Essentials of Dental Photography PDF

Essentials of Dental Photography

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Essentials of Dental Photography

Irfan Ahmad
Private Practice
Harrow, UK

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This edition first published 2020
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Library of Congress Cataloging‐in‐Publication Data

Names: Ahmad, Irfan, BDS, author.
Title: Essentials of dental photography / Irfan Ahmad
Description: Hoboken, NJ : John Wiley & Sons, 2020. | Includes
bibliographical references and index.
Identifiers: LCCN 2019026632 (print) | ISBN 9781119312086 (paperback) |
ISBN 9781119312130 (adobe pdf ) | ISBN 9781119312147 (epub)
Subjects: MESH: Photography, Dental–methods | Photography,
Dental–instrumentation | Image Processing, Computer-Assisted–methods
Classification: LCC RK51.5 (print) | LCC RK51.5 (ebook) | NLM WU 100 |
DDC 617.60022/2–dc23
LC record available at https://lccn.loc.gov/2019026632
LC ebook record available at https://lccn.loc.gov/2019026633
Cover Design: Wiley

Cover Image: © Irfan Ahmad
Set in 10/12pt Warnock by SPi Global, Pondicherry, India
10 9 8 7 6 5 4 3 2 1
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For my intrepid wife Samar, and my loving children, Zayan and Zaina.
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“And the swelling crescendo no longer retards” – Lou Reed
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vii
Contents
Foreword xi
Preface xiii
Acknowledgments xv
Section 1 Equipment and Concepts 1
1 Photographic Equipment 3
Cameras 4
Sensors 6
Resolution 9
Sensor Speed or ISO 13
Sensor Cleaning 13
Colour (Bit) Depth 15
White Balance 16
Focusing 16
External Flash 17
Remote Shutter Release 17
Lenses 17
Lighting 19
Supports 23
Other photographic items 25
References 25
2 Dental Armamentarium and Clinical Considerations 27

Retractors 27
Photographic Mirrors and Contrasters 27
Field of View 30
Cross‐infection Control 31
Health and Safety 32
Location 33
Supports 39
Delegation 40
Patient Consent 41
References 42
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viii Contents
3 Technical Concepts and Settings 45

Every Picture Tells a Story 45
Setting the Tone 48
Lighting 48
Depth of Field 52
Exposure and Histogram 57
White Balance 63
Resolution 64
Other Settings 68
References 68
4 Composition and Standardisation 69
Composition 69
Dominance 69
Positioning 72
Leading the Eye 79
Balance 83
Standardisation 84
Standardisable Factors 89
Non‐standardisable Factors 92
References 94
Section 2 Photographic Set‐ups 97
5 Extra‐Oral and Intra‐Oral Images 99

Positioning 99
The Essential Dental Portfolio 101
Extra‐Oral (Dento‐Facial) Compositions 103
Intra‐Oral Compositions 107
Optional Compositions 117
References 135
6 Portraiture 137
Lighting for Portraiture 137
Manipulating Light 138
Colour Temperature 138
Direction: Key Light 140
Intensity and Size 147
Fill Light 150
Background Light 153
Clinical Portraiture Set‐Up 154
The Essential Portrait Portfolio 156
Optional Clinical Portraits 164
Non‐clinical Portraiture Set‐up 166
Generic Studio Portrait 167
Flattering Portrait 167
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Contents ix
Profile Portrait 168

Coloured Gel Portrait 170
Classical Smile Line Portrait 171
Clinical vs. Non‐clinical Portraiture 173
References 173
7 Bench Images 175

Uses of Bench Images 175
Backgrounds and Supports 178
Lighting 183
Bench Image Set‐ups 184
Equipment Settings 186
Dental Casts (Models) with Black Background 189
Dental Cast with Coloured Background 190
Implant Supported Temporary Crown with Red Background 190
Perspex Backgrounds 193
Bokeh Composition 195
Stroboscopic Effect 196
References 202
8 Special Applications 203

Detailed Analysis of Hard and Soft Tissues 203
Opalescence and Fluorescence 208
Fibre‐Optic Illumination 215
UV Illumination 215
Colour Fidelity 216
Shade Analysis 221
Scale Reference Markers 227
Annotations 230
Bleaching (Tooth Whitening) 236
Phonetics 236
Occlusal Analysis 239
Treatment Sequences 242
Endodontic Documentation 246
Focus Stacking 247
Video 247
Promotional and Artistic Imagery 248
References 248
Section 3 Processing Images 251
9 Processing Images 253

Monitor Calibration 253
File Formats 254
Imaging Software 255
Image Processing 260
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x Contents
Colour Spaces 262

White Balance 265
Exposure 265
Orientation, Scaling and Cropping 273
Artefact Removal 285
Local Adjustments 286
Sharpening 287
References 293
10 Exporting, Managing and Using Images 295

Exporting Files 295
Output Location 295
Naming Conventions (Formats) 297
Export Recipes 299
Image Management 301
Using Images 306
Documentation 306
Communication 307
Marketing 313
Education 315
References 331
Index 333
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xi
Foreword
Original French text

La photographie incarne an même titre que l’écriture, un instrument de prédilection, un outil
efficace de formalisation de l’expérience apprécié pour son pouvoir de dénotation et son car-
actère d’empreinte fidèle et immédiate de la réalité.
C’est. vers la fin des années 1960 que la photographie, limitée à cette simple fonction docu-
mentaire ou support d’information va s’affranchir des antagonismes entre art et document à la
faveur de la naissance de deux mouvements artistiques qui, sous la dénomination de «concep-
tuel» et «minimal» font suite aux propositions et travaux de M. Duchamp et Man‐Ray et vont
soutenir une démarche qui favorise son introduction et acceptation dans le monde de l’art.
Exempte d’intérêt esthétique, impersonnelle et dans le retrait expressif mais suivant un
protocole de prise de vue immuable, rigoureux et systématique, cette démarche est en rupture
avec la conception traditionnelle de la création et de la notion d’originalité.
Le travail d’Irfan Ahmad en s’interdisant toute incursion vers une attention esthétique, se
situe parfaitement dans la ligne de cette mouvance qui va finalement servir et sublimer la final-
ité didactique qu’il s’était fixée: impressionnant.
Dr. Claude R. Rufenacht
English translation
Photography, like writing, embodies an instrument of predilection, an effective tool for for-
malising experience which is valued both for its capacity for denotation and its ability to offer
a true and immediate account of reality.
It was towards the end of the 1960s that photography, limited to this simple documentary
role of information carrier, freed itself from the opposition between art and documentation,
thanks to the emergence of two art movements which, under the nomenclatures ‘conceptual’
and ‘minimal’, followed on from the proposals and works of Marcel Duchamp and Man Ray,
sustained an approach that encouraged its introduction and acceptance in the art world.
Shorn of aesthetic interest, impersonal and utterly neutral, yet following an image‐capturing
protocol that is immutable, rigorous and systematic, this approach is at odds with the tradi-
tional art concept of creation and the notion of originality.
By excluding any hint of aesthetic sensibility, the work of Irfan Ahmad aligns perfectly with
this movement to finally serve and sublimate the didactic purpose he set himself: impressive.
Dr. Claude R. Rufenacht
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xiii
Preface
Photography represents an ineluctable modality of the visible (Joyce 1922). Recent technologi-
cal advances in digital photography have allowed even the novice to take photographs that are
so sharp they will cut your eye like a Buñuel film, with colours as tantalising as characters from
a Fellini movie, nuances comparable to a Bergman drama, the depth of a Kubrick odyssey, and
provocative as a Borowczyk tale. What was once reserved for the few, is now within reach of
the many.
Nowadays, analogue or film photography is reserved for die‐hard aficionados, an old school
reliving their youths. In the twenty‐first century, digital photography is the norm (Motta 2010),
but comes in many guises, and requires novel approaches for creating superlative results. This
is not unlike the demise of amalgam, and the rise of composite restorations, which requires a
change in mindset, abandoning old techniques and learning new tricks. The world around us
is analogue, everything is perpetual, days seamlessly fade into nights, time goes by without
interruptions or delays. We have digitised the world for our convenience, utilisation and
manipulation. Time is divided into second, minutes and hours, temperature into degrees of hot
and cold, distance into lengths of miles or kilometres. In our digitised world, photography is no
exception; light is expediently converted into binary or digital codes for producing visuals.
Today, dental photography is no longer an option, but an integral and indispensable tool for
practising dentistry at every level and for every discipline. Furthermore, no matter how metic-
ulously one articulates or writes clinical notes of an examination, a photograph will communi-
cate the clinical scenario in a few seconds. Therefore, it is surprising that this subject does not
form part of the undergraduate dental curriculum. Besides offering indisputable photodocu-
mentation, pictures are probably the most powerful learning method for clinical dentistry and
self‐development. A series of images allow assessment, diagnosis, planning, delivery of
treatment, and follow‐up that no other medium can offer. Furthermore, photography is a vital
communication tool between patients, fellow colleagues, specialists and technicians for dis-
cussing multi‐disciplinary and for complex therapies. In addition, pre‐ and post‐operative, as
well as procedural images provide an invaluable record if a therapy fails to yield the desired
results or satiate patients’ expectations.
However, many clinicians are reticent about incorporating dental photography into their
daily practice due to uncertainty about the choice of equipment, a steep learning curve and
initial capital expenditure. These fallacious notions are fuelled by the plethora of dental litera-
ture on the subject, some scientifically based, some anecdotal, while others perversely compli-
cate what is basically a simple procedure. It is the endeavour of this book to demystify many of
these erroneous beliefs by proposing protocols for standardising photographs that are invalu-
able for intra‐ and inter‐patient comparison. Once the essentials are mastered, a little experi-
mentation will allow the operator to develop his or her own style for the intended use, and
progress to the next level by modifying techniques for specific disciplines.
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xiv Preface
The dental team yearns for a book about photography that is reader‐friendly, shows simple
techniques, and gives pertinent advice for achieving repeatedly predictable results with a
minimum of effort. Rather than endless descriptive text describing the theoretical aspects of
photography, most of the discussion is focused on practical concepts. This is accompanied
by copious illustrations and images, taking the reader by the hand and guiding him or her to
learn about standardising images by showing simple set‐ups and requisite equipment set-
tings. Once assimilated, usually in a few days (preferably combined with a hands‐on session),
a routine photographic session should take no more than ten minutes. A small sacrifice,
compared to the innumerable benefits that this medium offers. After obtaining predictable
results, more advanced and special applications are presented for specific clinical and
laboratory requirements.
The book is divided into three sections. The first deals with equipment and concepts, the
second with photographic set‐ups and the third with processing images. Each section is com-
posed of modules that sequentially furnish the reader with the essentials, culminating in a
complete manuscript that covers all aspects of the CPD (Capture, Processing and Display) triad
of digital dental photography.
To summarise, this is a practical book, endeavouring to “show me” rather than “tell me”, and
informing the reader about what they want to know, rather than what they need to know.
Enjoy the journey into a world of infinite possibilities…
Irfan Ahmad
References
Joyce, J. (1922). Ulysses. Paris: Sylvia Beach.
Motta, R.J. (2010) The future of photography. Proceedings of the SPIE 7537: 753702.
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xv
Acknowledgments
The author would like to thank Fahad Al‐Harbi for procuring the necessary photographic
equipment for some of the pictures in Modules 5 & 6, and for arranging the model featured
throughout the book, particularly in Module 6.
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1
Section 1
Equipment and Concepts
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3
Photographic Equipment
The most frequently asked questions about dental photography are:
‘Which equipment do I need?’

‘What is the cost?’
‘How long will it take to learn?’
The aim of this opening module is to provide answers to these questions.

Photography should be regarded as an integral part of daily clinical practice (Reddy et al.
2014), and photographic equipment as part of the dental armamentarium, no different to a
dental handpiece. However, the common consensus is that a camera is an extraneous appara-
tus, exclusively reserved for specialists, or clinicians with a penchant for taking pictures.
These are erroneous assumptions since photographic documenting is essential for diagnosis,
treatment planning, treatment options, educating patients and ancillary staff, communicating
with colleagues, recording treatment sequences, assessing and monitoring outcomes, marketing,
and serves as irrefutable evidence if litigation ensues. Furthermore, it is important to empha-
sise that dental photography is not solely for specific treatments such as elective cosmetic
procedures, but a requisite for recording pathological conditions of the oral mucosa or even
the simplest treatment modalities such as tooth whitening.
The first thing to appreciate is that there are no ‘quick fixes’ and no ‘deals’, and fellow
colleagues or companies who propagate these myths are misguided and misleading. A
number of dental companies exploit photographic ignorance by offering ‘quick fixes’, with
low‐end cameras specifically adapted for dental photography, often sold at inflated prices
for the g ullible and uninitiated. However, most of these cameras are compromises, yielding
inferior image quality, which is hopeless for precise diagnosis, treatment planning, follow‐
up and communication. If the objective is simply to produce bland and boring pictures,
similar to passport or ‘mug shots’, then these devices fit the purpose. However, there is still
a learning curve with these modified cameras, and it is questionable whether the toil is
worthwhile for disappointing results. Alternately, the same time and effort can be chan-
nelled to learning correct techniques with appropriate equipment, which yield excellent
and gratifying results.
Similar to learning a particular clinical technique such as crown preparation or implant sur-
gical procedures, there is a learning curve for mastering dental photography that cannot be
ignored. However, the time required to learn basic photographic techniques is reduced with
proper advice and guidance. Taking pictures is probably easier than restoring a Class I cavity,
but does require a degree of patience and perseverance. As mentioned in the Preface, once
Essentials of Dental Photography, First Edition. Irfan Ahmad.

© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
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4 Photographic Equipment
basic techniques are mastered in a few days (preferably combined with hands‐on or online
training course),1 a routine photographic session should take no more than 10 minutes of
clinical time; a small sacrifice compared to the innumerable benefits if offers.
Cameras
Before choosing a camera and the accompanying accessories, it is crucial to establish the basic
requirements of dental photography. Dental photography is essentially divided into two types
of picture: portraiture and macrophotography. Portraits are necessary for several disciplines
and clinical scenarios such as orthodontics, prosthodontics, aesthetic/cosmetic dentistry, facial
enhancement procedures, external traumas to the dentition, or accidents involving soft tissue
bruising, lacerations and fractures of the facial skeleton. Macrophotography encompasses both
intra‐oral pictures of the oral environment consisting of the teeth and surrounding anatomy,
and extra‐oral pictures of the dento‐facial composition and bench images of diagnostic casts or
artificial prostheses/restorations. Therefore, it is essential to choose a camera and accessories
that fulfil the requirements of both portraiture and macrophotography.
The market is awash with cameras offering countless functions, some superfluous, others
essential, and deciphering which are useful or redundant is a challenging and annoying
endeavour (Ahmad 2009a). Many camera features that are supposedly added to make life
easier often end up as frustrating nuisances, and wading through never‐ending cascading
menus requires aptitude and endurance. This is probably the biggest turn‐off for potential
purchasers, who are bombarded with technical jargon, acronyms they do not understand and
features they are unable to comprehend. Therefore, it is important to ignore manufacturers’
hype and concentrate on salient specifications. The type of camera systems available is a
minefield, such as point‐and‐shoot, compact, CCS (compact camera systems), EVIL (elec-
tronic viewfinder interchangeable lens), MILC (mirrorless interchangeable‐lens compacts),
rangefinders, dSLR (digital single lens reflex) and, of course, not forgetting the smartphone
(cellphone) varieties (Figure 1.1).
Nowadays, no discussion on photography would be complete without mentioning smart-
phone cameras. In recent years the quality of smartphone cameras has increased exponentially,
and these devices are capable of delivering images that were once only possible with dedicated
digital cameras. In addition, many reputable camera manufacturers such as Leica®, Hasselblad®
and Carl Zeiss® are collaborating with phone companies to develop cameras and accessories for
mobile hardware. The convenience, expediency and connectivity offered by smartphones and
tablets is obviously the driving force for this rapidly evolving industry. Also, there has been a
discussion in the dental literature about the suitability of cellphones or tablets for dental pho-
tography (Manauta and Salat 2012). The main purpose of smartphone cameras is that they are
designed for social photography. Hence, to use these units for medical/dental purposes, the
in‐built cameras need to be calibrated and modified for macro use, which requires a degree of
training. Whilst the disseminating convenience offered by mobile devices is unmatched, to
achieve clinically useful images requires perseverance. Smartphones are ideal for random shots
showing patients’ particular oral problems, or sharing cursory images with dental technicians
regarding oral rehabilitation, but to take this a step further, training is essential. Nevertheless,
this technology is difficult to vilipend, because in the near future, mobile devices may evolve to
be the standard for photodocumentation for many fields, including dentistry.
1 https://www.dentalphotomaster.com/online‐training
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Camera 5
Smartphone Compact
Rangefinder dSLR
Figure 1.1 Different types of camera systems.
In order to satisfy the requirements of dental photography and produce images rich in detail,
vibrancy, nuances of colour, texture, form, conveying emotions, feelings and unparalleled qual-
ity, the only choice at present is a dSLR.2 Whilst other category of cameras can be tailored or
adapted for dental use, the task is onerous, and probably not worth the frustration for the small
cost saving that is often elusive. Having established that a dSLR is the ideal camera for dental
applications, the next question is: which proprietary brand to choose?3 The advice in this book
concentrates on generic photographic equipment, which fulfils basic requirements for dental
applications. Also, with technological advances, newer p roducts are perpetually being intro-
duced, which readily become obsolete in a short space of time. Furthermore, mid‐range dSLRs
from any major brands are almost identical in terms of features and the image quality they offer.
A dSLR consists of a body containing the mechanics and electronics, or brain, of the cam-
era. A camera body usually comes as a kit with a lens and other basic accessories. However,
most lens that form a kit are often unsuitable for dental applications, and, if possible, it is
advisable to purchase the body alone, or exchange the accompanying lens for one that is
more suited for dental use. The primary features to look for in a camera body are the physical
size of the sensor, megapixel count, colour depth, numerical white balance input, external
flash synchronisation via a hot‐shoe with TTL (through‐the‐lens) metering, switchable man-
ual focusing, sensor speed or ISO (International Standards Organisation) range, remote
2 http://www.dentalphotoapp.com/7.html
3 http://www.photomed.net
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shutter release, tripod thread(s) and ease of sensor cleaning. The secondary features include
exposure modes and metering, shutter speeds, sequential frames per second, colour space,
dust and water spray sealing, anti‐fingerprint and anti‐scratch coating of the LCD (liquid
crystal display) touch screen, RAW file formats, video capability, GPS (global positioning
system), WiFi, storage media, interface for data transfer, built‐in photo‐editing software,
build quality, size, weight and, of course, the price. Whilst there is no compromise of the
mandatory primary features, the secondary features are desirable, but not necessary.
Although the list of primary or secondary specifications may seem endless, there is no need
to fret, since most dSLRs have these features as standard. But, like anything in this world, you
get what you pay for; the higher the specifications, the higher the price. All major camera
brands, such as Canon, Nikon, FujiFilm, Sony, Panasonic (Lumix), Pentax and Olympus,
offer mid‐range or semi‐professional dSLRs suitable for dental requirements for around US$
500 at current prices. Table 1.1 itemises the specifications for choosing a camera, and for
those wishing to understand the relevance and importance of these features, an explanation
of the major specifications is given below.
Sensors
The heart of a digital camera is the sensor, a solid‐state device composed of tiny photosensitive
diodes called pixels, (abbreviation of ‘picture elements’). The pixels are stimulated by incoming
light through‐the‐lens to create an electrical charge that is an analogue signal. The electrical
signal is then converted by an analogue to digital converter (A–D converter) into a binary digi-
tal code, or data, for creating the image. The pixels are colour blind, only capable of registering
black and white, or brightness and darkness (Figure 1.2), and require some types of filters to
produce colour images using the additive red, green and blue (RGB) colour system. The addi-
tive RGB colour system represents the three primary colours RGB, which collectively produce
white when mixed together. This is in contrast to the substrative colour system: cyan, magenta,
yellow (CMY) – Figure 1.3. The colour filter system used by manufacturers for adding colour is
either the mosaic Bayer pattern, or the Fovean X3® colour filters. The former uses a single layer
with the imprinted Bayer pattern to add colour, whilst the latter has individual RGB filters
stacked on top of each for capturing the corresponding RGB channels. In the Bayer system two
green squares are included, representing greater sensitivity of the eyes to the colour green
(Figures 1.4–1.8).
There are two types of sensors, CCD (charged couple device) and CMOS (complementary
metal oxide semiconductors). CCD was the first type of sensor, offering superior image
quality but with higher power consumption. The newer CMOS sensors are more efficient,
better in low light conditions and offer high‐speed capture. Furthermore, recent technical
sophistication means that CMOS sensors are viable contenders to CCDs in terms of image
quality. Most contemporary cameras use CMOS as the preferred type of sensor. Sensors are
available in various physical sizes, some popular examples include medium format (up to
53.9 mm × 40.4 mm), full‐frame (similar to 35 mm film – 36 mm × 24 mm), APS‐H (Advanced
Photographic System‐type H – 28.7 mm × 17 mm), APS‐C (Advanced Photographic System‐
type C – ranging from 23.6 mm × 15.7 mm to 22.2 mm × 14.8 mm), four thirds, micro‐four
thirds (17.3 mm × 13 mm), 1″ (13.2 mm × 8.8 mm), 1 : 2/3″ (8.6 mm × 6.6 mm), 1 : 1.7″
(7.6 mm × 5.7 mm) and 1 : 2.5″ (5.76 mm × 4.29 mm) – Figure 1.9. To complicate matters fur-
ther, some sensors sizes are unique (or renamed) to a particular camera brand, e.g. the
Nikon DX‐format is equivalent to the APS‐C format. The key issue is the physical size (or
dimensions) of a sensor: the larger the sensor, the better the image quality, irrespective of
the pixel count.
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Camera 7
Table 1.1 Specifications of a digital single lens reflex (dSLR) camera for dental photography.
Specification Must have Wish list
Sensor size minimum Advanced full‐frame (36 mm × 24 mm),

Photographic System‐type‐C matching the focal length of lens
(APS‐C)
Pixel count in MP minimum 18 MP > 18 MP
(megapixels) (depending on physical size (depending on physical size
[dimensions] of sensor) [dimensions] of sensor)
No anti‐alias filter Desirable Mandatory
ISO (International minimum 100–200: any
Standards maximum
Organisation) range
Sensor cleaning Ease of manual sensor cleaning Automatic, built‐in sensor cleaning
mechanism
Colour depth 8 bit/colour (channel) 16 bit/colour (channel)
Dynamic range (human minimum 6 f‐stops ≥ 10 f‐stops
eye = 24 f‐stops)
White balance Auto, or numerical input [5500 K]
Focusing Manual focus capability
External flash Hot‐shoe, x‐jack Wireless/via smartphone
connections
Remote shutter release Wired hand/foot cable release Wireless/via smartphone
Tripod screw thread 1/4–20 UNC (Unified National 1/4–20 UNC or 3/8–16 UNC and
Coarse) a 1/4–20 UNC adapter
Exposure modes Aperture priority and manual
Metering modes Centre‐weighted, multi‐zone, spot
Shutter type Focal plane Built‐in lens
Shutter drives Single and multiple
Shutter flash 1/125 s or 1/250 s Any shutter speed possible with
synchronisation speed built‐in lens shutters
Colour space sRGB, Adobe® RGB
File format Proprietary RAW or Adobe DNG
(digital negative graphic), JPEG
Storage UHS I (30 MB/s writing speed) UHS II (100 MB/s writing speed)
SD card SD card or internal RAM storage
Data transfer USB 3 or greater, audio in/out WiFi
jacks, HDMI
Video recording HD 1080p (progressive) to 60 fps > 4 K (similar quality to
capability (frames per second) conventional cine film)
Location GPS (global positioning system)
LCD (liquid crystal Touch screen Anti‐fingerprint and anti‐scratch
display) coating
Camera protection Dust and water spray sealing
Build quality, weight, size Portable, light‐weight, die‐cast Milled aluminium
aluminium
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Figure 1.2 Pixels are only capable of registering lightness and darkness, i.e. black and white.
Additive RGB Subtractive CMY
Figure 1.3 The additive red, green and blue (RGB) and subtractive cyan, magenta and yellow (CMY) colour
systems.
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Camera 9
Fovean X3® sensor Bayer pattern
Figure 1.4 A colour image is created by colour filters corresponding to the three channels, red, green and
blue, e.g. the Fovean X3 system or the mosaic Bayer pattern.
Figure 1.5 Red channel colouration.
Resolution
The resolution of an image is complex, depending on many variables, including the resolving
power of the lens, sensor size, number and size of pixels, bit depth (range of colours), dynamic
range (degree of contrast), signal to noise ratio (amount of ‘noise’ or graininess in an image),
method of in‐camera analogue to digital conversion, file format, subsequent post‐capture
editing with computer software, circle of confusion (distant from which an image is viewed)
and the display media (monitor, projector, printing).
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Figure 1.6 Green channel colouration.
Figure 1.7 Blue channel colouration.
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Figure 1.8 The final coloured image combining the three red, green and blue (RGB) channels.
Lens image circle matching a full frame sensor
Medium format
Full frame (1.0x)

APS-H (1.26x)
APS-C (1.6x)
Micro-4/3 (2x)
1” (2.7x)
1:2/3” (3.93x)
1.7” (4.6x)
1:2.5” (6x)
Figure 1.9 Comparison of digital camera sensor sizes, together with the corresponding crop factor in
parenthesis.
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20 MP sensor
10 MP sensor
Figure 1.10 A sensor with a smaller megapixel count will result in deterioration in image quality when part of
the image is magnified.
The resolution of the human eye varies from 324 megapixels (90° angle of vision) to 576 meg-
apixels (120° angle of vision), which is far beyond any contemporary digital camera sensor.4 However,
one of the major misconceptions is relating pixel count to resolution, i.e. equating the number of
pixels to image quality, often misleadingly perpetuated by camera manufacturers. The number of
pixels determines the size of an image, not its ultimate resolution. However, a large pixel count is
significant if the resolution is not to be compromised when part of an image is magnified or
cropped. Hence, the resultant image quality depends on the number of megapixels (MP) and the
physical size of the sensor (Figures 1.10 and 1.11). Understanding the significance of physical
size of the sensor and its MP count are crucial when purchasing a camera. For example, a full‐
frame sensor with a pixel count of 20 MP yields a higher resolution than a smaller‐sized sensor
with the same or greater number of pixels. This is because the larger pixels found on large‐sized
sensors are capable of gathering more detail than the smaller pixels on small‐sized sensors.
Therefore, a small sensor with a large pixel count, often found in compact cameras, produces
inferior quality images compared to a larger sensor with fewer pixels in a dSLR. Another factor to
enquire about is the presence or absence of an anti‐alias filter on the sensor. Newer cameras
without anti‐alias filters offer superior resolution and therefore better image quality. Further
information about resolution can be found in Modules 3 and 8.
4 http://www.clarkvision.com/articles/eye‐resolution.html
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Camera 13
Large 20 MP sensor
Small 20 MP sensor
Figure 1.11 A large sensor will retain image quality when part of the image is magnified, compared to a small
sensor with the same megapixel count.
Sensor Speed or ISO

The sensitivity of the sensor to light is represented by its ISO number. The ISO scale deter-
mines the intensity of light that is necessary for correct exposure; a lower ISO number requires
more light, whilst a higher ISO number less light. Although higher ISO values have the benefit
of taking pictures in low lighting conditions, the drawback is that the pictures are more grainy
(with increased ‘noise’) and consequently with inferior resolution (Figure 1.12). As a general
guide, an ISO value of 50–100 will produce insignificant noise but requires brighter illumina-
tion, whilst the ideal for dental use is between ISO 100 and ISO 200, and certainly should not
exceed ISO 400.
Sensor Cleaning
Dust particles enter the camera at the junction where the lens is mounted onto the camera
body, and also by the movement of the internal mirror (if any) within the camera. This is par-
ticularly significant when changing lenses or focusing screens, which should be performed in a
dust‐free environment, preferably with appropriate vacuum suction. The dust particles are a
nuisance, adhering to the sensor surface and appearing as black or white specks on an image,
especially noticeable with light backgrounds such as teeth (Figure 1.13). Although these
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ISO 100 ISO 400 ISO 800
Figure 1.12 Increasing the ISO (International Standards Organisation) value has the advantage of taking
pictures in low light, but at the expense of introducing graininess or noise that degrades image quality.
Dirty sensor with dust particles Clean sensor
Figure 1.13 Dust particles adhering to the sensor surface are particularly conspicuous against light‐coloured
backgrounds.
lemishes can be erased with software during the editing stage, the process is tedious,
b
time‐consuming and best prevented at the outset. Sensors are difficult to access and clean
manually, requiring a degree of dexterity to prevent inadvertent damage to the most delicate
and expensive part of the camera body. Many proprietary sensor cleaning kits are available that
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Camera 15
16 bit/colour (channel) 8 bit/colour (channel)
Figure 1.14 Bit/colour (channel) significance: A grossly underexposed 16 bit/colour image is capable of
withstanding substantial exposure compensation without losing quality (left images), whereas an 8 bit/colour
image is labile to degrade, often with resulting unwanted colour casts (right images, notice greenish colour
cast after exposure compensation).
facilitate this process and provide invaluable and detailed instructions for mitigating irrevers-
ible damage to the sensors. In addition, many cameras have built‐in sensor‐cleaning mecha-
nisms that minimise dust accumulation and facilitate its removal. Whichever mechanism a
camera employs for sensor cleaning, it is important to enquire about ease of sensor cleaning,
or built‐in cleaning systems, when purchasing a camera body.
Colour (Bit) Depth

The colour, or bit depth, is a measure of the number of colours that can be captured by a sensor.
It is expressed as bits/channel or bits/colour of the three photographic additive primary col-
ours, red, green and blue. A camera with a colour depth of 8 bit/colour (channel) will have a
total bit depth of 24, or 224, and is capable of producing 16.7 million colours, far more than the
10 million colours that the human eye can perceive.5 High‐end cameras have digital sensors
with 16 bit/colour (channel) and are capable of discriminating 248, or 281 trillion colours. The
advantage of having a larger bit depth is reducing degradation of image quality that occurs if
substantial editing or manipulations are anticipated with post‐capture software. Therefore,
starting with a large bit depth at the outset compensates for this eventuality (Figure 1.14).
5 http://dmimaging.net/8‐bit‐vs‐16‐bit‐images
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1000 K 2500 K 3200 K 4000 K 5500 K 6500 K 10000 K

(tungsten) (fluorescence) (flash) (daylight)
Figure 1.15 White balance: An image showing different colour rendering by altering the white balance setting
on the camera (AWB = automatic white balance).
White Balance
Unlike our brains, cameras do not possess colour adaptation, and have to be ‘told’ about the
colour temperature of the illumination, a process known as setting or calibrating the white bal-
ance. Most cameras have pre‐set automatic white balance (AWB) options that signify the qual-
ity, or colour temperature of the light, e.g. natural daylight of 6500 K, or indoor tungsten
illumination of 3200 K. Photographic daylight is 5500 K because at this colour temperature all
the three photographic primary colours (RGB) are present in equal proportions. This is an
important issue for dental images because ensuring correct colour rendering is essentially from
a dento‐legal perspective. Therefore, the colour accuracy needs to be precise, without colour
casts, for faithfully reproducing the actual colour of the soft and hard tissues. This allows dis-
tinguishing between health and pathological changes, as well as matching the shade of artificial
restorations to natural teeth. Most dental photography uses artificial [flash] lighting, and it is
important to ensure that the white balance on the camera is either set to AWB, or preferably
input manually numerically to 5500 K (Figure 1.15).
Focusing
Almost every camera these days has auto‐focus (AF) as standard, which is indispensable for the
majority of photographic needs. However, for macrophotography, especially in the restricted
confines of the oral cavity, AF often malfunctions. This is due to incessant patient or operator
micro‐movements, and extreme light thresholds of the highly reflective surfaces of teeth with
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Lenses 17
the dark posterior regions of the mouth, which additively confuses the automatic focusing
mechanism. Therefore, the ability to switch to manual focus (MF) is a prerequisite to compen-
sate for the unique conditions of the oral environment. The usual method for ensuring sharply
focused dental images is either using a mechanical focusing stage (discussed below), or moving
hand‐held cameras backwards and forwards until focusing is accomplished. Another advan-
tage of MF is that it allows pre‐set magnifications (e.g. 1 : 1 or 1 : 2) for consistent scaling of
images that is useful for comparisons, whereas with AF, the magnification perpetually changes
according to the distance of the subject from the lens.
External Flash
There are two types of external flash lighting necessary for dental applications: compact flashes
and studio flashes or strobes. Compact flashes are mainly used for macrophotography and
require a hot‐shoe contact, usually found on top of the camera, to access the electronics of the
camera for TTL metering for ensuring correct exposure. Once an initial contact with the cam-
era is established via the hot‐shoe, additional compact flashes can be triggered by wired or
wireless interfaces, whilst the TTL function cuts off, or quenches, the flashes once correct
exposure is attained. Studio flashes utilised for portraiture are triggered either by a wired
standard x‐jack connection on the camera body, or by a wireless radio or infra‐red device
connected to the hot‐shoe, termed slave flash photography. Also, it is possible to control some
studio flashes, similar to compact flashes, by the camera electronics using TTL metering. This
requires purchasing additional camera brand specific remote controls, which allow the camera
to control the flash duration of the strobes for ensuring correct exposure.
Remote Shutter Release

The camera shutter is usually released by pressing a button on the camera body. This is satis-
factory for the majority of dental images, but for certain treatment modalities that require
photographs from various angles of view such as aesthetic dentistry, or surgical procedures
where cross‐infection control is paramount, it is necessary to mount the camera onto a tripod
and delegate this task to another member of the dental team. In these circumstances, it is help-
ful to have remote shutter triggering mechanisms that do not compromise or interfere with the
clinical procedure. Several options are available, including wireless, foot control and smart-
phone apps, which are operated by an ancillary not directly involved with the treatment.
Lenses
The technical requirements of a lens for dental photography is that it serves a dual‐purpose,
first for portraiture and second for close‐up or macrophotography. The ideal lens for portrai-
ture is around 100 mm focal length, and for macrophotography is a macro facility for achiev-
ing a 1 : 1 or 1 : 2 magnification. A 1 : 1 magnification ratio means that the image recorded on
the sensor is the same size as the object, whilst a 1 : 2 magnification means that the captured
image is half the size of the object. Macro lenses are either available as fixed focal lengths,
called prime lenses, or zooms with variable focal lengths. It is recommended to use prime
lenses, rather than zooms, which are usually impractical for dental photography. Furthermore,
fixed focal length macro lenses greater or less than 100 mm are unsuitable for the following
reasons. To achieve a 1 : 1 magnification with a 50 mm macro lens requires moving the camera
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extremely close to the subject, which may be intimidating for the patient. In addition, at this
close distance, the cheeks and lips block the flash lights illuminating the oral cavity. Another
problem with a 50 mm lens is that portraits at close distances result in spherical distortion,
making the nose or other prominent parts of facial features appear larger and less flattering.
Conversely, macro lenses greater than 100 mm, say 200 mm, require greater distances for
obtaining a 1 : 1 magnification. This is also a hinderance since brighter lights are necessary to
correctly illuminate the subject that is now further away, plus the physical size and weight of
these lens is inconvenient for hand‐held cameras. Many contemporary lenses offer image sta-
bilisation for preventing blurred images. However, this feature is superfluous for dental pho-
tography since the high flash synchronisation shutter speeds (1/125 seconds or 1/250 seconds),
and the fraction of a second flash burst ‘freezes’ the subject, obviating the need for image
stabilisation. It is important to realise that image stabilisation is different to focusing; the for-
mer compensates for involuntary micro‐movements referred to as ‘camera shake’ (for hand‐
held cameras), whilst the latter is concerned with focusing a sharp image onto the sensor
depending on the distance of the object from the camera.
Most dSLRs are sold with general‐purpose lenses, usually variable zooms, satisfying broad
photographic genres such as family shots, portraiture, landscape, sports, wildlife, etc. However,
these lenses are a ‘jack of all trades and master of none’. They offer acceptable resolving power,
but not superlative resolution. As mentioned above, the lens is a crucial factor for determining
the image quality, and its resolving power should match or be greater than the size of the pixels,
which vary from 5 to 12 μm. An array of lenses is available, either the same brand as the camera,
third‐party, or from different brands using appropriate adapters. The same brand lenses have
the advantage that they seamlessly synchronise or integrate with the camera electronics and
can be updated with the latest firmware, but are usually more expensive. The market is inun-
dated with third‐party lenses, some inferior, and others offering even better resolution than
same brand lenses. Lastly, lenses from old 35 mm film cameras can easily be fitted with rela-
tively inexpensive adapters to almost any camera. These offer excellent optics since they are
usually constructed of glass elements but are heavier, whereas newer versions are often made
of plastic elements, with reduced acuity, but are much lighter in weight. Some high‐end macro
lenses have the prefix ‘Apo’ and ‘ASPH’, which eliminate apochromatic and aspherical aberra-
tions, respectively. These optically corrected lenses may be the same brand as the camera or
third‐party lenses, with state‐of‐the‐art optics for exceptional resolution, but come with a hefty
price tag, e.g. Carl Zeiss, Schneider‐Kreuznach®, Meyer‐Optik Gorlitz®, Voigtlander® and Leica
to name a few. In addition, a search on e‐Bay™ offers many pre‐owned high‐end lens at a fraction
of the new retail price, and with appropriate adapters, e.g. from Fotodiox® or Novoflex®, can be
fitted to almost any camera body. The major disadvantage is that some electronic functions of
the camera, such as AF or auto‐exposure, are disabled, and therefore the lens has to be used in
manual mode. Other methods for achieving macro images are using various inexpensive attach-
ments on standard lenses, such as reversal rings, conversion rings, extension tubes, bellows, or
Lensbaby™ macro converters. The drawbacks are a slight deterioration in image quality, and the
additional weight, which may be off‐putting for hand‐held photography.
Irrespective of the lens, a wise precaution is to purchase a UV (ultra‐violet) filter that screws
onto the front of the lens for protection from dust, water or other oral effusions. In addition to
offering physical protection, a UV filter eliminates unwanted ‘haze’, enhancing the colour rendi-
tion of the image. Another useful attachment is a lens hood to eliminate flare from intense illumi-
nation (e.g. direct sunlight or flashes pointing towards the camera) that causes glare on images.
A further issue to contend with is whether the focal length of the lens matches the size of
the sensor. The focal length of lenses is usually quoted according to old 35 mm film cameras. If
the camera has a full‐frame sensor (36 mm × 24 mm), the image seen in the viewfinder will
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Lighting 19
almost be identical to what is recorded on the sensor (crop factor of 1). However, if the size of
the sensor is smaller, say APS‐C (22.2 mm × 14.8 mm), the lens image circle is greater than the
sensor size, and only the central part of the image is recorded on the sensor. For example, with
an APS‐C sensor the lens has a crop factor is 1.61 (see Figure 1.9). Also, for smaller sensors
found in compact cameras the crop factor becomes even greater, whilst for larger sensors in
medium format cameras, the crop factor reduces to less than 1. Therefore, it is desirable to
have a full‐frame sensor so that the focal length of the lens matches the sensor size, but the
additional cost of the camera body may be prohibitive. To summarise, the choice of a lens for
dental photography is empirical, dictated by personal preferences and cost, which can vary
from US$ 600 to UD$ 1000, or more, if image quality is an absolute priority.
Lighting
There are two types of lights required for dental photography: compact and studio flashes
Ahmad (2009b). Many cameras have built‐in flashes that pop‐up when the lighting conditions
are less than optimal. This is satisfactory for general photography but ill‐advised for macropho-
tography. First, the built‐in flashes are usually not congruous with the lens axis, and at close
distances cast an unwanted shadow which obscures essential parts of the image. Second, on‐
camera flip‐up flashes are relatively weak, with low intensity, and unable to adequately illumi-
nate the entire oral cavity.
The compact flashes are further sub‐divided into ring flash (ring‐light), compact off‐the‐
camera bilateral (bi‐directional or twin‐light) flashes, or a single unit consisting of both ring
and twin‐lights (Figures 1.16 and 1.17). Compact flashes, also known as hot-shoe flashes, con-
nect directly onto the hot‐shoe of the camera body and are subsequently controlled by the
camera electronics. Their intensities are measured in guide numbers at ISO 100, the higher the
guide number, the brighter the light output. Typical compact flashes have a guide number
ranging from 20 to 50 (100 ISO metre) or 65 to 165 (100 ISO feet). For dental use, a guide num-
ber of ISO 30 (metre) is more than adequate. All electronic flashes serve a dual purpose, first to
Figure 1.16 Ring flash on a digital single lens reflex (dSLR) camera system.
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Figure 1.17 Bilateral twin flashes on a digital single lens reflex (dSLR) camera system.
provide sufficient illumination for correct exposure, and second, to ‘freeze’ the object being
photographed due to the fraction of a second burst of light (up to 1/20 000 of a second). In addi-
tion, nearly all compact flashes (ring flash and lateral flashes) are compatible with camera
brand‐specific TTL metering for measuring exposure. Continuous lights sources such as day-
light, tungsten lamps, fluorescent tubes and LED (light emitting diode) are capable of deliver-
ing adequate illumination but cannot ‘freeze’ movement. The latter is significant since the
patient is unlikely to keep rigidly still during an arduous photographic session, feeling uncom-
fortable and claustrophobic with cheek retractors, photographic mirrors, dribbling saliva, not
to mention the operator contortions with hand‐held cameras. Therefore, a dental photographic
session should be conducted as quickly and efficiently as possible, which is expedited by
the endearing property of flashes because they allow pictures to be taken in rapid succession,
simultaneously illuminating and ‘freezing’ the subject.
Compact ring flashes attach directly onto the front of the lens, emitting uniform (360°) shad-
owless illumination, which is ideal for hand‐held pictures, especially in the darker posterior
regions of the mouth where access for light is restricted by the surrounding cheeks and lips.
The price for ring flashes ranges from US$ 100 to US$ 500, depending on the type, make and
guide number. The major drawback of ring flashes is that the light is harsh, uniform and char-
acterless. Whilst ideal for photographing posterior teeth, for anterior teeth this type of illumi-
nation produces images that are bland, boring and lacklustre. For anterior teeth, or for
restorations where aesthetics are of paramount concern, ring flashes are not recommended
since the uniform burst of light obliterates fine detail, translucency, surface texture, topography
and subtle colour transitions and nuances within teeth or artificial restorations.
To overcome the shortcoming of ring flashes, compact bi‐directional or bilateral flashes offer
lighting that sculpts the object giving it a three‐dimensional appearance with highlights and
shadows, allowing visibility of enamel characterisations such as mamelons, cracks, staining,
translucency, restorative marginal defects. Furthermore, by manipulating the light source
reveals colour nuances and depth of the underlying dentine strata, which is essential for mim-
icking these characteristics in indirect prostheses. The intensity of individual flashes can be
muted, or turned off, to enhance highlights or shadows that are ideal for capturing micro and
macromorphology.
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Lighting 21
Figure 1.18 Ring flashes produce lacklustre, bland two‐dimensional images.
Three are two varieties of lateral flashes. The first type attaches onto the front of the lens by an
adapter and has two projecting flashes, which can be positioned right, left, top, bottom or any-
where in between. Also, since the flashes fire wirelessly, they can be detached, hand‐held and
positioned as desired. The negative aspect of these flashes is their proximity to the teeth, and
depending on the guide number, the flash burst can be harsh, similar to ring flashes that obliterate
fine detail. To circumvent this undesirable effect, the second type of lateral flashes are mounted
with a bracket, or flash extension arms, beneath the camera and positioned behind the lens.
These units are also triggered wirelessly but emit much softer subtle light. In addition, the light
can be further attenuated by covering the flash heads with cloth or plastic diffusers to soften the
output. Soft lighting adds ambience to an image, and depending on intensity and distance can
reveal subtle detail by creating shadows and highlights, as well as emulating natural lighting con-
ditions in which teeth are usually viewed. As an analogy, using ring flashes is identical to taking a
picture of a subject head‐on in front of car headlights, whereas lateral flashes, dampened with
diffusers mimic realistic lighting of natural surroundings such as reflections and shadows from
people, buildings, water, foliage, furniture, walls, etc. (Figures 1.18 and 1.19). Both types of lateral
flashes, lens or bracket mounted, cost around US$ 500.
Lastly, several unusual light sources and light modification attachments are available for den-
tal photography. For example, ingenious contraptions such as flexible LED fibre‐optic ‘Medusa‐
like’ cables for directing light into the tiniest recesses of the mouth. Also, relatively inexpensive
flash accessories can be purchased to manipulate the emitted light, such as diffusers of various
sizes, reflector cards of different colours (matt white, glossy white, grey, silver). Also, elaborate
magnifying lenses attached to flashes can focus the light beam to highlight individual teeth or
particular areas of interest.
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Figure 1.19 Bilateral flashes produce three‐dimensional images conveying depth and vitality.
The second type of lighting is for dental portraiture, which may be hot lights, cool lights or
flashes. The first two types, hot and cool lights, offer continuous illumination that is suitable
for video but unsuitable for still photography. The preferred types of lights for portraits is stu-
dio flashes. Two varieties of studio flashes are available, the monolights, which connect directly
to the mains, or the pack and head, which require a separate power pack and are indicated for
location shooting. For dental applications, monolights are the most convenient, incorporating
integral modelling lights to help position and orientate the flashes before taking a picture. A
modelling light is a continuous light source that allows the photographer to visualise the light-
ing effect the flashes will produce, but does not affect the actual exposure (aperture and shutter
speed) when the flashes are triggered. These continuous pre‐flash, low‐intensity lights also
keep the pupils dilated, and together with ‘catch lights’ or Obies confer a shining aura to the
subject. Catch lights are tiny reflections on the cornea that create a glint or sparkle, attracting
the viewer to the eyes of an individual (Figure 1.20).
The flash intensity or output of a flash tube is measured either in watts/second (W/s), or
expressed as a guide number (GN), similar to compact flashes, e.g. a 120 W/s flash has a GN of
125 (100 ISO feet) or 38 (100 ISO metre), whilst a 300 W/s has a GN of 190 (100 ISO feet) or 58
(100 ISO metre). If the flashes are intended only for head‐shots of a single person, two 120 W/s
flashes are sufficient. However, if pictures of small groups, bigger objects in larger spaces, or
creative lighting with light‐modifying attachments is required, two or more >300 W/s flashes
are recommended.
Many light‐modifying attachments are available for manipulating light for creative effects,
e.g. reflective umbrellas, soft boxes, gels, barn‐doors, honeycomb grid diffusers, reflectors,
Fresnel lenses, etc. A good starting point is using two soft boxes, and once proficient, experi-
ment with more sophisticated modifiers for conveying ambience and mood. Unlike compact
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Support 23
Figure 1.20 Catch lights glints representing reflections of studio flashes or reflectors that attract the observer
to the eyes of the subject.
ring or lateral flashes that use TTL metering for correct exposure, studio flashes usually require
manual exposure settings. The exposure can either be assessed experimentally, or precisely
calculated using an incident light meter for determining the exact aperture and shutter speed.
Since purchasing a light meter is an additional expense, an economical approach is taking a few
test shots for determining exposure settings, distances of flashes and reflectors, which are
repeatable for a given set‐up. Studio flashes can either be triggered with synchronisation (or
sync.) cables plugged into the standard x‐jack on the camera, a radio or infra‐red wireless
device fitted onto the hot‐shoe, or via apps from a smartphone, tablet or computer. Usually
only one flash needs to be connected directly to the camera, whilst the remaining flashes are
simultaneously triggered by light receiving sensors on the additional flashes. A starter studio
flash kit with two monolights, two reflective umbrella or soft boxes, two air‐cushioned stands
or tripods and triggering mechanism costs around US$ 300–500, and is an ideal package for
starting portraiture photography (Figure 1.21).
Finally, portraiture requires backdrops or backgrounds, which are limited only by the imagi-
nation. These can simply be suspended coloured cloths or elaborate stage set‐ups; the choice
resides with the photographer.
Supports
Most clinician and dental technicians take photographs with hand‐held cameras for conveni-
ence and expediency. However, there are instances when supports are invaluable for stabilising
the camera and allowing hands‐free operation for precisely positioning flashes and ancillary
equipment. This could be during surgical procedures, a detailed aesthetic or soft tissues analy-
sis, and portraiture. The variety of supports available is perplexing and confusing, including
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Figure 1.21 Examples of studio flashes for portraiture.
Figure 1.22 Tripod‐mounted camera, compact flashes and focusing rail.
monopods, tripods, jibs, cranes, booms, cages, clamps, brackets, steady cams, rails, slides, dol-
lies and suction pads. To simplify matters, for dental photography, a tripod with a dolly (wheels),
and a four‐way focusing rail (stage) for fine focusing is all that is necessary. The tripod head
should have a pan (side to side) and tilt (up and down) movements, and be resilient enough to
carry the payload of the camera, lens, flashes and macro focusing rail. The focusing rail is
attached underneath the camera, and is indispensable for fine manual focusing at pre‐deter-
mined magnifications. The cost of a tripod with a dolly, tripod head and macro focusing stage
is around US$ 250 (Figure 1.22).
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References 25
Table 1.2 Budget photographic equipment for dental photographya
Item Cost (US$)
dSLR camera body 500

