before enlarging an
image any artefacts such as contour
fringes at the edge of objects will also
be enlarged and become more appar-
ent. Furthermore, excess sharpening
introduces grain and noise, which may Adjust levels until desired exposure is obtained
defeat the initial objective of sharpening
Fig. 5 Exposure: procedure for correcting exposure
the image.

PRACTICE
FILE FORMATS
An original in digital photography is only
possible at the operating level system, ie
within the initial proprietary software that
captured the image. Once the image data is
opened and subsequently saved in another
software package such as photo-editing,
graphics, desk top publishing or presen-
tation applications, the original data is
altered and irretrievably lost. Alterations
include change of colour space, reduc-
Step 1: Select ‘Image: Rotate: 180˚’from menu Step 2: Select ‘Image: Rotate: Free Rotate Layer’ tion of colour depth or dynamic range.
bar to upright image to finely rotate image to horizontal Although the deterioration is negligible
and rarely perceptible on a computer
monitor, vast numbers of manipulations
severely affect image quality if a section
of the image is enlarged. Therefore, before
opening the image in another type of soft-
ware, the original should be stored for sub-
sequent retrieval. Furthermore, the way in
which the data is archived is essential to
reduce alterations, including choosing an
Step 3: Crop if necessary, to remove superfluous pats of the image
appropriate file format. At present there
Fig. 6 Orientation: procedure for correcting orientation is no file format that is suitable for all
circumstances and therefore several types
are needed depending on the intended use
of the image.
The basic difference between formats is
whether the data is compressed or non-
compressed, and if compression is applied,
whether it is lossless or lossy. The choice
of file format is as perplexing as choosing
a digital camera. Some examples of image
file formats are RAW, PSD, GIF, TIFF, JPEG,
PNG, EPS, LZW, DCS, EPS, PICT, Bitmap,
etc (Fig. 9). In addition, each camera
manufacturer and software developer has
their own philosophies regarding the type
Select ‘Image: Rotate: Flip Horizontal’ from menu bar of image file that best serves digital image
data. As yet there is no industry stand-
Fig. 7 Procedure for laterally inverting the image ard, and this adds to the confusion dur-
ing decision-making. However, to simplify
matters, most DSLRs offer the option of
selecting three file formats: RAW data, TIFF
and JPEG (various varieties with different
quality levels) (Fig. 10). Table 1 summarises
their salient features and differences.
Proprietary RAW data

Many camera manufacturers have devel-
oped their own file formats to capture the
initial image as raw data. These files are
camera specific and cannot be opened in
any other software except that provided
by the camera company. The objective
Fig. 8 Final image after cropping, correcting exposure, orientation and laterally inverting is to capture as pure a digital signal as
(compare with Fig. 3)
possible before being processed in the

PRACTICE
capture software and exported into a

format that is recognisable by popular
manipulation software.
TIFF (Tagged Image File Format)

If there is an industry standard for image
file format, then TIFF is a strong contender. A selection of image file formats
Invented by the Aldus Corporation, TIFF
is as ‘generic’ as an image format can be,
and can be opened in nearly all types of
manipulation software for data exchange,
for example Adobe® Photoshop, Adobe®
InDesign, PageMaker™ or Quark Xpress™.
The most endearing feature of this for- Fig. 9 A selection of image file formats
mat is that the compression is lossless in
the LZW mode, named after its designers
Lempel-Ziv and Welch, and hence there
is no detail loss from the raw proprietary
precursor file. TIFF can be selected on
camera menus as the choice for captur-
ing an image. The advantage is that the
camera software performs the necessary
white balance and other calibrations to
Dental.tif Dental.jpg
the image, which is ready to be opened
in any software of choice. However, to be
absolutely pedantic the data is not as pure
as the proprietary raw format since the in-
camera software is rarely as sophisticated
as the proprietary capture software. The
files generated in the TIFF mode are large,
ranging from a few megabytes to over
200 MB, depending on camera specifica-
Dental.pdf Dental.png
tions. Consequently, large capacity storage
media are an essential requirement. Fig. 10 Icons of popular file formats, TIFF, JPEG 2000, PDF and PNG 24
JPEG (Joint Photographic