Marco lens – 100 mm (or equivalent) 600
Compact ring flash 100
Compact lateral (bi‐directional) flashes (2) 500
Bracket for lateral flashes 50
Flash accessories (diffusers, reflectors) 50
Studio flash kit for portraits 300
Backdrops and reflectors for portraits 100
Tripod, tripod head, focusing stage 250
Remote shutter release 100
SD, SDHC, SDXC, CF 16 Gb storage cards (2) 30
Data storage card reader 15
Rechargeable batteries with charger for compact flashes 20
Polarising filter (circular) 50
UV bulbs 40
Total: US$2705
a
Prices quoted from B&H Photo, Video, Pro Audio (https://www.bhphotovideo.com/
c/browse/Digital‐Cameras/ci/9811/N/4288586282/1).
Other Photographic Items

Some relatively inexpensive items are also useful for completing the photographic equipment
arsenal. These include rechargeable batteries, a multi‐card reader for transferring images to a
computer, UV bulbs for visualising fluorescence of natural teeth and artificial prostheses, or
porosity defects in porcelain restorations. A polarising filter is helpful for analysing shade by
eliminating specular reflections (glare) off the enamel surface. Polarising filters are available in
two varieties; linear or circular, and in practice, both do the same job. The former, linear, is
better suited for manual focusing but more costly, whilst the latter, circular, is cheaper and can
be used in both manual and AF modes. Finally, digital photography requires a computer and
processing software, and recommendations for the latter are given in Section 3, dealing with
editing, exporting and managing images.
Table 1.2 itemises the essential photographic equipment necessary for dental photography.
However, in the beginning, it may be prudent to start by purchasing equipment for only intra‐
oral photography, and eventually progressing to portraiture lighting with other ancillary equip-
ment. On a budget, the cost of purchasing all the requisite items is US$ 2705, but if finances are
unlimited, the sky is the limit.
References
Ahmad, I. (2009a). Digital dental photography. Part 4: choosing a camera. Br. Dent. J. 206 (11):
575–581.
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Ahmad, I. (2009b). Digital dental photography. Part 5: lighting. Br. Dental J. 207 (1): 13–18.
Manauta, J. and Salat, A. (2012). Layers. Milan: Quintessenza Edizioni.
Reddy, S.P., Kashyap, B., Sudhakar, S. et al. (2014). Evaluation of dental photography amongst
dental professionals. J. Educ. Ethics Dent. 4: 4–7.
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27
Dental Armamentarium and Clinical Considerations
Besides photographic equipment, there are additional items required for taking intra‐oral pic-
tures, as well as specific clinical considerations to bear in mind. The majority of these requisite
items are readily available as part of the dental armamentarium, but a few need to be acquired.
Retractors
In order to have access to the cavity, it is necessary to retract the surrounding lips and cheeks.
The most frequent method for retraction is cheek retractors, which come in a variety of ingen-
ious designs, sizes, colours and materials (Figure 2.1). The basic configurations are unilateral or
bilateral, the former for quadrants or sextants and the latter for full‐arch images. Also, it is
helpful to keep a stock of several sizes and shapes to accommodate varying degrees of mouth
opening. Cheek retractors are either made of plastic or stainless steel (SS). The plastic variety
are gentler but prone to fracture, especially the bilateral variety, and some can only be cold
sterilised, but single‐use disposable types are also available. The SS varieties are more rigid,
unlikely to fracture and are autoclavable. However, some patients object to the harsh piecing
sensation of steel against their cheek and lips. The choice is a personal preference of both the
clinician and the patient, but the author recommends the plastic unilateral and bilateral varie-
ties for comfort and ease of insertion and removal. In addition, the pliable plastic cheek retrac-
tors allow easier manipulation of the cheeks from right to left sides of the mouth for lateral
buccal views (Figure 2.1).
Photographic Mirrors and Contrasters

Dental photographic mirrors are used for taking pictures of the occlusal/incisal and buccal/
lingual/palatal surfaces of teeth. The mirrors are available in numerous shapes and sizes cater-
ing for macroglossia and visualising almost any aspect or angle of the teeth and surrounding
soft tissues (Figure 2.2). The larger mirrors are used for full‐arch views, while the narrower
types are more suited for quadrant and buccal or lingual surface views. Intra‐oral mirrors are
available in various materials including titanium, and glass with front‐coated chromium, rho-
dium or dielectric plated for eliminating double or ghost images. The titanium varieties are
more durable, costlier and usually only single sided. The glass coated varieties are slightly less
expensive but have the advantage of high reflectance. For example, the reflectance of titanium
is 80%, rhodium‐plated mirrors 75%, chromium 65–70% and SS 50–60% (Sreevatsan et al.
2015) – Figure 2.3. Also, glass mirrors are double‐sided, and if one side becomes scratched, the

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28 Dental Armamentarium and Clinical Considerations
Figure 2.1 Selection of cheek retractors of various configurations and sizes.
Figure 2.2 Dental photographic mirrors are available in various shapes sizes to cater for
photographing various fields of view.
reverse side can be used without having to purchase a new mirror. Depending on the manufac-
turer, some mirrors are autoclavable, while others can only be cold sterilised. Decontamination
of dental mirrors requires particular attention by using lint‐free cleaning cloths and mild deter-
gents so as not to scratch or degrade the surface coating. Another precaution is avoiding ultra-
sonic cleaning with abrasive or caustic disinfectant solutions, which cause irreparable damage
to the front plated‐surfaces.
There is a trend to photograph a section of the dental arch, especially the maxillary anterior
sextant (facial and palatal aspects) with a black background for excluding distracting extrane-
ous anatomy such as nostrils, tongue, opposing arch and soft tissues. This is achieved by using
contrasters that are made from metal and coated with silicone black paint, and available in
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Photographic Mirrors and Contrasters 29
Inc
ht ide
lig nt
lig
ct ed ht
fle
Re
Ti
80%
Rh %
75
Cr %
67
S
S
5
7
%
Intra-oral mirror
Figure 2.3 Percentage of light reflected off a mirror surface according to the type of coating.
Figure 2.4 Contrasters are made of metal with a black

silicone coating.
various shapes (occlusal, anterior and lateral) for various intra‐oral views, and are usually
autoclavable (Figures 2.4 and 2.5). They are also used for creating a black background for
emphasising translucencies at the incisal edges and interproximal areas of the teeth. The con-
trasters are judicially placed for concealing unwanted anatomy before taking the photograph.
If TTL (through‐the‐lens) metering is used for flash metering, the large area of a black
background of the contraster confuses the camera metering system, which results in an over-
exposed image. The exposure can be compensated either when taking the photograph, e.g.
by moving flashes further away or reducing their intensity, or correcting the exposure in
photo‐editing software.
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Without contraster With contraster
Figure 2.5 Contrasters are used to exclude unwanted anatomy, such as nostrils when using intra-oral mirrors.
Field of View
The field of view to photograph should be clean and clearly visible. Having displaced the lips
with check retractors, it is essential to maintain a dry field during a photographic session. A dry
field is required to capture details of the teeth, free gingival margin, attached gingiva and
mucogingival junction, which allows accurate analysis, treatment planning and discriminating
healthy and pathological changes for differential diagnosis of oral lesions.
The method used for achieving a clean and dry field depends on the clinical situation, and the
type of treatment being performed. The choices are rubber dam, gingival retractor cords, cot-
ton wool rolls, gauze, or aspiration using a slow‐speed saliva ejector or high‐speed suction. As
well as maintaining a contamination‐free environment for dental procedures, a rubber dam is
also an ideal method for isolating both the anterior and posterior teeth (Figure 2.6). This is
particularly relevant when documenting treatment sequences such as adhesive bonding tech-
niques, where absolute isolation is mandatory. Although a rubber dam conceals the surround-
ing soft tissues, it offers an arid environment without condensation, which is particularly useful
for preventing fogging of intra‐oral mirrors for occlusal, buccal and lingual images.
Intermittent use of a slow speed saliva ejector and/or surgical aspiration tip is invaluable for
ensuring patient comfort, and for aspirating dribbling saliva or haemorrhage while document-
ing surgical procedures. However, it is important to remove the ejector just before taking the
picture, so it does not appear in the image. Other methods for achieving and maintaining a dry
field include discreetly placing cotton wool rolls into the sulci, especially in the maxillary buc-
cal and mandibular lingual regions at the location of parotid and submandibular salivary gland
duct orifices, respectively. Gingival retraction cord, with or without a haemostatic agent, e.g.
buffered aluminium chloride is an effective method for halting haemorrhaging and absorbing
crevicular fluid seepage from the gingival sulcus.
Before taking the picture, all ancillary items should be made invisible, such as check retrac-
tor edges, contraster and intra‐oral mirrors. The cheek retractors should be large enough to
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Cross‐infection Control 31
Figure 2.6 A rubber dam is ideal for isolating the teeth and for documenting clinical restorative procedures.
adequately deflect the middle part of the upper and lower lips so that they do not appear in the
photograph and obscure the maxillary and mandibular frena. Any fingers holding mirrors or
other dental instrumentation should be excluded from the composition. This also applies to
drooping lips, glaring nostrils (in maxillary arch mirror views), flaccid tongue or double images
of the actual and reflected teeth when using intra‐oral mirrors. Unwanted elements can be
cropped later in processing software, but it is recommended that the shot be composed cor-
rectly at the capture stage to minimise post‐editing. This is particularly relevant with reflected
images taken with intra‐oral mirrors, as cropping can be time‐consuming and onerous (The
Academy of Laser Dentistry 2015).
Accumulation of surface biofilm, extrinsic stains, or food debris lodged between contract
areas are annoying since they obscure the underlying enamel and dentine. Unless it is the inten-
tion to photograph these deposits, flossing and polishing with prophylaxis paste is recom-
mended before taking photographs. Furthermore, gingival embrasures obscured by unwanted
debris hinder diagnosis of interproximal carious lesions as well as accurate shade assessment for
artificial restorations. The teeth should not be overly desiccated to minimise a shade shift, but
gently dried to remove salivary film with compressed air from a three‐in‐one, or preferably a
heated six‐in‐one, dental syringe, which also prevents condensation, or fogging, on intra‐oral
mirrors. In addition, air drying removes saliva droplets and trails on the teeth and gingiva (unless
these are intentionally being photographed for stylistic reasons). Other methods of preventing
misting of mirrors is using high‐speed suction, warming mirrors beforehand or wiping the mir-
ror surface with a surface tension reducer or anti‐condensation liquid. Finally, removable dental
appliances should be removed, unless their documentation serves a purpose.
For dento‐facial clinical images, it is advisable to tone down or remove lurid lipstick and
flamboyant make‐up. However, for marketing and promotional images, make‐up is justified for
beautifying an individual or conveying their persona.
Cross‐infection Control
Emphasising the importance of cross‐infection control to dentists is preaching to the converted.
There are already stringent guidelines for cross‐infection control, and therefore, many would per-
ceive it as condescending to have verbose text on this subject. However, a few key points warrant
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Figure 2.7 Draped photographic equipment as part of cross‐infection control.
discussion (Ahmad 2009). Whenever possible, an asepsis protocol is adopted. First, the camera
and lens are appropriately draped with cellophane covers, not excessively, as plastic coverings are
slippery and prevent access to camera settings (Figure 2.7). Drapes are mandatory when photo-
graphing surgical procedures, but optional for routine documentation for EDP (essential dental
portfolio) or EPP (essential portrait portfolio). Also, all camera, lens and flash settings are set
beforehand to prevent unduly touching the equipment during a photographic session. Second, all
team members participating in a photographic session should wash their hands with soap, or alco-
hol gel, before wearing gloves. It is generally good practice to wear gloves while taking photographs
as it is often necessary to use saliva ejectors and to adjust the position of the patient’s head and of
ancillary equipment such as check retractors or intra‐oral mirrors. In addition, the operator and
ancillary staff should change gloves when pausing treatment procedures to take photographs, and
subsequently wear a new pair when continuing treatment. Third, a remote camera shutter release,
preferably via foot control is invaluable for hands‐free operation. Photodocumentation during sur-
gical procedures is ideally delegated to a ‘dirty’ dental assistant, who can operate the photographic
equipment, preferably by a smartphone app. Fourth, intra‐oral accessories such as retractors,
mirrors, contrasters and reflectors should be appropriately sterilised, disinfected or discarded
(Vasileva et al. 2017). Fifth, corrosive sterilising solutions and paper tissues are not recommended
for cleaning photographic equipment, since they may cause irreparable damage. Instead, camera
and flashes are wiped with moist microfibre towels (Shorey and Moore 2009). Lastly, if black and
white specks or dots appear on successive images at the same position, the most likely cause is dust
on the sensor. Cleaning a camera sensor is an extremely delicate task, ideally commissioned to a
professional dealer. Alternately, if sensor cleaning is attempted, it is best performed using lint‐free
cloths and volatile liquids to avoid smears and streaks.
Health and Safety
Currently, there is a fetish for draping every piece of dental equipment with disposable cello-
phane sheets and covers. While laudable for cross‐infection control, there are times when
pragmatism should prevail. Dogmatic adherence to stringent guidelines can sometimes be
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Location 33
counterproductive. For example, unbridled use of plastic covers hinders access to photographic
equipment to change settings and are potentially hazardous, especially when wet and slippery.
Also, overheated studio lights can melt, or worse ignite cellophane coverings. However, these
extreme examples are not an excuse for abandoning cross‐infection control, but a measure of
common sense is necessary to avoid mishaps and accidents.
Other health and safety considerations include moving all mobile units, foot controls,
spittoons, handpiece consoles, operatory light and chair‐mounted monitor displays aside.
Also, dental handpiece and suction tubes should be stored in their receptacles to avoid trip-
ping or entangling. It is mandatory for the entire team to be aware of, and conform to, per-
sonal protection equipment (PPE), and for the patient to be offered safety sunglasses for
protection and shielding from intense light burst from flashes. It is worth remembering that
photographic equipment is additional to the plethora of dental armamentaria, and therefore
it is prudent to place the camera in a safe and secure zone of the operatory where it can
neither be knocked over, nor interfere with routine treatment, but nevertheless be readily
accessible when needed. All batteries for flashes, camera and computer should always be
charged in readiness. All sprawling flash or shutter triggering cables are tied or taped
securely, not loosely hanging, as they are a potential hazard for trapping or entangling with
dental equipment.
All unfastened clothing such as scarves or neckties is secured, and long hair tied back with
disposable scrunchies. Sharp items including necklaces, rings, bracelets, extravagantly long or
porcupine‐like earrings are removed, so that they cannot engage with photographic cordage. In
addition, facial tissues are constantly at hand to wipe excess dribbling saliva. The edges of
cheek retractors and lips are liberally lubricated with petroleum jelly for facilitating insertion
and removal, and avoiding chapping of the lips.
Finally, it is worth mentioning that the patient and dental team members be requested to
turn off all audible mobile devices, which are obviously distracting and annoying during treat-
ment and a photographic session.
Location
The location where dental pictures are taken is a contentious issue. For portraiture, there is
little disagreement: an allocated room, or indeed a tailor‐made studio away from the clinical
environment. However, for intra‐oral images, there is confusion, and the ideal location is
debatable. Some operators prefer a non‐clinical setting for placing patients at ease, and mak-
ing the photographic session a relaxing experience (Davda n.d.). However, this may be coun-
terproductive since there is no access to aspiration, compressed air, the patient cannot be
reclined in the supine position for certain photographic views. Ultimately, this necessitates
moving essential dental equipment to a non‐clinical setting with the associated compromises
in cross‐infection and health and safety. There is no doubt that dental photography is a unique
genre, and as discussed above, adhering to certain requirements is paramount. Therefore, it is
the author’s opinion that a clinical setting is best suited for intra‐oral photography, fulfilling
both clinical requirements and having access to essential dental armamentarium. This is par-
ticularly pertinent when photographing surgical procedures, when draping and other asepsis
protocols are mandatory for avoiding contamination and ensuring treatment success. To illus-
trate the importance of a clinical setting for dental photography, the sequential images in
Figures 2.8–2.23 demonstrate that this surgical procedure could not have been documented in
a non‐clinical environment.
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Figure 2.8 Photographing surgical procedures is particularly demanding because a strict cross‐infection
protocol is mandatory. This necessitates regularly changing gloves and minimising contact with
photographic equipment during a surgical procedure by ensuring that camera and flash settings are
optimally configured beforehand: flap elevation to reveal chronic infection associated with the right
maxillary lateral and central incisors.
Figure 2.9 Extraction of the right maxillary incisors and curettage of the site showing substantial bone loss.
Figure 2.10 Transitional acrylic denture in‐situ and grafting the site with bovine xenograft.
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Location 35
Figure 2.11 Suturing.
Figure 2.12 Five week healing.
Figure 2.13 Radiopaque surgical

stent for guiding flapless implant
placement.
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Figure 2.14 Flapless osteotomy.
Figure 2.15 Guides for ascertaining

correct implant angulation.
Figure 2.16 8 1/2 week healing

(occlusal view).
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Location 37
Figure 2.17 8 1/2 week healing

(facial view).
Figure 2.18 Closed tray impression

abutments.
Figure 2.19 Temporary acrylic

crowns.
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Figure 2.20 Customised CAD/CAM

titanium/zirconia abutments and
prepared left central incisor (right
lateral view).
Figure 2.21 Customised CAD/CAM

titanium and zirconia abutments
and prepared left central incisor
(frontal view).
Figure 2.22 Definitive all‐ceramic

crowns for implants at sites #12
and #11, and replacement lithium
disilicate (e‐max) crown for
tooth #21.
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Support 39
Figure 2.23 Hand‐held camera with compact flashes.
Supports
Another point of disagreement is whether the camera and mounted flashes are hand‐held
or supported by a tripod. In this case, the answer is not so clear‐cut. The advantage of
hand‐held cameras is manoeuvrability, and the photographer is free to position himself or
herself in any position without being encumbered by a tripod. This is particularly helpful
for accommodating children, or the elderly and frail, who may find a photographic session
arduous and trying experience. However, if the camera is hand‐held, to prevent it falling
accidentally, it is advisable to use a hand and neck strap. The drawback of carrying a hefty
camera and flashes is that the operator usually ends up contorting his or her body over the
patient, inadvertently bumping into dental equipment, or spraining back musculature
(Figure 2.23).
The tripod option offers a rigid platform, allowing the photographer to be comfortably
seated, freeing the hands for precisely positioning cheek retractors, mirrors, or holding
intra‐oral instruments to demonstrate a particular clinical technique. In addition, if the cam-
era is mounted onto a macro focusing stage, precise focusing is ensured. Furthermore, a
series of images can be taken with similar framing for demonstrating a particular treatment
protocol. The drawback of a tripod is that another piece of hardware needs to be accommo-
dated in the clinic, which may already be restricted for space. Nevertheless, the benefits of a
stable platform for consistent and standardised images outweigh the initial teething frustra-
tions (Figure 2.24).
Ideally, it is best to use both options depending on the type of photograph being taken. In
order to expedite a photograph session for compromised patients, or where access to the
posterior regions of the oral cavity is limited, hand‐held equipment is the best option with-
out fettering with a tripod. Alternately, for certain dental applications where composition
and framing are paramount, the solid platform of a tripod is indispensable for standardisa-
tion. Lastly, whichever option is chosen, it is helpful to draw markings on the floor for the
location of the photographic equipment, the patient, photographer and assistant for repeat-
able positioning.
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Figure 2.24 Tripod‐mounted camera and compact flashes with diffusers.
Delegation
Another frequently asked question is ‘Who should take the photographs?’
It is tempting to delegate photographic documentation to ancillary staff or assistants
(Christensen 2005), or indeed a professional photographer (Sandler and Murray 2002).
Delegating has its advantages; it frees up valuable time during a busy daily schedule to con-
centrate on other pertinent clinical matters. In addition, the clinician may lack competence,
or be indifferent to taking pictures. However, assigning this responsibility to assistants can
prove fruitless. This is not denigrating an assistance, without whom any dental procedure is
arduous, and often impossible. It is simply allocating tasks that an individual is best trained
for, and proficient in, for the followings reasons. First, the assignee should have adequate
training in dental photography and be versed with taking both extra‐ and intra‐oral pictures.
Second, trying to explain to assistants what an image should depict, is asking for a miracle.
After carrying out an examination of the patient, it is the clinician who possesses the depth of
knowledge and experience for assessing the dental status, including the visual appearance of
dental and oral pathology. Only he or she can decide on the type of image that is required, and
more importantly, what it should convey (McKeown et al. 2005). This is similar to taking
radiographs, which can only be requested by the clinical after an intra‐oral examination.
Asking an assistant to take on the role of the clinician is perhaps presumptuous, and also
expecting too much. Therefore, before appointing a proxy, it is worthwhile asking a few ques-
tions; can the delegate differentiate between diseased and healthy tissues, assess defective
restorations, perform shade analysis, and capture nuances and characterisations of teeth and
restorations? Furthermore, is the ensuing frustration of unusable images, and extra time
needed to repeat them, worth the hassle?
Alternately, employing a professional photographer will obviously produce technically
satisfactory images, but will they be clinically satisfactory? The same comments as those for
dental assistants apply to professional photographers, who are proficient in photography,
but not in dentistry. In addition, the extra expense of a professional photographer will
unnecessarily increase the cost of treatment for the patient. Finally, many dentists may
have attended lectures or presentations by competent clinicians demonstrating superlative
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Patient Consent 41
techniques but accompanied by poor‐quality images, which fail to convey the message and
wrongly reflect on the presenter’s competence. This is another reason why a clinician needs
to be is versed in photographic techniques for communicating his or her clinical knowledge
to an audience.
Ideally, a photographic session should be performed as a team including the clinician with
the help of an assistant, no different to four‐handed dentistry. The clinician is responsible for
operating the photographic equipment and framing the composition to include salient fea-
tures, while the assistant is indispensable for ensuring patient comfort by aspirating saliva or
blood, responding to concerns such as pressure from cheek retractor, preventing gagging reflex
from mirrors, vigilantly adhering to cross‐infection control and addressing health and safety
issues. Also, an extra pair of hands is essential for positioning cheek retractors, contrasters,
mirrors, flashes, reflectors, etc. In addition, the assistant is able to hold instruments adjacent to
the teeth or oral mucosa that are essential as reference markers, as well as using a three‐in‐one
syringe for maintaining a dry field of view and clearing condensation from mirrors. This applies
equally to dental technicians, who should work as a team for recording a particular technique,
showing intricate details they have created in artificial prostheses, or for visual communication
with the clinician about clinical deficiencies such as poor impressions. Hence, in the dental
laboratory, the dental technician is also the protagonist to operate the photographic equipment
and frame the picture, while the assistant is responsible for ensuring that the session is con-
ducted productively and effortlessly.
Patient Consent
There are varying opinions and ambiguity regarding guidelines about the type of consent nec-
essary for using dental images in both the clinical and non‐clinical context (Berle 2008). Some
believe that no consent is necessary when the images are utilised for therapeutic purposes or
for communicating with fellow professional colleagues for the benefit of the patient. This may
be justified for emergency treatment, or if the patient is incapacitated by a prevailing medical
condition and therefore unable to grant consent. However, when using images for non‐clinical
contexts, such as marketing and promotional endeavours, consent is unquestionably manda-
tory. Another contentious issue is responding to requests for images from criminal investiga-
tors or for forensic identification. In these circumstances, it be best to seek advice from dental
professional bodies before releasing images to third parties (Kornhaber et al. 2015).
In the current climate of escalating patient litigation and increasing demand for elective den-
tal therapies, it is wise not to tempt fate, and to obtain written consent even for the most
innocuous treatment.
Therefore, before embarking on photographic documentation, patient consent is unques-
tionably obligatory, and without a signed consent form a photographic session should not be
contemplated. In addition, the patient should be briefed about the intended use of the images,
whether they are purely for clinical documentation, liaising with specialists, monitoring treat-
ment progress, or whether the images will be used for marketing (including social media dis-
semination and websites), research, education, public relations, patient counselling, staff
training, lecturing and publishing (Bauer n.d.). Furthermore, it is necessary to inform the
patient that consent for photographic documentation is voluntary, and if declined, will in no
way compromise the provision of therapy. Various consent form templates are available from
defence societies, dental academies and organisations or publishers, each catering for specific
uses of the images that can be tailored to suit patients’ wishes.
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Figure 2.25 Pixelating the eyes is a simple method for concealing the identity of the patient.
For certain treatment modalities, dental photography is an essential diagnostic and commu-
nication tool. These include orthodontics, diagnosis of pathology by specialists, or shade
analysis for artificial restorations, and so on. In these circumstances, if patient consent is not
forthcoming, consent is still necessary, with the proviso that the images will not be used for any
purpose other than the treatment in question. Also, after completing treatment, the images
can either be handed over to the patient for safekeeping or permanently destroyed or deleted.
Another method for ensuring anonymity is by pixelating the eyes using image manipulation
software (Figure 2.25). However, if treatment involves visualising facial features for plastic sur-
gery, reconstruction or aesthetic enhancement with local muscle relaxants and fillers, pixella-
tion may not be a feasible option.
A cautionary footnote that cannot be overstressed, particularly involving aesthetic or elective
dental procedures, is the importance of involving the patient at each and every stage of treat-
ment. In addition, gaining written consent before starting or progressing to the next phase of
therapy is imperative. This may seem fastidious, but a few signatures during a course of treat-
ment can prevent unforeseeable future rage at a later date.
References
Ahmad, I. (2009). Digital dental photography. Part 8: intra‐oral set‐ups. Br. Dent. J. 207 (4):
151–157.
Bauer, R. (n.d.). Digital Photography Made Easy. Canada: Coordinator of Digital Media Education,
Faculty of Dentistry, University of Toronto.
Berle, I. (2008). Clinical photography and patient rights: the need for orthopraxy. J. Med. Ethics 34
(2): 89–92.
Christensen, G.J. (2005). Important clinical uses for digital photography. J. Am. Dent. Assoc. 136:
77–79.
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References 43
Davda, M. (n.d.). Standardization in dental photography. Dental Photography School.

Kornhaber, R., Betihavas, V., and Baber, R.J. (2015). Ethical implications of digital images for
teaching and learning purposes: an integrative review. J. Multidiscip. Healthcare 8: 299–305.
McKeown, H.F., Murray, A.M., and Sandler, P.J. (2005). How to avoid common errors in clinical
photography. J. Orthod. 32: 43–54.
Sandler, J. and Murray, A. (2002). Current products and practice: clinical photographs – the gold
standard. J. Orthod. 29: 158–167.
Shorey, R. and Moore, K. (2009). Clinical digital photography: implementation of clinical
photography for everyday practice. J. Calif. Dent. Assoc. 37 (3): 179–183.
Sreevatsan, R., Philip, K., Peter, E. et al. (2015). Digital photography in general and clinical
dentistry – technical aspects and accessories. Int. Dent. J. Stud. Res. 3 (1): 17–24.
The Academy of Laser Dentistry (2015). Guidelines for Clinical Photography 3: 1–4.
Vasileva, R., Kolarov, R., and Nikolov, N. (2017). Protocol for sterile conditions using dental
photography. MedInform 1: 551–558.
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45
Technical Concepts and Settings
Having acquired the requisite photographic equipment and gathered the necessary dental
armamentarium, the penultimate stage before taking photographs is understanding some basic
photographic principles. Whenever a new piece of equipment is purchased, there is undoubtedly
an eagerness to use it as soon as possible. However, instead of diving straight in and getting
frustrated by disappointing outcomes, it is better to take time out for grasping some theoretical
concepts and apply these to practical situations. This knowledge is invaluable for achieving
predictable results at the outset, rather than wasting time rectifying mistakes. Also, for
convenience, some of the information below is repeated in subsequent modules dealing with
Capture, Process and Display or the CPD triad (Figure 3.1).
Every Picture Tells a Story

Photography is a synæsthetic experience (Cytowic 2003), similar to the aesthetic experience or
aesthetic appreciation of beauty (Figure 3.2). Aesthetics is defined as elevating material enti-
ties, such as paint on a canvas or a sculpture carved from stone, to a psychological [usually]
pleasurable experience. Therefore, similar to art, the raison d’être of a picture is ‘to tell the story
that needs to be told’ so as to elicit a psychological response.
Hence, the aim of any picture, whether a painting or photograph, is to convey a message. All
that matters is that the intentional message reaches the intended audience. If this goal is achieved,
the picture has served its purpose. Essentially, all pictures are representations of objects or sub-
jects photographed in a particular light at a given moment in time. If the light is changed, the
object or subject appears different, conveying a difference message. Dental photography is no
exception. Therefore, before taking a photograph, the photographer should have a lucid idea of
what the image is supposed to convey, or its intended use. Without this mandate, a photograph
serves little or no purpose, and the exercise deemed pointless and futile.
The intended purpose of a photograph is essential for deciding the type of imagery required;
either for conveying clinical information or for inducing the desired inspiration. Hence, it is
pivotal to produce images that communicate a visual dental message or tell a story, no different
from watching a movie or reading a novel. Consequently, images for communicating with
patients convey a different message to those for communicating with professional colleagues.
The former is seductive, alluring and emotive, whilst the latter lacks figurative connotations
and is instead impassive, but informative for inter‐clinician tele‐consultations or tele‐
conferencing (Manjunath et al. 2011). For these purposes, standardised imagery is essential for
consistency and comparison.

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46 Technical Concepts and Settings
Capture Process Display
CPD triad
Figure 3.1 Digital photography consists of three distinct stages: capture, process and display (CPD).
Figure 3.2 Photography is a synæsthetic experience.
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Every Picture Tells a Stor 47
Figure 3.3 Image with high

marketing value, but low clinical
value.
Figure 3.4 Image with high clinical

value, but low marketing value.
Both the dental literature and the internet are awash with dental imagery that crosses the
clinical/artistic line. Furthermore, some literature on dental photography is preoccupied with
clinical fidelity and dismisses artistic imagery as facile. However, as mentioned above, each
type of picture serves a different purpose, and there is room for both styles (Figures 3.3 and
3.4). There is no doubt that images for marketing dental products or promoting dental services
are stylistic, devoid of clinical relevance, but their intention is different from providing infor-
mation for clinical diagnosis, treatment planning or treatment outcomes. Thus, the two types
of images are often incongruous, but nevertheless relevant because they are appealing to differ-
ent spectators. Creating stylistic, or artistic photographs depends on the creativity of the pho-
tographer rather than the type of camera or photographic equipment. The camera is merely a
machine, without feelings or emotions, but it is the individual taking the photograph who adds
these qualities to express his or her vision. Anyone can purchase a canvas and paints, but not
everyone can produce works of art. This aspect of photography is difficult, or even impossible
to teach. Artistic qualities develop with passion and time, and are beyond the scope of this
publication. Therefore, the aim of this text is showing techniques specifically for dental needs,
including clinical and marketing, which produce predictable and repeatable results, and most
importantly, tell a dental story.
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Setting the Tone
The oral cavity is a confined area of the body, and photographing it presents unique challenges.
After all, we are taking pictures of relatively small objects, the largest teeth in the arch, the
maxillary central incisors or molars are around 10 mm. Therefore, trying to capture details
within these small objects requires a degree of perseverance, endurance and imagination. In
addition, patient compliance and participation are paramount for achieving satisfactory results.
Hence, creating an atmosphere of serenity and tranquillity, concealing frustrations and agita-
tions, are prerequisites for a successful photographic session.
Lighting
Photography is light, and without light there is no photography. Photography is simply playing
with light, it can emphasise or suppress details or features, create an ambience of tranquillity or
excitement, evoke hopes or fears, kindle emotions or repulsion, inspire and aspire, be evocative
or provocative, and elicit approval or rejection. Although this text cannot begin to do justice to
what is possible with light, the discussion below outlines some basic lighting principles that are
relevant for dental photography (Ahmad 2009a).
The method by which a light source illuminates an object or subject is by distribution, which
is determined by its colour temperature, apparent size and direction. The colour temperature
sets the tone, the direction influences the location of shadows and highlights, whilst the physical
size dictates the intensity of the shadows and highlights.
The colour temperature is significant when shooting in daylight since the quality of light
changes at sunrise, midday, overcast skies or sunset. However, as most flashes are configured
to emit light at photographic daylight (5500 K), the ambient colour temperature is almost irrev-
erent for dental set‐ups. However, for creative imagery, the colour temperature can be altered
by either placing coloured gels over the flashes, or using coloured fill‐in reflectors. Reflectors
are available in a variety of reflective coloured surfaces for altering the temperature of light, e.g.
a gold surface reduces the colour temperature creating a warm glow, whilst a silver reflector
increases the colour temperature and ‘cools’ the quality of light. Also, a highly reflective surface
encouraging specular reflections for producing vibrant, high contrast images (Bazos and
Magne 2013), compared to a matt white card that produces subtle lighting for a serene
ambience.
There are two types of lighting: hard and soft. Hard lighting is harsh and usually unidirectional,
creating distinct shadows and specular reflections (glare). Conversely, soft lighting is subdued
with gradual transitions between darker and lighter parts of a picture. Furthermore, hard light-
ing emphasises edges of objects, whereas soft light attenuates, or ‘irons out’ details. Therefore,
for portraiture, softer lighting is generally preferred as it is more flattering and glamorises the
subject (Figure 3.5). Similarly, diffuse or soft lighting is ideal for capturing dentine strata char-
acterisations and chromatic distribution within a tooth, whilst unidirectional illumination
emphasises line angles and reveals enamel surface texture and lustre.
Various methods are available for achieving softer lighting. The first is moving the light
source closer to the subject, the second is by using an intermediate material to diffuse the
emitted light (e.g. soft box), third, bouncing the flash off reflective surfaces such as an umbrella
or a reflector, and lastly, increasing the physical size of the light source. Altering the direction
of a light creates a sense of depth in a composition. This type of directional lighting is used for
highlighting specific features of an object, and at the same time giving a three‐dimensional
quality to the image.
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Lighting 49
Hard lighting
Soft lighting
Figure 3.5 Hard lighting produces distinct shadows and highlights, emphasising edges of objects or
prominent facial features, whereas soft lighting produces subtle transitions between shadows and highlights,
and is more flattering by smoothing prominent facial features and wrinkles.
Key light
Figure 3.6 A key light is the primary source of illumination.
For any photographic set‐up, the protagonist light is termed the main or key light, which is the
primary source of illumination, whilst secondary light(s) are termed fill lights because they are
placed on the contralateral side to literally ‘fill in shadows’ created by the key light. The fill light
can either be ambient or natural daylight, a second flash, or a reflector that bounces light from
the key light back onto the subject (Figures 3.6 and 3.7). The degree that a fill light i lluminates a
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Key light Fill light
Figure 3.7 A fill light is the secondary source of illumination that fills in shadows created by the key light.
subject is expressed as a ratio of the key light. For example, if only one light is used, the ratio is
0 : 1, where 0 represents the absence of a fill light, and 1 is the key light. A 1 : 4 ratio signifies that
the fill light is a quarter of the intensity of the key light. It is important to note that the smaller
number always represents the fill light (Figure 3.8). Asymmetrical lighting is generally preferred,
as it coveys depth with increase contrast, e.g. an acceptable ratio for portraits is 1 : 2 (Figure 3.9).
An equal ratio of 1 : 1 produces a flat image (Figure 3.10), sometimes referred to as a ‘high key’
image, that excessively softens facial features, but is ideal for glamour shots, or pictures of chil-
dren for conveying joviality and playfulness. On the other extreme, a ‘low key’ image emphasises
shadows, giving the picture depth and character, and is ideal for portraying personality traits
such as insight and wisdom. In a similar manner to the key light, the position of the fill light also
produces different effects. The simplest set‐up for portraiture is two studio flashes angled at 45°
to the subject, and is ideal for clinical portraits. This arrangement produces consistently repeat-
able and standardised images, ideal for reference and comparison. Whilst these images serve the
purpose of clinical reality, they are construed as bland, and unsuitable for marketing and promo-
tional purposes. In order for a portrait to fulfil marketing criteria, more elaborate set‐ups are
necessary, and some ideas for these images are discussed in Module 6.
There is an ongoing debate in dentistry as to which type of lighting is best suited for intra‐oral
dental photographs: uniform (with ring flash) or unidirectional illumination (with bilateral
flashes). The ultimate aim of flash photography is producing images where it is difficult to detect
whether or not a flash was used. Due to inappropriate illumination, the major flaw with intra‐
oral dental photography is that it is often blatantly obvious that flashes were utilised to take the
photograph. The resultant images appear flat, unnatural and totally devoid of character. In real-
ity, teeth are illuminated by subtle ambient lighting that conveys depth, character and nuances
of the dentition, rather than being ‘washed out’ by harsh illumination. Hence, it is necessary to
decide which type of flashes are the ideal choice for a particular type of intra‐oral image.
The choices available for extra‐oral (dento‐facial), intra‐oral and bench images are either
compact bilateral or ring flashes. The first option of a twin bilateral configuration with the
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(Full power) (1/4 power)
Figure 3.8 1 : 4 ratio signifies that the fill light is a quarter of the intensity of the key light.