Table 1 Comparison of popular file formats
Experts Group)
Unlike TIFF, when JPEG files are opened RAW data TIFF JPEG (varieties)
and saved they suffer from severe lossy
Colour mode RGB RGB, CMKY, Lab RGB, CMYK
compression, with loss of detail especially
of diagonal lines in an image (Fig. 11). Colour depth/channel Up to 16 bit/channel Up to 16 bit/channel 8 bit/channel
Various levels of JPEG compression are ICC-profile - Yes Yes
possible, ranging from Level 10 to Level 1.
Compression No Optional Lossy
The higher the level, the larger and higher
the quality of the file. A newer version is Alpha channels No Yes No
available called JPEG 2000 with less dete-
Web-suitable No No Yes
rioration in image quality than its pred-
ecessor. JPEG files can be as small as a few
kilobytes to several megabytes depending before the memory card is full, and the Unfortunately, conversion in the reverse
on the level of compression. Because of image is automatically calibrated for white direction, that is, JPEG to TIFF will not
their smaller size, they are ideal for Internet balance, etc. However, the temptation regain the lost image quality.
use, particularly for email attachments for should be resisted because the resulting
communication between members of the image is of poor quality and unsuitable for PDF (Personal Document Files)
dental fraternity. Some cameras also offer archiving. Furthermore, it is better practice Similar to JPEG files, PDF files are lossy
the facility to choose JPEG as the initial to capture the initial image as either a raw compressed files that are relatively small
captured image. The temptation is that the or TIFF file which is subsequently easily in size and therefore ideal for electronic
file is small so more pictures can be taken converted to a JPEG for dissemination. transmission. In addition, PDF files also

PRACTICE
have different levels of quality, depend-

ing on the chosen parameters before the
file is exported. The advantage of PDF
files is that they can contain layouts
with text, vector drawings and photo-
graphic images for distribution via the
Internet. These files are very helpful for
assessing layout for publishing and can
also be used for communication with a
dental technician by writing text over
images, for example marking parts of a
restoration that requires adjustment at
the try-in stage. Most graphic software
allows files to be exported to a PDF for-
mat, and the email recipient can view the
files by installing Adobe® Acrobat, which
is freely available as a download from
the Internet. TIFF file format retains image quality (size = 30.9MB)
PNG (Portable Network Graphics)

PNG file format is a development of the
GIF (Graphic Interchangeable Format) file,
intended primarily for use on the Internet
and for building websites. The GIF format
has its origins from the very beginnings
of the Internet, but has the major draw-
back of yielding poor image quality. On
the other hand, PNG files have addressed
the quality issue as well as delivering
faster Interest access. The main reason
for this is that PNGs can support up to
24 bit (PGN 24) data, and are therefore
capable of retaining quality for developing
web pages.
EPS (Encapsulated PostScript) PNG 24 file format retains image quality for building websites (size = 9.1MB)
EPS files are worth mentioning because
they are primarily used for pre-press stages
of the printing process (to be discussed
further in Part 10). These are vector-ori-
entated files (text and drawings) but can
also store pixel-based images with loss-
less compression. Therefore, this format
is ideal for publishing that combines text
and images, such as practice stationery,
brochures and leaflets. After designing the
layout in a graphics application, the file is
converted into EPS, ready for transmission
to a printing house or an office laser printer
that supports the Adobe ® PostScript™
printer language.
IMAGE STORAGE AND TRANSFER

The final stage of processing is to store
JPEG file format results in deterioration of image quality (size = 812KB)
and transfer the image for safekeeping and
intended use, respectively. As previously Fig. 11 Comparison of an image saved as TIFF, PGN 24 and JPEG, with severe deterioration in
mentioned throughout this series, dental image quality in the latter format

PRACTICE
1. Create a folder with the

patient’s name
2. Within the folder, create sub-folders
according to when the series of
images were taken, for example ‘Pre-
operative status’, ‘Oral lesions’, ‘Tooth
preparation’, ‘Temporisation’, etc
3. Name each file with a unique name,
for example date of image and
specific views such as facial, dento-
facial, occlusal, etc
4. In addition to a unique name, also add
if the file is simply RGB or processed
RGB (ie with exposure and orientation
correction, etc) before archiving.
Many types of image data management