Figure 3.9 1 : 2 ratio signifies that the fill light is a half of the intensity of the key light.
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(Full power) (Full power)
Figure 3.10 A 1 : 1 ratio signifies that the fill and key light have equal intensity.
flashes positioned 45° to the subject, using a balanced flash ratio of 1 : 1 that produces u niformly
exposed images with few shadows or highlights. In effect, this set‐up behaves similar to a ring
flash that produces uniform and shadowless illumination. The resultant images are lifeless and
appear as if they were taken with a flash. To mitigate this effect, asymmetrical unidirectional
lighting using a fill flash to key flash ratio of 1 : 2 is recommended. This means that the key flash
(e.g. the right flash) is set to maximum power (full duration or 1/1), whilst the fill flash output
(e.g. the left flash) is muted to half its power (half duration or 1/2). Alternately, a single flash can
be used with a silver reflector on the opposite side to bounce light back to fill in the shadows.
This set‐up produces a flash ratio of 1 : 2 that creates highlights, without completely obliterat-
ing shadows on the opposite side, resulting in an image that appears three‐dimensional and
realistic (Figures 3.11 and 3.12).
The second option is using ring flashes, which are available in two varieties. The first type of
ring flash has a circular flash tube that delivers consistent, 360° uniform shadowless illumina-
tion. These units emit light at a predefined intensity, which is usually unchangeable. The sec-
ond variety of ring flash has individual flash tubes located arounds its axis; top, bottom, right
and left. In addition, the intensity of the individual flash tubes can be altered and offers flexibil-
ity for modifying the flash ratio to a desirable 1 : 2 for asymmetrical illumination.
Depth of Field
The depth of field (DoF) is the range, or linear distance, in front and behind the point of focus
that appears sharp. The DoF is not abrupt, but a gradual blurring of the foreground and
background around the object that is in focus. This depends on a multitude of factors including the
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Depth of Fiel 53
Figure 3.11 Symmetrical uniform

lighting produces lacklustre, bland,
two‐dimensional imagery.
Figure 3.12 Asymmetrical

unidirectional illumination
produces three‐dimensional
imagery rich in detail and depth.
type of sensor, focal length of the lens, distance from the object, aperture, circle of confusion,
diffraction, pupil magnification and hyperfocal distance. The hyperfocal distance is the area or
point in a scene where focusing will result in the maximum DoF. This is particularly relevant
for macrophotography to maximise sharpness by making the most of DoF. The hyperlocal
distance is calculated according to the focal length of the lens, the sensor crop factor and the
chosen f‐stop. An example is photographing the maxillary anterior sextant using a 100 mm
macro lens with a full‐frame sensor at f 22. If the point of focus (PoF) is the mesial aspect of the
central incisors, the posterior DoF is ‘wasted’ as only the centrals are sharply focused. Similarly,
if the point of focus is the canines, the anterior DoF is lost. Therefore, the ideal hyperlocal dis-
tance in this composition is the mesial aspect of the lateral incisors, to maximise the DoF
(Figure 3.13). Table 3.1 shows varying DoF according to different factors.
The DoF is related to the degree of magnification: the higher the magnification, the shallower
the DoF. The significance of DoF for dental photography is that a macro lens is extremely close
to the subject, and therefore the area of sharpness is vastly diminished, limited to only a few
millimetres (shallow DoF). Since the hardware specifications (camera, lens) and visual acuity
are unchangeable, the user settings that affect DoF are the aperture and distance of the object
(focus distance) from the lens. However, the distance is also be unchangeable because a chieving
a particular magnification, e.g. 1 : 1, requires a specific distance, or minimum focusing distance
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PoF:
+ + Middle of canines
PoF:
Distal of laterals
+ +
Ideal hyperfocal distance PoF:

for maximum DoF + + Mesial of laterals
PoF:
+ Mesial of centrals
Figure 3.13 The ideal hyperlocal distance for photographing the maxillary anterior sextant is the mesial
aspect of the lateral incisors, which ensures maximum depth of field (DoF) (PoF = point of focus, represented
by the blue cross‐line reticles).
Table 3.1 Depth of field (DoF) calculations.
Sensor Lens focal length (mm) Aperture (f) Focus distance (cm) DoF (mm)
APS 100 22 30 6
Full‐frame 100 22 30 8
Point‐and‐shoot compact 100 8 1 10
camera (1 : 2/3 in. sensor)
of a macro lens. Hence, the only parameter to manipulate is the f number, which varies inversely
with the aperture opening. A large aperture opening (small f numbers) results in a shallow DoF,
whilst a small aperture opening (large f numbers) results in a deep DoF (Figures 3.14–3.16).
Therefore, it is essential to use small apertures (large f numbers), e.g. f 22, for ensuring that
intra‐oral images have as many teeth as possible, or large areas of soft tissue in focus. Table 3.2
shows increasing DoF by reducing the f numbers at a fixed focus distance of 30 cm.
Another factor to consider is that DoF varies according to the focal length of the lens. Wide
angle lenses have greater DoF, but as the focal length increases, the DoF decreases. As well as
altering the DoF, the focal length of the lens also changes the distribution of the DoF. For exam-
ple, the DoF for a standard lens is located equally in front and behind the point of focus.
Whereas, with a macro lens the DoF is distributed approximately 1/3 in front and 2/3 behind
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Depth of Fiel 55
f4
Shallow
DoF
Figure 3.14 Shallow depth of field (DoF): large aperture (small f number), only the third mirror from the left is
in sharp focus.
f 22
Deep
DoF
Figure 3.15 Deep depth of field (DoF): small aperture (large f number), all five mirrors are sharply focused.
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f4
f 22
Figure 3.16 Turning on the focus mask (green areas) shows the parts of the image that are in focus.
Table 3.2 Depth of field (DoF) vs. aperture.
Sensor Lens focal length (mm) Aperture (f) Focus distance (cm) DoF (mm)
APS 100 2.8 30 1

APS 100 5.6 30 1
APS 100 8 30 2
APS 100 11 30 3
APS 100 16 30 4
APS 100 22 30 6
the point of focus (Ahmad 2009b) – Figure 3.17. Therefore, if the DoF is 6 mm at f 22, objects
2 mm in front, and 4 mm behind the point of focus will appear sharp. In theory, it is possible to
increase the DoF by using even smaller f‐stop numbers such as f 32 or f 64. However, f‐stops
greater than f 22 cause chromatic diffraction at the edges of objects (rainbow effect), deterio-
rating image resolution. Therefore, setting an aperture smaller than f 22 substantially dimin-
ishes image quality without a substantial gain in DoF. This is the reason why many high‐quality
macro lenses are designed with diaphragms limited to f 22. Another method for increasing DoF
is by a process called focus stacking. A series of images is taken at different focus points, which
are subsequently merged in dedicated focus stacking software to create a single image with a
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Exposure and Histogra 57
½ ½
50 mm lens 13 23
100 mm macro lens
Figure 3.17 The focal length of the lens influences the range and distribution of depth of field (DoF)
(PoF = point of focus, represented by the white cross‐line reticles).
larger DoF. This technique is ideal for stationary still life compositions, but unsuitable for intra‐
oral photographs.
For portraiture, the DoF is less significant, since the lens is a considerable distance from the
object. For example, a camera with an APS sensor, 100 mm lens, at a focus distance of 2.5 m,
will have a DoF of 15 cm at an aperture setting of f 5.6, almost the entire anterior–posterior
distance from the tip of the nose to the ears. Hence, even with relatively large aperture open-
ings (smaller f numbers), the entire face will appear in focus. Furthermore, unlike macropho-
tography, the DoF for portraiture is distributed evenly in front and behind the point of focus.
Manipulating the DoF is useful for emphasising certain facial features, e.g. eyes or teeth, whilst
throwing the remaining facial landmarks out of focus by using larger apertures, creating a
pseudo‐three‐dimensional quality.
Exposure and Histogram
Exposure determines whether an image is too dark, too bright or just right. It is influenced by
the intensity of the light source and three cameras settings; aperture, shutter speed and ISO
number. The aperture is a metal diaphragm located inside the lens and controls the amount of
light entering the camera, similar to the iris controlling the diameter of the pupil of the eyes. A
wide aperture opening (small f number) allows more light to enter, whilst a small aperture
(large f number) restricts the amount of light. The shutter is a mechanical flap, similar to the
eyelids, and is either built into the lens or located in front of the sensor. Its speed is expressed
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in seconds or fractions of a second, and controls the duration of light falling onto the sensor.
Lastly, the ISO number is the sensitivity of the sensor to incoming light. The sensor is analo-
gous to the retina, which has rods that are extremely sensitive to light and effective for low‐
resolution night vision, whilst the fovea is densely packed with cones and requires brighter
illumination for high‐resolution daylight vision.
For dental macrophotography (both intra‐ and extra‐oral), aperture, shutter speed and ISO
are virtually unchangeable for the following reasons. In order to gain the maximum DoF, close‐
up images require a small aperture, usually f 22. Since flashes are the most frequently used light
sources for dental pictures, the synchronisation shutter speed, indicated by a lightning symbol
on the shutter dial or the liquid crystal displays (LCD) display, is also fixed, usually at 1/125 or
1/250 seconds. Finally, a minimum ISO setting, ranging from 50 to 200, is necessary for avoid-
ing visually noisy or grainy images. Therefore, the only part of the exposure equation that can
be changed is the flash intensity and/or the distance of the flashes from the subject.
Consequently, if the exposure is too dark or too bright, the only way to correct this is either
increasing or decreasing flash intensity output, or moving the flashes closer or further away
(Figures 3.18 and 3.19). If the image is still underexposed, then additional flashes or those with
higher guide numbers are required. Adding extra flashes is not a concern with TTL metering,
as the camera automatically controls the duration of flash bursts to ensure sufficient illumina-
tion. However, TTL may not always result in correctly exposed images. This is particularly
significant for intra‐oral photography because the highly reflective enamel surfaces against a
dark background of the oral cavity often confuse the flash metering mechanism. Another prob-
lem is using black contrasters, which have the benefit of masking extraneous anatomy, but
Over exposed Correctly exposed

Figure 3.18 Overexposed image: for dental photography only two factors can be altered: attenuating the light
intensity and/or moving the flash(es) further way from the subject.
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Under exposed Correctly exposed

(1/2 power) (Full power)
Figure 3.19 Underexposed image: for dental photography only two factors can be altered: increasing the light
intensity and/or moving the flash(es) closer to the subject.
often produce overexposed images since the camera metering registers the scene as overly dark
and compensates by over‐illuminating the scene. This is usually inconsequential as minor over‐
or underexposure can be corrected in imaging software. However, significant exposure com-
pensation in editing software will result in image quality deterioration and unwanted colour
shifts. If using manual mode, the best way to control illumination is moving the flash(es) closer
or further away until the correct exposure is attained. Taking a few test shots for a given set‐up
allows precise settings to be repeated for subsequent images.
Portraiture photography offers much more latitude for changing f‐stops and shutter speeds,
as well as altering studio flash intensity and positioning for creating the appropriate mood for
capturing or creating an individual’s persona.
With digital photography, the easiest method for gauging exposure is by a histogram, which
is a graph consisting of peaks and troughs of light intensity within an image (Nordberg and
Sluder 2013). It is often displayed on the LCD on the back of cameras, and also in image pro-
cessing software. The histogram, on a continuum, shows the tonal values within an image rang-
ing from the brightest (highlights), midtones to the darkest (shadows), on a scale of 0–255. The
histogram is useful for determining several factors, but the most important are the exposure
and dynamic range (DR). If the peaks are concentrated to the left side, the image is underex-
posed, and vice versa for overexposed images (peaks are located to the right side) – Figures 3.20–
3.23. However, for a given image, there is no ideal histogram, and its appearance depends on
the subject matter or the creativity of the photographer.
The DR is a measure of the difference between the brightest and darkest part of an image,
and expressed as the number of f‐stops, represented on the x‐axis of the histogram. Its
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Figure 3.20 The histogram is a graphical representation of several parameters including exposure and
dynamic range (DR).
Figure 3.21 Correct exposure: the histogram of a correctly exposed image has peaks mainly confined to the
midtones middle area, with a few peaks located in the shadow and highlight regions.
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Figure 3.22 Overexposure: the peaks are located to the right side of the histogram.
Figure 3.23 Underexposure: the peaks are located to the left side of the histogram.
s ignificance is that detail in an image is only discerned within the DR, i.e. the larger the DR the
greater the detail. The human eye has a large DR ranging from 16 to 24 f‐stops, a high‐end digi-
tal camera around 15 f‐stops, semi‐professional cameras about 5 f‐stops, film transparency or
high quality photographic print 6 f‐stops, computer monitors 6 f‐stops and the printing press
3–5 f‐stops, depending on lithographic equipment and the quality of printing paper
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Human eye
≈ 24 f stops
Digital camera Under-

Over-exposed
≈ 15 f stops exposed
Computer monitor Under-

≈ 6 f stops exposed Over-exposed
Print Under-
≈ 4 f stops Over-exposed
exposed
Figure 3.24 Dynamic range (DR) comparison of various media/devices (Source: background image, courtesy of
Zayan Ahmad).
(Figure 3.24). This means that a high‐end digital camera records nearly 5 f‐stops more detail
than film.
As detail is only discernible within the DR of an image, if the peaks are too much on the left
side (dark) or right side (bright), detail is indiscernible, even if the image is manipulated by
photo‐editing software. It is very easy to move the sliders in imaging software to achieve the
desired exposure, but extensive shifts in tonal range can first, deteriorate image quality, and
second, result in unwanted colour casts (see Figure 1.14 in Module 1). Therefore, to avoid these
eventualities, it is important to achieve the correct DR at the time of taking the photograph.
The issue at the capture stage is that if the brightest part of a scene has a EV (exposure value)
of 12, and the darkest part EV 1, the DR is 11. This means that the camera sensor must be capa-
ble of recording a DR of 11 to faithfully reproduce every detail in the image. However, DR range
is an inherent hardware feature of the camera sensor, and if the sensor is limited to a DR of 4
f‐stops, it is impossible to manipulate exposure to record a greater DR or enhance detail. Most
camera manufacturers are coy about stating the DR because of numerous variable factors.
However, independent testing reveals that most mid‐range dSLRs, with APS sensors, have a DR
of around 9 f‐stops, whilst full‐frame and medium format camera sensors can achieve a DR of
up to 15 f‐stops. Therefore, depending on the camera, some detail is likely to be lost due to limi-
tations of the sensor. One approach to expand DR is by HDR (high dynamic range) photography
or image hallucination technique, which ‘virtually’ increases the DR using post‐processing
software (see Module 9 for more details).
So, what is the ideal DR for an image? As mentioned above, this depends on the scene being
photographed and the intended use of the image, and ultimately a compromise is necessary. If
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White Balanc 63
the purpose is using the image for a lecture or presentation with a projector, a high DR, nearer
to the perception of the human eye, is the ideal. However, for printing purposes, a high DR is
futile, since the printing process inherently degrades an image to 3–5 f‐stops. Hence, an image
with a DR of 11 will deteriorate to 4 f‐stops when printed, losing 7 f‐stops stops of detail. This
is the reason why an image that looks vivid and vibrant on a computer monitor or auditorium
screen appears dull and lacklustre when printed. Practically, it is advisable to achieve a median
DR of around 6 f‐stops, which allows acceptable screening, but also mitigates detail loss when
printed or published.
White Balance
The white balance (WB) is simply ‘telling the camera’ about the quality, or colour temperature,
of light. The term ‘white balance’ is used because any ‘white’ part in a scene should be faithfully
reproduced as ‘white’ in the image. It is a setting that constantly changes depending on the
prevailing illumination. There are three methods for setting the WB: automatic, manual or
using an 18% neutral density grey card.
Using the automatic method is the simplest, and is usually displayed in the camera menu as
AWB (automatic white balance). In AWB mode, the camera detects the light source and auto-
matically sets the WB accordingly, which works well for the majority of photographic scenar-
ios. However, extreme or subtle lighting conditions are challenging for camera detectors, and
may cause unwanted colour casts of the image. This is particularly relevant for low or bright
ambient light, or a mixture of different light sources in a given scene. Examples of some illumi-
nation are sunrise (2000 K), daylight (6500 K), twilight (8000 K), moonlight (4000 K), indoor
lights (3000 K) and photographic flashes (5500 K) – see Figure 1.15 in Module 1. In these cir-
cumstances, the camera gauges an average of the mixed lighting conditions, which may be
satisfactory, but sometimes the results are disappointing due to the dominance (or colour cast)
of a single light source. AWB is not recommended for intra‐oral photography since many light
sources are present, including daylight from widows, ceiling lights, operating light and fibre‐
optic illumination of dental loupes. Any of these may confuse the WB mechanism, often result-
ing in capricious colour cast images, which are diagnostically useless due to the altered colour
of healthy and pathological tissues.
The second method is manually setting the WB, either by selecting the quality of light, or
inputing a numerical value for the colour temperature. The former involves choosing various
symbols in the WB menu, representing different lighting conditions such as bright sunlight,
overcast or cloudy sky, indoor halogen bulbs, fluorescent tubes, flash illumination, etc.
Manually selecting a pre‐set WB symbol is pure conjecture regarding the true colour
temperature, perhaps acceptable for general photography, but inappropriate for clinical fidelity.
The second option is inputting a numerical value in Kelvins corresponding to a particular type
of illumination, for example matching the colour temperature of the flashes, which is
photographic daylight at 5500 K. Numerical input of colour temperature is more predictable,
but if the ambient light is overpowering or changes, this may affect colour rendering as well as
confusing the TTL flash metering of some cameras.
Finally, the third method for WB setting is using an 18% neutral density grey card, which
reflects all colours of the spectrum in equal proportions. This is not just any grey card, but one
specifically designed for calibrating light meters or camera WB, and is available from photo-
graphic outlets. Similar grey cards are also used for shade analysis and selection of ceramic
and resin‐based composite restorations, and are included in ceramic and composite kits. This
method of setting the WB is the most accurate, but somewhat tedious. However, for a specific
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Figure 3.25 White balance (WB) setting with an 18% grey card: an initial reference picture is taken with the
card in‐situ. The initial colour temperature is 7501 K.
recurrent set‐up, the procedure need only to be performed once. A photographic grey card is
placed within the scene, making sure that it is illuminated identically to the object/subject. For
intra‐oral pictures, the card should be in the same plane (optical axis) as the teeth or soft tis-
sues, avoiding shaded areas or obstructing the light source (flashes). A reference picture is then
taken with the card in‐situ, before proceeding with the remaining photographic session. All
images of the same session are imported into a photo‐editing software together with the refer-
ence picture. In the processing software, the ‘neutral grey’, ‘neutral picker’ or ‘pick white bal-
ance’ tool is selected (usually depicted by a pipette or eyedropper). The mouse pointer changes
shape to a pipette, and the latter is placed and clicked on the grey card in the reference pic-
ture, which immediately corrects its WB. This setting is saved as a ‘user preset’ and subse-
quent applied to images with a similar photographic set‐up. In this manner, multiple selected
thumbnails from the session can simultaneously and instantly be corrected by recalling the
saved WB settings with a single click of the mouse (Figures 3.25–3.28). Although the grey
card method for WB is the most accurate and predictable, flash angulations, distance and
intensity must be kept identical as for the reference picture in order to ensure consistent
results. If illumination or camera setting are changed, another reference picture is required
for the new set‐up.
Resolution
Resolution is the quality of the captured image. The quality of an image is influenced by numer-
ous factors, including the resolving power of the lens (Bengel 2006; Sajjadi et al. 2015), the size
of the digital camera sensor (Sajjadi et al. 2016), post‐capture editing and the display media.
Another variable is the degree of training of the observer to discern details in an image. A
trained eye can pick out details that may go unnoticed by the novice (Figures 3.29 and 3.30). For
example, a dental specialist is more trained to scrutinise the dentition compared to a layperson
(Ker et al. 2008). Furthermore, every observer will concentrate on different aspects of an image
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Resolutio 65
Figure 3.26 White balance (WB) setting with an 18% grey card: the neutral picker is selected in the processing
software and clicked on the grey card in the reference image. The colour temperature (WB) is instantly
corrected according to the reference grey card and is now 6368 K. Notice that the corrected image on the left is
slightly bluish compared to the uncorrected image on right that appears more yellowish.
Figure 3.27 White balance (WB) setting with an 18% grey card: the WB setting is saved as a user preset
(WB‐30Jan18)…
depending on his education or speciality. An orthodontist concentrates on tooth alignment, a

restorative dentist may be concerned with the marginal integrity of a filling, a periodontist with
gingival inflammation, and so on. Therefore, the resolution of an image depends on the amount
of detail required for a given speciality, and every speciality has different resolution needs. For
restorative dentistry, assessing nuances in colour, dentine mamelons or incisal and interproxi-
mal translucencies is essential for mimicking these characteristics in artificial restorations, and
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Figure 3.28 …and subsequently applied to all image(s) taken in the same session. Notice that the colour
rendering of both images is identical after correcting the white balance (WB).
Figure 3.29 Resolution is influences by

several factors including the trained
eye to discern detail. The intricate
capillary network within the free
gingival margin surrounding the
maxillary right central incisor may go
unnoticed by the untrained eye.
Figure 3.30 Magnified view of the

cervical region of the maxillary right
central incisor showing the intricate
capillary network.
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Resolutio 67
therefore, images with higher resolution for discerning fine detail are required. Conversely,
assessing tooth alignment before and after orthodontic treatment can be achieved with rela-
tively low resolution images. For aesthetic dentistry, the quality of an image impacts on the
perception of beauty, together with treatment outcomes after aesthetic improvement. In these
circumstances, a high‐resolution image is beneficial for conveying beauty, irrespective of the
modalities used for the aesthetic enhancement (Jacobsen et al. 2006; Tüzgiray and Kaya 2013).
Table 3.3 Synopsis of camera settings for close‐up and portraiture dental photography.
Close‐up or macro
(intra‐oral, extra‐oral and
Setting bench shots) Portraiture
Shutter speed Compact flash synchronisation Any, depending on camera brand and lens,
speed, either 1/125 s or 1/250 s usually 1/125 s
Aperture f 22 For standardised clinical portraits f 11 is
N.B. When using intra‐oral recommended to ensure sufficient depth of
mirrors, reduce by one f‐stop field (DoF). For non‐clinical portraits, any
to f 16 f‐stop is suitable depending on the desired
When using contrasters effect; a good starting point is f 5.6
increase by one by one f‐stop,
or reduce flash intensity
ISO 50–200 50–200
White balance Manually set to 5500 K, or take Depending on type of light, for studio flashes
(WB) reference picture with 18% manually set to 5500 K, or take reference
neutral density grey card shot with 18% neutral density grey card
Aspect ratio Camera default aspect ratio Camera default aspect ratio
Colour space Adobe® RGB, or sRGB Adobe RGB, or sRGB
Moiré reduction Default setting Default setting
Focusing Manual focus Manual or auto‐focus
Exposure modes Aperture priority or manual Manual
Exposure metering Compact flashes (TTL or Manual
manual)
Auto‐exposure Multi‐field or multi‐zone Any
metering mode
Exposure None None
bracketing
Shutter drive Single Single
modes
Image data format Proprietary RAW, Adobe DNG Proprietary RAW, Adobe DNG (digital
(file format) (digital negative graphic) negative graphic)
Date/time format Depending on country Depending on country
All other settings Default setting Default setting
Storage/data UHS I (30 MB/s writing speed) UHS I (30 MB/s writing speed) SD card or
transfer SD card or UHS II (100 MB/s UHS II (100 MB/s writing speed) SD card or
writing speed) SD card or internal RAM storage
internal RAM storage
Location (GPS – Personal preference Personal preference
Global Positioning
System)
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Other Settings
Contemporary cameras offer a huge number of additional settings, many beyond the scope of
this book. However, the best practice is initially keeping everything to factory default settings.
After gaining confidence and experience, and guided by referencing advanced photographic
literature, one can fine‐tune these settings for stepping up to the next level. Table 3.3 summa-
rises some commonly used options for dental photography and their corresponding values.
These settings need only be carried out once for a specific set‐up, and most cameras allow user
settings to be stored as ‘user presets’ and recalled when required. For dental photography, two
user defined settings are required, corresponding to two basic set‐ups: the first for intra‐oral,
extra‐oral and bench shots, and the second for portraiture.
References
Ahmad, I. (2009a). Digital dental photography. Part 5: lighting. Br. Dent. J. 207 (1): 13–18.
Ahmad, I. (2009b). Digital dental photography. Part 6: camera settings. Br. Dent. J. 207 (2): 63–69.
Bazos, P. and Magne, M. (2013). Demystifying the digital dental photography workflow. The big
picture: facial documentation with high visual impact photography. J. Cosmet. Dent. 29 (1):
82–88.
Bengel, W. (2006). Mastering Digital Dental Photography. New Malden, UK: Quintessence.
Cytowic, R. (2003). The Man Who Tasted Shapes. Cambridge, MA: MIT Press.
Jacobsen, T., Schubotz, R.I., Hofel, L. et al. (2006). Brain correlates of aesthetic judgment of beauty.
Neuroimage 29: 276–285.
Ker, A.J., Chan, R., Fields, H.W. et al. (2008). Esthetics and smile characteristics from the
layperson’s perspective. J. Am. Dent. Assoc. 139 (10): 1318–1327.
Manjunath, S.G., Ragavendra, R.T., Sowmya et al. (2011). Photography in clinical dentistry – a
review. Int. J. Dent. Clin. 3 (2): 40–43.
Nordberg, J.J. and Sluder, G. (2013). Practical aspects of adjusting digital cameras. Methods Cell
Biol. 114: 151–162.
Sajjadi, S.H., Khosravanifard, B., Esmaeilpour, M. et al. (2015). The effects of camera lenses and
dental specialties on the perception of smile esthetics. J. Orthod. Sci. 4 (4): 97–101.
Sajjadi, S.H., Khosravanifard, B., Moazzami, F. et al. (2016). Effects of three types of digital camera
sensors on dental specialists’ perception of smile esthetics: a preliminary double‐blind clinical
trial. J. Prosthodontics 25: 675–681.
Tüzgiray, Y.B. and Kaya, B. (2013). Factors affecting smile esthetics. Turk. J. Orthod. 26: 58–64.
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69
Composition and Standardisation
The preceding modules have concentrated on the technical aspects of photographic e quipment,
which are important but do not necessarily guarantee a good picture. Besides light, the second
most important aspect of photography is composition. Composing a picture is no different to
compositing a piece of music. After configuring the photographic equipment, similar to tuning
musical instruments, the next stage is making music. Photographic composition is about
framing a picture so that it has visual harmony. Put simply, it is guiding the eye to the most
important part of the picture,1 and elevating it to a psychological and synæsthetic experience.
Composition
A picture can be composed ad hoc or using a set of predefined rules. Many of the principles of
composition are also used for aesthetic dentistry when designing a smile. There are several rules
and principles for photographic compositions including figure‐to‐ground, the rule of thirds, Phi
grid, Fibonacci spiral, leading lines, diagonals, the rule of direction, visual weight, symmetry, bal-
ance and image content, to name a few. Although these rules are not applicable to every photo-
graph, and will not necessarily produce striking images, incorporating these principles while
composing a picture can help to effectively tell a story. Composing can either be orchestrated
before taking the picture by changing the position of the objects, subjects and the camera, or later
during the processing stage in imaging software. The latter is ideal for cropping extraneous objects
or positioning items so that they are spatially located in desirable positions. However, image pro-
cessing cannot correct poor composition, which should be addressed while taking the picture. The
following discussion suggests some food for thought for successfully composing a picture.
Dominance
The most popular method for achieving dominance is using the figure‐to‐ground rule. The
‘figure’ is the main subject, while ‘ground’ is the background. The idea is to enhance separation
between the two by varying contrast, size, colour or selective focusing (Figure 4.1). These are
effective methods for achieving dominance, similar to the maxillary central incisors that are
the dominant elements of the maxillary anterior sextant due to their larger size, position in the
arch and brighter colour.
The maxim, ‘less is more’ is worth bearing in mind when considering dominance. The con-
tent of an image plays a crucial role in visual perception, and if an image is cluttered with
1 https://photographylife.com/introducing‐composition‐in‐photography

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70 Composition and Standardisation
Figure 4.1 A simple but effective way to achieve figure‐ground is silhouetting the subject against a bright
background.
objects, the result is visual cacophony and tension since there is too much information for the
eyes to analyse. Therefore, minimising the image content by selective focusing or increasing
the magnification factor to frame a few objects, allows the eye to concentrate on the main point
of interest (Bengel and Devigus 2006) – Figures 4.2 and 4.3. Framing or cropping is an obvious
way to allow the observer concentrate on salient features without being distracted by extrane-
ous, irrelevant objects. This is particularly relevant when documenting sequential procedures
for demonstrating techniques. A series of pictures should be cropped to concentrate on the
salient teeth, rather than including the whole arch (Figure 4.4). Another dental example is using
a black contraster to enhance the contrast of the teeth against a dark background, and for
emphasising tooth characteristics such as incisal translucency (Figure 4.5).
Figure 4.2 Selective focusing and selective lighting achieves a desirable figure‐ground separation,
e.g. focusing on the frost on a leaf, which is thrown out of focus.
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Compositio 71
Figure 4.3 Selective focusing and

selective lighting achieves a
desirable figure‐ground separation,
e.g. the sharply focused #15c
surgical blade with an out‐of‐focus
oral cavity, guiding the eye to the
point of interest.
Figure 4.4 A series of images

depicting a clinical technique
should be framed to allow the
observer to concentrate on
specific teeth.
Figure 4.5 Placing a contraster

behind teeth increases contrast and
emphasises incisal translucency.
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Positioning
The basic concept of composition is arranging or positioning objects within the frame so they
have visual appeal. The first rule that is universally taught about composition is the rule of
thirds, which helps to position elements in a frame so that they are interesting and engaging
for the viewer.2 The rule of thirds divides an image with four lines into a nine‐part grid
(Figure 4.6). This is the most popular grid used by camera manufacturers and is either visible
through the viewfinder, or on the LCD display on the back of the camera body. If objects are
placed along or at the intersection of the four lines, the image is more appealing to the
observer.3 This is because the eyes are more attracted to objects that are off‐centre in a frame
than those that are in the centre. Therefore, placing points of interest to one side, or at the
Figure 4.6 The rule of thirds grid.
Figure 4.7 Portrait with the subject centralised in the frame.
2 Rule of Thirds – Digital Photography School, 2015

3 What is the mysterious ‘Rule of Three?, https://rule‐of‐three.co.uk
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Compositio 73
Figure 4.8 Portrait conforming to the rule of thirds, with the pupil of the subject’s left eye intersecting the grid.
Figure 4.9 The initial composition does not conform to the rule of thirds.
intersection of the four lines, adds interest to the composition. The rule of thirds is applicable
for any picture, including portraits (Figures 4.7 and 4.8), but particularly still life or bench
shots, as the photographer has full control to position the objects anywhere in the composi-
tion (Figures 4.9–4.11). This rule is also relevant for intra‐oral images, especially at the editing
and cropping stage, when points of interest can be shifted to the intersection of the rule of
third grid lines (Figures 4.12 and 4.13).
Instead of dividing the grid equally into 1 : 1 : 1 vertically and horizontally as in the rule of
thirds, the Phi grid divides the frame according to the Golden Proportion (GP) into 1 : 1.618 : 1
rectangles (Figure 4.14). Similar to the rule of thirds, the Phi grid is used to compose a picture
so that items of interest are located within the grid divisions or at the intersection of the lines.
The choice between using the rule of thirds or the Phi grid is a personal preference, the rule of
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Figure 4.10 At the cropping stage, the image is cropped and moved using the rule of thirds
grid to place the water droplets along and at the intersection of the grid lines.
Figure 4.11 The final image composed according to the rule of thirds.
thirds is not mathematically accurate, and therefore, may be perceived as too simplistic, con-
trived and obvious, but in practice is easier to use. The Phi grid provides a mathematically
precise and perfect composition, which may sometimes be difficult to attain. Also, the choice
depends on the subject matter, what the photographer is trying to convey, and which one ‘feels’
right for a particular composition (Figures 4.15 and 4.16).
Another grid is the Fibonacci spiral (Figure 4.17), which is also based on the GP and is ubiqui-
tously evident in nature such as the Milky Way, flower petals arrangements or spirals of sea-
shells. This grid is used by artists, architects and graphic designers for arranging elements to
enhance visual appeal. The principle of this grid is arranging elements along a curved path that
guides the eye to the protagonist object at the ‘eye’ of the grid. This is an extremely effective
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Figure 4.12 An image framed to conform to the rule of thirds by ensuring that the depth cut bur is located at
the intersection of the grid lines.
Figure 4.13 The cropped image in Figure 4.12 according to the rule of thirds.
Figure 4.14 The Phi grid.
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Figure 4.15 The Phi grid was used to frame this picture, ensuring that the text ‘CERAMICS’ was confined to the
middle row of the grid.
Figure 4.16 The final composition according to the Phi grid.
Figure 4.17 Fibonacci spiral grid.
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Compositio 77
method of framing a picture and can be carried out at either the capture, or post‐processing
stages. Figures 4.18–4.24 demonstrate framing a picture according to the Fibonacci spiral at
both the capture and processing stages. All the above three grids are accessible in imaging soft-
ware during the alignment and cropping stage, or as plug‐ins and apps from vendors (Figure 4.25).
Aligning grids are a useful guide and offer a systematic approach for composing images at the
capture and/or post‐processing stage in editing software. However, aligning images that con-
form to these grids is subjective, and may not be appropriate, or desirable, for every type of
image. A classic example is portraiture, when framing depends on the subject’s and photogra-
pher’s personal preferences, which may or may not conform to a particular grid
(Figures 4.26–4.29).
Figure 4.18 A 3‐D printed surgical guide with osteotomy drill. The main point of interest is the drill, which is
incorrectly framed since the ‘eye’ of the Fibonacci spiral does not corresponding to the position of the drill.
Figure 4.19 Correctly framed image with the ‘eye’ of the Fibonacci spiral corresponding to the position
of the drill.
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Figure 4.20 The final cropped

image according to the Fibonacci
spiral.
Figure 4.21 In order to frame this picture according to the Fibonacci spiral, the patient’s head was moved to
the left and the camera positioned to capture a lateral view ensuring that the point of interest (the tip if the
flowable composite) was in the ‘eye’ of the Fibonacci spiral.
Figure 4.22 The final framed image

according to the Fibonacci spiral.
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Compositio 79
Figure 4.23 The ‘eye’ of the Fibonacci spiral is located at the point of interest, which is the haemorrhage
emanating from the sulcus of the maxillary right canine.
Figure 4.24 The final image framed

according to the Fibonacci spiral.
Leading the Eye
Leading the eye means guiding the eyes with imaginary or actual line(s) to the point of interest
in the image. A leading line is any structure or part of an image that leads the eye to the main
subject (Figures 4.30 and 4.31). This concept is predominately employed for landscape photog-
raphy, but can also be creatively applied to both intra‐oral and bench images (Figures 4.32 and
4.33). For example, in landscape photography, this principle is effectively applied where roads,
railway lines, stairs, rivers or paths are framed in the foreground and guide the eye inwards and
upwards to the main point of interest. Another method is using leading lines to convey mystery
by deliberately placing the point of convergence outside the frame of the shot, which leaves
the viewer wondering what lies at the end of the lines. Furthermore, leading lines add depth
and perspective to a composition. For dental photography, imaginary lines such as the inter‐
pupillary line, Camper’s plane (ala‐tragus line), Frankfort plane, and dental or facial midlines
give stability to an image (Figure 4.34). Another example is parallelism of the maxillary incisal
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Figure 4.25 Most imaging software offer a selection of grids for composition pictures at the aligning and
cropping stages.
Figure 4.26 Original captured image.
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Compositio 81
Figure 4.27 Cropping according to the rule of thirds.
Figure 4.28 Cropping according to the Phi grid (Golden Proportion).
plane to the curvature of the mandibular lip during a relaxed smile, which adds cohesiveness to
a dento‐facial composition (Figures 4.35 and 4.36).
Diagonals or diagonal lines serve a similar purpose to leading lines by engaging the viewer.
Whereas leading lines guide the eye to a particular destination into the picture, diagonal lines
guide the viewer through the picture. As with leading lines, diagonals add a three‐dimension
quality to an image. An important distinction between leading (or converging) lines and diago-
nals is that the former creates static dramatic imagery, while the latter creates kinetic imagery
by adding a sense of motion (Figures 4.37 and 4.38).
The rule of direction is yet another way of guiding the eyes. In most western cultures, reading
and writing are from left to right, while the opposite is true for much of the Eastern Hemisphere
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Figure 4.29 Cropping according to the Fibonacci spiral grid.
Figures 4.30 and 4.31 Leading lines draw the viewer into the picture.
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Compositio 83
Figures 4.32 and 4.33 The periodontal probe handles guide the viewer to the tip of the probes, which are the
main point of interest in relation to the short clinical crown lengths of the maxillary anterior sextant.
(Figures 4.39 and 4.40). Therefore, similar to reading a book, the climax should be at the end of
the picture, and its direction should be left to right for Western societies, culminating to most
important part of an image on the right side, and vice versa for right to left cultures. The rule
of direction adds intrigue, allowing the observer to build up to the crescendo, rather than
knowing the ending beforehand.
Balance
Visual weight ensures that the right and left, or top and bottom, parts of an image are balanced.
This is achieved by placing objects to fill voids or negative spaces in a composition (Figures 4.41
and 4.42). This is achieved by either adding and incorporating objects within the frame, or by
altering the colour and lighting of a scene. For example, a dark colour carries more balance that
a light one, while an intense light is perceived as ‘bigger’ compared to a dim light.
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Frankfort plane
Inter-pupillary
line Camper’s plane
Occlusal plane
Facial midline
Figure 4.34 The imaginary facial lines act as cohesive and segregative forces to the facial composition.
To summarise, the basic rules for photographic compositions are guidelines, and not rigid
rules cast in stone. They are useful for composing a picture, but often involve trial and error
until a composition gels with the photographer’s vision, which develops with time, experience
and perseverance. Probably the most important factor for composing a picture is intuition,
which can subconsciously direct the photographer to produce striking images. Furthermore,
breaking rules can often produce innovative and visually striking results, but ignoring them
may result in catastrophic failures.
Standardisation
Dental photography is basically visual dental documentation; its value lies in comparison for
self and peer‐critique of the same or different patients, and historical cohort studies for moni-
toring and research (Bengal 1985; Ettorre et al. 2006; Galdino et al. 2001).
In order to realise these objectives, some form of standardisation is prerequisite, establishing
guidelines for consistency, comparison and communication (Graber 1946; Martins et al. 2013).
Furthermore, standardisation starts at the capture stage when an image is composed and ends
at the processing/display stage when the image is edited using computer software and repro-
duced with the chosen media (monitor, projector, print), respectively. There are three factors
that influence standardisation; human factors, technical factors and the intended use of the
image.
The human factors are the patient, assistant and the operator, usually the clinician, who is
taking the photographs while the assistant ensures patient comfort and helps with positioning
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Standardisation 85
Figures 4.35 and 4.36 Cohesiveness in a composition unites elements together such as parallelism of the
incisal plane to the curvature of the mandibular lip.
the dental armamentarium and photographic equipment. The operator factors include suffi-
cient knowledge, training and experience in dental photography, and the ability to adapt to
patients’ idiosyncrasies to avoid jeopardising the photographic session. The patient factors
include the physical and mental state of the patient, and whether they are able to fully cooper-
ate with and endure the photographic procedures. This could mean controlling excessive sali-
vary flow or taming involuntary gagging reflexes. In addition, paying attention to any local soft
and hard tissue anatomical variations that may hinder posture in the horizontal, vertical and
sagittal planes. Another issue is obtaining an unimpeded retraction of the extra‐oral soft tis-
sues for a clear field of view of the oral cavity.
The quintessential technical requirement of an image is that it is sharp, in focus, correctly
composed with the proper colour balance and exposure, and records with fidelity the object(s)
or subject(s) being photographed. This involves understanding basic photographic concepts
outlined in previous modules, and configuring the camera and ancillary equipment settings to
produce repeatable and predictable results. The technical aspects include several variables
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Figures 4.37 and 4.38 Diagonals add kinetic dynamism to a composition.
Figure 4.39 Left to right rule of direction for Western cultures: the eye is guided from left to right, culminating
at the tip of the blade, which is the point of interest.
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Standardisation 87
Figure 4.40 Right to left rule of direction for Eastern cultures: the eye is guided from right to left, culminating
at the tip of the blade, which is the point of interest.
Figure 4.41 Balance is lacking in this composition due to the extensive negative space on the right side…
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Figure 4.42 …by adding a streetlamp post, the composition becomes more balanced.
such as dental armamentarium, the camera sensor size, the focal length of the lens, equipment
settings, illumination (quality and quantity), lens axis or angle of view (vertical and horizontal
composition), background, and scaling or magnification.
The last factor to consider is the purpose or intended use of an image. The intended use may
be clinical documentation, marketing, or educational (lecturing/publishing). Clinical docu-
mentation also depends on the particular speciality, e.g. orthodontics, periodontics, surgery,
oral medicine, aesthetics, to name a few. A portfolio of stock views is adequate for basic docu-
mentation, but additional images are required depending on the speciality, or a specific treat-
ment modality. For example, a standard set of extra‐ and intra‐oral images are sufficient for
cranio‐maxillo‐facial surgery (Ettorre et al. 2006), but inadequate for a ceramist who is fabri-
cating a single unit crown to match an adjacent natural tooth. Another category is marketing
and promotion, where image requirements differ from clinical reality. Marketing images serve
an entirely different purpose to clinical documentation. They are intrinsically enticing, pro-
moting a given treatment and omitting clinical procedures that may be unpalatable for layper-
sons, e.g. graphical depiction of surgical procedures. Lastly, recording treatment sequences
and outcomes for lecturing and/or publishing are aimed at educating and inspiring a target
audience. Hence, these images are different to insipid clinical documentation, and incorporate
aspirational aspects for enhancing and encouraging the teaching and learning process.
In order to accomplish standardisation, two pertinent questions need to be asked. First, ‘Is
standardisation possible in dental photography?’, and if so, ‘What can, and what cannot, be
standardised?’
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Standardisation 89
There are certain aspects of dental photography that can be standardised. These include
predefined positions of the patient, photographic equipment and operator, and configuring
photographic and ancillary equipment to specific settings. However, some factors, predomi-
nantly hardware‐related, cannot be standardised. These include photographic equipment that
is unique to a particular manufacturer that is rarely interchangeable or inter‐compatible with
other brands. The market is awash with innumerable competitors with proprietary closed sys-
tems, which offers vast consumer choice, but at the expense of forgoing generic open systems.
Therefore, the factors that are standardisable will produce comparable and consistent images
for inter‐ and intra‐patient documentation, but are limited to an individual dental practice or
institution with specific brands of photographic equipment.
Standardisable Factors
The standardisable factors are related to photographic equipment settings, correct patient
positioning (Sommer and Mendelsohn 2004), dental armamentarium and the operator taking
the pictures. Ideally, a set of dental photographic protocols should be established and followed
for achieving direct comparisons, even if the photographs are taken by different operators.
The technical elements for standardisation are the equipment settings for consistent expo-
sure (Niamtu 2004), DoF, composition, framing, orientation, colour rendition, file formats,
elimination of extraneous artefacts, and the requisite number of images for a given portfolio. It
goes without saying that an image should be correctly exposed, neither too bright, nor too
dark. This is achieved by either using flash TTL (through‐the‐lens) metering, or alternately,
taking a few test images for identical set‐ups. Another essential item is precise colour render-
ing, without unwanted colour casts for distinguishing healthy and diseased tissues. This is
achieved by the correct white balance, periodically calibrating computer displays with calibra-
tion devices and keeping the same ICC (International Color Consortium) colour profile for all
images. Although resolution cannot be standardised due to unique hardware specification, this
is not an overwhelming concern since most contemporary cameras can deliver adequate reso-
lution for the majority of dental applications. Nevertheless, a dental image should have suffi-
cient detail for discerning salient features of hard and soft tissues. However, different specialities,
or images for special applications, require specific visual information, which is elaborated in
later modules. Finally, images in a standard portfolio should convey the following features with
clarity and clinical fidelity (Ahmad 2009) (Figures 4.43–4.45):
●● Distinction between healthy and diseased tissue, especially discriminating pathological
changes
●● Attached gingivae, showing degree of stippling (texture) for assessing periodontal biotypes
(thick, thin) and bioforms (scalloped, flat)
●● Transition between keratinised and non‐keratinised oral mucosa for assessing width of
keratinised tissue (attached gingivae, free gingival margin, gingival groves, clefts, scarring)
●● Shade transition in teeth traversing from cervical to body to incisal edges
●● Enamel characterisations, lobes, mottling, stains, chips, texture, hypoplasia, cracks, fractures
and perikymata
●● Incisal, interproximal translucency and mamelons
●● Attrition, abrasion, erosion, abfraction lesions
●● Hypocalcification, fluorosis, tetracycline staining
●● Cervical dentine exposure, extrinsic, intrinsic and internalised pigmentation
●● Defective restorative margins
●● Secondary caries, restorative material wear, chips and discolouration
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Figures 4.43–4.45 Clinical documentation should include features of diagnostic value (see above list for some
salient features).
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Standardisation 91
Lens image circle matching a full frame sensor
Full frame sensor (1.0x)
Figure 4.46 A full‐frame sensor has the same magnification factor as the focal length of the lens (crop
factor 1.0×).
Scaling or magnification is also a crucial aspect for ensuring consistency (Sugawara et al.
2014). The proverbially quoted magnifications for specific dental photographs – i.e. 1 : 1 and
1 : 2 for intra‐oral, 1 : 5 for dento‐facial compositions and 1 : 8 to 1 : 15 for full face or portraiture –
is based on 35 mm film photography. All analogue 35 mm cameras used the same celluloid film
consisting of identical 35 mm × 24 mm frames. Hence, for a given focal length lens, the magni-
fication factor was always the same for all 35 mm cameras, irrespective of the brand. However,
this is not the case with digital photography, since the film is replaced by sensors that have
different physical dimensions (see Figure 1.9 in Module 1). Therefore, the magnification factor
of a lens is only applicable for cameras that have a full‐frame sensor corresponding to the size
of a 35 mm film frame (Figure 4.46). If the sensor is smaller (usually) or larger than conven-
tional 35 mm film, a crop factor is applied, which varies according to the size of the sensor. To
overcome the issue of different sensor sizes and to ensure a consistent magnification, the focus-
ing distance on the lens barrel can be pre‐set for a particular view, e.g. intra‐oral, dento‐facial
or portrait compositions.
Besides the technical issues of scaling, the physical size of facial features and intra‐oral anat-
omy varies enormously between individuals. If the maxillary and mandibular arches are large
or small, a pre‐set magnification may crop vital features, or include extraneous objects such as
cheek retractors, respectively. Another approach for ensuring a consistent field of view is using
anatomical landmarks for composing both extra‐oral and intra‐oral dental images. For clinical
portraiture, instead of using a predefined magnification, the background area surrounding the
hairline and the auricles can be predefined with the lower margin bounded by the sterno‐clav-
icular joint. For dento‐facial views the landmarks could be the tip of the chin (menton) to the
middle of the nose (rhinion) – Figure 4.47. For intra‐oral images, the mucogingival junction,
retracted sulci, number of posterior teeth and buccal corridor are helpful anatomical pointers
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Trichion
Glabella
Nasion
Rhinion
Supratip
T ip of nose
Subnasale
Labrale superius
Stomion
Labrale inferius
Mento-labial sulcus
Pogonion
Menton
Cervical point
Figure 4.47 Facial anatomical landmarks are useful guides for farming a particular view.
Figure 4.48 Reference makers such

as periodontal probes are an ideal
way to depict scale within an
image.
for ensuring reproducible and consistent compositions, irrespective of the magnification scale
on the lens. A useful approach for conveying scale within an image is including reference mark-
ers such as periodontal probes or rulers for indicating dimensions of teeth, restorations, soft
tissue landmarks or lesions (Figure 4.48). The major items that can be standardised are sum-
marised in Table 4.1.
Non‐standardisable Factors
Although not exhaustive, the standardisable factors outlined above are sufficient to allow com-
parisons for the majority of inter‐ and intra‐patient photographic documentation. However,
there are several factors, mainly hardware‐related, which are impossible to standardise. Factors
such as resolution, colour space, bit depth, absolute colour rendition, quality and quantity of
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Standardisation 93
Table 4.1 Standardisable factors for dental photography.
What? Why? How?
Positioning To expedite photographic Patient position: seated upright, partially

(patient, operator, session, repeatable images for relined or supine (depending on the type of
assistant, diagnosis, treatment image required).
equipment) planning, sequencing Mount camera on tripod, makings on floor for
outcome, and inter‐ and positions of camera, lights, photographer and
intra‐patient comparisons assistant
Image orientation For same perspective Landscape orientation
Spacial orientation For same angle of view in Use orientation guides such as the horizon,
vertical, horizontal and Frankfort plane, Camper’s line, inter‐pupillary
sagittal planes line, facial midline, camera viewing screen
grids, spirit level
Composition (field Consistent views for Magnification factor, pre‐set focusing distance
of view) compassion on lens, intra‐oral and extra‐oral anatomical
landmarks
Framing Cropping irrelevant parts of Capture image with larger framing for
image for concentrating on subsequent cropping in imaging software
points of interest
Exposure For faithfully reproducing For intra‐oral images: manipulating intensity
subjects with a given lighting and distance of flashes.
set‐up For extra‐oral images: manipulating shutter
speed, f‐stop, ISO, histogram and illumination
(intensity and distance)
Colour rendition For true colour reproduction Setting the white balance, identical ICC profiles
Shapness For discerning details Fast shutter seeds, flash illumination, ideal
hyperfocal distance, sufficient depth of field
Extraneous For avoiding visual Judicial placement of saliva ejector, cotton
objects or distractions wool rolls, edges of mirrors, cheek retractors
artefacts and contrasters. Remove saliva, blood, biofilm,
extrinsic stains, food debris. Prevent scratches,
droplets, fogging (condensation) on mirrors
Number of images For inter‐patient comparison, Predefining the number of images according
in portfolio and comparing pre and to the dental discipline or specific application
post‐operative treatment
outcomes
Post‐capture Consistent criteria for Use same photo‐editing software for exposure
processing comparisons correction, orientation, cropping extraneous
artefacts or parts of image
Metadata For recall and archival Date, patient details, camera and software
settings
Image data format Different formats for Small JPEG files for internet communication,
(file format) different needs large TIFF files for publishing and archiving
illumination are all device‐specific, with little standardisation between different brands. It is
worth noting that although the relative colour rendition for a given computer display can be
standardised using colour calibration devices and ICC profiles, absolute colour rendition
between different monitors presents a challenge. Nowadays, images are disseminated and
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exchanged rapidly through the internet and viewed on innumerable mobile devices such as
smartphones, tablets or smart televisions. The colour space for all these displays is unique, and
therefore an image will have a different colour rendition, which is virtually impossible to stand-
ardise. A simple method for circumventing different colour rendition on display devices is to
include a reference picture taken with a neutral density grey card when transmitting a particu-
lar portfolio. The reference image can be used by the recipient to calibrate all images within a
portfolio to ensure correct colour rendition.
In addition, post‐capture image processing by in‐camera processors and various imaging
software all yield disparate results depending on their unique algorithms (Bister et al. 2006).
Lastly, human fallibility also plays a part in standardising, e.g. patient and operators factors.
Young children, the elderly and patients with limited mouth opening or debilitating illness may
be unable to endure, or fully participate in, a photographic session. This includes maintaining
a particular position or tolerating cheek retractors and other intra‐oral dental armamentarium
for correct image framing and composition. Also, the operator taking the pictures should be
versed in dental photography, and most importantly, have the aptitude for tolerating and
accepting negative prevailing eventualities.
The last aspect to standardise is honesty (Schaff et al. 2006). Current photo‐editing software
allows even a novice with little or no computer knowledge to transform the ‘girl next door’ into
a ‘Mona Lisa’. Whilst this frivolity is harmless narcissism, manipulating clinical documentation
is potentially bordering on criminality. This could involve concealing pre‐preoperative pathol-
ogy or enhancing post‐operative treatment results by camouflaging defects (Chowdhry 2016).
In addition, altering images for publishing or lecturing for personal advancement is obviously
deceitful. To reiterate, photographs are essentially visual dental documentation, no different to
dental records or radiographs. Therefore, strict adherence to medical ethics is paramount, and
as professionals, we ultimately rely on fellow colleagues to follow a code of conduct befitting
our vocation. Put succinctly, honesty is professional de rigueur.
References
Ahmad, I. (2009). Digital dental photography. Part 1: an overview. Br. Dent. J. 206 (8): 403–407.
Bengal, W. (1985). Standardization in dental photography. Int. Dent. J. 35 (3): 210–217.
Bengel, W. and Devigus, A. (2006). Preparing images for publication: part 2. Eur. J. Esthet. Dent. 1:
112–127.
Bister, D., Mordarai, F., and Aveling, R.M. (2006). Comparison of 10 digital SLR cameras for
orthodontic photography. J. Orthod. 33: 223–230.
Chowdhry, A. (2016). Seeing is no longer believing. Indian J. Dent. Educ. 9 (2).
Ettorre, G., Weber, M., Schaaf, H. et al. (2006). Standards for digital photography in cranio‐
maxillo‐facial surgery – part I: basic views and guidelines. J. Craniomaxillofac. Surg. 34: 65–73.
Galdino, G.M., Vogel, J.E., and Vander Kolk, C.A. (2001). Standardizing digital photography: it’s
not all in the eye of the beholder. Plast. Reconstr. Surg. 108: 1334–1344.
Graber, T.M. (1946). Patient photography in orthodontics. MSD thesis. Northwest University
Dental School.
Martins, R.F.M., Costa, L.A., Bringel, A.C.C. et al. (2013). Protocol for digital photography in
orthodontics. Rev. Clín. Orthod. Dental Press 12 (4): 102–111.
Niamtu, J. (2004). Image is everything: pearls and pitfalls of digital photography and PowerPoint
presentations for the cosmetic surgeon. Dermatol. Surg. 30: 81–91.
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References 95
Schaff, H., Streckbein, P., Ettorre, G. et al. (2006). Standards for digital photography in cranio‐
maxillo‐facial surgery – part II: additional picture sets and avoiding common mistakes. J.
Cranio‐Maxillofac. Surg. 34: 366–377.
Sommer, D.D. and Mendelsohn, M. (2004). Pitfalls of nonstandardized photography in facial
plastic surgery patients. Plast. Reconstr. Surg. 114: 10–14.
Sugawara, Y., Saito, K., Futaki, M. et al. (2014). Evaluation of the optimal exposure settings for
occlusal photography with digital cameras. Pediatr. Dent. J. 24: 89–96.
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Section 2
Photographic Set‐ups
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99
Extra‐Oral and Intra‐Oral Images
This module covers the most frequently documented images in dentistry; extra‐oral and intra‐
oral compositions (Ahmad 2009). The former is also referred to as the dento‐facial composi-
tion since it includes the lips, extra‐oral soft tissues and their relationship to the intra‐oral
dentogingival elements.
Positioning
As discussed in Module 2, unlike conventional photography, dental photography has additional
factors to consider, such as cross‐infection control, health and safety and confidentiality.
Therefore, optimal settings of the camera, flashes and ancillary equipment, outlined in Module
3, are repeated in this module for convenience. Before starting, it is worth browsing through
Module 3 for a detailed analysis of cameras settings, and Module 4 about composing and
standardising images. Besides these fundamental requirements, positioning the patient,
photographer, assistant, photographic equipment, flashes and dental adjuncts are crucial for
extra‐ and intra‐oral pictures.
The position of the patient is pivotal, and synergistically determines the position of the
photographer, assistant and equipment (Devigus 2012). The type of image dictates the position
of the patient, who can be seated upright, partially reclined or supine. For the majority of
standardised extra‐oral and intra‐oral images, the ideal position of the patient is seated upright.
This position is repeatable, whereas the degree of recline varies, and compromises
standardisation. However, for promotional and marketing images, positioning is somewhat
lackadaisical, since a rigid posture is perceived as uptight and possibly confrontational.
For the majority of extra‐ and intra‐oral clinical images, the patient’s head and the camera
axis is perpendicular to the facial midline and parallel to the horizon (Figures 5.1–5.3). The lens
axis is centred exactly at the mesial contact point areas of the maxillary centrals. Using
orientation facial landmarks, such as the inter‐pupillary or inter‐commisure lines for
orientation, prevents eschewed or incorrect alignment of the incisal plane and/or dental
midlines. In the sagittal plan, the head should neither be pointing up, nor down, i.e., parallel to
the ala‐tragus (Camper’s line) or Frankfort plane and perpendicular to the lens axis (Figure 5.2).
Maintaining a perpendicular lens axis ensures correct perspective; if the lens axis is superior or
inferior, the teeth appear elongated or shortened, especially the maxillary and mandibular
anteriors. In addition, if a ring flash is mounted on the front of lens, a superior or inferior lens
axis will unduly illuminate the ‘red’ oral mucosa, and the light reflected back onto the palatal
aspects of the teeth will make them appear more reddish, conveying an incorrect colour
rendition that may affect precise tooth shade evaluations. Also, it is important to avoid using

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Figure 5.1 Incorrect angulation of the camera or the patient’s head in the vertical plane causes distortion of
perspective or unwanted shadows.
Figure 5.2 Incorrect angulation of the camera or the patient’s head in the sagittal plane causes distortion
of perspective, unwanted shadows and/or conveys a reddish colour rendition of the teeth that are
unintentionally illuminated by the reflected ‘red shadows’ of the oral cavity.
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Figure 5.3 Incorrect angulation of the camera or the patient’s head in the horizontal plane causes distortion of
perspective or unwanted shadows.
the occlusal or incisal planes for orientation as the latter may be misaligned, and instead use the
horizon for alignment for recording the true inclination, which is essential for diagnosing cants
of the maxilla or altered eruption patterns.
After orientating the patient, the photographer positions himself/herself accordingly with
the photographic equipment, depending on the angle of view to be recorded. The assistant
stands either to the right or left of the patient, ensuring easy access to an aspirator, three‐in‐one
dental syringe and other dental armamentarium. Alternately, the assistant may stand behind
the patient for holding two unilateral cheek retractors for displacing the lips and cheeks.
However, the latter ties up the assistants’ hands, and therefore may require another assistant
for aspiration, etc. Since there are several different types of images with different angles of
views, the section below graphically depicts the set‐ups required for each type of photograph.
In addition, each set‐up is accompanied by the necessary photographic equipment settings and
technical notes for expediting the photographic session.
The Essential Dental Portfolio

Depending on the discipline in question, different dental organisations and clinicians advocate
varying number of images for a dental portfolio (Bengel 2006; Ettorre et al. 2006; Evans et al.
2008; Haddock et al. 2018; Pani 2017; Steel et al. 2009–2013). In addition, extra images are
required according to individual patient needs, clinical findings and the proposed treatment.
This module concentrates on an essential dental portfolio (EDP) that caters for most dental
applications, irrespective of the discipline. Since the intended use of an EDP is clinical
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102 Extra‐Oral and Intra‐Oral Images
hotodocumentation, standardisation is mandatory, and the guidelines below are intended to

p
ensure that intra‐ and inter‐patient comparisons are possible. Furthermore, an EDP should
form part of the patient’s dental records, no different to charting or radiographic documenta-
tion. This portfolio serves as a record, even if no treatment is contemplated, and is an invalua-
ble reference if the patient suffers acute trauma, especially involving the anterior teeth, as a
guide for restitution of the traumatised dentition. Furthermore, an EDP is vital for forensic
identification, should the patient befall a fatal tragedy.
The EDP consists of nine basic dental views (Figure 5.4); three extra‐oral (dento‐facial) and
six intra‐oral compositions, as follows:
●● EDP Image #1: extra‐oral, frontal habitual or ‘rest’ lip position
●● EDP Image #2: extra‐oral, frontal relaxed smile
●● EDP Image #3: extra‐oral, frontal laughter
●● EDP Image #4: intra‐oral, frontal view in maximum intercuspation (MI)
●● EDP Image #5: intra‐oral, frontal view with separated teeth
●● EDP Image #6: intra‐oral, right lateral view in MI
●● EDP Image #7: intra‐oral, left lateral view in MI
●● EDP Image #8: intra‐oral, occlusal full‐arch maxillary view
●● EDP Image #9: intra‐oral, occlusal full‐arch mandibular view
The full face, or clinical portraiture, is excluded from the EDP since some patients may with-
hold consent for photographing their face due to personal, social, cultural or religious reasons.
However, if this is not a concern, seven full face images of the essential portrait portfolio (EPP)
can be added to the EDP, bringing the total number to 16 images, see Module 6: Portraiture.
Essential Dental Portfolio

(EDP)
Dento-facial
EDP Image #1 EDP Image #2 EDP Image #3
Intra-oral
EDP Image #4 EDP Image #5 EDP Image #6 EDP Image #7
Intra-oral + mirror
EDP Image #8 EDP Image #9
Figure 5.4 Thumbnails of the essential dental portfolio (EDP).
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Extra‐Oral (Dento‐Facial) Compositions

●● EDP Image #1: Extra‐oral, frontal habitual or ‘rest’ lip position
An extra‐oral or dento‐facial composition centres on a commissure‐to‐commissure view of
the lips in static and kinetic states. The static position is often referred to as the ‘rest position’.
However, this is erroneous, since the oro‐facial muscles are contracting to maintain this posi-
tion and are not truly at rest. The true rest position is whilst sleeping, when all the oro‐facial
muscles are completely relaxed, and the mandible drops down, causing the mouth to open.
A better terminology to describe the so‐called ‘rest position’ is the habitual lip position,
e.g. whilst ambling or concentrating on a task. This view is usually the starting point for most
dental portfolios, and its set‐up is similar to that for subsequent intra‐oral views. Dento‐facial
images, together with portraits, are the most appealing and relevant to patients’ aesthetic
sense. Furthermore, most laymen assess the outcome of aesthetic dental treatment by these
compositions, rather than clinical intra‐oral images. The best method for attaining the habit-
ual lip position is asking the patient to iterate the letter ‘m’ or ‘Emma’ and then relaxing to
achieve an inter‐labial gap or habitual lip separation. The composition is framed to include
the tip or rhinion of the nose above, and the menton below (Figure 5.5). This allows assess-
ment of the dental midline in relation the facial midline (philtrum), and the axial inclination
of the maxillary anterior teeth during a relaxed smile. The mesial axial inclinations of the
teeth in maxillary anterior sextant should ideally converge at the menton (Figure 5.6).
The patient is seated upright in the dental chair and asked to turn around 90° towards the
camera. The positioning of the photographer and assistant are shown in Figure 5.7 (sagittal
Facial midline
T ip of nose
Philtrum
Commissure line
Lateral surrounding
space around
cheeks
Menton Neutral backdrop,

e.g. sky blue or
Inferior surrounding grey
space
TTL I S O ≈ 10 0 f 22
Figure 5.5 Photographic settings and field of view for dento‐facial compositions, essential dental portfolio
(EDP) images #1, #2 and #3. (PoF [point of focus] = blue cross‐line reticle. NB. For a relaxed smile the PoF is the
central incisors and for laughter the PoF is the canine tips.)
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Figure 5.6 Imaginary lines representing the mesial axial inclination of the maxillary anterior
teeth converging at the menton.
Figure 5.7 Essential dental portfolio (EDP) Images #1, #2 and #3 set‐up: The patient is seated upright facing
the camera, the camera is tripod‐mounted with bilateral flashes. The assistant is out of the frame, but standing
to the side ready to assist and ensure patient comfort (sagittal view).
view), Figure 5.8 (bird’s‐eye view) and Figure 5.9 (photographer’s point of view (PoV)). It is
advisable to take the extra‐oral pictures first before moving onto the intra‐oral images to avoid
transient creasing or redness of the lips caused by the cheek retractors, which may be apparent
in the photographs. Also, the flashes, either twin bilateral, or ring flashes, should have the facil-
ity of altering the light intensity output to enable the flash ratio to be adjusted to 1 : 2 (fill flash: key
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Figure 5.8 Essential dental portfolio (EDP) Images #1, #2 and #3 set‐up: The patient is seated upright facing
the camera, the camera is hand‐held with a ring flash (bird’s‐eye view).
Figure 5.9 Essential dental portfolio (EDP) Images #1, #2 and #3 set‐up: Photographer’s point of view (PoV).
flash) for producing three‐dimensional images with highlights and subtle shadows. The techni-
cal settings and guidelines for extra‐oral images #1, #2 and #3 are summarised in Table 5.1, and
EDP Image #1 is shown in Figure 5.10.
●● EDP Images #2 and #3: Extra‐oral, frontal relaxed smile and laughter
The next two extra‐oral images are a relaxed and exaggerated smile (laughter). The degree of
contraction of the lips influences elevation of the commissure line, smile line parallelism, oral
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Table 5.1 Settings and guidelines for extra‐oral essential dental portfolio (EDP) images #1, #2 and #3.
Item Setting/description Notes
Focus Manual
Exposure metering TTL or manual Manual: take a few test shots to ascertain
correct exposure, or use histogram
ISO 50–200
Aperture f 22
Shutter speed 1/125 s or 1/250 s Flash synchronisation speed depends on a
specific camera brand
Image data format RAW or DNG
(file format)
White balance AWB (automatic white Manual: numerical value input, or take a reference
balance) 5500 K or manual image with an 18% neutral density grey card
Flash Twin bilateral with diffusers Adjust fill light: key light ratio to 1 : 2. If images
angled 45°, or ring flashes are too bright or too dark, adjust intensity of
flashes, or move flashes closer or further away
until correct exposure is achieved (only
applicable for bilateral flashes as ring flashes
are usually fixed on the front of the lens)
Magnification 1 : 5 Only relevant for full‐frame sensors, or set
factor predefined focusing distance on lens, or use
anatomical landmarks (see Field of view below)
Point of focus (PoF) Habitual lip position: Hand‐held cameras: for predefined
represents the ideal central incisors magnification or focusing distance, move
hyperfocal distance Relaxed smile and laughter: camera backwards and forwards until focus is
for maximum DoF canine tips obtained, or use anatomical landmarks for
(depth of field) composing (see Field of view below)
(The PoF will depend on the
shape of the face, if parts of Tripod‐mounted camera: for predefined
the image are out of focus, magnification or focusing distance use macro
change the PoF either stage for focusing, or use anatomical landmarks
anterior or posterior to the for composing (see Field of view below)
suggested areas.)
Field of view Anatomical landmarks Right/left: lateral aspects of cheeks (with
(composing) surrounding lateral space)
Superior/inferior: tip of nose to menton (if
possible, with surrounding inferior space)
Anterior/posterior: tip of nose to lateral aspects
of cheeks
Background Variable Standardised clinical images: Neutral, e.g. sky
blue or grey
Promotional images: Vivid colours – carte blanche
mucosa visibility (bilateral negative spaces), tooth display and amount of gingival exposure,
which is particularly relevant for disciplines such as orthodontics, cranio‐maxillo‐facial
surgery, periodontics and dental aesthetics. However, the smile is highly contentious, since
many patients train themselves to smile in a particular way to enhance their personality. This
may involve concealing dental anomalies such as excessive gingival display (gummy smile),
diastemata, imbrications, discolourations, decay, fractured teeth or poor‐quality dentistry
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Figure 5.10 Essential dental

portfolio (EDP) Image #1.
Figure 5.11 Forced, contrived

smile with little diagnostic value.
(unsightly fillings, crowns, veneers, etc.). Therefore, capturing a relaxed smile is challenging,
and may require several attempts until the patient feels comfortable and builds up a profes-
sional confident relationship with the dental team. Nevertheless, it is important to capture
smiles that have diagnostic value, including a relaxed smile as well as laughter, so that all rele-
vant factors are visible for assessment and treatment planning (Figures 5.11 and 5.12). These
include incisal embrasures whilst the teeth are separated, as well as the incisal plane inclination
relative to the curvature of the mandibular lip (essential for elucidating maxillary or incisal
plane cants), and dental midline shifts in relation to the facial midline. This is another reason
for including that the tip of the nose and chin in the dento‐facial composition for assessing the
relationship of the facial midline to the dental midlines (maxillary and mandibular). The set‐up
and settings are identical to photographing the habitual lip position shown in Table 5.1, and
EDP Images #2 and #3 are shown in Figures 5.13 and 5.14.
Intra‐Oral Compositions
●● EDP Image #4: Intra‐oral, front view in MI

●● EDP Image #5: Intra‐oral, front view with separated teeth
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Figure 5.12 Relaxed smile showing

contralateral asymmetrical gingival
zeniths of the maxillary lateral
incisors and canines.


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The first two intra‐oral images are frontal views showing the teeth in MI (Kandasamy et al.
2018; Keys and Agar 2002), and separated approximately 5 mm to show the incisal edges,
occlusal plane inclination, curves of Spee and Wilson, sphere of Monson and incisal embra-
sures angles, which are particularly relevant if tooth wear or tooth surface loss (TSL) is sus-
pected due to attrition or other aetiology. Both these views require cheek retractors to displace
the lips and cheeks for a clear view of the oral cavity, and the assistant ready with aspiration and
a three‐in‐one dental syringe. The set‐up and settings are similar to those for extra‐oral images,
with a few exceptions such as magnification factor, field of view and background, summarised
in Table 5.2 and Figures 5.15 and 5.16. The set‐up from various perspectives are shown in
Figures 5.17–5.19, and the EDP Images #4 and 5 in Figures 5.20 and 5.21.
Table 5.2 Settings and guidelines for intra‐oral essential dental portfolio (EDP) images #4 and #5.
Focus Manual
Exposure TTL or manual Manual: take a few test shots to ascertain correct exposure
metering or use histogram
ISO 50–200
Aperture f 22
Shutter speed 1/125 s or 1/250 s Flash synchronisation speed depends on a specific camera
brand
Image data format RAW or DNG
(file format)
White balance AWB (automatic white Manual: numerical value input, or take a reference image
balance) 5500 K or with an 18% neutral density grey card
manual
Flash Twin bilateral with Adjust fill light: key light ratio to 1 : 2. If images are too
diffusers angled 45°, or bright or too dark, adjust intensity of flashes, or move
ring flashes flashes closer or further away until correct exposure is
achieved (only applicable for bilateral flashes as ring flashes
are usually fixed on the front of the lens)
Magnification 1 : 2 Only relevant for full‐frame sensors, or set predefined
factor focusing distance on lens, or use anatomical landmarks (see
Field of view below)
Point of focus Maxillary canine tips Hand‐held cameras: for predefined magnification or
(PoF) (The PoF will depend on focusing distance, move camera backwards and forwards
the shape of the arches, until focus is obtained, or use anatomical landmarks for
if all teeth are not in composing (see Field of view below)
focus, change the PoF Tripod‐mounted camera: for predefined magnification or
either anterior or focusing distance use macro stage for focusing, or use
posterior to the canines.) anatomical landmarks for composing (see Field of view below)
Field of view Anatomical landmarks Right/left: buccal corridors (negative bilateral spaces)
(composition) Superior/inferior: apical to maxillary and mandibular
mucogingival junctions and showing labial frenum
attachments
Anterior/posterior: as many teeth as possible from central
incisors to second or third molars
Background n/a
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Frenum attachment
Mucogingival
junction Maximum number
of molars visible
Bilateral negative
space
Frenum attachment Mucogingival

junction
T T L I S O ≈ 10 0 f 2 2 1/250 S R AW
Figure 5.15 Settings and field of view for intra‐oral compositions, essential dental portfolio (EDP) images #4
(point of focus [PoF] = blue cross‐line reticle).
Frenum attachment
Mucogingival
junction
Maximum number
Bilateral negative of molars visible
space
≈ 5 mm
Frenum attachment Mucogingival

junction
T T L I S O ≈ 10 0 f 2 2 1/250 S R AW
Figure 5.16 Settings and field of view for intra‐oral compositions, essential dental portfolio (EDP) images #5
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Figure 5.17 Essential dental portfolio (EDP) Images #4 and #5 set‐up: The patient is seated upright facing the
camera and holding the bilateral plastic cheek retractors, the camera is tripod‐mounted with bilateral flashes.
The assistant holds the saliva ejector and three‐in‐one dental syringe (sagittal view).
Figure 5.18 Essential dental portfolio (EDP) Images #4 and #5 set‐up: The position of the patient, assistant and
photographer with hand‐held camera and ring flash (bird’s‐eye view).
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Figure 5.19 Essential dental portfolio (EDP) Images #4 and #5 set‐up: Photographer’s point of view (PoV).


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●● EDP Image #6: Intra‐oral, right lateral view in MI

●● EDP Image #7: Intra‐oral, left lateral view in MI
The next two intra‐oral images are a repetition of EDP image #4, the only difference is that they
are photographed from the right and left sides to show the lateral (or buccal) aspects of the teeth.
Hence, the field of view is different, and ideal for showing Angle’s molar, canine and incisal rela-
tionships, curve of Spee, over‐erupted teeth and available interocclusal space for replacing miss-
ing teeth. There are two method for capturing lateral views: direct and indirect. The direct
method is simply asking the patient to turn their head to the opposite side to the side being pho-
tographed, and rotating the cheek retractor on the side being photographed to reveal the buccal
aspects of as many posterior teeth as possible. The lens axis is positioned 45° to the dental midline
(Figures 5.22 and 5.23). The indirect method is using a narrow or lateral intra‐oral mirror to
reflect the buccal surfaces of the teeth. This involves placing a unilateral buccal cheek retractor
on the contralateral side to be photographed, and then sliding a mirror into the buccal corridor
on the side to be photographed to displace the cheek for capturing the reflection of the lateral
surfaces of the teeth. The lens axis is positioned and aimed at the centre of the intra‐oral mirror
(Figures 5.24–5.26). Table 5.3 and Figure 5.27 detail the salient differences to previous EDP
images, and EDP Images #6 and #7 are shown in Figures 5.28 and 5.29. Also, the reflected images
need to be laterally inverted (flipped) in imaging software for ensuring the correct perspective.
●● EDP Image #8: Intra‐oral, occlusal full‐arch maxillary view
●● EDP Image #9: Intra‐oral, occlusal full‐arch mandibular view
The last two EDP images are full‐arch occlusal views of the maxillary and mandibular arches,
These are the most challenging pictures for the clinician, and the most claustrophobic and
Figure 5.22 Essential dental portfolio (EDP) Images #6 and #7 set‐up (direct method): The patient is asked to
rotate the cheek retractors laterally to the side being photographed. The photographer moves 45° to the side,
whilst the assistant holds the saliva ejector and 3‐in1 dental syringe (sagittal view).
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Figure 5.23 Essential dental portfolio (EDP) Images #6 and #7 set‐up (direct method): Photographer’s
point of view (PoV).
Figure 5.24 Essential dental portfolio (EDP) Images #6 and #7 set‐up (indirect method): A narrow intra‐oral
lateral mirror is placed on the side to be photographed and held by the patient. The assistant holds a unilateral
cheek retractor on the opposite side, and prevents condensation on the mirror by blowing air from a three‐in‐
one dental syringe. The photographer moves 45° to the side, aiming the lens axis to the centre of the lateral
mirror (sagittal view).
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Figure 5.25 Essential dental portfolio (EDP) Images #6 and #7 set‐up (indirect method): Alternately, the
patient can hold both the mirror and cheek retractor, whilst the assistant holds a saliva ejector and three‐in‐
one dental syringe (bird’s‐eye view).
Figure 5.26 Essential dental portfolio (EDP) Images #6 and #7 set‐up: Photographer’s point of view (PoV).
cumbersome for the patient. For both arches, the mirror is positioned so that the incisal edges
or cusp tips are clearly visible. Also, the sulci are sufficiently deflected so that the lips are off
the buccal surfaces of the teeth, with a clear view of the buccal gingiva. Furthermore, when-
ever possible, the cheek retractors and intra‐oral mirrors should not be visible in the picture.
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Table 5.3 Salient differences for lateral view essential dental portfolio (EDP) Images #6 and #7.
Aperture f 22 (direct method) Reduce aperture by 1 f‐stop to compensate for

f 16 (indirect method) using intra‐oral mirror with the indirect method
Point of focus Maxillary first premolar cusp tip Hand‐held cameras: for predefined magnification
(PoF) (The PoF will depend on the or focusing distance, move camera backwards and
shape of the arches, if all teeth forwards until focus is obtained, or use anatomical
are not in focus, change the PoF landmarks for composing (see Field of view below)
either anterior or posterior to Tripod‐mounted camera: for predefined
the first premolars) magnification or focusing distance use macro
stage for focusing, or use anatomical landmarks
for composing (see Field of view below)
Field of view Anatomical landmarks Right/left: Extending from second or third molars
(composition) to the canine on the opposite side
Superior/inferior: apical to maxillary and
mandibular mucogingival junctions and showing
labial frena attachments
Anterior/posterior: Contralateral buccal mucosa
background to buccal surfaces of the molars on
the side being photographed
Maximum number of
molars visible Contralateral
canine
Contralateral
buccal mucosa
Mucogingival
junction
Frenum
attachment
TTL ISO ≈ 100 f 16/22 1/250 S RAW
Figure 5.27 Settings and field of view for intra‐oral compositions, essential dental portfolio (EDP) image #6
For maxillary occlusal views, the nostrils should be obscured by using a contraster (see
Figure 2.5 in Module 2). Also, the reflected EDP Images #8 and #9 need to be laterally inverted
(flipped) and rotated in imaging software for ensuring the correct perspective.
For the maxillary arch, EDP Image #8, the patient is asked to open as wide as possible and point
their chin downwards. The reverse surface of the mirror touches the mandibular anterior teeth
and the lens axis positioned 45° to the centre of the mirror in order to capture an image that
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Optional Composition 117


appears to be taken perpendicular to the occlusal plane of the maxillary arch. If mouth opening
is limited, the resulting shallow or reduced intra‐oral mirror angle will alter perspective and pre-
vent visualisation of buccal and lingual surfaces of the teeth. (Figures 5.30–5.32). Table 5.4 details
the salient differences between EDP Images #8 and #9 and other EDP images, The settings and
field of view for EDP Image are shown in Figure 5.33, EDP Image #8 is shown in Figure 5.34.
For the mandibular arch, EDP Image #9, the patient is asked to point the chin upward, allow-
ing the reverse surface of the mirror to touch the maxillary anterior teeth, with the lens axis 45°
to the centre of the mirror. The tongue is gently elevated and pushed back with the mirror to
exclude it as much as possible from the frame so that the lingual surfaces of the teeth are visible
(Figures 5.35 and 5.36). The settings and field of view for EDP #9 are shown in Figure 5.37, and
EDP Image #9 is shown in Figure 5.38.
Optional Compositions
Depending on the speciality, in addition to the EDP, several optional extra‐ and intra‐oral
images may be required. These can either be deferred to a later date, or preferably taken at
the same session to make use of the photographic set‐up of the EDP. The optional dento‐
facial images are similar to the first three EDP images, but the lips and teeth are viewed from
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Figure 5.30 Essential dental portfolio (EDP) Images #8 set‐up: The patient’s head is titled downward. The
patient holds the intra‐oral occlusal mirror, whilst the assistant holds the contraster and three‐in‐one dental
syringe to blow air onto the mirror. The photographer aims the lens axis 45° to the mirror (sagittal view).
Figure 5.31 Essential dental portfolio (EDP) Images #8 set‐up: The position of the patient, assistant and
photographer with hand‐held camera and ring flash (bird’s‐eye view).
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Figure 5.32 Essential dental portfolio (EDP) Images #8 set‐up: Photographer’s point of view (PoV).
Table 5.4 Salient differences for occlusal view essential dental portfolio (EDP) Images #8 and #9.
Aperture f 16 Reduce aperture by 1 f‐stop to compensate for

using intra‐oral mirror
Magnification 1 : 2 or 1 : 3 (depending on size Only relevant for full‐frame sensors, or set
factor of the arches) predefined focusing distance on lens, or use
anatomical landmarks (see field of view below)
Point of focus Maxillary and mandibular Hand‐held cameras: for predefined
(PoF) occlusal surfaces of second magnification or focusing distance, move
premolars camera backwards and forwards until focus is
(The PoF will depend on the obtained, or use anatomical landmarks for
shape of the arches, if all teeth composing (see Field of view below)
are not in focus, change the PoF Tripod‐mounted camera: for predefined
either anterior or posterior to magnification or focusing distance use macro
the second premolars.) stage for focusing, or use anatomical
landmarks for composing (see Field of view
below)
Field of view Anatomical landmarks Right/left: buccal sulci
(composition) Superior/inferior: bordered by labial sulcus to
soft palate or deflected inferior surface of
tongue
Anterior/posterior: incisal edges or cusp tips
to buccal attached gingiva
different angles. These compositions are useful for assessing lip competence, maxillary
incisal edge position and inclination in relation to the mandibular lip, aesthetic analysis such
as smile line, excessive gingival display (gummy smile), curves of Spee and Wilson, sphere of
Monson and over‐erupted teeth. The optional extra‐oral images are as follows:
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Labial sulcus
Attached
Incisal edge gingiva
Right buccal sulcus
Cusp tip
Soft palate
TTL I S O ≈ 10 0 f 16 1/250 S R AW
Figure 5.33 Settings and field of view for essential dental portfolio (EDP) image #8 (point of focus [PoF] = blue
cross‐line reticle).

portfolio (EDP) image #8.
1) Extra‐oral: right profile view – habitual or ‘rest’ lip position

2) Extra‐oral: right profile view – relaxed smile
3) Extra‐oral: right profile view – laughter
4) Extra‐oral: left profile view – habitual or ‘rest’ lip position
5) Extra‐oral: left profile view – relaxed smile
6) Extra‐oral: left profile view – laughter
7) Extra‐oral: right oblique view – habitual or ‘rest’ lip position
8) Extra‐oral: right oblique view – relaxed smile
9) Extra‐oral: right oblique view – laughter
10) Extra‐oral: left oblique view – habitual or ‘rest’ lip position
11) Extra‐oral: left oblique view – relaxed smile
12) Extra‐oral: left oblique view – laughter
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Figure 5.35 Essential dental portfolio (EDP) Images #9 set‐up: The patient’s head is tilted upwards.
The assistant holds the intra‐oral occlusal mirror and three‐in‐one dental syringe to blow air onto
the mirror. The photographer aims the lens axis 45° to the mirror (sagittal view).
Figure 5.36 Essential dental portfolio (EDP) Images #9 set‐up: Photographer’s point of view (PoV).
The set‐up and setting are identical to those shown in Table 5.1, but the patient is asked to turn
their head right or left for the profile or oblique views (Figure 5.39). The oblique images are also
termed the 3/4 or 45° view. For each view, both static and kinetic states are photographed. The
oblique view is particularly useful for assessing phonetics, since people usually speak from an angle
rather than head‐on. Examples of a few of these compositions are shown in Figures 5.40–5.45.
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Tongue
deflected out
of view
Cusp tip
Right buccal sulcus
Attached
Labial sulcus
TTL I S O ≈ 10 0 f 16 1/250 S R AW
Figure 5.37 Settings and field of view for essential dental portfolio (EDP) image #9 (point of focus [PoF] = blue
cross‐line reticle).

portfolio (EDP) image #9.
The next optional images are intra‐oral compositions, including lateral views with the teeth
separated and detailed anterior sextant and quadrant views for visualising various tooth sur-
faces. These perspectives allow assessment of marginal integrity of restorations, gingival reces-
sion and calculus deposits. The first two optional intra‐oral images are lateral views, which are
identical to EDP images #6 and #7, but with the teeth separated:
13) Intra‐oral, right lateral view with separated teeth
14) Intra‐oral, left lateral view with separated teeth
The set‐up and setting for optional intra‐oral images #13 and #14 are the same as those
shown in Table 5.3, and can either be taken with the direct method or indirect method using a
lateral (buccal) mirror.
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Frontal view Oblique view Profile view
Figure 5.39 Positioning the patient’s head for oblique and profile views.
Figure 5.40 Optional image #1 (right profile habitual).
The sextant and quadrant views can be obtained by enlarging EDP images #5, #8 and #9,
respectively. However, this depends on the quality of the initial images, which is predominantly
influenced by the photographic hardware. If the initial images can withstand enlargement and
cropping of a segment without losing resolution, additional sextant and quadrant images are
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Figure 5.41 Optional image #2 (right profile relaxed smile).
Figure 5.42 Optional image #3 (right profile laughter).
Figure 5.43 Optional image #7 (right oblique habitual).
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Figure 5.44 Optional image #8 (right oblique relaxed smile).
Figure 5.45 Optional image #9 (right oblique laughter).
superfluous (unless buccal and/or lingual surfaces of the teeth are required). However, if the
resolution of the lens is insufficient and/or the camera sensor is small with a reduced pixel
count, enlargement may substantially deteriorate the image quality, making them useless for
diagnosis. Therefore, capturing only a sextant or quadrant exploits the maximum potential of
the photographic hardware, irrespective of its specifications.
The optional anterior maxillary and mandibular sextant images concentrate on the buccal
and palatal (lingual) surfaces of the anterior teeth:
15) Intra‐oral: anterior sextant – maxillary buccal aspect with separated teeth
16) Intra‐oral: anterior sextant – mandibular buccal aspect with separated teeth
17) Intra‐oral: anterior sextant – maxillary palatal aspect of teeth
18) Intra‐oral: anterior sextant – mandibular lingual aspect of teeth
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These views are invaluable for visualising various lesions including palatal surface erosion of
the maxillary teeth due to gastric regurgitation, calculus deposits on the lingual surfaces of
mandibular teeth (Figure 5.46), gingival recession, palatal fistula and abscesses, tori, as well as
defective restorations that otherwise may be overlooked (Figure 5.47). The increased magnifi-
cation is also ideal for documenting treatment sequences in a particular region of the mouth,
or on a specific tooth. The first two images (buccal surfaces) have the same set‐up as EDP
image #5 (Table 5.2), but the magnification factor is increased to 1 : 1 to concentrate on the
anterior sextant of both arches. The next two images (lingual/palatal surfaces) utilise intra‐oral
mirrors, similar to EDP images #8 and #9, but the angle of the mirror is manipulated to reveal
the palatal or lingual surfaces with a magnification factor of 1 : 1. Whilst EDP images #8 and #9
capture the entire arch and are centred on the incisal edges or cusp tips, the optional images
17 and 18 are restricted to only the anterior six teeth and capture detailed views of the palatal/
lingual aspects.
The last of the intra‐oral optional images are three perspectives of the right and left quad-
rants of each arch, making a total of 12 images. Each of the four quadrants are photographed
from three perspectives: occlusal, buccal and palatal/lingual. The entire set of 12 images are not
necessary for every patient, and may be limited to certain quadrants depending an individual
needs. Similar to the anterior sextant views, the quadrant views concentrate on capturing
Figure 5.46 Mandibular lingual

sextant view showing calculus
deposits.
Figure 5.47 Maxillary palatal

sextant view showing defective
restorations.
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detailed views of different perspectives for assessing healthy and diseased hard and soft tissues,
and for documenting treatment sequences isolated to a specific region of the mouth.
19) Intra‐oral: quadrants – maxillary right occlusal/incisal aspect of teeth
20) Intra‐oral: quadrants – maxillary right buccal aspect of teeth
21) Intra‐oral: quadrants – maxillary right palatal aspect of teeth
22) Intra‐oral: quadrants – maxillary left occlusal/incisal aspect of teeth
23) Intra‐oral: quadrants – maxillary left buccal aspect of teeth
24) Intra‐oral: quadrants – maxillary left palatal aspect of teeth
25) Intra‐oral: quadrants – mandibular right occlusal/incisal aspect of teeth
26) Intra‐oral: quadrants – mandibular right buccal aspect of teeth
27) Intra‐oral: quadrants – mandibular right lingual aspect of teeth
28) Intra‐oral: quadrants – mandibular left occlusal/incisal aspect of teeth
29) Intra‐oral: quadrants – mandibular left buccal aspect of teeth
30) Intra‐oral: quadrants – mandibular left lingual aspect of teeth
The quadrant shots are best accomplished with the patient in the supine position. The pho-
tographer is positioned either on the same or contralateral side to be photographed depending
on which side of the mouth is being photographed. The assistant holds the lateral (buccal) mir-
ror angling it until the desired surface is in view. Since illuminating the posterior regions of the
mouth is challenging, a ring flash is the ideal light source, ensuring uniform illumination
(Figures 5.48 and 5.49) Also, the magnification factor varies from 1 : 1 to 1 : 2 depending on the
number of teeth in the frame and the configuration of the arches.
Figure 5.48 Maxillary quadrant view: This view is best accomplished with the patient in the supine position,
the photographer on one side and assistant on the opposite side, holding a lateral intra‐oral mirror and a
three‐in‐one dental syringe (bird’s‐eye view).
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Figure 5.49 Mandibular quadrant view: This view is best accomplished with the patient in the supine position,
the photographer at the front and assistant on the opposite side, holding a lateral intra‐oral mirror and a
three‐in‐one dental syringe (bird’s‐eye view).
An entire quadrant, a group of teeth, or a single tooth can be framed or subsequently cropped
in imaging software. As stated above, the quality of the cropped images depends on the speci-
fications of the photographic hardware. The difference in settings between for EDP images #8
and #9 (full‐arch) and quadrant images are summarised in Table 5.5 and Figure 5.50, whilst
Figure 5.51 shows examples of some quadrant images.
Although not exhaustive, the EDP and optional compositions outlined in this Module serve
as a comprehensive and invaluable photographic record for photodocumentation, publishing,
marketing and teaching (Figures 5.52–5.61). The following modules discuss portraits, bench
images and special applications, which expands dental photographic documentation for fur-
ther needs and uses.
As a closing comment, it is worth remembering that to obtain textbook standard images
requires an ideal patient, ideal nurse, ideal photographer, ideal equipment, ideal temperament
and ideal environment. However, in reality, these utopian conditions are elusive. Therefore, a
compromise is inevitable. This may include accepting less than ideal fields of view, visible edges
of cheek retractor or mirrors, poor angulations, copious saliva or fogging of mirrors, to name a
few fallibilities. Whilst poor photographic technique is unforgivable, even an intrepid operator
may be confronted with unsurmountable hurdles such as uncooperative patients, limited
mouth opening, technical issues with equipment and so on. Although certain mistakes such as
poor exposure or visible extraneous objects can be corrected at the editing stage, other errors
including poor framing, eschewed perspectives, gross blemishes due to saliva or blood drop-
lets, or excessive condensation on intra‐oral mirrors are impossible to rectify. Hence, a degree
of pragmatism is necessary, and although the aim is to produce flawless images, sometimes
seeking this Xanadu may prove enigmatic.
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Table 5.5 Salient settings for optional quadrant images #19–30.
Aperture f 16 Reduce aperture by 1 f‐stop to compensate

for using intra‐oral mirror
Flash Ring flash Set flash to maximum intensity burst, alter
intensity, if necessary, to obtain correct
exposure
Magnification 1 : 1 to 1 : 2 (depending on width and Only relevant for full‐frame sensors, or set
factor length of the arches and number of predefined focusing distance on lens, or use
teeth being photographed) anatomical landmarks (see field of view below)
Point of focus Variable: start with the maxillary and Hand‐held cameras: for predefined
(PoF) mandibular second premolars, and magnification or focusing distance, move
alter as necessary camera backwards and forwards until focus
(The PoF will depend on the shape of is obtained, or use anatomical landmarks
the arches, if all teeth are not in for composing (see Field of view below)
focus, change the PoF either anterior Tripod‐mounted camera: for predefined
or posterior to the second premolars, magnification or focusing distance use
or focus on the specific tooth of macro stage for focusing, or use anatomical
interest.) landmarks for composing (see Field of view
below)
Field of view Anatomical landmarks Right/left: buccal sulci and palatal or lingual
(composition) mucosa
Superior/inferior: depending on
perspective, i.e. occlusal, buccal or palatal/
lingual surfaces bounded by attached
gingiva and mucosa
Anterior/posterior: Depending on the
number of teeth being photographed. For
an entire quadrant, the central incisor to the
second or third molars
Buccal perspective Occlusal perspective Palatal perspective
TTL I S O ≈ 10 0 f 16 1/250 S R AW
Figure 5.50 Settings and field of view for optional quadrant images (point of focus [PoF] = blue cross‐line
reticle). Each quadrant is photographed from three perspectives: buccal, occlusal and palatal/lingual.
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Buccal Occlusal Palatal Buccal Occlusal Lingual

perspective perspective perspective perspective perspective perspective
Maxillary quadrant Mandibular quadrant
Figure 5.51 Examples of some maxillary and mandibular quadrant images.
Figure 5.52 Quadrant images are ideal for showing

a technique by concentrating on a few teeth.
The defective composite fillings in the maxillary right
premolars require replacement.
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Figure 5.53 After removing the fillings, gross decay is

evident.
Figure 5.54 The decay is judicially removed, avoiding

pulpal exposure.
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Figure 5.55 Steel matrices with an interdental wedge

are placed to create transient separation of the
premolars for building tight contact areas.
Figure 5.56 The mesial interproximal wall of the second

premolar is built‐up with resin‐based composite (RBC)
after the requisite etching and bonding stages. The
initial RBC increments convert the prevailing Class II
cavity to a Class I cavity.
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Figure 5.57 Further increments are added to restore

occlusal morphology of the second premolar.
Figure 5.58 The process is repeated for the first

premolar, starting with application of a dentine
bonding agent…
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Figure 5.59 …followed by resin‐based composite (RBC)

incremental layering.
Figure 5.60 The penultimate stage is removing the

rubber dam, checking occlusion and refining
morphology.
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References 135
Figure 5.61 A week later, the final stage involves

checking the shade, refining occlusion and morphology
before finishing and polishing the fillings.
References
Ahmad, I. (2009). Digital dental photography. Part 8: intra‐oral set‐ups. Br. Dent. J. 207 (4):
151–157.
Bengel, W. (2006). Mastering Digital Dental Photography. London: Quintessence.
Devigus, A. (2012). A picture is worth. J. Cosmet. Dent. 28 (1): 82–88.
maxillo‐facial surgery – part I: basic views and guidelines. J. Craniomaxillofac. Surg. 34: 65–73.
Evans, S., England, P., Jones, M. et al. (2008). Orthodontic Photography IMI National Guidelines,
1–27.
Haddock, F.J., Hammond, B.D., and Romero, M.F. (2018). Guide to dental photography. Decisions
in Dentistry 4 (12): 1–4.
Kandasamy, S., Greene, C.S., and Obrez, A. (2018). An evidence‐based evaluation of the concept of
centric relation in the 21st century. Quintessence Int. 49: 755–760.
Keys, L.G. and Agar, J.A. (2002). Documentation of maxillomandibular relationships during dental
photography. J. Prosthet. Dent. 87 (4): 466.
Pani, S. (2017). A review on clinical digital photography. Int. J. Appl. Res. 3: 10–17.
Patient photographic records (2012). Patient photographic records. http://aligntechinstitute.com/
GetHelp/Documents/pdf/PhotographicQSG.pdf (accessed 25 September 2012).
Steel, C., Behle, C., Bellerino, M. et al. (2009–2013). Photographic Documentation and Evaluation
in Cosmetic Dentistry: A Guide to Accreditation Photography. Madison, WI: American Academy
of Cosmetic Dentistry.
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137
Portraiture
The salient question regarding portraiture is, ‘Should it depict harsh reality, or enhance
attractiveness?’
The answer is both.
There are two types of portraits, clinical and non‐clinical. The former yields unadulterated
information that is essential for analysis and diagnosis, whilst the latter is seductive and alluring,
tainted by the subject’s wishes and the photographer’s vision. Since clinical portraiture is harsh
reality, standardisation is essential for comparison, interdisciplinary communication, as well as
gauging treatment progress and monitoring treatment outcomes. Alternately, non‐clinical por-
traiture enhances attractiveness and is primarily narcissistic. Both types of images serve differ-
ent purposes, clinical portraits deliver reality, whilst non‐clinical portraits steers into glamour,
fantasy, artistic and surreal territory. Therefore, for clinical portraiture, adhering to strict guide-
lines is mandatory, while for the non‐clinical variety, the rule book is discarded. The photogra-
pher has carte blanche, and depending on his or her artistic slant, is free to experiment and
‘paint’ a unique picture of the patient’s persona (Ahmad 2009a; Jung 1933) – Figure 6.1.
Lighting for Portraiture
The crucial factor for portraits, irrespective of whether they are clinical or non‐clinical, is
understanding and manipulating light. Throughout this book, the subject of lighting is
mentioned as the quintessential element for photography, and nowhere is this more relevant
than with portrait photography, which can literally depict a person in a ‘different light’.
Therefore, the discussing below focuses on fundamental principles of lighting a subject, and
shows how this crucial entity can be tailored for conveying different messages (Ahmad 2009b).
The three basic lights to consider for portraiture are:
●● Key light
●● Fill light
●● Background light (if necessary)
All the above may be utilised simultaneously, individually, or in any combination for creating
innumerable types of images with a particular ambience, or emphasising specific facial features.
The protagonist light is termed the main or key light, which is the primary source of illumina-
tion. This can be natural sunlight, or artificially generated continuous or flash lights placed
anywhere in the composition depending on the intended type of portrait. A ‘fill light’ is perhaps a
misnomer since these secondary ‘light(s)’ are not always another light source, but can be reflec-
tors bouncing light from the key light back onto the subject. They are mainly used as counter