Fig. 12 A selection of portable storage media and database software are available which
expedite the above procedures, making
Table 2 Image transfer guidelines retrieval easier and more efficient.
High quality images demand huge hard-
Intended use File Method of transfer ware storage capabilities. As well as fixed
Communication between colleagues JPEG Email attachments storage devices such as computer hard
drives, many portable options are available
Layout approval for stationery, brochures PDF Email attachments
such as CD, DVD, flash sticks and memory
Web publishing PGN, JPEG Internet, CD, DVD, flash drives cards (Fig. 12). Each of these media should
CD, DVD, flash drives or high speed be stored in different locations and if nec-
Print publishing TIFF, EPS
Internet transfer essary, periodically updated and checked
Via DVI or VGA ports from computer to verify the stored data.
Presentations High quality JPEG, TIFF
to projector Before an image file is transferred, the
Laser or inkjet office printing
High quality JPEG, high USB or wireless connection to intended use must be defined. The use
quality PDF, TIFF, EPS printer
of the picture will determine the type
of export file required and the physical
images are sensitive data and stringent for future retrieval. The best format to method of transfer. Table 2 summarises the
practice protocols must be in place for their store the original is in an unadulterated intended uses of the images and the ideal
storage and transfer to prevent inadvertent manner, either in a raw data or a TIFF file file formats and modes of transfer.
loss. Before an image is transferred, the format. The following storage protocols 1. Ahmad I. Digital dental photography. Part 6: camera
original file must first be securely archived are advisable: settings. Br Dent J 2009; 207: 63–69.

• A print is as popular as it was a century
Part 10: printing, publishing ago, and is unlikely to become obsolete.
PRACTICE
• While traditional chemical processing
remains a popular choice for making
and presentations prints, newer methods such as laser

and inkjet printing have made printing
accessible for the wider population.
• A practice brochure can easily be
1 designed in-house.
I. Ahmad • A computer presentation is a useful
teaching aid for colleagues and patients.
The final part of this series on digital dental photography details how to use images to their maximum potential. The pur-
pose and uses of dental photography have previously been covered in Part 2,1 and the ensuing discussion concentrates on
the technical aspects of printing, publishing and audio-visual presentations.
PRINTING birthdays, weddings or ceremonial func- Laser printing

Before the advent of digital photography, tions. Therefore, the printed image, unlike This process involves a laser beam creating
the only method of viewing a picture was film, is not and probably will never become an electrostatic charge on a drum for the
after it was developed and printed. This obsolete. Today, there are many methods exposed parts of an image. The charged
is no longer the case with digital images, available for printing a photograph includ- drum then attracts the powered toner and
which can be instantly viewed on built- ing traditional chemical processing, laser, transfers it onto the paper. Pressure and
in LCD camera displays or by transferring inkjet and thermal sublimation printing. heat is applied to ensure that the toner
them to a computer. However, for many powder tenaciously adheres to the paper.
applications, printing on photographic Chemical processing Although the price of both black-and-white
paper is still preferred and indeed, is very Chemical processing still remains a popu- and colour printers are rapidly decreasing,
popular. A print can be easily viewed lar option for making photographic prints. the price of replacement toner cartridges
by many people, posted and transported Although chemicals and techniques have is relatively high. The quality of the prints
with ease. In addition, printed images are been refined, the basic principles are iden- depends on the equipment specifications,
essential for memorable events such as tical to those used more than a century but the major drawback is that only plain
ago. The procedure is as follows. A paper paper can be used due to the inherent
coated with light-sensitive dyes is exposed process of applying heat and pressure to
FUNDAMENTALS OF DIGITAL by either light or lasers to leave an ‘impres- prevent the toner lifting off the paper. For
DENTAL PHOTOGRAPHY sion’ of the image. The sensitised paper is this reason, laser printing has not gained
then developed by a series of chemicals to popularity for photographic applications
‘reveal’ the image. The process is identical since true photographic or textured papers
to developing radiographs using devel- cannot be used.
oper and fixer solutions. The ubiquitous The main advantage of laser printers is
photo-minilab outlets automate this proc- speed, making them ideal for letter writ-
5. Lighting
ess, delivering prints in less than an hour. ing and incorporating clinical images for
6. Camera settings
This is a very cost effective and economical specialist advice or referral. Both digital
method for making prints of an acceptable images and radiographs are easily cut and
quality of 300 to 400 dpi (dots per inch). pasted into word processing software,
However, if an entire camera memory card which is invaluable for depicting pathology
is sent for printing without prior vetting or other prevailing clinical situations.
on a computer screen, substantial wast-
1 age is highly probable since some prints Inkjet printing
Surgery, 173 The Ridgeway, North Harrow, Middlesex, may be unacceptable and subsequently If the quality of a laser print is unaccept-
HA2 7DF
Correspondence to: Irfan Ahmad discarded. In order to avoid this wastage, able, the next option for in-house printing
Email: iahmadbds@aol.com a prudent approach is to view the images is using an inkjet printer. Inkjet print-
on a computer monitor and compile a ers use single or multiple cartridges that
Refereed Paper selection before forwarding the memory deposit droplets of ink onto the receiving
DOI: 10.1038/sj.bdj.2009.814 card, or other storage media, to a minilab paper. The droplets are extruded from the
© British Dental Journal 2009; 207: 261–265
for printing. cartridge either by heat or piezoelectric