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138 Portraiture
Figure 6.1 Portraiture can be clinical and non‐clinical. The non‐clinical variety offers the photographer and
patient to express themselves without limits.
illumination to literally ‘fill in’ shadows cast by the key light. Finally, a third light, if necessary,
is used to illuminate the background. The background light not only illuminates the backdrop
or scenery, but visually separates the subject from the background for conveying a three‐
dimensional quality to the photograph (Figure 6.2).
Manipulating Light
The method by which a light source illuminates an object or subject is by distribution, which is
influenced by its colour temperature, direction, intensity and apparent size (Portraiture light
2005–2017). The colour temperature sets the mood, the direction determines the location of
highlights and shadows, whilst the intensity and physical size determines the intensity of the
highlights and shadows.
Colour Temperature
The colour temperature is more relevant when shooting in daylight, for example at sunrise, mid-
day, overcast skies or at sunset, as the colour temperature of the light varies depending on the
time of day. However, when shooting indoors with studio flashes, the colour temperature is less
important. This is because most electronic flashes (or strobes) are configured to emit photo-
graphic daylight around 5500 K, and when using a fast synchronising shutter speed, the ambient
light plays little or no part in illuminating the subject. However, for creative imagery, the colour
temperature can be altered either by placing coloured gels over the flashes, or using fill‐in reflec-
tors of different colours. Reflectors are available in a various reflective coloured surfaces, for
example gold, which reduces the colour temperature and conveys a warm skin tone. Alternately, a
silver reflector increases the colour temperature and ‘cools’ the quality of light Figure 6.3. Besides
altering the colour temperature, the surface finish (or texture) of the reflector also affects the
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Manipulating Ligh 139
Background
light
Fill light
(silver reflector)
Key light
Camera
Figure 6.2 A typical portrait lighting set‐up consisting of a key light, fill light and background light.
Gold reflector
Silver reflector
Figure 6.3 The colour temperature sets the mood, a gold reflector conveys warmth, whilst a silver reflector
conveys a cool ambience.
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140 Portraiture
mood of the scene. A highly polished surface not only increases colour temperature but also
encourage specular reflections that result in vibrant high contrast images (Bazos and Magne
2013). Alternately, using a matt white reflector also increase colour temperature, but yields sub-
tle lighting that depicts a serene ambience.
Direction: Key Light

The location of the illumination, or its relative position to the subject’s face allows sculpting
of facial features, either emphasising, or camouflaging anatomical structures. Furthermore,
directional lighting creates shadows that conveys depth, both in a physical and metaphorical
sense. Although the position where a light is placed is endless, there are several ‘tried and
tested’ positions for portraiture.1
These positions are useful for understanding basic lighting principles, and once the funda-
mentals are grasped, the photographer can be adventurous and expand his/her creativity for
achieving more artistic or personalised effects.
The simplest way to learn about manipulating light is starting with a single light source,
which is the key light, or main source of illumination. Once the key light positions are mas-
tered, additional light sources can be added to complement and create the desired effect. The
first position of the key light is above the head, which casts shadows below the eyes (‘bags
under the eyes’), with an indistinct jaw line, making the person appear tired or sleepy
(Figure 6.4). When the light is placed below, it emphasises unflattering features such as a
prominent chin, glaring nostrils, or upper eyebrow ridges. Hence, an inferiorly located light
Figure 6.4 A light placed above the head conveys a sleepy appearance.
1 Cinematic lighting techniques: Part 1. https://www.youtube.com/watch?v=eZ5hpcn6tIM
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source conjures a sinister appearance, and should be avoided, unless the intention is portraying
a satanic persona (Figure 6.5).
A light positioned head‐on renders a flat image, similar to using a ring flash for taking intra‐
oral images. This is the least dramatic set‐up with a single light source, but ideal for beautify
shots as blemishes, warts and wrinkles magically disappear by the uniform, lacklustre illumina-
tion that is devoid of shadows (Figure 6.6). However, the images appear two‐dimensional,
conveying frivolity and superficiality.
If the light source is moved upwards from the head‐on position until a ‘butterfly’ shadow
appears below the nose, the effect is termed papillon lighting. This lighting pattern is preferred
for feminine portraits since it accentuates the cheek bones with subtle shadows below the zygo-
matic process (Figures 6.7 and 6.8). However, if the light is incorrectly positioned from above,
the effect is unwanted long shadows cast by the eyebrows and nose, obscuring the eyes and lips,
respectively.
Another position is altering the light angle from above until the nose casts a loop shadow
on the opposite side (Figure 6.9). Loop lighting is ideal for round faces because it makes the
face look slimmer and longer. Continuing to move the light further will connect the nose
shadow with the cheek shadow and result in Rembrandt lighting, used by the Dutch artist
in several of his portrait paintings. This is the most widely used lighting for portraiture, and
is sometimes referred to as ‘front upper side’ lighting, as the light is positioned slightly
above the face to one side (right or left) and 45° from the camera. The position achieves
drop shadows on the contralateral side by forming a triangle of light. The shape of the ‘tri-
angle’ depends on the position of the light and individual facial contours. Rembrandt light-
ing produces a dramatic effect with substantial depth for a three‐dimensional quality to a
portrait (Figures 6.10–6.12). Also, the set‐up smoothly sculpts facial features and produces
Figure 6.5 An inferiorly located light conjures up a sinister appearance.
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142 Portraiture
Figure 6.6 A light shone head‐on produces a flat, two‐dimensional image.
Figure 6.7 Papillon lighting is defined by the appearance of a butterfly shadow below the nose, and is ideal
for feminine shots.
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Figure 6.8 Papillon lighting is due to the shadow cast below the nose in the shape of a butterfly.
Figure 6.9 Loop lighting makes the face look slimmer and longer.
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144 Portraiture
Figure 6.10 Rembrandt lighting is the most popular lighting for portrait photography.
Figure 6.11 Rembrandt lighting is distinguished by the classic triangle of light below the eye
on the contralateral side of the key light.
soft skin tones. However, this lighting position is subjective, and not suited for every face,
but nevertheless, is a good starting point for achieving portraits with visual impact. Another
endearing feature of Rembrandt lighting is that it creates beautiful catch lights, which fur-
ther enhances the image and attracts the viewer to the subject. Catch lights are reflections
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Figure 6.12 Rembrandt lighting produces a sculpted three‐dimensional portrait.
Figure 6.13 Square catch lights, which represent reflections of a square reflector placed just below the chin.
of flashes or reflectors on the cornea of the eyes, symbolising vitality and liveliness; in a
manner of sense ‘seeing the light in someones eyes’ (Figure 6.13). The shape of the catch
lights is identical to the shape of the light source, for example, round lamp, ring flashes,
square soft boxes, octagon soft boxes, round reflectors, or reflective umbrellas. Finally, the
position of the camera determines whether the broad light (light source side), or the oppo-
site darker side of the face, termed short light (or dark side), is photographed. Broad lighting
is obviously brighter, whilst short lighting (the dark side), as its name implies, creates more
depth (Figure 6.14).
The next position is called split lighting, where the light is placed on one side of the face to
completely throw the opposite side in total darkness. Compared to papillon lighting that is ide-
ally suited for feminine shots, split lighting is ‘tougher’ and emphasises features as rugged, and
is therefore, more appropriate for conveying masculinity (Figure 6.15). Lastly rim light is a light
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146 Portraiture
Broad light Short light
Figure 6.14 Broad lighting vs. Short lighting.
Figure 6.15 Split lighting emphasises facial features and is suited for masculine portraits.
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source that is located behind the subject for a contre‐jour effect, either sunlight or artificial
light that illuminates the outline or boundary of objects. In portraiture, a rim, edge or hair light
is used for creating a glow around the subject’s head by a rim of light around the hair or scalp
(for bald individuals). The light source is pointing towards the camera, placed hidden behind
or to the side of the subject’s head. The emanating glow creates an angelic halo around the
head, giving the person an evangelical or virginal quality (Figure 6.16).
A summary of the various types of portrait lighting using a single light source is shown in
Figure 6.17.
Intensity and Size
While the direction of lighting determines the position of the highlights and shadows, the
power and size of the illumination determine the intensity of the highlights and shadows. It is
important to realise that the intensity or power of electronic flashes is determined by the dura-
tion of output; the longer the duration, the greater the power.
The intensity of the light in relation to its distance is determined by the inversely square law:
Intensity of light 1 / distance2

This means that doubling the distance of the light source reduces its intensity by 75%. In
practical terms the light drop‐off from 1 to 2 m is significant at 75%, but as the distance increases
the drop off becomes less significant, e.g. from 6 to 7 m the reduction in intensity is only 1%.
Therefore, for portraiture, to create intense sharp [closed] shadows, the light source needs to
Figure 6.16 Rim lighting creates a halo or outline of light around the head.
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148 Portraiture
Top Bottom Head-on Papillon Loop Rembrandt Split Rim
Figure 6.17 Summary of the basic types of lighting for portraiture using a single light source.
be smaller or further away from the subject, and for softer edges [open] shadows the light
source needs to be closer or larger. The distance of the light from the subject also affects the
background illumination. If the subject remains stationary whilst the light is moved away, the
background becomes darker (Figure 6.18).
Light is classified as hard or soft. Hard lighting is harsh, smaller size and usually unidirec-
tional for creating distinct shadows with specular reflections. It is characterised by sharp
shadow outlines accompanied by areas of burnt out (or clipped) highlights. Conversely, soft
lighting is larger and diffuse, creating indistinct (blurred) shadows with subtle and gradual
transitions between darker and lighter parts with softer highlights. Hard lighting emphasises
details such as skin blemished, pores and wrinkles, whereas soft light attenuates, or ‘irons
out’ details, and is generally more flattering. Therefore, for portraiture, softer lighting is gen-
erally preferred to glamorise the subject (Figure 6.19). There are several methods for achiev-
ing softer lighting. The first is moving the light source closer to the subject (potentially
making it brighter and larger), the second by using an intermediate material to diffuse the
emitted light (e.g. soft box), third to bounce the flash off reflective surfaces such as an
umbrella or a reflector, and lastly, increasing the physical size of the light source. Moving the
light closer to the subject also has the effect of creating a greater subject‐to‐background
separation, which is advantageous for emphasising a figure‐ground relationship and convey-
ing a three‐dimensional quality.
There are innumerable light shaping attachments for modifying light. The most popular is
attaching various reflectors or diffusers onto the flash heads for altering the emitted output.
For example, if hard light is required, a silver bowl reflector with or without a honeycomb grid
will suffice. However, to limit hard light to a spot, lens and fresnel dishes are attached to focus
a beam of light to a specific size. To soften light, umbrellas and soft boxes are the preferred
choice. Umbrellas are either reflective, or translucent catering for varying degrees of light soft-
ness. Soft boxes diffuse light as well as increasing the apparent size of the light source. The
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Light source = 1 metre Light source = 2 metre Light source = 5 metre
Figure 6.18 Inverse square law: if the subject remains stationary and the light source moves further away, the
following occur:
1) background becomes darker
2) shadow of the face on the background becomes intense and sharper
3) facial shadows close up [become softer] and reveal fewer facial features on the contralateral side of the illumination
Hard lighting
Soft lighting
Figure 6.19 A hard light, produced by a naked light source, emphasises facial features (notice the shadows on
the right side of the face contralateral to the light source), whilst soft light attenuated by diffusers, such as soft
boxes, tends to smooth out detail.
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150 Portraiture
shapes and sizes of soft boxes on the market is staggering, made of different materials that
allows innumerable modifying effects. Added to this are beauty lights, sting lights, snoots, col-
oured gels, to name a few. However, unless one is contemplating photography as a profession,
for dental use, a bowl reflector with two or three honeycomb grids and a couple of soft boxes
(or umbrellas) is all that is necessary, which are often included in a two or three studio flash kit
from several manufacturers.
Fill Light
The secondary lights are termed fill lights because they are placed on the contralateral side to ‘fill
in shadows’ from the key light. The fill light can be ambient lighting or natural daylight, a second
flash, or a reflector that bounces light from the key light back onto the subject (Figure 6.20). The
degree that a fill light illuminates a subject is expresses as a ratio of the key light. For example, if
only one light is used, the ratio is 0 : 1, where 0 represents absence of a fill light, and 1 is the main
or key light. A 1 : 4 ratio signifies that the fill light is a quarter of the intensity of the key light. It
is important to note that the smaller number always signifies the fill light. An acceptable ratio for
portraits is 1 : 2, whereas an equal ratio of 1 : 1 totally eliminates shadows and is referred to as a
‘high key’ image. A high key image excessively softens facial features, but is ideal for glamour
shots or pictures of children for expressing joviality and playfulness (Figures 6.21 and 6.22). On
the other extreme, a ‘low key’ image emphasises shadows, giving the picture depth and charac-
ter, and is ideal for portraying personality traits such as insight and wisdom (Figures 6.23
and 6.24). The computer company Apple® predominantly uses high key images to promote its
Key light
Fill light Key light
Flash ratio 1:2
Figure 6.20 A fill light ‘fills in’ shadows from the key light (notice the pronounced shadows on the right side of
the face without a fill light). A flash ratio of 1 : 2 (fill light: key light) is a good starting point for portraiture.
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Background light with Background light with

white bowl reflector white bowl reflector
Fill light with

soft box Key light with
soft box
Figure 6.21 High key portrait lighting set‐up with white backdrop.
Figure 6.22 A high key portrait.
g littering and shiny products. Conversely, Baroque period painters such as Caravaggio use low
key lighting that is unidirectional for conveying drama, depth and realism.
In a similar way to positioning the key light, the location of the fill light also creates different
effects. The simplest set‐up is two studio flashes angled 45° towards the subject, which is a fool
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152 Portraiture
Key light with silver

bowl reflector
Figure 6.23 Low key portrait lighting set‐up with black backdrop.
Figure 6.24 A low key portrait.
proof arrangement and ideal for clinical portraiture. This set‐up produces consistently repeat-
able and standardised portraits for reference and comparison. Whilst these images serve the
purpose of clinical fidelity, they are construed as bland, and usually unsuitable for marketing
and promotional purposes. However, a little flair, combined with a vivid imagination, can
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osition both key and fill lights to create emotive and seductive compositions, which are
p
inspirational for both marketing and lecturing.
Background Light
As well as illuminating the subject, lights are also necessary for illuminating the background for
subject‐background or figure‐ground separation for simulating a three‐dimensional effect. All
backgrounds, with the exception of black, require some form of illumination, which may be
extraneous light fall‐out from the key or fill lights, or extra strobes directed to a suspended
cloth or other backdrop. Backlit illumination also avoids projection shadows cast by the key
light onto coloured backdrops, and for ensuring a smooth, evenly lit and non‐distracting back-
ground (Figure 6.25).
Finally, it is worth turning on modelling lights, if available on the studio flashes. Most con-
temporary studio lights, or strobes, are equipped with continuous halogen modelling lights.
These low‐level lights serve two purposes. First, the continuous light avoids the distracting ‘red
eye’ phenomena, and second, it allows pre‐visualisation of the effect of flash positioning and
intensity on facial features before taking the picture (Glazer 2009).
Background illumination
Figure 6.25 A projection shadow cast by the key light can be distracting and annoying, and is eliminated by
illuminating a coloured background with an additional flash.
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154 Portraiture
Clinical Portraiture Set‐Up

Before embarking on portrait photography, as discussed in Module 2, a signed consent from
the patient is prerequisite. More than any form of dental photography, consent is essential for
portraiture. If consent is forthcoming, the ensuing pictures should be treated with the utmost
confidentiality, and archived safely and securely. However, if consent is withheld, the portrait
session should be abandoned.
The ideal location for taking portraits is a dedicated room, or an allocated space within a
dental clinic, preferably remote from the clinical environment. This allows a relaxed and unfet-
tered atmosphere to put the patient at ease. Music soothes the soul, and an appropriate melody
does wonders for setting the mood. This is particularly important for taking non‐clinical por-
traits when the patient needs to feel comfortable to express his or her true inner self.
For clinical portraits, the patient is seated upright in a revolving chair, hair tied back to expose
the auricles, ostentatious jewellery removed and cosmetic make‐up muted or washed off to
capture natural skin tones and texture. There are several reference lines that are useful for ori-
entating the head in the vertical and horizontal planes, including the inter‐pupillary and facial
midlines, ala‐tragus line (Camper’s plane), or Frankfort plane (Figure 6.26). However, it is impor-
tant not to rely on the incisal or occlusal plane as a reference, as this may be eschewed and result
in pseudo‐alignment. The photographer is situated behind camera, which can be tripod‐
mounted [ideal for standardisation] or hand‐held about 1–2 m away from the patient. The cam-
era is adjusted so that the lens axis is at the same level as the middle of the face (see Figures 5.1–5.3
in Module 5). The dental assistant is at hand helping set up the photographic equipment, acting
as a chaperone, and keeping a vigilant eye on the patient for ensuring their comfort.
The photographic inventory for clinical portraits consists of three studio flashes with light‐
modifying soft boxes or umbrellas, trigger mechanism for simultaneously firing the flashes,
and a cloth or paper backdrop. The preferred backgrounds are neutral sky blue or grey, which
Inter-pupillary Frankfort plane

line
Camper’s plane
Occlusal plane
Facial midline
Figure 6.26 The imaginary facial lines are useful guides for orientating the head in the horizontal and vertical
planes.
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Clinical Portraiture Set‐U 155
complement patients’ complexion. White or black backgrounds should be avoided since the
former creates annoying shadows, while the latter is not conductive for patients with darker
skin tones (Ettorre et al. 2006). The patient is positioned sufficiently in front of the background
to avoid distracting projection shadows, and to throw the background out of focus for greater
visual separation between the subject and background.
As disused in Module 1: Photographic Equipment, portraiture requires slave flash photogra-
phy. The electronic flashes output photographic daylight at a colour temperature of around
5500 K. They are either triggered wirelessly by radio controllers and apps, or cables connected
from the flashes to the sync cord pin on the camera. The exposure is usually calculated manu-
ally, using an incident light meter, or taking test shots at a given aperture and shutter speed, and
adjusting the distance or power of the flashes until the correct exposure is attained. Some stu-
dio flashes offer TTL (through‐the‐lens) metering using an adapter mounted onto the hot‐shoe
of the camera that controls the flash bursts for ensuring correct exposure. This is similar to
camera mounted compact flashes controlled by TTL metering.
The location of the studio lights is determined by available space and funds. There are two
options, the first is mounting the flash heads onto tripods placed on the floor, and the second,
more elaborate and expensive, is suspending the flashes from ceiling mounted tracks. The
retractable ceiling mounts are advantageous as they eliminate cables trailing on the floor, but
need a room with sufficient ceiling height. Tripod‐mounted units have the advantage of greater
mobility, especially if mounted on a dolly, but require substantial floor space. In both circum-
stances, a minimum of three flashes are required, two angled 45° towards the patient with a fill
light: key light ratio of 1 : 2, and the third directed to the backdrop (Figure 6.27). The key and
Background
illumination with
white bowl
reflector
45° - fill light 45° - key light

with soft box with soft box
Flash ratio 1:2
Figure 6.27 A standardised clinical portrait set‐up consists of two flashes positioned 45° in front of the patient
with a flash ratio of 1 : 2, and a third flash to illuminate the background, which is usually neutral sky blue or grey.
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156 Portraiture
fill light output is muted to soft light by attaching soft boxes or umbrellas onto the flash heads,
whilst the third flash has a white bowl reflector for uniformly illuminating the background.
This set‐up is very ‘clinical’, devoid of distinct shadows or highlights, producing a relatively flat
image. However, the remit of clinical portraiture is to convey reality, without glamourising or
denigrating the subject, and therefore, this lighting set‐up is fit for the intended purpose. The
predefined positions of the patient’s revolving chair, camera, flashes and backdrops should be
marked on the floor (or ceiling) with markers or adhesive masking tape so that their location is
repeatable. The studio set‐up for clinical portraiture is shown in Figures 6.28.
The Essential Portrait Portfolio

While the essential dental portfolio (EDP) concentrated primarily on the teeth, the essential
portrait portfolio (EPP) consists of basic full face images and the relationship of the teeth to the
Figure 6.28 An example of a photographic studio set‐up for standardised clinical portraiture.
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face. The EPP is quintessential for a variety of dental disciplines including orthodontics,
prosthodontics, periodontics, restorative dentistry, implantology, peadodontics, smile analysis,
smile design, facial enhancement, and cranio‐maxillio‐facial procedures. The clinical portraits
were previously excluded from the EDP since some patients are reticent to give consent to
photograph their face due to personal, social, cultural or religious reasons. However, if this is
not a concern, and appropriate consent is obtained, the EPP can be added to the EDP, see
Module 5: Extra‐oral and Intra‐oral Images.
The EPP consists of seven views (Figure 6.29), as follows:
EPP Image #1: Fontal view with inter‐labial separation
EPP Image #2: Fontal view – relaxed smile
EPP Image #3: Fontal view – biting wooden spatula
Essential Portrait Portfolio

(EPP)
Frontal
EPP Image #1 EPP Image #2 EPP Image #3
Profile
EPP Image #4 EPP Image #5
Oblique
EPP Image #6 EPP Image #7
Figure 6.29 Thumbnails of the essential portrait portfolio (EPP).
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158 Portraiture
EPP Image #4: Profile right side – inter‐labial separation

EPP Image #5: Profile left side – inter‐labial separation
EPP Image #6: Oblique right side – inter‐labial separation
EPP Image #7: Oblique left side – inter‐labial separation
The photographic equipment settings for standardised clinical portraits are as follows. The
magnification factor ranges from 1 : 8 to 1 : 15, depending on the size of the patient’s physical
build and whether the camera has a full‐frame sensor. An alternate approach is setting a prede-
fined focusing distance on the lens barrel, or framing the picture according to the field of view.
A f 11 aperture is recommended for adequate depth of field with a 1/125 or 1/250 seconds shut-
ter speed to eliminate the influence of ambient light. The salient camera/flash settings and
guidelines for these views are outlined in Table 6.1.
Table 6.1 Settings and guidelines for standardised clinical portraits.
Focus Manual or auto‐focus

Exposure Manual or through‐the‐lens Manual: use light meter, histogram or take test shots to
metering (TTL) ascertain correct exposure
ISO 50–200
Aperture f 11
Shutter speed 1/125 s or 1/250 s Flash synchronisation speed depends on a specific
camera brand
Image data RAW or DNG
format (file
format)
White balance Automatic or manual Manual options: numerical value input (5500 K), or take a
reference image with an 18% neutral density grey card
Flash Two studio flashes with soft Set the two flashes aimed at patient to a fill light: key
boxes or umbrellas, angled 45° light ratio of 1 : 2, alter intensity or distance of flashes to
towards patient, third flash to achieve correct exposure
illuminate background
Magnification 1 : 8 to 1 : 15 Only relevant for full‐frame sensors, or set predefined
factor focusing distance on lens, or see below for Field of view
Point of focus The PoF will depend on the Hand‐held cameras: for predefined magnification or
(PoF) angle of view, e.g. rhinion or focusing distance, move camera backwards and forwards
bridge of the nose for frontal until focus is obtained, or use anatomical landmarks for
views composing (see Field of view below)
Tripod‐mounted camera: for predefined magnification
factor or focusing distance use macro stage for focusing,
or use anatomical landmarks for composing (see Field of
view below)
If using auto‐focus, ensure that the lens axis is centred on
the tip of the nose for frontal views
Field of view For frontal full face images Right/left: bounded by background space
(composition) Superior: bounded by background space
Inferior: sterno‐clavicular joint
Anterior/posterior: tip of nose to auricles
Background Variable Clinical images: Neutral, e.g. sky blue or grey
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The frontal views, EPP Images #1, 2 and 3, are taken with the patient looking straight towards
the cameras, while for profile and oblique views the patient is asked to turn on the revolving
chair until the desired angle of view is obtained. Similar to the dento‐facial compositions
discussed in the previous module, inter‐labial separation is achieved by asking the patient to
iterate the letter ‘m’ or ‘Emma’. For EPP image #2, a relaxed smile is captured [usually accompa-
nied by narrowing of the inter‐eyelid spaces]. The EPP image #3 is biting into a wooden spatula
with the head positioned to the horizontal. The angulation of the spatula is ideal for assessing
incisal/occlusal plane alignment to the inter‐pupillary line.
The field of view, or composition, depends on the aspect ratio setting on the camera, or the
aspect ratio used in imaging software to crop the image. For portraiture, the chosen aspect
ratio determines the amount of background space at the upper, right and left borders of a
composition (the lower border is bounded by the sterno‐clavicular joint). There are two
options, the first is to be consistent with the EDP and use a landscape aspect ratio, which
ensures standardisation for both the dental and EPPs. However, landscape orientation for
portraits results in larger empty spaces right and left sides of the face compared to the upper
border. The second option is to frame/crop the images with reduced amounts of background
on the right and left sides, using the so‐called ‘portrait’ aspect ratio, but the framing is obvi-
ously disparate with the EDP (Figure 6.30).
The point of focus (PoF) also differs according to the angle of view. For frontal views, the
PoF is usually the rhinion or bridge of the nose (Figures 6.31–6.34). For profile views, EPP
Images #4 and #5, the contralateral side should be totally invisible and the PoF is on the ala‐tragus
Figure 6.30 Landscape vs portrait aspect ratios.
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160 Portraiture
Upper background
space above head
Neutral backdrop,
e.g. sky blue or
grey
Hair tied back to

expose auricle
Lateral background
Eyes wide open
space
No cosmetic
make-up
Sterno-clavicular
joint
MANUAL/AUTO FOCUS TTL/MANUAL

ISO ≈ 100 f 11 1/250 S RAW
AWB OR 5500 K 3 STUDIO FLASHES
MAGNIFICATION 1:8 TO 1:15
Figure 6.31 Standardised clinical portraiture settings, field of view and point of focus (PoF) (blue cross‐line
reticle) for essential portrait portfolio (EPP) images #1, #2 and #3.
Figure 6.32 Essential portrait portfolio (EPP)

image #1.
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image #2.

image #3.
line, at the midpoint between the tragus and lateral canthus of the eye (Figures 6.35–6.37).
Finally, for oblique views, EPP Images #6 and #7 the contralateral eye and its upper and lower
eyelashes are visible, and the PoF is on the ala‐tragus line at the intersection of the lateral can-
thus (Figures 6.38–6.40).
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162 Portraiture
Upper background
space above head
Neutral backdrop,
e.g. sky blue or
grey
Lateral background
space
Hair tied back to

expose auricle
No cosmetic
make-up
Sterno-clavicular
joint

ISO ≈ 100 f 11 1/250 S RAW
reticle) for essential portrait portfolio (EPP) images #4 and #5.

image #4.
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image #5.
Upper background
space above head
Neutral backdrop,
e.g. sky blue or
grey
Lateral background
space
Hair tied back to
expose auricle
Contralateral
Lateral canthus eyelashes visible
No cosmetic
make-up
Sterno-clavicular
joint

ISO ≈ 100 f 11 1/250 S RAW
reticle) for essential portrait portfolio (EPP) Images #6 and 7.
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164 Portraiture

image #6.

image #7.
Optional Clinical Portraits

The first four optional clinical portraits are a repetition of the EPP #4 to #7 (profile and oblique
views), but during a relaxed smile instead of inter‐labial separation:
1) Profile right side – relaxed smile
2) Profile left side – relaxed smile
3) Oblique right side – relaxed smile
4) Oblique left side – relaxed smile
The above images are taken with identical settings, angle of view and PoF described for EPP
images #4 to #7 (Figures 6.41 and 6.42).
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Optional Clinical Portrait 165
Figure 6.41 Optional essential portrait

portfolio (EEP) image #1 (profile right side
relaxed smile).
Figure 6.42 Optional essential portrait

portfolio (EEP) image #4 (oblique left side
relaxed smile).
Depending on the discipline and/or type of therapy being undertaken, there may be additional
specific facial views that are required for analysis, diagnosis, treatment planning, or reviewing
and monitoring inter‐treatment stages. Hence, it is impossible to show every type of clinical
portrait in addition to the optional views mentioned above. However, the specialities that
require particular facial images from different angles of view are orthodontics, aesthetic den-
tistry, cranio‐maxillo‐facial and aesthetic/cosmetic surgery. These extra images taken from
specific angles of view allow assessment of skull deformities such as dysgnathia, cleft lip and
palate, palsies, or acute traumas of the face, e.g. due to brawls or road traffic accidents. The set‐
up described for EPP can be used for any additional clinical portraits by varying the angle and
position of the patient’s head or camera, e.g. submental vertical view, supracranial oblique view,
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166 Portraiture
Supracranial oblique
Submental oblique
Back with auricles visible
Figure 6.43 Examples of some views for specific modalities or discipline.
back view auricles visible, profile or frontal views with the chin pointing upwards, backwards, or
downwards (Figure 6.43). Further images may be taken during different facial expressions such
as frowning, grimace or various gazes of the eyes including squinting, glaring or shut (Schaff
et al. 2006). Photographing children presents a challenge and is tedious and frustrating since
patients are fidgety, and often agitated in the ‘foreign’ dental environment. The best practice is
placing toddlers on the parent’s lap so that they feel more comfortable, and create auditory or
visual distractions as diversions form the task at hand. Also, setting the camera to auto‐focus
may circumvent blurred images, but not a guarantee as the focusing mechanism tries to negoti-
ate a child’s perpetual movements.
Non‐clinical Portraiture Set‐up

For non‐clinical portraiture, the photographer needs to think with his or her eyes for creating
tableaus that have visual panache (Figure 6.44). An impassioned portrait is created by unleash-
ing the imagination and conveying the depth of the soul. This is entering into the realms of art
and creativity, a subject that is sought rather than taught. However, for the sake of completion,
a few non‐clinical portraits, together with their set‐ups, are presented below to tantalise the
senses and stimulate the imagination.
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Non‐clinical Portraiture Set‐u 167
Figure 6.44 Non‐clinical portraiture is limited only by the imagination.
Generic Studio Portrait

The generic studio portrait is typified by a coloured dappled background using an established
set‐up with three flashes. The key flash has a soft box to produce soft light, which is placed
above and to the right or left side for classical Rembrandt lighting. A second fill light with
a honeycomb grid for harder light is placed on the opposite side behind the subject to act
as an edge (accent or rim) light. The background is illuminated separately with the third
flash, which has a white bowl reflector to achieve substantial figure‐to‐ground separation
between the subject and background. The intensity (power) and distance of the
three flashes is tweaked for achieving the correct exposure (Figures 6.45 and 6.46). This
set‐up is ideal for business and formal portraits, as well as job applications or promotional
purposes.
Flattering Portrait
A simple, but effective set‐up yields spectacular results. In the following portrait, only a single
flash is used as the key light above and behind the model, whilst a silver reflector acts as a fill
light to bounce light onto the face. The effect is a faltering portrait that floods the subject with
a burst of soft light, ironing out wrinkles and blemishes. The arrangement is reminiscent of
shooting outdoors, with bright sunlight above and behind the subject with a judicially placed
reflector to illuminate the face with a ‘glow’ of light. The set‐up is also conductive for photo-
graphing the lips and teeth, since the light from the reflector can be manipulated to ‘shine’ on
the smile. An optional black backdrop can be utilised, but is unusually superfluous since the
reflected light from the fill light is insufficient to illuminate unwanted background objects
(Figures 6.47 and 6.48).
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168 Portraiture
Rim or edge light

with honeycomb grid
Background light with

white bowl reflector
Key light with

soft box
Figure 6.45 Generic studio portrait set‐up using three flashes.
Figure 6.46 Generic studio portrait: f 11, 1/125 seconds.
Profile Portrait
The easiest method to emphasise a facial profile is illuminating the face head‐on, whilst throwing
the remainder of the head into partial darkness. The set‐up consists of two flashes, the key light
with a honeycomb grid produces relatively hard light, whilst a softer fill light of reduced intensity
is used to illuminate the hair and cast a diffuse shadow of the face onto a cloth backdrop. The
ensuing shadow further accentuates the brightly lit facial profile (Figures 6.49 and 6.50).
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Key light with silver

bowl reflector
Fill light: silver

reflector
Figure 6.47 A simple but effective set‐up for a flattering portrait.
Figure 6.48 Flattering portrait: f 16, 1/125 seconds.
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170 Portraiture
Key light with

honeycomb grid
Fill light with silver

bowl reflector
Figure 6.49 Profile portrait with head‐on illumination by the key light, and a shadow cast by a fill light onto
the background.
Figure 6.50 Profile portrait: f 8, 1/125 seconds.
Coloured Gel Portrait

Besides utilising coloured backdrops, another method for adding colour is placing a filter or
gel over the flash head. Gels are available in several colours and offer a quick and convenient
method for colouring light directed to specific parts of the face. In this set‐up, a blue gel is
used for the rim flash positioned just behind the subject to backlight the hair. The hair on
the contralateral side is not illuminated to add colour contrast with the opposite side and the
maroon background. The key light is relatively hard, located to the front left side of the
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Rim light with

honeycomb grid +
blue gel

Fill light: white card
reflector
Key light with

honeycomb grid
Figure 6.51 Coloured gel portrait set‐up using two honeycomb grid attachments, one with blue gel as a rim
or hair light.
Figure 6.52 Coloured gel portrait: f 9.5, 1/125 seconds.
model, a white card on the right side as the fill light to fill in shadows, and a third flash
illuminates the cloth backdrop (Figures 6.51 and 6.52).
Classical Smile Line Portrait

Although all non‐clinical portraits potentially have high marketing value, dental marketing
relies heavily on the lower third of the face or the smile, which is stereotypical for promoting a
dental clinic or practice. The set‐up for the classical smile line portrait is another take on the
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172 Portraiture
profile portrait (shown above) using a single key light placed above the subject instead of head‐
on. The model has a celestial gaze, that is emphasised by the overhead illumination. The relaxed
smile beautifully conveys the parallelism of the maxillary incisal plane to the curvature of the
mandibular lip. The overhead light is muted with a soft box and Velcro grid so that the face is
awash with diffuse soft light that adds a pensive, heavenly quality to the composition. A second
light is placed behind to illuminate the background and a white card reflector bounces light
from the overhead soft box to illuminate the neck and chin (Figures 6.53 and 6.54).
Key light with soft

box + Velcro grid

Fill light: white card

reflector
Figure 6.53 Smile line profile portrait with an overhead diffuse key light.
Figure 6.54 Smile line profile portrait: f 9.5, 1/125 seconds.
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References 173
Figure 6.55 Smile line frontal portrait: f 9.5, 1/125 seconds.
Clinical vs. Non‐clinical Portraiture

Finally, the last image aptly illustrates the difference between clinical and non‐clinical portraiture.
The set‐up is similar to the previous image, but the overhead light illuminates both the model
and background. The model is looking directly towards the camera, and again, notice the
pleasing smile line characterised by the coincidence of the incisal edges of the maxillary teeth
with the curvature of the lower lip (Figure 6.55).
A side‐by‐side compassion of Figures 6.33 and 6.55 clearly demonstrates the different visual
impact of each image; the former depicts clinical reality, whilst the latter is a dopamine releasing
portrayal of the same individual.
References
Ahmad, I. (2009a). Digital dental photography. Part 7: extra‐oral set‐ups. Br. Dent. J. 207 (3):
103–110.
Ahmad, I. (2009b). Digital dental photography. Part 5: lighting. Br. Dent. J. 207 (1): 13–18.
Bazos, P. and Magne, M. (2013). Demystifying the digital dental photography workflow. The big
picture: facial documentation with high visual impact photography. J. Cosmet. Dent. 29 (1):
82–88.
maxillo‐facial surgery – part I: basic views and guidelines. J. Craniomaxillofac. Surg. 34:
65–73.
Glazer, B. (2009). Portrait Photography in Prosthodontics. http://www.oralhealthgroup.com/
features/portrait‐photography‐in‐prosthodontics (accessed 23 May 2019).
Jung, C.G. (1969[1933]). Archetypes and the Collective Unconscious. Collected Works of C.G. Jung,
Volume 9 (Part 1). Princeton, NJ: Princeton University Press.
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174 Portraiture
Cambridge in Colour (2005–2017). Portraiture lighting. www.cambridgeincolour.com (accessed 23

May 2019).
Schaff, H., Streckbein, P., Ettorre, G. et al. (2006). Standards for digital photography in cranio‐
maxillo‐facial surgery – part II: additional picture sets and avoiding common mistakes.
J. Cranio‐Maxillofac. Surg. 34: 366–377.
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175
Bench Images
This module, more than any other in this book, allows the photographer to unleash creativity
and free the imagination for producing pictures that have unique mood and composition,
where an object or product can be shot from any angle, with any light source, and with any
background (Figure 7.1). The so‐called bench image is basically still life macrophotography,
and allows the photographer complete control over subject matter and lighting, with few rules
or limitations to express his or her vision in vibrant ways (Figures 7.2 and 7.3). Since the objects
are ’still’, the permutations for positioning are endless. Furthermore, similar to a painting, a still
life photograph can tantalise the mind with a surreal ’hidden’ meaning or message.
Uses of Bench Images

Dental bench images document a variety of dental items for communicating with fellow profes-
sional colleagues as well as patients. The most frequently photographed dental items are plas-
ter casts or 3D‐printed models of the maxillary and mandibular arches, diagnostic wax‐ups,
thermoplastic or 3D‐printed surgical guides, transparent vacuum stents for intra‐oral mock‐up
and chair‐side temporisation, crowns, veneers, inalys/onlays, bridges and removable partial,
full or implant‐supported prostheses. Bench images can simply be for documentation, or anal-
ysis, treatment planning, research and teaching clinical and laboratory techniques (Ahmad
2009) – Figures 7.4.
In addition, many treatment modalities, such as orthodontics, require mandatory photographs
of models for pre‐operative records, treatment progress, post‐operative outcomes and
monitoring. Also, photographic communication facilitates second opinions form specialists, or
approval from patients before finalising treatment plans. This may include assessing mounted
casts on semi‐ or fully adjustable articulators for assessing lateral excursions, anterior guidance,
raising the VDO (vertical dimension of occlusion), smile design and diagnostic wax‐ups of
proposed aesthetic and functional rehabilitation (Figures 7.5–7.8). Visual documentation also
facilitates communication between patient/ceramist/clinical, such as scrutinising flaws in
impressions before fabricating indirect restorations, which saves time and money and avoids
clinical embarrassment in front of patients if the restoration fails to fit. A pre‐operative plaster
cast is also indispensable for reminding the patient of the starting point of dental therapy, its
progress and final result. In addition, the dental technician can inspect and record porosity,
fractures and fluorescence properties of ceramic restorations before delivery to the clinician.
Implant planning also benefits from photodocumentation, especially for multidisciplinary
prosthetically driven treatment planning by liaising with oral surgeons, periodontists, prostho-
dontists and dental technicians for arriving at a feasible and predictable treatment plan. This

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176 Bench Images
Figure 7.1 Bench shots are ideal for creating promotional images, when an object can be photographed
from any angle, with any light, to convey the intended message to an audience.
Figures 7.2 and 7.3 The creativity

potential of bench images is
limitless.
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Uses of Bench Image 177
Figure 7.4 Stylised bench images are ideal for teaching techniques, e.g. ceramic etching of the intaglio surface
of an inlay with hydrofluoric acid.
Figure 7.5 Pre‐operative cast of a

patient with altered passive
eruption with short clinical crown
lengths. The existing
measurements are marked on the
teeth, and with the proposed
gingival zeniths after aesthetic
crown lengthening. The marked
areas at the incisal edges indicate
the anticipated reduction
necessary for achieving the correct
width/length ratio of the teeth.
Figure 7.6 The proposed aesthetic

crown lengthening and incisal
edge reduction for rehabilitating
pink and white aesthetics.
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178 Bench Images
Figure 7.7 Plaster cast of the

diagnostic wax‐up showing the
proposed crown lengths after
perio‐plastic surgical and
restorative procedures.
Figure 7.8 Plaster cast of the

diagnostic wax‐up cast with
silicone index for guiding incisal
edge reduction.
involves gaining input from specialists about 3D‐printed surgical guides (designed using intra‐
oral and radiographic CBCT scans) or implant placement with concomitant soft and hard
tissue augmentation (Figures 7.9–7.11). Finally, a clinical technique is often easier to explain
and teach with a sequence of bench images, particularly for treatments involving posterior
teeth (Figures 7.12–7.18). Similarly, a series of bench photographs are ideal for showing
step‐by‐step laboratory techniques such as porcelain layering of ceramic crowns.
Backgrounds and Supports
The basic items required for bench images are a support to place the items to be photographed
on and a suitable background. A backdrop is desirable for bench images to add interest to the
composition and create figure‐ground separation. A background and support can either be a
single entity for a seamless transition between the foreground and background, or a bench to
place the items and a separate background. Whichever option is chosen, the amount of
background is crucial to a composition; too much background gives a sense of isolation and
alienation, while too little signifies clutter and claustrophobia.
Several configurations are available for backgrounds/supports for bench images. The first is
purchasing a professional still life table or macro studio that serves the dual purpose of
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Backgrounds and Support 179
Figures 7.9–7.11 A second opinion from a specialist is invaluable before proceeding with treatment, e.g. a
flapless procedure for implant placement using a 3D‐printed surgical guide.
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Figures 7.12–7.18 It is often easier to take a series of bench images with a consistent field of view for
documenting a technique for didactic teaching, e.g. preparing and restoring a Class II cavity.
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Backgrounds and Support 181
s upporting the item(s) and acting as a background.1 The table is readily adjusted to any height,
the background changed to any colour and numerous flashes attached by brackets, clips and
poles at any angle (Figure 7.19). The obvious advantage is that the photographic session is
expedited with finesse, and the set‐up is reusable for consistent and standardised images. This
apparatus is also ideal for photographing a series of images showing a step‐by‐step technique.
The drawbacks are that a macro studio contraption requires considerable space for the table,
props and lighting, not to mention the additional financial outlay.
The second option is an improvised set‐up, which is frugal, and somewhat tedious and time‐
consuming, but comes at a fraction of the cost. The essential items are a background which can
either be suspended coloured cloths, cards, translucent Perspex® or a piece of black painted
wood. If a piece of wood is used, various interchangeable coloured cards cut to size can be
temporarily stuck onto the wood with reusable putty adhesive such as Blu‐Tack® or Velcro®. The
other items are reflective cards for fill‐in reflectors, including a bench reflector of aluminium
(kitchen) foil placed underneath the item to eliminate projection shadows. This set‐up requires
very little space, easily placed on worktops in a clinic or dental laboratory (Figure 7.20). The
drawback is difficulty in obtaining standardised images, as most of the items are collated ad
hoc. However, with a little patience this is overcome by marking positions of the background,
lights and item to be photographed for consistent reproductions. Nevertheless, both profes-
sional and improvised set‐ups yield equally satisfactory results, and the choice ultimately
depends on available space, finances and perseverance.
For either set‐up, it is preferable to mount the camera on a tripod and trigger it via a remote shutter
release. This is advantageous for several reasons. First, it frees the hands for adjusting angles and
positions of objects and playing with light. Second, it prevents camera shake if using continuous
low‐level illumination with long exposures, and third, for standardised images ensures the same
framing (field of view), which is necessary for a series of shots documenting a particular technique.
Figure 7.19 Professional still life table with ancillary equipment for macrophotography (MagicStudio,
Novoflex, Germany).
1 https://www.novoflex.de/en/products‐637/desktop‐studio‐magic‐studio/magicstudio.html
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182 Bench Images
Figure 7.20 Improvised set‐up for bench images, consisting of various coloured backgrounds, reflectors,
mirror, Perspex sheets, clamps, grey card, etc., which can be tailored as necessary for a specific photograph.
The most frequently photographed objects are dental casts (models), which are usually mono-
chromatic, bland and visually boring. Several techniques are employed for adding interest to the
composition for attracting the attention of the viewer. The main item that adds interest is creative
lighting (discussed below), which can make or break a picture. Another approach is adding col-
our. This could be in the form of coloured lighting by covering flashes with gels, UV (ultra‐violet)
lamps, focused coloured beams of light (fibre‐optic halogen, LED or lasers) or interesting col-
oured and textured backdrops for enhancing colour contrast between the object and the back-
ground. A further approach for enhancing figure‐ground separation is selectively focusing on a
specific items(s) or part of an item and throwing the surroundings out of focus (Figure 7.21).
Figure 7.21 Selective focusing is an

effective method for highlighting
protagonist parts (enhancing
figure‐ground separation) while
throwing the surroundings out of
focus.
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Lightin 183
Figures 7.22 and 7.23 Although these two images using creative lighting have high visual impact, the
entangled background distracts from the main item of interest, which is the surgical guide for placing two
implants at the maxillary lateral incisor sites.
The choice of backgrounds is bewildering and daunting, but generally, light objects warrant
darker backgrounds and vice versa for dark objects. The choice of colour also affects how an
image is perceived, vivid colours are dynamic and create drama, whilst pale hues are placid, and
convey serenity. It is also important that the background colour or texture is appropriate for a
given object and harmonises with it. If the background is incongruous with the main subject,
visual tension ensues causing rejection. Also, backgrounds should add interest, but at the same
time not distract or overpower the main subject/object of interest (Figures 7.22 and 7.23).
Lighting
There are several choices of light sources for bench images, either flashes or continuous light.
The flash options are studio flashes used for portraiture (Module 6) or twin bilateral compact
flashes used for intra‐oral views (Module 5). Ring flashes are not recommended as the light
output produces flat, dull images. Since the objects to be photographed are relatively small,
studio flashes are cumbersome, time‐consuming to set up, and perhaps an overkill. The compact
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184 Bench Images
flashes are easily manoeuvred, but with a few provisos. First, compact flashes should be detach-
able so they can be hand‐held, and second, the trigger mechanism is wireless to facilitate posi-
tioning at any angle without having to worry about trailing or tangling cables that interfere with
the composition or are visible in the picture. Furthermore, if an improvised set‐up is used,
compact flashes are an ideal accompaniment, requiring little space and easy to manipulate.
Another point to remember is that instead of splashing out on several flashes, still life photog-
raphy offers the option of judicially using reflectors and mirrors to bounce light, which is both
effective and economical.
Continuous light sources include incandescent or halogen Anglepoise® table lamps, fluores-
cent tubes, fibre‐optic cables, HMI (hydrargyrum medium‐arc iodide) or UV lamps (black
lights). A continuous light source has the benefit of seeing the visual effect of shadows and
highlights before taking a picture. However, the potential drawback with continuous light
sources is that the camera must be mounted on a tripod if long exposures are anticipated, white
balance must be carefully calibrated to avoid colour casts and the high cost if using HMI illu-
mination. Other types of lights include fibre‐optic cables that focus light to various size spots
for special effects.
The basic principles of lighting discussed in Module 3, and for portraiture in Module 6, are
also applicable for bench images. Directional lighting creates depth with shadows and high-
lights, emphasising texture and surface detail, whilst uniform illumination results in flat, two‐
dimensional bland images. One of the endearing aspects of bench photography is that time is
not a concern, and the photographer is liberated by the constraints of clinical photography.
Objects and lighting can be changed endlessly until the desired effect is attained. However, in
a busy dental practice, this luxury may not be affordable for everyone, and therefore, it is pru-
dent to have a set‐up that is perpetually ready and accessible for expediting a bench image
photographic session.
The position of the lights determines which parts of the object(s) are highlighted. Also, the
flash ratio is discretional, but should be asymmetrical for achieving three‐dimensional imagery.
A single detachable flash is ideal for unidirectional illumination from various angles, such as from
one side, above, below, behind or any angle in between. Placing flashes head‐on creates a similar
effect to a ring flash, and therefore should be avoided. When photographing a dental cast, either
with or without restorations/appliances, placing the flash to one side emphasises surface texture,
gingival architecture, gingival stippling, incisal embrasures and facial topography and lines angles
(Figure 7.24). A flash placed below or above (depending on whether the maxillary or mandibular
teeth are being photographed) highlights the free gingival margins, crown finish lines, incisal
lobes and incisal edge chips or wear facets (Figure 7.25). Placing a flash behind transilluminates
wax‐ups or ceramic restorations revealing translucencies and characterisations of ceramic layer-
ing including mamelons and incisal halos, emphasises incisal edge morphology, and accentuation
finish lines for detecting undercuts in tooth preparations (Figures 7.26 and 7.27). Finally, a bench
reflector, e.g. aluminium foil, placed below models is ideal for filling in shadows from the key light
on the lingual/palatal aspects of the teeth (Figure 7.28).
Bench Image Set‐ups

Unlike standardised set‐ups for extra‐oral, intra‐oral (EDP) and clinical portraiture (EPP)
portfolios, it is difficult, or even impossible, to standardise bench images. Hence, the set‐up
for bench images is unique for a specific modality or discipline, and the intended purpose of
the image, i.e. for clinical documentation or marketing and promotion. Also, the allocated
space in a clinic or institution determines the type of set‐up, which may be rudimentary or
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Bench Image Set‐up 185
Right side
Figure 7.24 A single flash placed to one side creates distinct highlights and shadows, emphasising surface
detail.
Below
Figure 7.25 A single flash placed below (for maxillary teeth) is ideal for visualising crown preparation finish
lines, free gingival margins and incisal lobes.
grandiose. Figure 7.29 shows the schematic for a generic bench image set‐up, consisting of key
light, fill light and reflectors, which can be reflective cards (white, silver, gold), foil, or an intra‐
oral or face mirror. A separate flash illuminates the backdrops, which are either cloth, paper,
Perspex or bespoke scenery to complement the main object(s). A bench reflector, if required,
is placed below the object to fill shadows. Alternately, a seamless surface (cloth, paper, plastic)
can support the object as well as acting as a backdrop. Moreover, the generic set‐up is a guide,
which can be tailored by adding or omitting ancillary equipment/items for achieving the
desired photographic effect.
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186 Bench Images
Behind
Figure 7.26 A single flash placed behind a dental cast highlights translucencies of diagnostic wax‐ups.
Behind, below
Figure 7.27 A single flash placed behind and below creates silhouettes of the teeth, which is particularly
useful for detecting undercuts in tooth preparations.
Equipment Settings
The equipment settings are determined by the intended use of the images. If consistency and
repeatability is paramount, the set‐up is devised with constant settings and positions all con-
cerned items. This is achieved by marking the position of the object and photographic equip-
ment and any accessory items with a pen or adhesive masking tape. In addition, the flashes are
supported by brackets and not hand‐held, and all camera and flash settings are noted, or a user
preset is created in the camera menu that can be recalled for a specific type of image. Table 7.1
summarises settings and guidelines for bench image.
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Without bench reflector
Bench reflector
With bench reflector
Figure 7.28 A bench reflector placed underneath the model fills in shadows on the lingual/palatal aspects of
the teeth.
Interchangeable
coloured backdrops
Background
illumination
for coloured
backdrops
Fill light:
wireless
compact flash,
Anglepoise®
lamp or
reflectors
Fill light: bench reflector,
e.g. aluminium foil
Key light: wireless Key light:

compact flash Anglepoise®
lamp
Flash ratio - variable
Figure 7.29 Schematic representation of a generic bench image set‐up.
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188 Bench Images
Table 7.1 Settings and guidelines for bench image set‐ups.
Focus Manual or auto‐focus

Exposure Manual or TTL Manual: histogram or take a few test shots to
metering ascertain correct exposure
ISO 50–200
Aperture Any, depending on the the For selective focusing on a specific part of an
desired effect. For object(s), f 4 is a good starting point
standardised images use f 22
Shutter speed 1/125 s or 1/250 s Flash synchronisation speed depends on a
specific camera brand
format (file
format)
White balance Automatic or manual Manual: numerical value input, or take a
reference image with an 18% neutral density
grey card
Flash/continuous Flash: detachable, wireless Single flash: alter distance or intensity for
light flashes (single or bilateral) correct exposure
Continues light sources: Bilateral flashes: adjust fill light: key light
halogen, fluorescent, LED, ratio to 1 : 2. If images are too bright or too
laser, HMI, UV dark, alter intensity of flashes, or move
flashes closer or further away until correct
exposure is achieved
Continuous light: use slow shutter speeds,
ensure camera is tripod‐mounted
Magnification 1 : 1 to 1 : 3 (depends on Only relevant for full‐frame sensors, or set
factor size of object(s)) predefined focusing distance on lens, or see
below for field of view
Point of focus Variable, depending on Hand‐held cameras: for predefined
(PoF) object(s) and desired effect magnification or focusing distance, move
camera backwards and forwards until focus is
obtained
Tripod‐mounted camera: for predefined
magnification or focusing distance use macro
stage for focusing
If using auto‐focus, ensue that lens axis is
centred on point of focus
Field of view Use rule of thirds, leading Experiment by breaking rules for unique and
(composition) lines, diagonal and interesting images
converging lines, visual
weight, balance, Golden
Proportion, dominance,
figure‐ground
Background Black or any colour Velvet cloth, e.g. black, cards, translucent
depending on desired Perspex, plastic, or textured/coloured
effect backdrops
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The examples below illustrate some examples of set‐ups for bench images, which can be
tailored for specific needs.
Dental Casts (Models) with Black Background

The first set‐up is useful for photographing plaster casts or 3D‐printed models, e.g. before,
during and after orthodontic treatment, or for any modality that requires documentation of
models for analysis, treatment planning and monitoring. A black background is chosen to
complement the relatively insipid models, whilst equipment settings and positions are noted
for ensuring consistency. The black backdrop can be black velvet cloth, card or a painted
wood block.
The object to be photographed is placed in front or on top of the background with a bench
reflector (e.g. aluminium foil) underneath to fill in shadows on the lingual or palatal aspects of
the arch. The recommended lighting is either continuous light from an Anglepoise lamp, twin
bilateral flash configuration (similar for taking intra‐oral pictures), which should be mounted
on bracket below the camera. Instead of using two flashes, a single flash and a reflector judi-
cially placed on the opposite produces the same result. Ring flashes are contraindicated as they
render a dull image devoid of shadows and highlights that and obliterates fine detail. A con-
tinuous light source offers the advantage of visualising the lighting effect before taking the
picture, but the drawback is that a slower shutter speed is required due to the relatively low‐
level light output. (Figures 7.30 and 7.31).
Fill light: bench reflector
Fill light: compact Key light: wireless

flash, Anglepoise compact flash, 45°
lamp or silver or Anglepoise lamp
reflector, 45°
Figure 7.30 Schematic set‐up for photographing dental models with a black background.
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190 Bench Images
Figure 7.31 Plaster casts photographed with the set‐up shown in Figure 7.30.
Dental Cast with Coloured Background

Colour adds interest to a composition, especially for achromatic objects. However, colour
should be used carefully. If the object itself is colourful, a black or white background is more
appropriate, rather than a coloured background that causes visual chaos. Conversely, mon-
ochromatic items benefit from a textured or colourful backgrounds by counterbalancing
bland objects. This bench set‐up uses a lilac background with the key flash positioned
above. An overhead light is ideal for highlighting the incisal edges, and clearly visualising
tooth surface loss (TSL) or tooth wear. Since a coloured backdrop is placed behind the
object, background illumination is required to avoid projection shadows, which also creates
visual separation of the object from its surroundings, giving an enhanced figure‐ground
appearance (Figures 7.32–7.34).
Implant Supported Temporary Crown with Red Background

Photographing individual items such as artificial restorations usually require various angles of view
to capture different aspects of the prosthesis. This is accomplished by placing the item on the
bench and then altering its position to capture various views. Alternately, small items are best held in
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Key light: wireless

compact flash, above
Figure 7.32 A single overhead light causes projection shadows onto a coloured background, which is
avoided by…
Key light: wireless

Background
illumination for
coloured
backdrop
Figure 7.33 …illuminating the background with a separate flash.
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192 Bench Images
Figure 7.34 Mandibular plaster

cast showing incisal edge wear
facets, photographed with the
set‐up shown in Figure 7.33.
tweezers or Spencer Wells forceps and turned around to show different aspects of the restoration.
In this case implant supported temporary crown was secured with an implant screwdriver, which
was grasped with dental tweezers. Several angles were photographed using the following set‐up.
Highly reflective stainless steel items rely on specular reflections to highlight their shiny surfaces.
Therefore, several flashes, combined with shiny silver reflectors, are used to maximise specular
surface reflections. Two flashes are needed, one overhead and the second to one side, whilst the
reflectors are placed underneath and to the contralateral side to bounce light back onto the metal
surfaces. The red background is lit separately with a third flash (Figures 7.35 and 7.36).
Key light: wireless

Background
illumination for
coloured
backdrop
Key light: wireless

compact flash,
Fill light:silver towards objects
reflector, opposite
key light
Figure 7.35 Set‐up for photographing reflective objects.
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Figure 7.36 Implant supported temporary crown photographed from different angles of view using the set‐
up shown in Figure 7.35.
Perspex Backgrounds
Another method for creating dynamic images with colour is using translucent Perspex
sheets. Perspex sheets are available in various colours from art and craft or hobbyist suppli-
ers, who can cut the sheets to the appropriate dimensions depending on the size of the
object to be photographed. The sheet acts as a background and a key flash is placed behind
the Perspex to create a spectacular glow of colour. For solid objects the effect is a silhouette,
whilst for translucent items such as vacuum stents or surgical guides, the effect is a semi‐
silhouette that highlights intricate details. The flashes are positioned carefully to be per-
pendicular to the lens axis to avoid projections shadows (Figure 7.37). In addition, the
coloured glow can be manipulated to produce either uniform illumination, or a vignetting
effect, that is centralised or located at the top, bottom, right, left, or anywhere on the back-
ground with a seamless transition, depending on the position and distance of the rear flash
(Figure 7.38). The set‐up for this composition is shown in Figure 7.39 and the resulting
image in Figure 7.40.
If a silhouette effect is not required, the item can be directly illuminated by another key light
with a fill light to fill in the shadows. This approach combines the coloured glow background of
the Perspex sheet as well as correctly illuminating the main item(s). The second key light is
placed to one side so as not to point the light directly onto the item, as this causes unwanted
reflections in the Perspex sheet. The set‐up is shown in Figure 7.41 and the resulting photo-
graph in Figure 7.42 shows the same surgical guide as in Figure 7.40, captured in a different
light. Another example using this set‐up is shown in Figure 7.43.
A variation of the above set‐up is using two Perspex sheets with different opacities (or col-
ours), which creates an abrupt transition of colour. In addition to the key flash located behind
the sheets, another key flash is placed below to highlight the crown preparation finish lines
or incisal edges of artificial restorations. To complete the set‐up, two silver reflections on
both sides of the 3D‐printed models act as fill lights to illuminate the sides of the model
(Figures 7.44–7.46).
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194 Bench Images
Incorrect flash position
Perspex
Camera lens
Correct flash position

(perpendicular to lens axis)
Figure 7.37 Flash positioning is crucial for avoiding unwanted projection shadows.
Flash close to Perspex sheet
Uniform illumination
Centralised
Top
Bottom
Left Right
Flash away from Perspex sheet
at different positions
Figure 7.38 The location and type of coloured glow depends on the distance and location of the rear flash.
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Figure 7.39 Set‐up for Perspex

background with a single key light Lilac Perspex sheet
flash.
Key light: wireless compact

flash, behind Perspex
Figure 7.40 3D‐printed surgical

guide for implants photographed
using the set‐up shown in
Figure 7.39.
Bokeh Composition
Bokeh is the manner in which a lens captures out of focus, or blurs, point light sources. The
shape of the Bokeh is an inherent property of the lens and is determined by the shape and
degree of opening of the aperture diaphragm. The shape of the polygon Bokeh is created by the
diaphragm leaves, e.g. pentagon or heptagon, but can also be a perfect circle. The effect adds a
magical twinkle appearance in the background as blurred dots of lights, whilst the subject is
sharply focused in the foreground. The set‐up consists of a foil placed behind the object, with
a key flash above and behind to transilluminate the translucent/transparent object, while
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196 Bench Images
Lilac Perspex sheet

flash, behind Perspex
Fill light: Key light:

silver reflector, wireless
opposite key compact flash,
light towards objects
Figure 7.41 Set‐up for Perspex background with a key light flash behind the Perspex and another key light
and fill light to directly illuminate the 3D‐printed surgical guide.
Figure 7.42 3D‐printed surgical

guide for implants photographed
using the set‐up shown in
Figure 7.41.
another flash is angled to create point specula reflections off the foil surface. The distance
between the foil and flash is varied until the desired bokeh is obtained (Figures 7.47–7.48).
Stroboscopic Effect
The stroboscopic effect is a method of freezing movement of an object or subject as it traverses
across the frame, analogous to stop‐motion images. It is useful for illustrating moment, or sim-
ply creating a stylish image for captivating an audience. This is a creative effect involving as
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Figure 7.43 3D‐printed maxillary

model with a thermoformed
transparent guide for aesthetic
crown lengthening of the maxillary
anterior sextant using the set‐up
shown in Figure 7.41.
Red Perspex sheets of different opacities
Key light: wireless compact flash,

behind Perspex sheets
Fill light:silver Fill light:silver

reflector, right side Key light: wireless reflector, left side
compact flash,
below
Figure 7.44 Set‐up with two Perspex sheets of different opacities, a key light flash behind the Perspex and
another below, plus two silver reflectors as fill lights.
many as 40 flash burst/second, far greater than taking successive multiple shots that are limited
to usually 10 frames/second.
The effect is possible with both studio and compact flashes by selecting the ’Strobo’ mode in
the menu. Most contemporary flashes offer this option as standard, but lower spec flashes may
not have this facility. There are three variables to consider: the power or duration of output, the
number of flashes and the frequency of the flashes (flashes/second), expressed in Hertz (Hz).
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198 Bench Images
Figure 7.45 3D‐printed models

highlighting the crown preparation
margins on the maxillary central
incisors using the set‐up shown in
Figure 7.44.
Figure 7.46 3D‐printed models

highlighting the incisal edges of
the e‐max® all‐ceramic crowns on
the maxillary central incisors using
the set‐up shown in Figure 7.44.
The intensity or output of a flash is determined by its duration – a faster duration means less
power, but a greater number of flashes that can be fired per second, i.e. a faster burst rate. The
three variables are interlinked, and a little experimentation is required to achieve optimal
results. For example, if the power (duration) is reduced to 1/128, frequency set at 20 Hz and
number of flash count set to 10, the shutter speed is calculated as follows:
Shutterspeed numberof flashes / frequency Hz

In the illustration above, this would mean a shutter speed of 0.5 second. However, the expo-
sure is also influenced by the ISO and f‐stop, which need to be adjusted accordingly. Once the
flash(es) and camera are configured, the set‐up is fairly straightforward. The key flash is placed
on one side and fill‐in reflectors on the opposite side and bottom or top of the object. A black
background is ideal, preferably in a darkened room to avoid blurring of motion due to stray
ambient light. Also, it is essential to mount the camera on a tripod to prevent camera shake.
Figure 7.49 shows the set‐up for a stroboscopic effect and examples of three images are shown
in Figures 7.50–7.52.
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flash, above & behind
Key light: wireless

compact flash.
directed towards
foil with teal gel
Figure 7.47 Set‐up for a Bokeh composition with a foil background and two key lights, the first flash placed
above and behind, and a second flash directed towards the foil.
Figure 7.48 Bokeh composition: fractured ceramic

crown on fractured tooth photographed with the
set‐up shown in Figure 7.47.
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200 Bench Images
Key light: Strobo,

Fill light:
1/128 duration,
silver
20 Hz, 10 flash
reflector
count
Fill light: bench reflector (foil)
0.5 s, ISO 100, f 11
Figure 7.49 Stroboscopic effect set‐up.
Figure 7.50 Stroboscopic effect with the

set‐up described in Figure 7.49 showing a
brush being dipped into a plaque disclosing
liquid in a dappen dish.
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Figure 7.51 Stroboscopic effect with the set‐up described in Figure 7.49 showing a micro‐brush being dipped
into a plaque disclosing liquid in a dappen dish.
Figure 7.52 Stroboscopic effect with the set‐up described in Figure 7.49.
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202 Bench Images
Reference
Ahmad, I. (2009). Digital dental photography. Part 7: extra‐oral set‐ups. Br. Dent. J. 207 (3):
103–110.
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203
Special Applications
The special applications presented in this module are advanced principles for maximising the
full potential of digital dental photography. These include taking additional images for
elucidating certain features, or analysing images for effective communicating with patients and
fellow colleagues. Whilst the essential dental portfolio (EDP), essential portrait portfolio (EPP)
and optional images discussed in previous modules are sufficient for most modalities, some
procedures require specific types of imagery for multi‐diagnosis and facilitating collaborative
care. Also, the topics covered in this module are more demanding than routine dental photog-
raphy, require extra equipment and specialised training to become fully conversant with these
techniques.
Detailed Analysis of Hard and Soft Tissues

A good standard of practice for dental photodocumentation is the obligatory nine EDP, com-
bined with the seven EPP, plus selective optional images depending on the needs of the given
speciality. However, these standardised images may not ‘tell the whole story’, and additional
photographs are necessary to complete the story. Therefore, the photographic set‐ups need to
be modified for capturing salient features for detailed evaluation. This involves minor recali-
bration of camera and light settings, but the main difference is the positioning of the patient
and photographic equipment for visualising pertinent points of interest.
The major problem with analysing dentine and enamel is that natural teeth have an anisotropic
structure. The outer enamel layer is highly reflective, encouraging specular reflections that
obscure the underlying characterisations within the teeth. However, specular reflections (glare)
off the surface are ideal for assessing micro and macromorphology, texture and lustre of the
outer enamel layer. In order to visualise tooth characterisations, light needs to pass through the
tooth rather than be reflected off its surface. Hence, it is difficult to simultaneously visualise
texture and characterisations, and two different types of illumination are necessary for
discerning each of these entities. This usually entails taking two separate pictures with different
lighting for the right and left sides of an arch; one side to visualise texture, and the other side to
visualise characterisation of the enamel and dentine strata.
In order to encourage specular reflections, a single unidirectional flash (key light) is placed
on one side, and a reflector on the opposite side to bounce light back to fill in the shadows. The key
light is muted by a diffuser to attenuate its harsh output. The reflectors can either be a silver or
white card, the former produces a cooler light, while the latter reflects a more neutral light. On
the key light side, the light is essentially hard and unidirectional that encourages specular
reflections, while on the contralateral reflector side the light is diffuse and softer that facilitates

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204 Special Applications
transmission through the tooth. In addition, changing the position of the key light and reflec-
tors alters the locations of the highlights and shadows, allowing subtle nuances of the dentog-
ingival elements to be visualised (Figure 8.1). Furthermore, the highlights and shadows
produced with this set‐up create images that are three‐dimensional for conveying depth, and
full of detail for analysing dentogingival anatomy. On the key light side the following are clearly
discernible, the macro and micromorphology of enamel, including facial undulations (Figure 8.2),
incisal lobes, incise edge wear, chips (Figure 8.3), fractures, perikymata (Figure 8.4), surface
Key light: below
Silver
reflector
Key light: left side
Key light: above
Figure 8.1 Unilateral illumination with a key light and a silver reflector on the contralateral side to diminish,
but not eliminate shadows. Alerting the positions of the key light and reflector changes the location of
highlights and shadows.
Figure 8.2 Macromorphology:

facial undulations.
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Detailed Analysis of Hard and Soft Tissue 205
Figure 8.3 Serrated incisal edge

tooth wear.
Figure 8.4 Perikymata and incisal

edge lobes.
irregularities as well as texture and lustre. In addition, the specular reflections also emphasise
soft tissue topography such as peaks and troughs of the gingival architecture, presence or
absence of gingival stippling, gingival clefts, frenal attachments, demarkation of the free gingi-
val margins, and assessment of periodontal biotypes (thick, thin) and periodontal bioforms
(flat, normal, scalloped). Also, as unidirectional light stresses edges, defective filling or crown
margins are more noticeable (Figures 8.5 and 8.6). Finally, the interproximal shadows are con-
ducive for revealing gingival embrasures or ‘black triangles’ (Figure 8.7).
On the opposite reflector side, the light is transmitted through the tooth to reveal characteri-
sations. The diffuse light is ideal for visualising incisal and interproximal translucencies, den-
tine mamelons, incisal halos, secondary or sclerotic dentine, islands of hypocalcification
(Figure 8.8) and physiological or traumatic fracture lines (Figure 8.9). A black contraster placed
behind the teeth further emphasises translucencies, but exposure compensation is required,
especially if using TTL metering. Also, optical properties such as goniochromism of natural
teeth and composite fillings are clearly visible. The latter is particularly relevant when match-
ing composite shades to natural teeth so that the restorative material has a similar translucency
parameter as dentine and enamel. This avoids conspicuous composite fillings, which may
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Figure 8.5 Delaminated veneering

porcelain exposing the opaque and
metal layers of a porcelain fused to
metal crown on the left maxillary
central incisor.
Figure 8.6 Directional lighting

highlighting the defective
restoration in the maxillary right
central incisor that is impinging
and inflaming the gingival margin.
Figure 8.7 Selective lighting

highlighting the pronounced
gingival embrasure between the
left maxillary central and lateral
incisors.
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Figure 8.8 Island of

hypocalcification within the
enamel layer.
Figure 8.9 Diffuse light created by

a silver reflector on the left side of
the patient emphasises the
characterisation within the left
maxillary central incisor, including
internal fracture lines, dentine
striations and defective composite
restorations.
appear too opaque or too translucent, failing to blend with the surrounding tooth substate
(Ryan et al. 2010).
The photographic set‐up for achieving unidirectional lighting is a modified version of EDP
Image #5 (Module 5), but with a higher flash ratio. The images can either be dento‐facial, intra‐
oral of the entire arch, or a few teeth or areas of soft tissue that require scrutiny. The magnifica-
tion ratio is variable ranging from 1 : 2 to 1 : 1, depending on the shape and size of the lips,
arches and teeth, and therefore it is difficult to specify the exact positions of the patient, cam-
era, key light and reflector. The best approach is to take a series of images until the desired
features are captured either by altering the angles of the flash/reflector, the patient, the camera,
or a combination of all three (Figure 8.10). A ring flash can be used if it has the facility to turn
off the right or left flash tubes for achieving unidirectional lighting. However, compared to a
detachable unilateral flash, a ring flash does not allow the flexibility in positioning as it is usu-
ally fixed onto the front of the lens. The salient guidelines for detailed analysis of hard and soft
tissues images are summarised in Table 8.1.
In order to demonstrate detailed analysis of hard and soft tissues, the case study below shows
replacement of defective composite restorations in the maxillary sextant. The photographic
set‐up uses a single compact flash as the key light on one side, which alternates from the right
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Patient
Fill light:
silver Key light
reflector
1:1 magnification
Camera
Figure 8.10 The position of the patient, camera, key light and reflector is altered until the desired features are
captured. At a 1 : 1 magnification, the field of view is approximately the four maxillary incisors.
to left with a silver reflector on the opposite side. The set‐up yields a flash ratio of the key light:
silver reflector of approximately 1 : 4, but varies depending on the intensity of the light output
and the angle and proximity of the reflector to the compact flash. A pre‐operative reference
shot is taken with uniform illumination using a ring flash (flash ratio of 1 : 1) that produces a
flat, two‐dimensional image (Figure 8.11). The subsequent images were taken using a key light
and silver reflector (fill light), alternating the flash and reflector on the right and left sides. The
side of the key light produces hard lighting, while the reflector side produces soft lighting
(Figures 8.12 and 8.13). This set‐up creates images that display depth and three‐dimensional
quality for clearer analysis. On the key light side the edges of defective filling margins, periky-
mata, enamel texture and gingival stippling are emphasised, while on the reflector side, charac-
terisation within the teeth are more noticeable such as decay, translucencies and
hypocalcification. (Figures 8.14 and 8.15). Also, altering the field of view by increasing the mag-
nification factor to 1 : 1, altering the position of the patient’s head, the camera, key light and
reflector to various angles reveals subtle nuances that can be studied in detail (Figures 8.16 and
8.17). After replacing the defective restorations, the post‐operative images are taken using a
similar set‐up to the pre‐operative pictures to show salient features by altering illumination on
the right and left sides (Figures 8.18–8.20).
Opalescence and Fluorescence
There are two further optical properties of teeth that require special lighting for visualisation:
opalescence and fluorescence. Opalescence is the optical property of an object to appear bluish
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Table 8.1 Settings and guidelines for detailed analysis images.
Focus Manual
Exposure TTL or manual Manual: take a few test shots to ascertain correct
metering exposure or use histogram
ISO 50–200
Aperture f 22
Shutter speed 1/125 s or 1/250 s Flash synchronisation speed depends on a specific
camera brand
format (file
format)
White balance Automatic or manual Manual: numerical value input, or take a reference
image with an 18% neutral density grey card
Flash Single unilateral flash or Unilateral flash: with diffuser, reduce intensity to
ring flash on one side and 1/2 or 1/4
a silver or white reflector Ring flash: turn off right or left side flash
on the opposite side. The tubes
flash ratio should be
greater than 1 : 2 If images are too bright or too dark, alter intensity
of flashes, or move flash closer or further away
until correct exposure is achieved
Magnification 1:2 to 1 : 1 Only relevant for full‐frame sensors, or set
factor predefined focusing distance on lens
Point of focus On selected teeth or Hand‐held cameras: for predefined magnification
(POF) point of interest or focusing distance, move camera backwards and
forwards until focus is obtained
Tripod‐mounted camera: for predefined
magnification or focusing distance use macro
stage for focusing
Field of view Centre of frame At 1 : 1 magnification with full‐frame sensor
(composition) cameras, the field of view approximately frames
the four maxillary incisors
Background Black contraster or oral For black contraster with TTL metering: exposure
cavity compensation required by either increasing 1
f‐stop (smaller aperture), or moving the light
source further away
with reflected light and amber with transmitted light. Natural enamel possesses opalescence,
rendering a bluish appearance with reflected light, and an amber glow with transmitted light,
particularly at the incisal edges where the enamel layer is thickest. Many aesthetic dental
restorative materials, such as ceramics and composites, also mimic this property for emulating
natural enamel. The second optical property, fluorescence, is primarily a feature of dentine that
confers vitality to a tooth. A metarmeric fluorescent artificial restoration often is conspicuous
under ultra‐violet (UV) illumination, which is prevalent in night clubs or discos. Also, restora-
tions with a brighter shade usually have greater fluorescent emissions, whereas the opposite is
true for darker shades.
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Figure 8.11 Uniform illumination using a
ring flash with a 1 : 1 flash ratio that
creates a flat, two‐dimensional image
(pre‐operative status).
Figures 8.12 and 8.13 Hard and soft lighting with flash and silver reflector, respectively.
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Figure 8.14 Hard (left side of

patient) and soft lighting (right side
of patient) – pre‐operative image
appears dynamic and three‐
dimensional, compared to
Figure 8.11. The specular reflections
are limited to the left side
corresponding to the key light,
while on the right side the diffuse
light is created by a silver reflector.
Figure 8.15 Hard (right side of

patient) and soft lighting (left side
of patient) – pre‐operative image
appears dynamic and three‐
dimensional, compared to
Figure 8.11. The key light and silver
reflector are reversed from right to
left side of the patient, respectively.
In order to photograph opalescence and fluorescence requires using specific continuous light
sources that often have low intensity. Hence, a large aperture, or slow shutter speeds are neces-
sary for ensuring sufficient illumination for correct exposure. Since a large aperture compro-
mises depth of field (DoF), a slower shutter speed is the better option, but with the proviso that
the camera is secured on a tripod and assuming the patient stays still to prevent blurred images.
However, with bench images of still objects, longer shutter speeds are less problematic. For
capturing intra‐oral opalescence, a fibre‐optic light is placed behind the incisal third of the
tooth at various angles to record the amber glow or orange shinning from the enamel
(Figures 8.21 and 8.22). For intra‐oral fluorescent images, UV lamp(s) are judicially positioned
so that they do not appear in the picture, and the patient and all dental personnel wear tinted
safety glasses for protection from UV radiation. As well as recording fluorescence of dentine,
UV illumination is also useful for detecting early carious lesions, ascertaining the depth of
dental fluorosis lesions, extent of intrinsic staining, porosity in artificial restorations and visu-
alising plaque biofilm accumulation with disclosing tablets or liquids (Figures 8.23 and 8.24).
The equipment required for generating fibre-optic and UV illumination is discussed below,
followed by photographic set‐ups for capturing opalescence and fluorescent of artificial resto-
rations or extracted teeth.
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Figures 8.16 and 8.17 Increasing the magnification to 1 : 1 and altering the position of the patient, camera or
lighting reveals further nuances of the dentogingival anatomy for a detailed analysis.
Figure 8.18 Hard (left side of patient) and soft lighting (right side of patient) – post‐operative image showing
replacement composite restorations. The specular reflections from hard lighting on the left emphasises the free
gingival margins, gingival stippling, surface texture and lustre of enamel, incisal edges and perikymata. On the
opposite side, soft lighting emphasises colour nuances within the teeth, hypocalcification islands and incisal
translucencies. Also, notice the outline of the distal composite filling in the maxillary right central incisor which
appears more translucent compared to the surrounding tooth substate. However, in the next image, the filling is
almost inconspicuous as specular reflections conceal the filling outline. This phenomenon is termed goniochromism,
i.e. the property of a material to appear different when the angle of view or illumination is altered.
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Figure 8.19 Hard (right side of

patient) and soft lighting (left side
of patient) – post‐operative image
showing replacement of defective
composite restorations. The key
light and silver reflector are
reversed from right to left side of
the patient, respectively. Notice
that the distal composite filling in
the maxillary right central incisor
is camouflaged by specular
reflections.
Figure 8.20 Magnified post‐

operative view with the key light on
the right side of the patient. The
specular reflections emphasise the
free gingival margin, gingival
architecture and stippling, facial
undulations on the maxillary right
central incisor, and perikymata on
the mandibular teeth. On the left
side of the patient (softer lighting),
the incisal edge translucencies of
the maxillary left central and lateral
incisors are clearly visible (compare
with image Figure 8.17).
Figure 8.21 Intra‐oral fibre‐optic

transillumination allows
visualisation of enamel
translucencies and incisal halos.
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Figure 8.22 Changing the angle

of intra-oral fibre-optic
transillumination reveals the
orange glow reminiscent of
opalescence located at the incisal
edges where the enamel layer is
thickest.
Figure 8.23 Ultra‐violet (UV)

illumination showing metarmeric
fluorescence of artificial
restorations that fail to optically
integrate with the surrounding
natural dentition.
Figure 8.24 Ultra‐violet (UV)

illumination for visualising plaque
biofilm after rinsing with a
disclosing agent.
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Fibre‐Optic Illumination
Fibre‐optic light sources are a special type of illumination for highlighting certain details, or for
unique photographic effects. Fibre‐optic light is delivered by flexible encased cables containing
bundles of minute light transmitting fibres. The continuous light is generated by either halo-
gen, LED or lasers, and the intensity is alterable by a rheostat, e.g. Kaiser Macrospot 1500
Fiber‐Optic Lighting System (Kaiser, Germany) – Figure 8.25. The dental applications of fibre‐
optic illumination are intra‐oral transillumination for showing dentine and enamel characteri-
sation, carious lesion, enamel porosity or depth of fluorotic or hypocalcified lesions. The
extra‐oral uses include selectively illuminating certain parts of extracted teeth and artificial
restorations, or discerning fine details of dental instruments. Furthermore, the orange glow of
natural enamel at the incisal edges due to opalescence is clearly visualised with fibre‐optic tran-
sillumination. A simple set‐up is transilluminating all‐ceramic units by placing a single fibre‐
optic light source behind and towards the camera, making sure that it is not visible in the
picture. An optional second flash with a coloured gel illuminates the background to add inter-
est by colour contrast with the main object (Figures 8.26 and 8.27).
UV Illumination
The ability of an object to emit light when illuminated with an UV light source is termed fluo-
rescence. Fluorescence is an inherent property of dentin, and to a lesser extent enamel. Also,
certain pathology such as pre‐cancerous or early carious lesions are easier to detect with UV
light. In the natural dentition, fluorescence confers vitality, and many restorative materials such
as ceramics and resin‐based composites emulate this feature (Ahmad and Chu 2003). In order
to visualise fluorescence, the tooth or artificial restoration is illuminated by a UV lamp. Since
most UV lamps emit low‐intensity light, extended exposure times are necessary, and it is
mandatory to mount the camera on a tripod to prevent camera shake and blurred images.
Another precaution when using UV lamps is to wear tinted safety or dark sunglasses to protect
the eyes from UV irradiation. Figure 8.28 shows the set‐up using sectioned teeth illuminated by
UV light to show fluorescence within a natural tooth (left), and an all‐ceramic crown on a
prepared tooth (right) – Figure 8.29.
Figure 8.25 Fibre‐optic unit with various sizes of flexible light transmitting cables (Kaiser, Germany).
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Figure 8.26 A simple set‐up using