PRACTICE
Cyan
Red channel
Magenta
Green channel RGB captured CMYK printed

image image
Yellow
Blue channel
Key (black)
Fig. 1 Schematic representation of RGB image capture and CMYK printing
elements. Newer printer models offer Therefore, the expensive refill cartridges Thermal sublimation and
thermal transfer printers
ports for inserting camera memory cards and paper usually offset any savings on
as well as wireless connection from cam- purchasing the printer. There are numer- The technology employed by thermal
eras or computers. Although plain paper ous retail outlets offering to refill car- printers consists of a donor band housing
can be used, the endearing feature is that tridges at nominal prices, but this is a false the dyes, either RGB or CMYK, which is
photographic as well as textile media economy and usually counterproductive. released onto special receiving paper by
can be used. This offers vast latitude and Firstly, if the cartridge leaks during use, the application of heat. The resolution is
the results are identical or even supe- the picture and printer are irreparably acceptable at 300 dpi, and some equipment
rior to conventional chemical process- damaged. Secondly, proprietary inks con- also seals the print. The advantage of these
ing. The image resolution often exceeds tain a lacquer that protects the print from printers is their compactness, portability
4,800 × 1,200 dpi using either RGB or mechanical damage and prevents colour and direct connection to digital cameras or
CMYK colour printing modes. The selec- fading due to exposure to light, which ports for accepting memory cards, thereby
tion of photographic paper is enormous, may be absent from cheaper third party by-passing a computer. The selling point of
with a range of different textures and sur- refilling inks. thermal printers is expedience at a modest
face finishes, for example canvas, matte, Inkjet printers in a dental surgery offer price. The Kodak P712 dental camera uses
gloss, etc. Also, the sizes of the prints can quality prints in minutes, which can be thermal printing with its EasyShare dock-
range from the familiar 5 × 4 print to A1 used for communication between dental ing port printer for instant prints.
posters. Inkjet printers are extensively used colleagues, patients and dental technicians Thermal printers have similar uses in den-
for printing pictures at home, as well as or included in a referral letter to a special- tistry as inkjet printers but without the flex-
by professional photographers working ist. Furthermore, larger prints can be used ibility of using different types of paper.
in studios. The cost of an inkjet printer to build a portfolio of different treatment
is insignificant compared to the ink car- modalities for patient and staff education, PUBLISHING
tridges and quality photographic paper. or even posters for in-house marketing. There are many occasions when in-house