Key light: Fibre
fibre‐optic illumination.
optic cable, behind
Background light:
wireless compact
flash with maroon
gel, below
Figure 8.27 Transillumination is

particularly useful for visualising
incisal edge opalescence,
translucency, staining and dentine
mamelons in artificial restorations,
photographed with the set‐up
shown in Figure 8.26.
Finally, fibre‐optic lights can be coloured by filters, focused with lenses, and combined with
flashes and UV lamps for creating visually stunning images: Figures 8.30–8.32 show some
examples of creative effects using fibre‐optic and UV illumination.
Colour Fidelity
An image that faithfully reproduces colour is prerequisite for any medical or dental use. This is
particularly relevant for distinguishing between healthy and diseased tissues, and shade analy-
sis of teeth for prosthodontic and restorative dentistry. The correct colour rendition of the soft
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Colour Fidelity 217
Key lights: UV
lamps placed at
different angles
Fill light: wireless

compact flash with
red gel, below
Figure 8.28 Set‐up for ultra‐violet (UV) illumination with a flash below covered with a red gel.
Figure 8.29 Ultra‐violet (UV) illumination

showing fluorescence of a natural tooth (left)
and ceramic crown (right).
tissues is essential for disciplines such as oral medicine, periodontology, and oral surgery. A
colour shift from pink to red to blue can signify health, inflammation or cyanosis, respectively.
Also, the apparent shade of a tooth or teeth is useful for elucidating aetiology, differential diag-
nosis and treatment options. For example, discolouration of the entire dentition due to intrin-
sic staining may warrant tooth whitening, whereas isolated discolouration of a single tooth may
signify trauma or haemolytic breakdown following root canal therapy. Dental images are also
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Figure 8.30 Exfoliation (fibre‐optic + compact flash).
Figure 8.31 Barbed wire (fibre‐optic + ultra‐violet [UV]).
Figure 8.32 Waves (ultra‐violet [UV]).
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Colour Fidelity 219
used for matching the shade of artificial restorations with adjacent teeth. Therefore, for diag-
nosis, comparison and communication, colour accuracy and colour consistency are manda-
tory. Although this appears straightforward, due to several variable factors, achieving colour
fidelity in dental photography is not as easy as it seems.
The first item to consider is the object(s) being photographed, i.e. the teeth and surrounding
soft tissues. The interaction of light with a tooth is complex, involving reflection, refraction,
transmission as well as other optical characteristics such as fluorescence and opalescence men-
tioned above (Chu et al. 2004). The shade of a tooth is also affected by the degree of hydration,
the colour temperature of the illumination (metamerism) – Figures 8.33 and 8.34, CRI (colour
rendering index) rating of the light source and the angle of illumination (goniochromism). In
addition, the tooth has three optical layers, consisting of the pulp, dentine and enamel, which
all influence its perceived colour. The colour of the oral mucosa and gingival apparatus also
shows considerable variations, influenced by systemic conditions such as anaemia and local
factors such as melanin pigmentation or pathological changes.
Figures 8.33 and 8.34 Meteramism: a shade tab may match under one type of illumination (5500 K), but
mismatch when viewed with light having a different colour temperature (6500 K).
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The second item to consider is the imaging chain that produces an image, consisting of the
CPD triad: starting at the Capture stage (camera), moving on to Processing (software) and
ending with the Display media (monitor, projector, printer) (Figure 8.35). At present, there
is a lack of interconnectivity and consistency among systems for digital photography.
Furthermore, at each stage of the imaging chain, the hardware and software from several
manufacturers is used, often with different colour spaces and ICC (International Color
Consortium) profiles (Badano et al. 2015), and therefore the apparent colour is device‐depend-
ent. This is compounded by the unique white balance algorithms of cameras from different
manufacturers, with little or no standardisation. The quality or colour temperature and CRI
rating of light is another issue, combined with flash diffusers that can alter the colour rendi-
tion beyond the visually perceivable threshold, ranging from ΔE 1.22 to ΔE 2.66 (Witzel et al.
1973; Paravina et al. 2015). Hence, devices at each stage of the digital workflow require cali-
bration if colour consistency is to be a realistic possibility. At the capture stage, a reference
grey card image (Hein and Zangl 2016) is indispensable for calibrating pictures for a particular
lighting set‐up. At the processing stage, it is important to ensure that the colour space in the
software matches that of the camera, e.g. sRGB or Adobe RGB, and finally, each display device
is periodically calibrated for colour consistency (see Module 9). A crucial point worth remem-
bering is that excessive manipulation in imaging software not only degrades image quality, but
also changes colour. For example, correcting a grossly under‐ or overexposed image will
severely affect the colour rendition of the image, resulting in unwanted colour casts that
reduce its diagnostic or comparison value (Snow 2006). Nevertheless, even with the above
Capture Process Display
CPD triad
Figure 8.35 CPD triad: the colour of an image varies according to a particular medium or device, i.e. camera,
software or monitor.
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Shade Analysi 221
contingencies, the key issue is that digital photography offers relative, rather than absolute,
colour assessment. However, for the majority of clinical documentation this limitation is
acceptable for diagnosis and communication.
Shade Analysis
The advent and wide acceptance of digital cameras has opened up a new method for shade
evaluation using dSLR cameras in conjunction with imaging software (Hein et al. 2017). This
digital shade analysis allows an assessment of colour that can readily be used for selecting com-
posite shades, or sharing the shade analysis information with dental technicians for fabricating
indirect restorations (Lee et al. 2015).1 Colour, similarly to dental occlusion, is shrouded in
mystery: perplexing for the novice and challenging for the expert (Chu and Tarnow 2001).
There are three methods for assessing tooth shade: visual, instrumental and photographic
(Ahmad 2000). The visual is a comparative approach, using either prefabricated or custom‐
made shade tabs. Shade analysis for direct restorations can either be with shade tabs, or placing
increments of various composite shades on the tooth to be restored for choosing the best
match (Yap et al. 1995; da Costa et al. 2010) (Figures 8.36 and 8.37). For indirect restorations,
the only option is shade tabs placed adjacent to the teeth for judging the colour. When photo-
graphing shade tabs, it is important that the tabs are positioned in the same optical axis as the
teeth, and the light is positioned to avoid specular reflections that may alter the perceived
colour (Llop 2009).
The second method for shade assessment is instrumental that directly measures the shade of
the tooth using devices such as colorimeters or spectrophotometers (Ishikawa‐Nagai et al.
2010; Yoshida et al. 2010), and outputs a numerical value according to the CIE L*a*b* colour
co‐ordinates (Paravina 2002). Examples include Crystaleye Spectrophotometer® and Vita
EasyShade®, which give acceptable and repeatable colour measurements (Odaira et al. 2011).
Another instrumental method for shade evaluation is intra‐oral scanners (IOS), which have
built‐in shade assessment tools for providing an instant read out of tooth shade according to
either the Vita Classical®, or Vita 3D® shade guides (Figure 8.38).
The third approach is photographic, involving taking a photograph of tabs from the cho-
sen shade guide (e.g. Vita 3D or Vita Classical) in line with optical axis of the tooth, and a grey
Figure 8.36 Direct shade analysis

for composite restorations can
either be accomplished with a
prefabricated shade guide, or
placing increments of composite
on the tooth to be restored. It is
important to carry out shade
assessment before isolating with
rubber dam to ensure that the
teeth are not dehydrated.
1 http://www.clearmatch.com/index.htm (accessed 6 April 2010).
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Figure 8.37 Composite increments placed directly on the right maxillary central incisor.
Figure 8.38 Instrumental shade evaluation using an intra‐oral scanner (IOS).
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Shade Analysi 223
card for colour calibration (Figure 8.39). The teeth are hydrated and not desiccated to prevent
a colour shift. The image should be devoid of specular reflections, which is achieved by either
using muted reflection set‐up described above, or attaching a polarising filter onto the front of
the lens that optically eliminates the enamel layer. Using a polarising filter requires exposure
compensation by increasing the aperture by 1 f‐stop, or moving the light source closer
(Figure 8.40). Also, the flashes should not be positioned inferior or superior to the lens axis as
the unwanted illumination of the background ‘red’ oral cavity conveys a reddish appearance of
the teeth. This is particularly relevant for ring flashes mounted on the front of the lens. The
image is then imported into the appropriate photo-editing software, and the white balance cali-
brated with the grey card. The next step is taking colour measurements at various sites of the
tooth, e.g. incisal, middle third (body), and cervical aspects. At each site, the software calcu-
lates colour co‐ordinates that are translated into shade tab equivalents of the chosen shade
guide, and used for selecting appropriate shades of ceramic powders or composite increments
(Khoo 2015; Oh et al. 2010). In order to concentrate on hue and chroma of the teeth and shade
tabs, the background oral-cavity can be converted to black and white in the processing soft-
ware. A formidable challenge is assessing the value (brightness and darkness) of a tooth, since
the hue and chroma components of colour dominate a composition. To mitigate this influence,
Figure 8.39 Vita Classical shade

guide photographed with an 18%
grey card in line with the optical
axis of the maxillary teeth.
Figure 8.40 A polarising filter is

useful for eliminating superficial
specular reflections to allow
analysis of the shade and
characterisations within the enamel
and underlying dentine layers.
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Figure 8.41 Photographic digital shade analysis: Comparative colour readouts (red, green, blue and value in
white text) of the prepared abutment, contralateral maxillary left central incisor and shade tabs.
an achromatic image is necessary for judging value, especially at the incisal edges where the
enamel layer is thickest. The easiest way for achieving this is in processing software by moving
the saturation slider to zero for producing a black and white image.
The example below illustrates photographic digital shade analysis for matching the colour of
a crown on the right maxillary central incisor to the contralateral left central incisor. Following
tooth preparation, the tooth abutment is photographed with a Vita Classical shade guide,
which is in line with the optical axis of the maxillary anterior sextant. After performing a colour
calibration with a grey card, the images are evaluated with colour readouts at specific sites. The
colour swatches have four numerical values, red numbers represent the red channel, the green
numbers the green channel, the blue numbers the blue channel, and the white numbers the
value or brightness on a greyscale from 0 to 255 (Figure 8.41). The best way to visualise shade
is by chromatically isolating the teeth in imaging software. This is relatively easily using the
colour editor by selecting the colour of the teeth and rendering the remainder of the image as
black and white (Figure 8.42). From the edited image, it is apparent that the closest colour
match of the maxillary left central incisor is the A2 shade tab (Figure 8.43). For assessing value,
the hue and chroma of the teeth are digitally removed, leaving a black and white image of the
teeth (Figure 8.44). This allows assessment of the value without being distracted by hue and
chroma of the teeth. Although the shade (hue and chroma) of tooth #21 match only one tab, i.e.
A2, its value matches two tabs, i.e. A2 and B1 (Figure 8.45).
Although digital shade analysis is not an absolute method for colour determination, it is nev-
ertheless invaluable for analysing the chromatic nuances within teeth, which allows mapping
geographical distribution of shades as a guide for artificial restorations. The starting point for
chromatic mapping is taking an image that is devoid of specular reflections, either with judicial
lighting, or using a polarising filter. After importing the image into imaging software, the
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Shade Analysi 225
Figure 8.42 Photographic digital shade analysis: The teeth and tabs are chromatically isolated by the colour
editor for evaluating hue and chroma.
Figure 8.43 Photographic digital shade analysis: The colour readouts indicate that the best match of the
contralateral maxillary left central incisor is the A2 shade tab (red circles).
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Figure 8.44 Photographic digital shade analysis: To assess value, hue and chroma of the teeth are digitally
removed, leaving only a black and white image of the teeth and shade tabs.
Figure 8.45 Photographic digital shade analysis: Notice that the value of tooth #21 matches the value of both
A2 and B1 shade tabs (red circles, value = 185).
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Scale Reference Marker 227
Figure 8.46 Chromatic mapping:

pre‐operative image showing acute
fractures of the maxillary right
central and lateral incisors.

the brightness is reduced and the
contrast increased to visualise
chromatic distribution and
characterisations.
brightness is reduced and contrast increased, which not only emphasises ‘hidden’ tooth char-
acterisations, but also the gradual colour transitions traversing from the cervical regions to the
incisal edges (Salat et al. 2011). A drawing software is then used to map out the chromatic
distribution, and annotate specific characterisations (Figures 8.46–8.49).
Scale Reference Markers

A scale reference marker is usually a graduated ruler or periodontal probe, which is included in
the photograph for measuring dimensions of teeth or soft tissue anatomy. As the dimensions of
images change during enlargement or reduction in processing software, a reference marker is
a useful guide, irrespective of the relative scaling or magnification (Figures 8.50–8.53). This
allows scaled measurements, which can be used for calculating the width/length ratio of teeth,
distal width progression for smile design, size of incisal embrasures, anterior overjet and over-
bite (Figure 8.54), diastemata, occlusal clearance, vertical dimension of occlusion (VDO),
degree of maxillary gingival exposure during smiling, tooth exposure during the habitual lip
position and smiling, width of keratinised gingiva, degree of gingival scalloping, interdental
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Figure 8.48 Chromatic mapping: a

drawing software is used to chart a
chromatic map, including
characterisations such as dentine
mamelons and incisal halos.

post‐operative result showing
coronal restitution of fractures with
direct resin‐based composite
incremental layering.
Figure 8.50 Existing uneven

gingival zeniths around teeth #11
and #21.
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Scale Reference Marker 229
Figure 8.51 Esthetic crown

lengthening for correcting uneven
gingival zeniths using a periodontal
probe as a reference marker: initial
clinical crown length of tooth
#11 = 7.5 mm.
Figure 8.52 Symmetrical gingival

zeniths around teeth #11 and #21
after crown lengthening.
Figure 8.53 Post‐operative result

after one week healing.
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Figure 8.54 Periodontal probe

measuring the anterior overjet.
papilla fill (Ahmad 2005) and the size of soft tissue pathological lesions. Finally, a proportional
reference is also useful for scale calibration in smile design software, and for designing manual
or virtual wax‐ups, temporaries and definitive restorations.
Annotations
Starting a course of aesthetic treatment without taking pre‐operative pictures is inviting trou-
ble, no different to placing implants without a CBCT (cone beam computed tomography).
This is particularly relevant if the proposed treatment is elective or purely for enhancing
beauty. Also, aesthetics is fraught with subjectivity and idiosyncrasies, and if the outcome is
not as anticipated, or fails to satisfy the patient, lack of photographic documentation is inde-
fensible if litigation ensues. Therefore, anything that helps facilitate aesthetic treatment is a
godsend.
A simple and effective method for aesthetic treatment planning is adding annotations to
images that serve as a starting point for analysis. This involves using drawing software for add-
ing text and reference lines of salient features on images taken from different perspectives. For
example, most aesthetic treatments start with a diagnostic wax‐up, and annotated instructions
for the dental technician are invaluable for finalising the proposed aesthetic treatment plan.
Also, most drawing software offer the facility to covert the annotated images into PDFs
(Personal Document Files), which can be attached to e‐mails for communication with patients,
ceramists and specialist. The case study depicted in Figures 8.55–8.61 shows annotated instruc-
tions to the ceramist for altering the initial wax‐up to satisfy patient’s wishes.
Drawing software is available either as free or paid downloads. Most major software houses
such as Adobe®, Apple®, Corel® and Microsoft® offer several packages that are user‐friendly, with
intuitive features that require little training. For dental purposes, a simple software that can
add text, draw lines, curves and shapes is all that is required, and is often part of the pre‐
installed software that comes with all computers. Examples of popular drawing programmes
include Adobe Illustrator, CorelDraw® or ACD Canvas™. Alternately, a Google® search for ‘draw-
ing software’ offers a vast list to choose from.
Many key reference lines for aesthetic appraisal can be annotated on photographs including
the inter‐pupillary line, facial and dental midlines, Rickett’s E‐plane, naso‐labial angle, gonial
angle, commissure line, inclination of the incisal plane, smile line (maxillary incisal plane with
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Initial wax-up
The right & left gingival zenith are NOT

identical, please make the left gingival
zeniths identical to the right gingival zenith
(red dotted lines)
Reduce height of 21 so it is the same

Reduce the length of the as the height of 11 Reduce the length of the
right lateral by 1.5 mm left lateral so it is the
same as the right lateral
1. The facial profile of ALL six teeth is too BULBOUS. Please reduce bulbosity to create a FTATTER PROFILE
2. The line angles are TOO CURVED (green line), please make all line angles SHARPER and STRAIGHTER
(white dotted line)
3. Incisal embrasures are TOO ROUNDED (pink lines), please SHARPEN LINE ANGLES of ALL EMBRASURES
(Yellow dotted lines)
4. Ensure MORPHOLOGY OF (13, 12, 11) and (21, 22, 23) are identical MIRROR IMAGES
Move ALL teeth palatally,

and reduce BULBOSIY
(white dotted lines)
DO NOT overlap canine over lateral
Figures 8.55–8.61 Annotated instructions are invaluable for designing and finalising a diagnostic wax‐up
before commencing a course of aesthetic treatment.
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Move ALL teeth palatally,

and reduce BULBOSIY
(white dotted lines)
DO NOT overlap canine over lateral
4 OVATE pontics
Move teeth apically to create 1 mm VERTICAL overlap over mandibular incisors
Figures 8.55–8.61 (Continued)
lower lip coincidence), axial inclination of teeth, mesial‐distal width progression, gingival aes-
thetic line (GAL), gingival display at rest and smiling, and bilateral negative space. These, and
other reference lines, are essential for a multidisciplinary co‐treatment approach, and for com-
municating with patients about the present state of affairs, and whether the proposed aesthetic
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Annotation 233
Teeth are not in line with maxillary arch (light blue line)
Correct alignment (lime

dotted line)
ENSURE HORIZONTSL
OVERLAP IS 1 mm by
moving ALL teeth
palatally
Move teeth apically to create 1 mm VERTICAL overlap overlap over mandibular incisors
Revised wax-up
prescription is clinically feasible. Similar to aesthetic treatment, orthodontic therapy and

cranio‐maxillo‐facial surgery also benefit from annotations by marking key reference lines
such as the Frankfurt plane, ala‐tragus plane (Camper’s line), Rickett’s E‐plane, Steiner plane
(angle of lower border of mandible Go‐Gn), curves of Spee and Wilson and sphere of Monson,
overjet and overbite, and molar and canine relationships.
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As mentioned above, annotations are used for creating chromatic and characterisation dis-
tribution maps following a digital shade analysis. As well as outputting numerical values for
shade, a digital shade analysis shows characterisation and chromatic distribution within a
tooth. This information is used for creating maps using drawing software that serve as a guide
for reproducing subtleties within composite incremental layers using effect tints and stains.
Similarly, a chromatic map is useful as an annotated laboratory prescriptions for indirect
restorations (Figures 8.62–8.66). Finally, annotations are ideal for conveying anomalies that
Incisal
stained Vita A3 shade
exposed porcelain fused to non-
dentine facet precious metal pontic
in Vita A3.5 to replace tooth # 31
shade
Locator hook onto buccal Enamel

surface, to be removed surround in
after cementation Vita A2
shade
Grey translucency
- on mesial & distal Cervical Simulate
aspects proximal clear fracture
Ensure pontic fits into staining, Vita lines
ovate site preparation A3.5 shade
and appears
emerging from
gingiva
Laboratory prescription for a Maryland bridge
Vita A3 shade
porcelain fused to non-
preciousmetal pontic
to replace tooth # 31.
Non-precious
metal lingual wing
Locator hook onto buccal within enamel.
surface, to be removed Ensure fitting
after cementation Incisal surface is
Enamel
stained sandblasted
surround in
exposed Vita A2
dentine facet shade
in Vita A3.5
shade
Figures 8.62–8.64 Annotated laboratory instruction for fabricating a Maryland bridge for replacing a missing
mandibular incisor.
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Annotation 235
Ovate pontic site

preparation
Pre-op = total Pre-op - Occlusal Wax-up
Post-bleaching and Shade post-bleaching Un-deflected gingival margin and

crown-lengthening tooth preparation
Laboratory prescription for an all-ceramic crown and PLVs for the maxillary incisors
Figures 8.65 and 8.66 Annotated laboratory instruction for fabricating an all‐ceramic crown and porcelain
laminate veneers (PLVs) for the maxillary incisors.
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Close diastema, and eliminate gingival embrasure

(‘black triangle’)
Inter proximal 6 mm apical

blue/grey Cervical - Vita A2.5 contact area from
translucency incisal edge
A 2.5
A3
A 2.5
A2
Sinuous
rounded line Incisal blue/grey Unique, individual
Body - Incisal opalescent
angles translucency dentine mamelons
Vita A2 halo
for each tooth
Laboratory prescription for an all-ceramic crown & PLVs for the maxillary incisors
Figures 8.65 and 8.66 (Continued)
require correction at the try‐in stage before definitive cementation of indirect restorations
(Figure 8.67).
Bleaching (Tooth Whitening)

Tooth whitening, either in‐office or home bleaching, is an innocuous, minimally invasive pro-
cedure for dental aesthetic enhancement. However, careful documentation is essential for
comparison to standard reference shade guides for assessing and monitoring the bleaching
process (Figures 8.68 and 8.69).
Phonetics
The majority of aesthetic treatment involves altering the anterior teeth, which are predomi-
nantly responsible for speech. This is also true for orthodontics, where positioning of the
anterior teeth should not interfere with speech. A detailed evaluation of phonetics is
required, before and after treatment, for ensuring that any prescribed treatment has not,
and will not, affect phonetics. A phonetic analysis involves asking the patient to iterate vari-
ous sounds for determining existing speech impediments or preventing them afterwards.
The ‘m’ ‘Emma’ or ‘me’ sound determines the amount of tooth display at the habitual or
‘rest’ position, which is Image #1 of the EDP. The extra images required are as follows. The
‘s’ sound assesses the vertical dimension of speech; typically a 1–2 mm separation between
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Phonetic 237
Ensure central incisors Bulbous veneer

are mirror Fractured porcelain
images of each other Open contact areas
Good colour match and

beautiful characterisation: please Central too long, reduce
reproduce in new PLV and length to same height as
Smooth sharp incisal canines
crown
embrasure line angle
Figure 8.67 Try‐in‐stage of a porcelain laminate veneer (PLV) on maxillary right central incisor and an all‐
ceramic crown on the maxillary left central incisor.
Figure 8.68 Pre‐bleaching with reference shade guide.
the maxillary and mandibular anterior teeth is necessary to avoid lisping (Figure 8.70). The
‘f ’ or ‘v’ sounds determine the axial inclination of the maxillary central incisors, i.e. the buc-
cal aspects of the maxillary incisors touch the mucosal rather than the cutaneous aspect of
the mandibular lip (Figure 8.71). Other sounds including ‘th’ or words such as ‘Mississippi’
that do not require photographic documentation, but their audio clarity should be noted.
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Figure 8.69 Nine weeks post‐bleaching with reference shade guide.
Figure 8.70 Phonetics: with the ‘s’

sound, a 1–2 mm separation is
noticeable between the maxillary
and mandibular anterior teeth.
Figure 8.71 Phonetics: with the ‘f’

or ‘v’ sounds, the mucosal aspect of
the mandibular lip partially covers
the labial surfaces of the maxillary
incisors.
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Occlusal Analysi 239
Furthermore, the impact of proposed treatment on phonetics can be assessed during i ntra‐
oral mock‐ups with either acrylic, or composite restorations that are copied from the diag-
nostic wax‐up simulations. A mock‐up also allows changes to be made by removing or
adding flowable composite until phonetics are satisfactory, and the final tooth shape can
then be copied for the definitive restorations.
Occlusal Analysis
An analysis of the occlusion is warranted for several dental disciplines. The photographic
set‐ups for these image is identical to that for EDP intra‐oral images, but the patient is asked to
position the teeth in various positions for reviewing maximum intercuspation (MI), centric
relation, anterior guidance (protrusion) and lateral movements for canine guidance or group
function (Figures 8.72–8.74). Also, intra‐oral submental oblique views with the head retroclined
Figure 8.72 Occlusal analysis:

maximum intercuspation (MI).

protrusion.
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lateral excursions (canine guidance/
group function).
Figure 8.75 The intra‐oral submental oblique view involves retroclining the head, and positioning the camera
inferiorly.
and the cameras positioned inferiorly, are useful for viewing the teeth from an inferior perspec-
tive (Figure 8.75). From this angle in MI, the Angle’s anterior relationship is clearly visible, and
with the teeth separated, allows clear visualisation of prepared crown margins of teeth in the
maxillary anterior sextant (Figures 8.76–8.78).
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Occlusal Analysi 241
Figure 8.76 The frontal view in

maximum intercuspation (MI) does
not allow assessment of the overjet.
Figure 8.77 The same patient as in

the previous figure with an intra‐
oral submental oblique view in
maximum intercuspation (MI)
allows visualisation of Angle’s
anterior relationship.
Figure 8.78 An intra‐oral

submental oblique view with the
teeth separated allows tooth
preparation finish lines of the
maxillary teeth to be clearly
discernible.
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Treatment Sequences
Treatment sequencing involves documenting step‐by‐step clinical or laboratory techniques.
Also, a sequence of images can demonstrate the use of particular instruments or materials for
a restorative or surgical modality. A series of images should follow standardisation protocols
ensuring that photographic settings, lighting and position of the object or subject are as identi-
cal as possible with the same magnification and field of view. These images can either be intra‐
oral, or bench shots. The former is trying and challenging for procedures such as surgical
techniques, and a compromise if often inevitable. Conversely, bench images allow greater con-
trol for positioning and framing, so that each image in the series is more conformative.
Whichever the method, a series of images is indispensable for teaching, publishing, marketing
and dento‐legal documentation. Figures 8.79–8.89 show a step‐by‐step perio‐plastic surgical
procedure for root coverage using a regenerative tissue matrix, AlloDerm.
Figure 8.79 Pre‐operative status

showing gingival recession around
maxillary left lateral incisor.
Figure 8.80 The root surface is

planed with a curette…
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Treatment Sequence 243
Figure 8.81 …followed by

conditioning with citric acid gel.
Figure 8.82 An intra‐sulcular flap

elevation around the lateral incisor
is started on the mesial aspect and
continued…
Figure 8.83 …to the mid‐facial and

distal aspects.
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Figure 8.84 A periodontal probe

passed under the closed flap
(mesial aspect of lateral incisor)
shows sufficient elevation of a full
thickness flap without encroaching
the interdental papilla.
Figure 8.85 A periodontal probe

passed under the closed flap (distal
aspect of lateral incisor).
Figure 8.86 AlloDerm grafting

material cut to the appropriate size…
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Treatment Sequence 245
Figure 8.87 …and eased under the

elevated closed flap approaching
from the sulcus
Figure 8.88 4/0 black silk sling

suture to secure the graft and
simultaneously position the flap in
a coronal direction.
Figure 8.89 Completed perio‐

plastic root coverage surgical
procedure.
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Endodontic Documentation
The use of an operating microscope for endodontic treatment is becoming increasing com-
monplace. Today, it is rare to encounter an endodontist specialist who does not use magnifi-
cation for root canal therapy. The ability to visualise the minutest detail and explore additional
or accessory canals has truly revolutionised endodontic therapy. Many reputable optical man-
ufacturers such as Carl Zeiss® and Leica® have entered the arena, producing high‐end, ergo-
nomically designed operating microscopes. Taking photographs with operating microscopes
is relatively simple, either with the built‐in digital still or video camera, or attaching a dSLR
with an appropriate adaptor. A beam splitter divides the light for the eyepiece and the camera
so that ancillary illumination is usually superfluous. The image quality depends on the resolu-
tion of the camera sensor, as well as adequate illumination. Since space and access are limited,
a dental mirror is ideal for taking reflected images, which can subsequently be laterally
inverted (flipped) in editing software to correct orientation. The resulting images are useful
for analysing canal morphology, detecting fractures and co‐diagnosing with colleagues
(Figure 8.90).
Beam splitter
dSLR
Eyepiece
Transillumination Crown/root fractures Visualising internal anatomy
Access cavity Retrograde cavity Obturation
Figure 8.90 An operating microscope with beam splitter plus attached dSLR is ideal for photographing
endodontic procedures (Source: clinical images courtesy of Dr. Faisal Alonaizan).
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Vide 247
Focus Stacking
The ever‐increasing processing power of computers and innovative software have popu-
larised techniques such as focus stacking. Focus stacking is a method for increasing the
DoF for landscape and macrophotography. Since DoF diminishes with increased magnifi-
cation, having a method for apparently having all parts of an object or subject in focus is
extremely advantageous for macro and microscopic analysis. The process involves taking a
series of images at different points of focus (PoF), which are subsequently combined in
dedicated focus staking software to create a single image with vastly increased DoF
(Figure 8.91). The process is similar to HDR (high dynamic range) photography for increas-
ing the dynamic range of an image.
Video
Nearly all cameras and smartphones have the capability to record video footage, and although
it is not the remit of this manuscript to describe motion pictures, it is with mentioning that this
facility opens up new horizons. If a picture is worth a thousand words, imagine the value of a
video. It goes without saying that recording clinical or laboratory procedures is an adjunct for
training and lecturing. However, similar to still photography, a learning curve should be antici-
pated, since the time and perseverance involved is substantial and challenging. Nevertheless,
the option to make videos is worth contemplating, maybe not imminently, but perhaps at some
future time.
Figure 8.91 Focus stacking is combining a series of images with different points of focus (PoF) to form a
composite image with increased depth of field (DoF).
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Figure 8.92 An artistic image in the

style of Roy Lichtenstein.
Promotional and Artistic Imagery

Images for marketing, promotion and lecturing, accentuate clinical achievements and beautify
patients. Hence, their intended use is to set the senses reeling for engaging the audience.
Although having limited clinical significance, these images are indispensable for promoting a
product or service. Therefore, the photographer has a certain degree of artistic licence for
expressing his or her creativity by visually enhancing a particular product or treatment out-
come that is enticing and attention seeking. Some examples of non‐clinical portraits are shown
in Module 6, and this book has copious examples of treatment sequences for many modalities.
Finally, dental artistic images are conceived from within rather than learned by didactic teach-
ing, and their ulterior motive is visual impact rather than clinical usefulness.
Artistic imagery requires an imaginative, and not necessarily a mescalinized individual,
which is beyond the scope of this book (Huxley 1954) – Figure 8.92.
References
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Ahmad, I. (2005). A Clinical Guide to Anterior Dental Aesthetics. London: BDJ Books.
Ahmad, I. and Chu, S. (2003). Light dynamic properties of a synthetic low‐fusing quartz glass‐
ceramic material. Pract. Proc. Aesthet. Dent. 15 (1): 49–56.
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251
Section 3
Processing Images
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253
Processing Images
The penultimate stage of the CPD (Capture, Process, Display) imaging chain is processing or
developing an image. This is analogous to film photography, which involved forwarding the
exposed film for developing or processing in a darkroom. With digital photography, developing
is performed with a computer using photo‐editing or imaging software. At the outset, it is
worth mentioning that while imaging software can correct many failings in technique, it cannot
perform miracles (Ahmad 2009a). Also, there is no substitute for proper photographic tech-
nique, and if equipment settings and positioning are correct, only a few adjustments are
required. Furthermore, any processing, no matter how insignificant, will ultimately deteriorate
image quality. Therefore, before embarking on endless futile corrections, it is worth deciding
whether it is fruitful to spend the time and effort, and not forgetting the frustration, trying to
salvage an image, or whether it is easier to discard it and just take another one.
Monitor Calibration
Before importing images from the camera to a computer, it is essential that the display monitor
is correctly, and periodically, calibrated. Calibrating a computer monitor ensures that images
are viewed and edited with optimum colour fidelity, and any ensuing prints match as closely as
possible to the image displayed on the monitor. In addition, proper calibration produces a more
relaxing and comfortable viewing experience by reducing eye strain and fatigue. Also, editing
images without calibration is not only counterproductive, but defeats the object of standardisa-
tion for comparison and photographic consistency.
There are several methods for calibrating a monitor, included built‐in utilities within
operating systems (Windows or Macintosh), web‐based free or paid testing, or external
hardware colorimeter devices. The first two methods are subjective, relying on the viewer’s
feedback for assessing variables such as gamma, brightness, contrast and colour balance set-
tings. This is an expedient and economical method and adequate for the casual photographer
who occasionally processes images. For the aficionados, a more precise and objective method
involves using an external colorimeter device that is placed onto the monitor, e.g. Spyder5Elite
(www.datacolor.com) (Ramsthaler et al. 2016). These devices are connected via a USB port, and
the accompanying software guides the viewer through an automated calibration process
(Figure 9.1). Although more expensive, this is a sure way for precise and accurate calibration for
both viewing and editing dental images.

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254 Processing Images
Figure 9.1 A colorimeter based monitor calibration device.
File Formats
There is only one virgin file format (RAW), i.e. the original image data that is captured with the
digital camera. Once the image is opened in a photo‐editing, imaging, drawing or publishing
software, changes to the image occur, resulting in irretrievable loss of the original data. These
changes include alterations to the bit depth, dynamic range and colour spaces. Therefore, before
opening a RAW file in a software, it is prudent to back up the originals, preferably onto an exter-
nal hard drive for safekeeping. This is not archiving the files, which is carried out after editing the
images, but a precautionary measures to safeguard the original data files captured by the camera.
The plethora of image file formats on the market is worthy of a PhD thesis. However, for dental
applications, familiarity with only a few formats is required (Figure 9.2). At present, there is no
single file format that serves all purposes, and therefore several formats are necessary depending
on the intended use. There are two classes of image files, either uncompressed or compressed,
and if compression is applied, it may be lossy or lossless. Furthermore, there is varying opinion as
to which format is the ideal for image data storage, which leads to confusion and incompatibility.
The first file format to consider is the proprietary RAW format, which is usually specific for a
given brand of camera. This file contains the original unadulterated data, which can subsequently
be converted into any file of choice. The three other ubiquitously accepted formats are TIFF
(Tagged Image File Format), JPEG (Joint Photographic Experts Group) and PDF (Personal
Document File). To this list can be added PNG (Portable Network Graphics) and EPS (Encapsulated
PostScript), which are used for web‐publishing and printing, respectively.
TIFF is the leading generic image file format offering lossless compression, but the size of
these files is large and require substantial storage space on hard drives. Invented by the Aldus
Corporation, and when opened in the LZW mode, named after its designers Lempel‐Ziv and
Welch, a TIFF file is as near as possible to the original RAW format. In addition, TIFF files can
be imported into any imaging software for processing, and converted into other compressed
file formats such as JPEGs. JPEGs are smaller size files at the expense of sacrificing quality by
lossy compression. However, due to their smaller size, they are an ideal format for internet
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Imaging Softwar 255
Image File Formats
Virgin
Original data file
Uncompressed
Archiving, printing, publishing, presentations
Compressed
E-mail, printing, E-mail, printing, E-mail, web-publishing, Printing

proofing, presentations, presentations, web- social media
web-publishing, social publishing, social media
media
Figure 9.2 Image file formats for dental use.
communication such as attachments to e‐mails. There are various varieties and qualities of
JPEGs, ranging from Level 10 to Level 1; the higher the level, the greater the quality. Most
cameras offer the option of capturing the initial image in JPEG format. While this offers
advantages of taking more images before depleting the memory card storage capacity, the
resulting images have inferior resolution, and cannot be converted later into the higher
resolution TIFF format. The third file format is PDF, which also exhibits lossy compression
with smaller file sizes compared to TIFF. The endearing feature of PDFs are that annotations
can be added (see Module 8), which are invaluable for communicating various diagnostic
detail, prescriptions to dental laboratories or proofing documents prior to printing. Due to
their small size, PDFs can readily be attached with e‐mails, and universally viewed by recipients
with free downloads of Adobe® Acrobat software. The PNG file format offers small file sizes
that are primarily intended for building websites. This format has essential features for creating
and viewing websites with minimum upload times with reasonable quality. The EPS file format
combines text and graphics, and is mainly used for publishing. Table 9.1 summarises some
popular image file formats, their properties and intended uses.
Imaging Software
Although image processing is a complex procedure, it can broadly be categorised as editing or
manipulation (Sandler and Murray 2002). This is analogous to writing a prose or narrative,
where editing text involves corrections that allow the reader to more easily comprehend the
message that is being conveyed, but not altering the message. On the other hand, manipulation
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Table 9.1 Image file format properties and uses.
Tagged Image File Joint Photographic Personal Document

RAW Format (TIFF) Experts Group (JPEG) File (PDF)
Colour mode RGB RGB, CMYK, CIE RGB, CMYK RGB, CMYK
(colour space) L*a*b*
Colour (bit) 16 bit/ 16 bit/channel 8 bit/channel 8 bit/channel
depth channel
ICC profile — Yes Yes Yes
Compression No Optional Yes Yes
Alpha channel No Yes No No
Web‐friendly No No Yes Yes
Uses Archiving Archiving, printing, E‐mail, printing, E‐mail, printing, proofing,
publishing, presentations, web‐ presentations, web‐
presentations publishing, social media publishing, social media
RBG – red, green, blue.

CMYK – cyan, magenta, yellow, key (black).
CIE L*a*b* – Commission Internationale de l’éclairage colour co‐ordinates.
alters the message or tells a different story to that of the original. Similarly, editing an image
simply corrects technical issues without making alterations to the content of the image, i.e. the
song remains the same. Conversely, image manipulation disguises or alters the image content,
and therefore, its tune, to tell a different story. However, depending on disparate opinions, the
line between editing and manipulation is often blurred, and some regard even the slightest
alterations as forms of manipulation (Sheridan 2013).
The abundance of imaging software on the market is bewildering. There is innumerable
choice aimed at every level of expertise, starting with the novice, enthusiast to the professional.
The decision for selecting a particular product is influenced by three factors, cost, features, and
the dedication of the user to utilise the full, or partial potential a software has to offer. These
entities are interlinked and inseparable, and each factor determines the ultimate choice. Before
recommending an imaging software for dental photography, a brief discussion about various
products is necessary so that the purchaser is aware of what is available in terms of price, fea-
tures and learning curves before making an informed decision.
All imaging software are not created equally, many are freely downloadable as open‐source
versions, which are readily accessible and instantaneous. Furthermore, all computers and cam-
eras come with preloaded editing software such as Apple® Photos or Microsoft® Photos, or
camera‐specific packages, which are ready to use once the equipment is registered on the man-
ufacturer’s website. It is important to realise that whichever software is chosen, all are capable
of accomplishing basic tasks such as altering colour temperature, exposure, orientation, crop-
ping and dust removal with relative ease. However, these basic packages do not offer sophisti-
cated features necessary for creativity and productivity.
The first item to consider is cost. The contenders for free software are the preloaded com-
puter or camera specific programmes. The latter are usually basic packages that allow essential
alterations mentioned above. Among the most popular free downloads are open‐source prod-
ucts such as GIMP, Pixlr or Google Photos. The next bracket is the under US$ 100, which
include Movavi Photo Editor, Corel AfterShot Pro, Pixelmator, Serif Affinity Photo and Adobe
Photoshop Elements. The last category is the above US$ 100 price tag, such as Adobe Creative
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Imaging Softwar 257
Cloud, which includes Lightroom and Photoshop, ACDSee and Capture One. There are two
options for purchasing photo‐editing software, the first is outright purchase with periodic
updates at a fraction of the initial outlay. The second option is a monthly subscription that can
add up to over US$ 1000 per annum, depending on selected plug‐ins for specific tasks or special
effects. The advantage of subscription based software is that it is perpetually updated without
having to purchase periodic updates, but the down‐side is that the subscription is also perpetual,
and one never actually owns the product.
The second item to consider is the number of features offered by the software, which varies
considerably depending on the product. Besides price, the number of features or tools are
crucial for choosing a product that suits the particular needs of the photographer. Below are
some items worth considering before making a decision:
●● System requirements – although obvious, it is prudent to check that the system requirements
of the software are compatible with the computer specifications, e.g. the amount of disc
space required, memory and graphics card
●● Cross‐platform capability – whether the software works exclusively on Windows® or Apple
Mac®, or both operating systems
●● Tethering or compact flash card reader – instead of using a flash card reader to transfer images
from the camera to a computer, many software offer support for selected cameras (as many as
400 different cameras) to transfer images via a USB cable directly to a computer hard drive. In
addition, some software has a live tethering feature that allows instant capture of the image
directly into the software on the computer, and therefore bypassing storage onto a flash card
●● Basic functions – most imaging software is capable of basic editing tasks such as correcting
white balance, exposure, orientation, cropping, ‘red eye’ or dust artefacts removal, etc.
However, it is beneficial to have the facility to make these adjustments both globally as well
as locally, i.e. limited to certain parts of an image. Also, the editing should be non‐destructive
for maintaining image quality
●● Image manipulation – these are features that alter the image by adding, removing, boosting
or subduing parts of an image that the photographer feels are irrelevant, or the alterations
will enhance the image for artistic or dramatic effects. This involve using filters, pre‐set
styles, LUTs (lookup tables), layers and masking tools for manipulating all, or part of an
image. Many of these special effects are useful for creating images for marketing or promotion,
but unwarranted for clinical fidelity
●● 16‐bit depth editing – some software, such as Photoshop Elements, limits some features to
only an 8‐bit file. However, since 16‐bit editing allows greater processing without image
degradation, it is advantageous to choose a software that permits 16‐bit mode editing
●● Web‐based or hard‐drive‐based – particular software can only be used online for editing
images without having to install them onto a computer hard drive. This is beneficial if hard
drive space is limited, especially as graphic intensive software requires considerable disc
storage capacity
●● Cloud integration – another method for saving hard disc storage space is saving images on a
virtual hard drive or digital cloud. The disadvantage is that uninterrupted and high‐speed
access to the internet is prerequisite for retrieving the images. In addition, cloud storage
presents a potential security compromise, which is paramount for medically sensitive
information such as photographs of patients
●● Touch screen operation – this option is useful if using tablets or hybrid laptop‐tablets for
processing images
●● Cataloguing – many imaging software are only capable of processing images, which must
then be exported outside the software for storage. However, other programmes offer browser
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and storage facilities within the software itself for easy access and retrievability. Cataloguing
involves using keywords to tag images, for instance retrieving images of a specific treatment
for showing patients before and after results. However, some practices or institutions may
find cataloguing superfluous if they use practice management systems that allow images to
be stored directly with the patient’s dental records. Alternately, some clinics may prefer to
archive images separately as a precaution that in the event the management software crashes,
retrieving images is safeguarded, rather than having to wait for costly and protracted IT
repairs
●● File support – while most software support TIFF and JPEG file formats, not all support
camera‐specific RAW formats. If images are captured in proprietary RAW file format, it is
worth checking if the software supports a particular camera brand and model. Another
useful feature is the ability to output the edited files to the CMYK colour space, which is used
for printing and publishing
●● Output features – after editing or manipulations, it is helpful to have built‐in export presets,
or recipes, which facilitate outputting or exporting images for different purposes, e.g.
archiving, printing or web‐publishing
●● Templates, plug‐ins – these are usually third‐party add‐ons that facilitate specific tasks,
including one‐click preset fixes for editing, exporting, pre‐formatted templates for bro-
chures, calendars, flyers, greeting cards, or business stationary, to name a few. Another use-
ful plug‐in is LUTs, which alters the colour profile of an image to another predefined colour
profile. This is beneficial for standardising a series of images so that colour rendition is iden-
tical for all images in particular portfolio
●● Drawing tools – annotating images is helpful by adding lines, shapes and text for
communicating with patients, colleagues or dental technicians. Many imaging software
incorporate built‐in drawing tool palettes for facilitating this process. However, some
photographers may prefer to export the images after editing into a dedicated drawing
software that they are familiar with
●● Presentation apps – it is often beneficial to show patients a series of images depicting
treatment sequences for education or treatment acceptance. This is usually accomplished
with dedicated presentation software such as PowerPoint™ or Keynote.™ However, having
apps build into a photo‐editing software for creating mini presentations is advantageous and
expedient
●● Web and social media integration – newer software has the option of directly creating images
that can be instantly shared on social media for e‐marketing by e‐mails or e‐brochures. This
offers convenience, but the caveat for confidentiality is paramount
●● Soft proofing – this is a feature that allows the user to preview the printed version of the
image before forwarding it to a printing device or printing house, ensuring that the printed
image matches as close as possible to what is seen on the display monitor
●● Automated back‐up – is a particularly useful feature that facilitates backing‐up images either
to internal or external hard drives, or cloud storage, but respecting guidelines according to
the HIPAA law (Health Insurance Portability and Accountability Act of 1996)1
●● Training and technical support – is a must for novices, even for simple tasks such as correct-
ing white balance or exposure. The established software houses excel in offering video tutori-
als, webinars, training, FAQ, guides, forums, and 24/7 online support that is indispensable
for beginners, or even seasoned experts who stumble on software glitches or bugs requiring
professional input for resolution
1 https://www.hhs.gov/hipaa/for‐professionals/privacy/laws‐regulations/index.html
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Imaging Softwar 259
●● The final point to consider before choosing a software is the learning curve for negotiat-
ing the graphic user interface (GUI) of a programme. While most software interfaces
appear similar, the ease of use can be challenging, and require professional training. Hence, a
compromise is necessary; more features translate to a steeper learning curve, whereas less
features translate to a vertical learning curve. If time is of the essence, it is better to select a
software with an intuitive and simple interface having basic features that can be mastered
within a relatively short space of time. This is where a polished commercial product wins
hands down, compared to an open‐source development product that may be trial and error
for achieving the desired goals. Furthermore, if a problem is encountered with freebies, the
user is often left stranded to struggle with insurmountable issues
To conclude, the ultimate choice of imaging software is unique to every photographer
depending on cost, features and ease of use (Figure 9.3). At this juncture, the clinician or dental
technician needs to decide whether photographic documentation is limited solely for dental
use, a quasi‐passion, or aiming to be creative and/or achieving professional heights? If the
answer is solely for dental purposes, then any simple photo‐editing software with basic func-
tions will suffice, e.g. Apple Photos, Microsoft Photos, Google® Photos, etc. These software
packages are free, have intuitive interfaces, a vertical learning curve, with many one‐click preset
options, easy to use and serve the majority of dental needs. For the intermediate or enthusiastic
level, the choices are GIMP, Movavi Photo Editor, Corel® AfterShot Pro, Pixelmator, Serif
Affinity Photo, IrfanView and Adobe Photoshop Elements. These programmes are more time‐
intensive to master, but offer many creative and preset features unavailable in basic versions.
Lastly, if the intention is to be more creative, spend unlimited time learning new features, and
jump to a professional level, the software of choice is Adobe Creative Cloud, ACDSee or
Capture One. Photoshop (part of Adobe Creative Cloud) is undoubtedly the industry standard,
Basic Intermediate Professional
Apple® Photos GIMP Adobe® Creative Cloud

Microsoft® Photos Movavi Photo Editor ACDSee
Google® Photos Corel AfterShot Pro
®
Capture One
Pixelmator
Serif Affinity Photo
IrfanView
Adobe® Photoshop
Elements
Figure 9.3 Choice of imaging software.
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offering both image editing and manipulation, and creativity limited only by the imagination; if
you can’t do it in Photoshop, it probably can’t be done. ACD Systems offer several software
for processing, a powerful drawing and painting programme, plus a cataloguing image
management system. Capture One is essentially an image editing software, with extensive
presets, LUTs, a few manipulation effects plus comprehensive cataloguing facilities. The
philosophy behind this software is processing images, without compromise, to their maximum
potential, i.e. image quality, and only image quality, is the order of the day. Capture One ( current
version 12) is made by Phase One®, a company that manufactures high‐end digital cameras.
The software interface is geared for the professional, with intuitive menus and unique features
that bring out the best in any image. Furthermore, the software is backed by helpful technical
support, video tutorials, forums and blogs for expediting the leaning process.
Image Processing
Image processing begins with in‐camera processing, during and after an image is taken. The
camera software performs many processing tasks such as calculating exposure, white balance,
file format conversion and other functions according to settings input by the user. For example,
if JPEG or TIFF files are selected, processing the white balance and file conversion is performed
inside the camera, and no further adjustments are required. However, for dental or professional
photography, it is advisable to use RAW file formats, which require processing outside the
camera by using imaging software (Snow 2013). The interface of most imaging software is very
similar, consisting of a main viewer, browser, cascading menu options, fixed or floating tool-
bars, and tabs, which can be customised according to personal preferences. In addition, default
and personalised keyboard shortcuts help access functions with relative ease and speed.
As mentioned above, processing standardised dental pictures should be concerned only with
image editing, rather than image manipulation. The pertinent questions are:
What requires editing?