PRACTICE
desktop publishing is sufficient for print- printing today. Similar to earlier print-
ing circulars or memos, but when large ing methods, the portions to be printed
volumes of practice stationery, brochures are treated to accept oil-based inks,
or newsletters are required, it is cost effec- while the remainder of the plate accepts
tive to use a printing house. water-based dyes. The reason for the
There are four main types of printing term ‘offset’ is because the paper does
processes, relief, intaglio, offset lithogra- not directly make contact with the plates
phy and screen. Before an image can be but instead contacts a rubber blanket,
printed using a printing press, the addi- which collects ink that is subsequently
tive RGB colour mode that captured the transferred to the paper.
picture must be converted into CMYK sub- Fig. 2 Templates for popular stationery items
Screen printing in a word processing software package
tractive colour mode (Fig. 1). This conver-
sion process is termed colour separation. This process uses fine meshes such as silk
The subtractive colours are cyan, magenta cloths that are blocked out for the non-
and yellow, with black representing the printable areas, while the naked parts
key colour, forming the acronym CMYK. allow ink to squeeze through the mesh
Two printing process are available, three- and onto the paper. This form of printing
colour printing, which requires colour is creative, allowing many artistic effects,
conversion only into the three subtrac- and was used with tremendous vigour by
tive colours, CMY, or four-colour print- the 1960s artist Andy Warhol to create his
ing that requires the addition of black, iconic works of art.
CMYK. The conversion process is crucial The choice of printing method depends
for ensuring that colours are reproduced on the printing house and the need of the
as accurately as possible to correspond to client. As mentioned above, litho printing
the original in the RGB mode. It is also is the most prevalent with many standard-
worth remembering that conversion from ised protocols. For example, for business
RGB to CMYK for printing will diminish cards of a small printing run, professional
the dynamic range and alter the colour digital laser printing is cheaper than litho. Fig. 3 The completed brochure design and
layout is first saved in the propriety software
space. The RGB mode enjoys both larger On the other hand, for large runs of bro- file format
dynamic ranges and colour spaces that the chures with text, drawings and images,
printing process lacks, and if separation litho is more economical.
is inadequately performed the printing
image will lose the vitality and quality of Publishing a practice brochure
the original. The process of colour separa- Publishing a practice brochure is a good
tion is complex, and unless one has the example to illustrate the steps involved
experience or training, is best assigned in the printing process. The first stage is
to a lithographer. designing. This can be assigned to a graphic
house or easily carried out in-house using
Relief printing a variety of inexpensive layout software,
Relief printing was the first printing proc- which allows greater control and can be
ess developed, using woodcuts or metal an exciting task. Most drawing and word
plates that were raised and coated with processing software are shipped with Fig. 4 Exporting a file to a ‘best quality’ PDF
format
ink to be deposited onto paper, hence the numerous templates for popular stationery
name relief printing. Nowadays, wood and items such as letterheads, businesses cards,
metal are replaced with plastic materials, brochures and newsletters (Fig. 2). The tem- printing house. Also, if the design soft-
the so-called flexography. plates have placeholders for images and ware does not allow colour separation into
text, and the desired images are simply cut CMYK for four-colour printing, the file will
Intaglio or gravure printing and pasted and the software crops or scales need to be exported into a type that allows
Instead of having raised areas, as in relief them to fit the allotted placeholder size. this facility. One option is to export the file
printing, in intaglio printing the printable Next, text is typed into the assigned boxes, in a PDF file format using a high quality
parts are recessed and soak ink from a for example, headings, sub-heading and mode, and then forward it to the print-
well and then deposit it onto the print- body text. Once the design is finalised, the ing house (Figs 4-6). The lithographer can
ing paper. file is saved in the propriety software file open and edit the PDF file before proceed-
format (Fig. 3). Because of the abundance ing to colour separation and preparing a
Offset lithography printing of graphics applications on the market, the digital proof.
Offset lithography or ‘litho’ is the most software used to design the brochure may The ultimate goal is trying to approxi-
popular and widely used method for not be the same as the one used by the mate as closely as possible the colours in

PRACTICE
Fig. 6 Icon of exported PDF file, to be Fig. 9 The printed practice brochure
Fig. 5 PDF conversion of original file forwarded to the printing house
Change colour of
sub-heading (blue)
to that of main
heading (green)
Brighten images
Lighten main text - similar

to page 2 heading text Fig. 10 Keynote™ is a presentation software
package exclusive to Apple Mac computers
Turn off
hyphenation Darken 2008 text
the CMYK printed images to that of the

original RGB capture. In reality, this task
Brighten logo image,
remove black background is rarely achieved unless one spends vast
Match colour of ‘2008’ text
to that of blue tooth
amounts of money for colour corrections
by employing a colourist to match CMYK
Fig. 7 First digital proof of a practice brochure showing errors that require amending to RGB both subjectively and objectively
by using colour-measuring devices such
as colorimeters. Furthermore, since poten-
tial readers of the brochure will rarely see
Corrected colour of
sub-heading (blue) the original RGB image for comparison, a
to that of main CMKY approximation suffices. There are
heading (green)
instances where practice logos, drawings
or parts of images require precise colour
reproduction. If this is the case, a spot col-
Brighter images
our can be added in addition to the CMYK
processed colours. There are many colour
selection charts and wheels available from
Lighter main text - similar printing houses, for example Pantone®, for
to page 2 heading text
choosing specific spot colours. In theory,
Hyphenation the number of additional spot colours is
turned off Darker ‘2008’ text
limitless so long as the budget allows for
these extravagances.
Brighter logo, removal It is always advisable to order a digital
of black background
proof for visualising the layout, review-
Improved match colour
of ‘2008’ text ing text, checking spelling, and gaug-
ing the approximate colour rendition of
Fig. 8 Second digital proof of practice brochure incorporating the necessary changes
the images and any coloured text and

PRACTICE
drawings. As well as revealing overlooked offering powerful tools for building crea-
mistakes at the designing stage, a proof tive audio-visual presentations (Fig. 10). A
also allows scrutiny of the anticipated res- pitfall to avoid is trying to incorporate too
olution of the images, drawings and text many animations within a single presenta-
(Fig. 7). If changes are necessary, these tion. While animated effects are dramatic, it
are amended in the software and a second is advisable to use them sparingly. Having a
proof requested (Fig. 8). It is also advis- disproportionate number of acrobatic ani-
able to ask other members of the dental mations is visually annoying and distract-
team to view and proof-read the document ing, often to a point that the message being
Fig. 11 A good starting point for creating with a ‘fresh pair of eyes’ for errors and conveyed is rejected.
a presentation is choosing the PowerPoint
Wizard for a step-by-step guide through omissions. Alternately, one can employ The best starting point when creating
various stages the services of a professional proof-reader. a presentation is either to choose a pre-
Once approval is forthcoming, the type of defined template or to use a PowerPoint
paper for the stationery is chosen and the Wizard that guides the operator through
print run is initiated (Fig. 9). the stages for making a presentation
(Figs 11-12). All the included templates are
PRESENTATIONS designed by professional graphic artists,
In addition to lecturing to fellow col- with pleasing colour combinations rather
leagues, building an audio-visual presen- than haphazard lurid chromatic orgies!
tation is an ideal tool for patient and staff Also, similarly to templates for station-
education, as well as promotional purposes. ery, PowerPoint templates have place-
There are many types of software for mak- holders for text and images. The images
ing slick and stylish presentations which are cut and pasted and text typed into
Fig. 12 PowerPoint offers an innumerable can incorporate video footage, music and the assigned boxes. The font sizes of the
choice of templates
narration. If music is added, it is essential headings and sub-headings are predefined
to obtain the permission of the artist or and are proportionate and helpful for a
the record company. Illicit use of music visually pleasing layout. In a few hours,
or images is an infringement of copyright a simple presentation can be created, for
or intellectual property and could result example showing the clinical stages for
in litigation. a particular treatment modality such as
Over the last decade, Microsoft ® fillings, crowns, implants, etc. If one is
PowerPoint™ has become the industry adventurous and patient, PowerPoint is
standard as the presentation software of a powerful application capable of very
choice. Newer versions of this software sophisticated presentations and a lit-
incorporate an ever-increasing number of tle training with an expert is invalu-
audio-visual effects, and their use is limited able for creating stunning and enticing
only by the imagination. Another software graphics (Fig. 13).
Fig. 13 PowerPoint is a powerful application, package exclusive to Apple Mac® computers
capable of sophisticated presentations 1. Ahmad I. Digital dental photography. Part 2: pur-
is Keynote™, which is similar to PowerPoint, poses and uses. Br Dent J 2009; 206: 459–464.


BDJ - I Ahmad - Fotografia Digital

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

BDJ - I Ahmad - Fotografia Digital

Caricato da

Copyright:

Formati disponibili

Digital dental photography.

Part 1: an overview every discipline of dentistry, and is an

BRITISH DENTAL JOURNAL VOLUME 206 NO. 8 APR 25 2009 403

© 2009 Macmillan Publishers Limited. All rights reserved.

and subsequent gains that yield gratifi-

404 BRITISH DENTAL JOURNAL VOLUME 206 NO. 8 APR 25 2009

© 2009 Macmillan Publishers Limited. All rights reserved.

BRITISH DENTAL JOURNAL VOLUME 206 NO. 8 APR 25 2009 405

© 2009 Macmillan Publishers Limited. All rights reserved.

fully reproduce the colour of both hard

etc. Similarly, a correct colour rendi-

as well as cervical dentine exposure

ite fi lling placement, bleaching and

406 BRITISH DENTAL JOURNAL VOLUME 206 NO. 8 APR 25 2009

© 2009 Macmillan Publishers Limited. All rights reserved.

BRITISH DENTAL JOURNAL VOLUME 206 NO. 8 APR 25 2009 407

© 2009 Macmillan Publishers Limited. All rights reserved.

Part 2: purposes and uses dental photography has a host of

BRITISH DENTAL JOURNAL VOLUME 206 NO. 9 MAY 9 2009 459

Fig. 5 Facial profile pictures are useful

Fig. 4 A set of pre-operative images is ideal for examination, diagnosis and

devices (Fig. 3). While this plethora of Examination, diagnosis,

460 BRITISH DENTAL JOURNAL VOLUME 206 NO. 9 MAY 9 2009

alternative treatment options rather than

BRITISH DENTAL JOURNAL VOLUME 206 NO. 9 MAY 9 2009 461

visual presentation is invaluable so that

462 BRITISH DENTAL JOURNAL VOLUME 206 NO. 9 MAY 9 2009

Fig. 21 The crown on the right central

BRITISH DENTAL JOURNAL VOLUME 206 NO. 9 MAY 9 2009 463

464 BRITISH DENTAL JOURNAL VOLUME 206 NO. 9 MAY 9 2009

Part 3: principles of technological advances have offered

VERIFIABLE CPD PAPER

BRITISH DENTAL JOURNAL VOLUME 206 NO. 10 MAY 23 2009 517

that with so many variables, the scope

TECHNICAL ASPECTS Fig. 1 Full-frame CCD with a large fill factor

518 BRITISH DENTAL JOURNAL VOLUME 206 NO. 10 MAY 23 2009

to form an image. This procedure is time

BRITISH DENTAL JOURNAL VOLUME 206 NO. 10 MAY 23 2009 519

use 16 bit per channel, which translates

520 BRITISH DENTAL JOURNAL VOLUME 206 NO. 10 MAY 23 2009

Missing inter-pixel information

Fig. 10 The filtered pixels record the amount

3-shot, 1-shot, 4-shot, microscan and

BRITISH DENTAL JOURNAL VOLUME 206 NO. 10 MAY 23 2009 521

Fig. 17 An image with a file size of 30.3 MB

Fig. 16 LCD display on camera back

522 BRITISH DENTAL JOURNAL VOLUME 206 NO. 10 MAY 23 2009

BRITISH DENTAL JOURNAL VOLUME 206 NO. 10 MAY 23 2009 523

Part 4: choosing a camera use camera for dental applications is the

The number of cameras on the market is

BRITISH DENTAL JOURNAL VOLUME 206 NO. 11 JUN 13 2009 575

Fig. 5 Before digital photography, Polaroid

The second is the Polaroid Marco 5 SLR

576 BRITISH DENTAL JOURNAL VOLUME 206 NO. 11 JUN 13 2009

Canon EOS 450D Canon EOS 50D Canon EOS 5D MKII

Fig. 10 A high quality macro-telephoto is the

teeth or parts of individual teeth may be

DIGITAL SINGLE LENS REFLEX

BRITISH DENTAL JOURNAL VOLUME 206 NO. 11 JUN 13 2009 577

low chromatic and spherical aberrations,

578 BRITISH DENTAL JOURNAL VOLUME 206 NO. 11 JUN 13 2009

measure of sharpness, not influenced by

BRITISH DENTAL JOURNAL VOLUME 206 NO. 11 JUN 13 2009 579

Fig. 14 The tripod supports a mechanical