What is ethically permissible?
What is technically beneficial?
What is technically detrimental?
As dental images are dento‐legal records, alterations should be restricted to technical issues
that allow the observer to ‘read’ the image more clearly, not unlike correcting typographical
errors in text. In addition, limiting the amount of alterations also preserves image quality,
which is essential for maintaining consistency. Hence, for clinical fidelity, image editing is
ethically permissible, and indeed beneficial. On the other hand, stringent restrictions do not
apply to images intended for marketing purposes, and therefore, manipulations for enhancing
appeal and attention are acceptable.
While there is no substitute for good photographic technique at the capture stage, nearly
all images require some form of retouching to polish the final result, no different to polish-
ing a diamond for maximising its optical properties. These adjustments are part of the post‐
processing workflow that is performed sequentially starting with colour spaces, white
balance, exposure, orientation and cropping, removing artefacts (dust particles), local
adjustments (layers) and, lastly, sharpening. Although this is a truncated list of tasks that
are not applicable for every image, but nevertheless, represents the salient adjustments that
are essential for image editing. There are many other corrections that can be performed
such as noise reduction, lens correction, moiré, colour and curves edits, applying LUTs,
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perspective changes, conversion of colour space to CMYK for printing and so on. However,
these tasks are reserved for more experienced photographers, and usually superfluous for
routine dental photography.
The last aspect to consider before making adjustments is choosing the most appropriate file
format for editing or manipulation. The tolerance level of a file depends on its bit depth. In
order for the human eye to perceive a smooth continuum from black to white, a bit depth of 8
is necessary, i.e. 256 shades of grey (28 = 256) (Figure 9.4). Therefore, to produce colour images,
each of the three colour channels, red green, and blue (RGB), must have a bit depth of 8, which
translates to 16.7 million colours (256 red × 256 green × 256 blue = 16.7 million) – (Figure 9.5).
This is far greater than the human eye, which can discriminate around 10 million colours.
Hence, in theory, an 8 bit/channel is more than adequate for colour perception. However, each
edit and manipulation progressively reduces the bit depth, and extensive adjustments result in
a bit depth that is below the visual perception of colour. Therefore, starting with a higher bit
depth of 16 bit/channel with 65 536 brightness levels/channel, compared to 256 brightness
levels/channel for 8‐bit depth, allows greater flexibility and leverage for ensuring that the final
bit depth is sufficient for visual perception. This is the reason that processing should be carried
out using RAW files, or image captures with a higher bit depth, allowing greater manoeuvrabil-
ity or ‘editing headroom’ without causing image posterisation (Ahmad 2009b).2 Posterisation
occurs when the tonal range of an image exceeds its bit depth, causing visible colour banding
reminiscent of bill board posters. The reason why this occurs with posters is because the print-
ing process uses only a few coloured inks, that are unable to reproduce seamless and subtle
colour transitions. Posterisation of an image literally means ‘tonal spaces’ and is evident when
the histogram is jagged with pronounced banding and spaces representing missing bits of
information, or there is a colour space mismatch between the camera hardware and processing
software (Figures 9.6–9.8).
Small bit depth Jagged edge
Larger bit depth Smoother edge
8 bit depth (28 = 256 Sharp edge

shades of grey)
Figure 9.4 A minimum of 8 bit depth is necessary for the human eye to perceive sharp edges of objects or a
seamless transition from black to white.
2 http://laurashoe.com/2011/08/09/8‐versus‐16‐bit‐what‐does‐it‐really‐mean
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Red channel Green channel Blue channel

(28 = 256) (28 = 256) (28 = 256)
16.7 million colours
Figure 9.5 An 8 bit/channel is capable of producing 16.7 million colours by stimulating retina cells sensitive to
the red, green, and blue (RGB) channels.
Figure 9.6 Posterisation: original

image.
Colour Spaces
Colour spaces or colour profiles are illustrations of colour models, and the area they represent is
called a gamut. A colour space of a device determines the amount of colour it can record (cam-
era or scanner), display (monitor) or output (printer) (Devigus and Paul 2006). Every device has
a specific colour space, with little standardisation between different manufacturers. However,
the three widely accepted colour spaces are sRGB (standard red, green, blue), Adobe RGB and
CMYK (cyan, magenta, yellow and key or black). Furthermore, discussions are in progress to
create a medical RGB (mRGB) for standardising colour for medical and dental photography
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Figure 9.7 Posterisation: colour histogram showing a spiky appearance representing colour banding without
seamless transition between missing colours.
Figure 9.8 Posterisation: luminosity histogram with a jagged appearance indicating banding of colours.
(Badano et al. 2015). The sRGB can be regarded as a generic colour space, and although it has
many variations, most camera and computer manufacturers have adopted it as a default. The
proprietary Adobe RGB is a larger colour space, but requires a greater bit depth to take advan-
tage of its bigger gamut. The CMYK is the smallest space and is primarily used for printing
(Figure 9.9). When importing images from the camera to a computer, most imaging software
automatically ensures that the colour space is appropriately matched. However, it is worth
checking to avoid a mismatch between the colour space of the camera and the imaging soft-
ware. Also, the colour space can readily be changed, for example from sRGB to Adobe RGB, to
take advantage of a larger colour gamut when editing in 16‐bit mode (Figure 9.10).
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Human eye
Adobe® RGB
sRGB
CMYK
Figure 9.9 Comparison of various colour spaces.
Figure 9.10 Colour spaces (profiles) can easily be changed in imaging software to take advantage of a larger
gamut when editing in 16‐bit mode (blue circles).
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White Balance
The next item to check is the white balance. If the WB was set on the camera, no further cali-
brations should be necessary. However, if an 18% neutral density grey card was used for setting
the white balance, which is probably the most accurate method for ensuring colour accuracy
and consistency, calibration within the software is required. The reference image with the grey
card is located and the ‘neutral grey’ or ‘white balance’ tool selected, depicted by a pipette. The
computer mouse cursor is then clicked on the grey card in the image to calibrate the white bal-
ance. This setting is then saved and recalled for correcting the white balance of subsequent
images in the same session (see Figures 3.25–3.28 in Module 3). Also, the reference image
can be included with images from the same session for transmission via the internet, so that
the recipient can calibrate the images on different monitor displays for ensuring colour
consistency.
Exposure
After setting the white balance, the exposure needs to be evaluated. Imaging software offer a
variety of adjustments for altering the exposure including increasing or decreasing the f‐stop
(exposure), contrast, brightness, brilliance, saturation, highlights, shadows, to name a few.
Whilst these variables alter the exposure instantaneously, the process is ad hoc and whimsical.
A more systematic and methodical approach is using the histogram. The histogram is one of
the most misunderstood tools of digital photography, even though it offers precise control over
many variables. As well as displaying exposure, the histogram is also used for determining col-
our distribution, contrast and dynamic range of an image.
The histogram is a graphical representation of the darkest, brightest and midtones in an
image. The x‐axis represents the tonal range, (256 graduations for an 8‐bit depth image), while
the y‐axis is the amount of these tones distributed within an image (Nordberg and Sluder 2013).
The darkest areas are the shadows on the left side of the x‐axis, midtones in the middle, and the
brightest areas are the highlights on the right side (Figure 9.11).The histogram is the equivalent
of a light meter, and is found on the LCD screens of cameras, and in virtually all image process-
ing software. There are many types of histograms such as total RGB (colour overlay)
(Figure 9.12), individual red, green and blue channels (Figures 9.13–9.15), and luminosity (or
luminance) (Figure 9.16). Each type displays different information, but the most widely used is
the total RGB version. The histogram is an 8‐bit function, regardless of the characteristics of
the image being analysed, and shows 256 shades of grey. However, when editing in 16‐bit mode,
a histogram cannot show 65 536 values due to its small physical size on the screen, and is still
represented as a 256 scale.
There is no ideal histogram, and its peaks and troughs are influenced by the subject matter
of the photograph. For example, a black object has peaks confined to the left side (low key
image), while a white object has peaks located on the right side (high key image). If the shadows
are too dark, or the highlights too bright, the areas are said to be clipped, where detail is lost.
Clipping is viewed by turning on the exposure warnings for highlights and shadows (Figure 9.17).
Some detail may be retrievable by exposure correction, but if the clipped areas are extreme,
detail is completely lost, irrespective of the amount of exposure compensation. As a general
guide, the histogram of a correctly exposed picture (without excessively dark or bright [reflec-
tive] objects), has the majority of peaks concentrated in the midtone range with a few peaks in
the shadows and highlight regions. This balanced, or average, exposure represents a numerical
value of 128 (halfway between 0 and 255), and is used for calibrating most camera metering
systems (Figure 9.18). The specific areas of highlights, midtones and shadows in any part of an
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Total RGB
Red channel
Green channel
Blue channel
Tonal distribution
Greyscale values from

0 to 255
Shadows Midtones Highlights
Dynamic range
Figure 9.11 Schematic representation of a histogram.
Figure 9.12 Histogram: total red, green, and blue (RGB).
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Figure 9.13 Histogram: individual red channel.
Figure 9.14 Histogram: individual green channel.
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Figure 9.15 Histogram: individual blue channel.
Figure 9.16 Histogram: luminosity or luminance.
image can be displayed on a histogram by hovering the mouse pointer over the image
(Figure 9.19).
The crucial issue is the extent to which exposure can be altered without affecting resolution or
introducing unwanted colour casts. This depends on the initial bit depth of the image, and the
amount of correction necessary. If an image is over or underexposed, it may be ‘pushed’ (exposure
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Figure 9.17 Clipping: red areas represent overexposed highlights, while blue areas signify underexposed
shadows.
Figure 9.18 Average metering is the aim of most cameras for ensuring ‘correct’ exposure, represented by a
large midtone region, with a few peaks in the shadow and highlight regions.
compensation) in editing software, by increasing or decreasing the level of brightness or dark-

ness. But to what extent can it be ‘pushed’ without compromising quality? As a rule‐of‐thumb, an
8‐bit overexposed or underexposed image can withstand a 1 f‐stop exposure compensation with-
out a noticeable deterioration in quality, while a 16‐bit image allows greater latitude. The easiest
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Figure 9.19 The tonal range of an image can be ascertained by hovering the mouse pointer to various sites of
an image. The white text in the colour swathes indicate the shadows (5), midtones (128) and highlights (254).
method for correcting exposure is turning on the exposure warning to display over and underex-
posure areas. The exposure, contrast, brightness, brilliance, saturation, highlights or shadows are
adjusted until the correction is acceptable. Care should be exercised not to completely eliminate
areas of highlights and/or shadows to avoid a bland, flat image (Figures 9.20–9.23). However, if
extreme exposure corrections are necessary, it is better, if possible, to take another picture rather
than risking severe degradation in image quality (Figures 9.24–9.27).
The second element that a histogram is useful for is assessing the contrast of an image. This
is determined by the aggregation or segregation of the peaks in a histogram. For a low contrast
image, the peaks are clustered together, while for a high contrast image, the peaks are spread
out (Figures 9.28–9.30). A hight contrast image, within limits, is vibrant, punchy and attracts
attention. Conversely, a low contrast picture is dull, lacklustre and perceived as boring.
Another use of a histogram is ascertaining the dynamic range (DR). DR is a hardware prop-
erty of the camera sensor, and indicates total tonal range from the darkest to the brightest,
expressed as the number of f‐stops that a sensor is capable of recording. The human eye can
discern a DR of around 24 f‐stops,3 while most digital devices, in theory, are capable of record-
ing an infinite amount of DR. However, it is the amount of usable DR that is important, and
depends on bit depth of the imaging chip or sensor in a camera. The DR of digital cameras vary
enormously, ranging from 4 to 15 f‐stops (Figure 9.31). A large DR is ideal for display devices
such as monitors or projectors, but the DR of printed media is limited to around 4 to 5 f‐stops,
and therefore suffers from detail loss by several f‐stop4 (see Figure 3.24 in Module 3). This is the
reason why a picture that appears full of vitality on a computer monitor, is often insipid when
printed. However, having a large DR spread over a small bit depth is futile and results in image
3 http://www.cambridgeincolour.com/tutorials/dynamic‐range.htm
4 https://petapixel.com/2015/05/26/film‐vs‐digital‐a‐comparison‐of‐the‐advantages‐and‐disadvantages
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Figure 9.20 Initial image with excessive highlights (depicted by peaks on the right side of the histogram),
which are obscuring surface detail of the maxillary right incisors and canine.
Figure 9.21 Turning on the exposure warnings shows the distribution of highlights (red areas).
posterisation, since the smaller bit depth cannot accommodate a large DR. There are two
methods for circumventing this limitation, the first is using camera that has a 16‐bit sensor, or
using high dynamic range (HDR) photography, often referred to as image hallucination. HDR
photography is a software process of ‘stitching’ together multiple bracketed exposure images
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Figure 9.22 Adjusting the exposure reduces the highlights and the peaks on the right side of the histogram,
which allow visualisation of the surface texture on the maxillary right incisors and canine. Notice that some of
the highlight areas are intentionally left intact to maintain vitality and a three‐dimensional quality of the image.
Figure 9.23 Adjusted image with exposure warnings turned off (compare with Figure 9.20).
for increasing the DR of an image.5 This involves taking several pictures with different expo-
sures that the imaging software converts into 32‐bit open‐ended brightness files. The files are
then digitally merged into a single image for achieving a higher DR.
5 http://www.stuckincustoms.com/hdr‐photography
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Figure 9.24 Initial grossly overexposure image. Notice the peaks isolated to the right side of the histogram.
Figure 9.25 Turning on the exposure warnings shows the distribution of highlights (red areas).
Orientation, Scaling and Cropping

After correcting the exposure, the next stage is orientating and scaling the image in preparation
for cropping. Orientation involves straightening the image so that it is parallel to the horizon.
A frequent mistake is pseudo‐aligning the incisal or occlusal plane so that it appears horizontal
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Figure 9.26 After drastically reducing the highlights by exposure compensation, the image quality
deteriorates with a green colour cast. Although the peaks on the histograms are now located in the midtones
region, the image is still overexposed.
Figure 9.27 Another image taken

with correct exposure (compare
with Figure 9.24).
in intra‐oral images. The correct alignment of the incisal plane is judged from the dento‐facial
or full face perspective with the head positioned correctly in the horizontal plane (see EPP
Image #3: Fontal view – biting wooden spatula in Module 6). If the incisal plane is canted in this
view, it should not be falsely re‐aligned in the intra‐oral views. However, most images require
minor tweaks to orientate them correctly. It is best practice to turn on the vertical and horizon-
tal grid lines option in the software for aiding orientation.
The next process is scaling. If the image was taken with pre‐set magnification or a predefined
focusing distance set on the lens, no further scaling is required. This ensures standard images
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Figure 9.28 Normal contrast image with peaks evenly distributed on the x‐axis.
Figure 9.29 Low contrast image with peaks clustered together on the x‐axis.
for inter‐ and intra‐patient comparison. However, if the image was framed with a larger view,
extraneous objects such as cheek retractors or mirrors will require cropping. Also, intra‐oral
images taken with mirrors need to be rotated and laterally inverted (flipped) – (Figures 9.32–9.38).
In some circumstances it is necessary to crop or enlarge part of an image to show particular
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Figure 9.30 Hight contrast image with peaks spread out on the x‐axis.
Figure 9.31 The dynamic range (DR), expressed as the number of f‐stops, determines the amount of detail
that a camera sensor can record from the darkest to the lightest part of an image.
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Figure 9.32 Original image.
Figure 9.33 Rotate right 90°.
points of interest. The technical terminology for enlarging is interpolation, which is a mathe-
matical algorithm process used by imaging software. Interpolation literally means stretching
the image by inserting empty pixels (with no detail) to the desired enlargement. There are
several types of interpolation formulae, but the important issue is that enlarging is not limit-
less, and should be judicially performed to prevent pixellation, which negates the initial scaling
objective (Figure 9.39).
Some cropping is usually necessary if images have been re‐aligned, and consists of two parts:
aspect ratio and the physical size of the image. The aspect ratio ensures that the width/height
of a series of images is constant, irrespective of their physical size. The aspect ratio can either
be set on the camera or in the imaging software, and can either be portrait, or landscape. For
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Figure 9.34 Rotate right 90°.
Figure 9.35 Align to horizontal (6.3°).
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Figure 9.36 Flip horizontally.
Figure 9.37 Crop to ‘Original’ aspect ratio by 4500 pixels.
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Labial sulcus
Attached
Right buccal Left buccal

sulcus sulcus
Soft palate
Figure 9.38 Final standardised image comforting to EDP image #8.
Figure 9.39 Excessively enlarging an image

causes unwanted pixillation.
ensuring consistency, the aspect ratio can be left unchanged (original) corresponding to the
camera sensor, or changed manually in the software for specific ratios such as square, 2 : 3, 5 : 7,
16 : 9, etc., (Figures 9.40–9.43). Imaging software also offer an unconstrained option for freely
cropping the image to an unattributed ratio. However, this results in images with different
widths and heights that compromise standardisation. The second point to consider is the phys-
ical size of the image. Once again, to ensure uniformity, all images should be the same size. This
is achieved, concurrently with cropping, by numerically inputting the size of the image using
the preferred units, e.g. pixels (px), inches (in), mm, or cm (Figures 9.44–9.46).
As well as ensuring the correct aspect ratio and size, cropping is also invaluable for composing
an image so that it conforms to chosen composition rules, and standardising fields of view men-
tioned in Module 4. Ideally, a picture should be composed at the capture stage to minimise edit-
ing. However, obtaining a proper field of view for dental images is challenging. The field of view
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Figure 9.40 Aspect ratio – square (notice that the width is constant at 2500 pixels for all the examples below,
but the height of the image varies according to the aspect ratio).
Figure 9.41 Aspect ratio – 2 : 3.
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Figure 9.44 The size of an image can be numerically input using the number of pixels, e.g. 3500 × 2333
(determined by aspect ratio)…
Figure 9.45 …or 3000 × 1999 pixels, etc.
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Figure 9.46 The size of an image can also be numerically input by dimensions in cm, e.g. 29.63 × 19.75, which
is equivalent to 3500 × 2333 pixels (constrained by the aspect ratio).
may be less than ideal due to movements of the patient, operator or incorrect equipment
positioning. These failings can partially be compensated at the processing stage by cropping
extraneous objects to concentrate on the points of interest, as well as aligning the image so that
it is standardised according to guidelines for the EDP (essential dental portfolio) and EPP (essen-
tial portrait portfolio) discussed in Module 5 and Module 6, respectively (Figures 9.47–9.49).
Figure 9.47 A misaligned captured image. In order to realign this image, a vertical grid line (vertical orange
line) is placed at the dental midline, and horizontal grid lines (horizontal orange lines) at the cervical and
incisal aspects of the maxillary anterior teeth, and the image rotated accordingly to coincide with these
orientation lines.
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Image Processin 285
Figure 9.48 Correctly aligned and cropped image to exclude extraneous objects such as cheek retractors and
superfluous extra‐oral anatomy.
Bilateral negative
space
Mucogingival Frenum
junction attachment
Maximum number
of molars visible
Frenum Mucogingival
attachment junction
Figure 9.49 Final image corresponding to standardised EDP image #4.
Artefact Removal
One of the most annoying things about digital photography is accumulation of dust or fluff
particles that adhere to the camera sensor by static electricity. This is particularly pronounced
with cameras that have a mirror, or if lenses are constantly interchanged. Many cameras have
built‐in sensor cleaning mechanisms to mitigate this phenomena. Also, numerous sensor
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cleaning kits are available for cleaning sensors consisting of lint‐free cloths, mild detergents
and mini vacuum cleaners. It is worth emphasising that sensor cleaning is a very delicate and
fiddly procedure, and if performed causally, can cause irreparable damage to the sensor.
Therefore, it is prudent to delegate this task to a skilled professional who is proficient in this
field. Dust particles tenaciously stuck to the sensor appear as tiny white and black dots or blem-
ishes on the image, which are particularly conspicuous on light or white surfaces such as teeth.
If the sensor is scratched, the artefacts are larger and even more conspicuous. Most software
has spot removal, healing or cloning tools for removing these artefacts, but if dust particles are
widespread, the process is onerous and time‐consuming (see Figure 1.13 in Module 1).
Another issue is condensation on the glass covering the sensor that occurs with extreme
changes in ambient temperatures. This may occur when using the camera at the beginning of
the day during the winter months, or taking the camera outside from an air conditioned room.
The resultant images are hazy, and the only solution is to allow the camera to acclimatise to the
new temperature before starting a photographic session.
Local Adjustments
The editing described above affects the entire image, and the adjustments are termed global.
However, in certain circumstances, it may be beneficial to edit only particular parts of an image
that perhaps maybe underexposed, or require some form of enhancement for conveying the
intended message. This is probably the most gratifying aspect of digital photography for
compensating inadvertent photographic mistakes, which can be rectified after taking a picture.
In theory, any variables such as colour, exposure, sharpness, cloning, etc., can be adjusted locally.
However, local adjustments are highly contention for ethical reasons, and steer into image
manipulation territory. For example, changing the colour of inflamed tissues from red to pink in
a particular region can fraudulently convey health, and lead to misdiagnosis of an underlying
pathology. Therefore, local adjustments should be limited to those variables that are compensat-
ing for fallings in photographic technique, rather than surreptitiously masking pathology or defi-
ciencies in treatment for enhancing post‐operative outcomes.
An example of a justifiable local adjustment is correcting exposure in part of the image that
was poorly illuminated. Furthermore, some pictures cannot be repeated, but nevertheless ben-
efit from minor corrections, e.g. recording treatment sequences or surgical procedures. The
image in Figure 9.50 shows surgical crown lengthening of the maxillary anterior teeth using a
Figure 9.50 Poorly illuminated

piezo tip and Zekrya gingival
retractor.
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Image Processin 287
piezo surgery tip for performing ostectomy and osteoplasty. Although the picture is correctly
exposed, the piezo tip and Zekrya retractor are poorly illuminated and could benefit by increas-
ing brightness to make them more conspicuous to guide the eye to the main point of interest.
The local adjustment tool creates a separate layer, consisting of an airbrush (depicted by an
airbrush emoji) to draw a mask (green) delineating the parts requiring an increase in exposure.
The exposure was increased by 1 f‐stop and the shadows lifted by a factor of 11 (Figure 9.51).
The final image shows the effect of the local adjustment, restricted only to the piezo tip and
part of the Zekrya gingival retractor, making them brighter and more visible (Figure 9.52).
Sharpening
The last item to consider in post‐image processing is the sharpness of an image. Sharpness is
determined by the hardware, the magnification factor and the viewing distance. In addition,
Figure 9.51 Local adjustment limited to piezo tip and Zekrya gingival retractor.
Figure 9.52 Adjusted image with a

brighter and clearly visible piezo tip
and Zekrya gingival retractor
(compare with Figure 9.50).
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Sharpness
Resolution Acutance
High resolution High acutance
Low resolution Low acutance
Figure 9.53 Sharpness depends on resolution (property of lens to discriminate fine detail) and acutance
(ability to discriminate edges of objects).
proper photographic technique plays a crucial role such as correct focusing, preventing camera
shake, and setting an appropriate ISO number for mitigating ‘image noise’. The sharpness of an
image is highly subjective, varying from individual to individual, and for the same person at
different times depending on their state of mind. In objective terms, in order for an image to
appear sharp depends on two fundamental parameters: resolution and acutance. Resolution is
unchangeable since it is an intrinsic property of the lens and its ability to discriminate detail
between closely spaced objects, e.g. the number of lines resolvable per millimetre. Acutance is
the ability to clearly discern the edges of objects, i.e. the tonal contrast between two objects,
and is the parameter that is adjustable in imaging software6 (Figure 9.53).
Most images captured by digital cameras are unshaped due to the colour filters covering the
pixels for adding colour, usually Bayer or Fovean interpolation filters (see Figure 1.4 in Module 1).
There are two methods for compensating this unwanted side‐effect, either applying immediate
sharpening by in‐camera processing, or sharpening in imaging software. The latter method is
preferred since it allows greater control for increasing sharpness both globally and locally to
only selected parts of an image. However, most cameras, by default, are configured to perform
6 http://www.photoreview.com.au/tips/shooting/sharpness,‐acutance‐and‐resolution
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Image Processin 289
Figure 9.54 The image on the left is out of focus at its periphery, which cannot be sharpening by imaging
software, and therefore it is better to take another in‐focus image (right).
in‐camera sharpening before displaying the image on the LCD screen for previewing. If the
intention is to use imaging software, the factory default settings for sharpening in the camera
menu should be disabled beforehand. Also, it is important to realise that no amount of processing
will render sharpness to blurred or out‐of‐focus images (Figure 9.54).
The basic principle of sharpening is increasing the relative contrast between the edges of
objects by altering three variables, ‘amount’, ‘radius’ and ‘threshold’, thereby giving an illusion
that the objects appear sharper. It is advisable to create a separate layer to perform the
sharpening so that the original image is left intact in case the results are not as anticipated.
Also, the image should be viewed at 100% zoom, and sharpening is always the last step in the
imaging (editing) chain. The extent of sharpening depends on the subject of the image (skin
tones, gingiva, teeth), intended use of the image (e.g. websites), or the media on which the
image will be displayed (monitor, projector screen, or paper). Coated or glossy paper is usually
more punchy and sharper as it confines ink ‘bleeding’, whereas matt paper allows inks to dis-
perse, and therefore the image appears softer.
There are two options for sharpening an image, the easiest is using built‐in presets in imaging
software that offer numerous choices for the degree of desired sharpening (Figures 9.55 and 9.56).
For experienced photographers, the manual option involves individually adjusting values for the
three variables; amount, radius and threshold (Figures 9.57 and 9.58). Some guideline parameters
for manually sharpening dental images are summarised in Table 9.2 (Kelby 2003; Benz 2003).
However, these recommendations are broad guidelines, and a little experimentation is neces-
sary for achieving optimal results. Finally, over‐zealous sharpening is counterproductive as it
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Figure 9.55 The easiest method of sharpening is using built‐in software presets, and preview the effect before
accepting the changes. Original image before sharpening.
Figure 9.56 After sharpening: notice the effect of sharpening on the perykymata on the enamel surfaces of
the maxillary left lateral incisor and canine and the mandibular left lateral incisor. The gingival stippling and
incisal edges are also markedly sharper.
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Image Processin 291
Figure 9.57 Manual sharpening involves inputting values for the three parameters: amount, radius and
threshold: Original image before sharpening.
Figure 9.58 After sharpening: notice the effect of sharpening on the perykymata on the enamel surfaces of
the maxillary left lateral incisor and canine and the mandibular left lateral incisor. The gingival stippling and
incisal edges are also markedly sharper.
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Table 9.2 Parameters for manually sharpening dental images.
Type of image Amount (%) Radius Threshold
Intra‐oral 100 2 1
Extra‐oral/portraits 75 2 3
Bench images 65 4 3
Web use 400 0.3 0
Figure 9.59 Over‐zealous sharpening is detrimental to image quality as it introduces image noise, and creates
unwanted halos at the edges of objects, e.g. at the incisal edges of teeth. Notice the Halo suppression slider
indicated by the red circle.
creates unwanted halos at edges of objects and introduces image noise,7 which can mimic
pathology, especially when applied to intra‐oral radiographs (Brettle and Carmichael 2011)
(Figure 9.59). Some imaging software have a halo suppression tool for reducing this nuisance,
but the results are contentious.
After completing the editing process, the final stage is exporting the images for the intended
use, which is the topic of the last module.
7 https://helpx.adobe.com/photoshop/atv/cs6‐tutorials/sharpening‐an‐image‐with‐unsharp‐mask.html
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References 293
References
Ahmad, I. (2009a). Digital dental photography. Part 9: post‐image capture processing. Br. Dent. J.
207 (5): 203–209.
Ahmad, I. (2009b). Digital dental photography. Part 3: principles of digital photography. Br. Dent. J.
206 (10): 517–523.
Badano, A., Revie, C., Casertano, A. et al. (2015). Consistency and standardization of color in
medical imaging: a consensus report. J. Digit. Imaging 28: 41–52.
Benz, C. (2003). Digital photography: exposures, editing images, and presentation. Int. J. Comput.
Dent. 6: 249–281.
Brettle, D. and Carmichael, F. (2011). The impact of digital image processing artefacts mimicking
pathological features associated with restorations. Br. Dent. J. 211: 167–170.
Devigus, A. and Paul, S. (2006). Preparing images for publication: part 1. Eur. J. Esthet. Dent.
1: 20–29.
Kelby, S. (2003). The Photoshop CS Book for Digital Photographers. Berkeley, CA: New Riders.
Nordberg, J.J. and Sluder, G. (2013). Practical aspects of adjusting digital cameras. Methods Cell
Biol. 114: 151–162.
Ramsthaler, F., Birngruber, C.G., Kröll, A.K. et al. (2016). True color accuracy in digital forensic
photography. Arch. Kriminol. 237 (5–6): 190–203.
Sandler, J. and Murray, A. (2002). Manipulation of digital photographs. J. Orthod. 29: 189–194.
Sheridan, P. (2013). Practical aspects of clinical photography: part 2 – data management, ethics
and quality control. ANZ J. Surg. 83: 293–295.
Snow, S.R. (2013). Myths vs reality. J. Cosmet. Dent. 29 (1): 62–70.
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10
Exporting, Managing and Using Images
The last module of this book deals with exporting, managing and using images for a variety of
purposes, and disseminating via various media. This is the final part of the CDP (Capture,
Process, Display) imaging chain triad, discussing how images are displayed. After editing
images in processing software, the next stage is understanding how and where to export
the image files.
Exporting Files
The first priority is deciding the intended use of the images and the requirements of the
recipient. These criteria also determines the file format, file size, image dimensions, aspect
ratio, naming conventions, and the necessary embedded metadata. The use or recipient of
the images have different requirements, and it is better to anticipate these at the outset so
that the export process is efficient and productive. Besides archiving, the array of uses include
documentation (e.g. dento‐legal, treatment planning/monitoring), communication (e.g. e‐
mail attachments, sharing pictures on mobile devices), marketing (web‐publishing, e‐mar-
keting, social media, office stationery, treatment portfolios) and education (e.g. lecturing,
training) – Figure 10.1. The ensemble of recipients are patients, dental colleagues, dental
laboratories, printing houses and publishers. Finally, the images can also be exported exter-
nally for manipulation in drawing, image management or practice management software
(Figure 10.2).
As explained in the previous module, basic image processing is accomplished with relatively
simple and inexpensive software. However, choosing an intermediate or professional level
software pays dividends by offering additional features such as bespoke exporting recipes
or managing the rich media assets. Rich media assets are any multimedia data, including
photographs, annotated images or audio‐visual files that are digitally captured, and stored for
sharing on various devices such as computers, tablets, smart television, or smartphones.
Output Location
Before exporting files, it is necessary to specify the location where the images are to be stored.
The destination can be directly into the patient’s named folder and subfolders created by the
user, within the editing software (if it offers cataloguing facilities), or alongside dental records
of the patient in a dedicated image or practice management software. Also, the files can either
be stored on local internal, or peripheral external storage hard drives. In addition, the files may

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296 Exporting, Managing and Using Images
Archiving
Training Dento-legal
Lecturing Treatment
planning/
monitoring
Stationery/ E-mail
portfolios attachments
Social media
Mobile devices
e-marketing Web-publishing
Figure 10.1 Intended uses of dental images.
Patients
External software
Professional colleagues
Publishers Dental laboratories
Printing houses
Figure 10.2 Recipients of dental images.
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Exporting File 297
be output to a cloud storage application. Irrespective of the destination, it is advisable to regu-

larly back‐up onto remote, preferably off‐site, storage devices.
Although digital dental photography offers convenience and accrues possibilities, it also calls
for responsibility by safeguarding the integrity of patients, no different to radiographs or dental
records. This includes conforming to guidelines according to the HIPAA law (Health Insurance
Portability and Accountability Act of 1996). The foremost intention is, of course, to archive and
safe keeping of the images. Whichever option is chosen for storing files, the paramount con-
cern is that confidentiality is not compromised, and the medically sensitive data is secure and
accessible with stringent security and password protection protocols (Sheridan 2013). The
cloud storage option is relatively new, and although it offers benefits by saving local hardware
disk space, security may be breached if the server is hacked or fails. Another drawback is that
cloud storage requires constant high‐speed internet access to retrieve data, and download
speeds can be painfully slow for large files. Although no electronic device is foolproof, the
hardware storage option is more suited for protecting sensitive data, and offers the benefit of
easy and rapid access without having to rely on WiFi connection.
Naming Conventions (Formats)

A naming convention for images is no different to organising a conventional filing system. As
an image library expands it soon becomes overwhelming, and trying to find images is a labori-
ous and time‐consuming task. The naming convention, or format, can either be custom made
by the user, or predefined in dedicated dental asset management programmes. Since dental
photography is a niche category, most generic photographic imaging software do not offer a
naming convention catering specifically for dentistry. However, it is relatively simple to modify
keywords and tokens in any imaging software for dental needs (Figure 10.3). The example
shown below is easily saved as user preset, and recalled for future use (Figures 10.4 and 10.5).
Figure 10.3 A bespoke naming format for dental images.
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Figure 10.4 Example of a naming convention for CompositeFilling.
Figure 10.5 Example of a naming convention for PLV.
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Exporting File 299
Export Recipes
An efficient method for exporting images is using export presets, or recipes, which define
certain criteria or parameters for specific export requirements. In addition, multiple export
recipes can simultaneously be applied to a single or a collection of images for different uses.
Most software offers several built‐in export recipes containing export settings for helping to
export images quickly and efficiently. These recipes can be modified to suit specific needs by
changing any parameter, or new ones created and saved for future use. Also, many service or
application vendors including printing/publishing houses or website designers have specific
requirements for images, and supply export recipes in the form of plug‐ins that can be installed
in the p
rocessing software for exporting the images with the necessary customised settings.
Some important ingredients to consider for export recipes are detailed below.
●● File properties – It is possible to either export the original files (masters) as captured by the
camera, or variants (versions) that have had adjustments applied to them during the editing
and manipulation process. However, since the initial captured image always requires some
form of modification, in most circumstances it is the edited version of the image that is
exported. The file properties include file format, bit depth, compression, resolution, scaling,
sharpening for screen or printing, and assigning a default software for viewing the images.
Every programme has its unique interface for these items, which are accessed by toolbars,
tabs, dialogue boxes and floating or cascading menus.
●● Colour spaces – Other useful information to attach when exported files are the ColorSync or
ICC (International Color Consortium) profiles (colour spaces), LUTs (Look Up Table) and
XMP (Extensible Metadata Platform) sidecar or ‘buddy’ files. The ColorSync or ICC profiles
allow the recipient to match colour profiles on different monitors for ensuring colour con-
sistency, which is essential for diagnosing pathological lesions or shade analysis (Figure 10.6).
Figure 10.6 An International Color Consortium (ICC) profile using the sRGB colour space profile.
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Although there are innumerable colour spaces to choose from, the most frequently used are
the sRGB, Adobe® RGB and CMYK (see Figure 9.9 in Module 9). The XMP files contain all
processing (developing) changes made while editing the original captured file. This allows
the recipient to open the file in another software, or on another computer, and still have
access to the original file as well as all data relating to any subsequent developing that was
performed. Also, if processing is delegated to an external editing house, after completing the
editing, only the XMP file containing the editing changes needs to be returned to the client
who can apply them instantly to the original file for reviewing the changes.
●● Metadata – In addition to exporting the image file, it is useful to attach technical, administra-
tive and copyright information about an image. These details are termed metadata and are
embedded with TIFF or JPEG files. PNG (Portable Network Graphics) files, which are often
used for web‐publishing, do not support the inclusion of metadata. There are two universally
accepted forms of metadata called EXIF (Exchangeable Image File Format)1 and IPTC
(International Press Telecommunications Council) information.2 The EXIF metadata con-
tains information about the type of camera, lens, flash, camera settings, file format, colour
space, date, and GPS location (Figure 10.7). The IPTC information header has three catego-
ries of information; administrative, descriptive, and rights. These categories list the creator’s
name, address, description or content of the image, and can also include patient details and
consent, keywords, ratings, colour labels, plus intellectual property and copyright limitations
(Figure 10.8). When disseminating images, the metadata can be included or excluded,
depending on the intended use or recipient. For example, it is appropriate to include IPTC
information containing patient details when liaising with a specialist or professional col-
league for co‐diagnosis, but inappropriate if the image is intended for web‐publishing.
Figure 10.7 An example of Exchangeable Image File Format (EXIF) metadata.
1 http://home.jeita.or.jp/tsc/std‐pdf/CP3451C.pdf
2 https://iptc.org
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Image Managemen 301
Figure 10.8 An example of International Press Telecommunications Council (IPTC) metadata.
●● Watermarks – These are semi‐transparent text or logos placed over the image to prevent
copyright infringement. It is, of course, easy to save any image from the internet by simply
clicking on the right mouse button, but placing an indelible watermark on the image acts as
a potential deterrent for unauthorised usage or dissemination (Figure 10.9).
●● Parameters – As previously mentioned, most photographic software contain several prede-
fined export recipes for a variety of uses. However, the number of recipes can be reduced to
four fundamental types that fulfil almost every requirement. Table 10.1 summarises the rec-
ommended parameters for export recipes, which are readily modified to suit individual
needs by changing any criteria.
To summarise, there are five easy steps for exporting files (Figures 10.10 and 10.11):
1) Select file(s) to export
2) Select export recipe(s)
3) Select, and/or create, output location folder(s)
4) Type file name(s) according to naming format (convention)
5) Click ‘Process’ or ‘Export’
Image Management
After exporting images, the next stage of the digital dental workflow (Goldstein 2015) is manag-
ing the rich media assets. There are several options for image management ensuring security
and accessibility of data. Compared to conventional photography, the digital dental workflow
presents unique challenges, the most important of which is maintaining confidentially. There
are two protocols for organising images, either patient based, or treatment based. The first
protocol is sorting according to personal details of the patient, including name, date of birth,
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Figure 10.9 A watermark on an image acts as a deterrent for unauthorised usage.
contact information and hospital or practice reference numbers. The second is labelling images
according to the types of treatment, and forming a keyword tree that grows over time to include
clinical finding, diagnosis, procedures, phases of treatment, outcomes and follow‐up (Niamtu
2004). Both options can be combined for filtering and accessing the relevant images for particu-
lar needs. Also, images should be processed immediately after a photographic session to facili-
tate labelling while the memory is fresh to prevent misfiling at a later date.
The first method for storing images is manually creating a hierarchy of folders and subfolders
for managing patient images (Nayler 1998). A simple schematic is a main folder titled ‘Patient
Images’ that contains patient name subfolders, followed by date subfolders, which contain
consecutively numbered images corresponding to the date folder (Figure 10.12). This manual
workflow strategy should be familiarised by members of staff and followed precisely for
ensuring consistency. The limitations of the manual option are that the images are not linked
with the patient’s dental records, and filtering is impossible for retrieving images for specific
criteria such as the type of treatment, or stage of treatment.
The second option for storage is purchasing dedicated image management software, which can
be a standalone, or integrated within an editing or dental practice management package.3 Since
standalone image management software are catering for many photographic genres, a degree of
customisation is necessary for dental use. Examples of the latter include Image Fx, Adobe
Lightroom, Capture One, Cumulus, IrfanView and Apple® Photos. These software organise
images by systematically cataloguing them in folders, albums, smart albums, etc. This is essen-
tially creating an image database, no different to a patient database for electronically filing dental
records (Figure 10.13). The advantage of this method, compared to creating manual folders, is
that filters can be applied for retrieving particular images by using keywords such as ‘composite
fillings’, ‘implants’ and so on. Furthermore, entire folders and albums, which are stored within the
software, can be exported to other imaging or dental practice management software.
3 http://www.dentalcompare.com/Restorative‐Dentistry/4454‐Dental‐Image‐and‐Management‐Software/
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Image Managemen 303
Table 10.1 Recommended parameters for export recipes.
Parameter/principal Web‐
use Archiving Archiving publishing Print ready
File format TIFF JPEG JPEG, PNG TIFF, JPEG

Colour (bit) depth 16‐bit or 8‐bit/ 8 bit/channel 8 bit/channel 8 bit/channel
channel
Compression/ Maximum or – Uncompressed
quality 100% quality TIFF or maximum
quality JPEG
International Color sRGB, Adobe RGBa sRGB, Adobe sRGB, Adobe sRGB, Adobe
Consortium (ICC) RGBa RGBa RGB, CMYKa
profile
Resolution 300 dpi 300 dpi 300 dpi 300 dpib
Scale 100% 100% Long Long edge (never
edge,1600 pxc upscale), 4724 pxc
Sharpening None None Output Output
sharpening for sharpening for
screend printd
Metadata Exchangeable Image EXIF and IPTC Copyright EXIF and
File Format (EXIF) copyright
and International
Press
Telecommunications
Council (IPTC)
Watermarks None None Optional None
Other uses Publishing, Publishing, E‐mail Offset printing,
presentations/ presentations/ attachments, proofing,
lectures lectures e‐brochures, publishing
e‐marketing,
social media
dpi: dots (pixels)/inch.

px: pixels.
a
Recommended colour spaces.
b
Increase to 600dpi or 800 dpi for line drawings.
c
Variable, according to requirements of recipient.
d
Automatic output sharpening by imaging software.
A surfeit of software is available that satisfies dental needs, but each is configured for spe-
cific tasks such as image editing, radiographic or cone beam computed tomography (CBCT)
imaging, smile design and cosmetic simulations, practice management, accounting and
invoicing, payrolls, ordering supplies, and so on. The major advantage of dental management
software is the ability to link images with the patient’s dental records so that everything is in
one place. It is difficult to recommend a particular dental software since every practice and
institution is unique, with unique requirements. If a practice already has a dental manage-
ment software and is looking to incorporate dental imaging into their daily workflow, it is
obviously useful to purchase software that can be integrated within the existing programme.
Alternately, other practices may prefer software for specific purposes such as digital smile
design or simulating aesthetic/cosmetic enhancement procedures for treatment plan accept-
ance. Furthermore, practices specialising in periodontics may require DICOM (Digital
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Figure 10.10 Summary of steps for exporting image files.
Figure 10.11 Simultaneously exporting TIFF (.tif ) and JPEG (.jpg) files to an output folder.
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Image Managemen 305
Figure 10.12 Custom hierarchical folders for organising and storing patient images.
Figure 10.13 Image cataloguing within an image editing software.
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Imaging and Communications in Medicine) file format compatibility for viewing CBCT scans
for planning implant placement. Examples of popular dedicated dental software include
Dentrix, CS Imaging Version 7, MacPractice DDS, Planmeca, Visora and Extensis Portfolio,
but many others are available that concentrate on specific tasks. In addition, training and
technical assistance from the vendor are indispensable for realising the maximum potential of
these programmes, especially the dental digital assets management (DAM) varieties.
Whichever software is chosen, either standalone or integrated programme, each has specific
images requirements. This is especially relevant for dental imaging or management software,
which require particular file formats, sizes, and dimensions, etc. Therefore, it is advisable
to contact the software house to enquire about plug‐ins, or image parameters, so that export
recipes are tailored for exporting images.
Using Images
Having exported and securely stored the image files, the last item to consider is how and when
to use them (Ahmad 2009; Wander and Gordon 1987). Besides recording the clinical manifes-
tations of the oral cavity, there is a host of applications for dental imagery, which is broadly
categorised into documentation, communication, marketing and education (Christensen 2005)
(see Figures 10.1 and 10.2). However, the lines between these categories are nebulous, and the
same image if often used for several purposes at different times.
Documentation
The first and foremost usage is dento‐legal documentation before starting any therapy, and for
subsequent monitoring, progress and outcome of treatment. A collection of pre‐operative and
treatment progress images form an invaluable record, which should be incorporated into a
code of good practice, for defending against litigation of negligence or malpractice.
The second use is for the provision of dental care including clinical findings, diagnosis,
treatment planning, outcomes, anticipating complications, and rectifying mistakes. A photo-
graphic record is a diagnostic tool, similar to radiographs, study casts or CBCT scans for
analysing the clinical status and devising treatment options. Furthermore, any overlooked
conditions during an intra‐oral examination may be scrutinised at leisure so that a comprehen-
sive plan is devised encompassing all oral lesions and predicaments. Several studies have con-
cluded the importance of photographic documentation for facilitating diagnosis of conditions
such as caries (Boye et al. 2013), developmental defects of enamel (DDE) (Chen et al. 2013)
and acute trauma (Pinto et al. 2015; Casaglia et al. 2015). Another topical issue is safeguarding
vulnerable adults and children; and having a photographic record is irrefutable evidence if
abuse is suspected. In addition, dental records, including photographs, are one of the main
forms of forensic identification of body remains (Bernstein 1983; Pinto et al. 2015), and for
criminal investigations involving matching victims’ bite marks to potential suspects (Levine
1977; Golden 2011).
Monitoring is not limited to treatment progress, but also reviewing pathological lesions that
fail to heal over a period of time, or following the success or failure of a prescribed modality. In
these circumstances, early referral, or intervention, is essential to halt local progression and
systemic spread, especially for pre‐cancerous lesions such as leukoplakia or suspected
squamous cell carcinoma. With the rising demand for elective medical procedures, particularly
esthetic dentistry, a series of images showing the initial, during and after status is imperative.
Aesthetic dental procedures are highly subjective, and a clinically acceptable outcomes may be
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Using Image 307
greeted with ambivalence and dissatisfaction by the patient. Although any form of treatment is
a potential legal nightmare, particular attention is warranted for documenting aesthetic and
surgical procedures.
Communication
Every picture not only tells a story, but is also worth a thousand words, especially when faced
with the task of typing them. It is far easier to show something rather than explain something;
words can be misconstrued or forgotten, but a visual record is unambiguous and indelible. In
addition, a photographic depiction compensates for inaccuracies resulting from variations in
descriptive ability. The mode of communicating with pictures is either electronic or paper‐
based. Nowadays, the former is the preferred method, provided stringent security measures
are in place such as encrypted e‐mails and adhering to HIPAA 1996 guidelines. The main par-
ties to communicate with are patients, dental technicians, professional colleagues or specialist
and healthcare providers. Furthermore, the type of image varies according to the intended
recipient.
Most patients are unfamiliar with dental modalities, or oblivious to the latest advances in
dental therapies. However, other patients are extremely tuned in; a Google® search displays a
plethora of information about any dental procedure. Therefore, the type of image that is
suitable, or demanded by a given individual, varies considerably. Some patients are indifferent
to seeing harsh clinical reality, while others only wish to see the before and after shots, without
the intermediary stages of how the outcome was achieved. This is particularly the case for
treatment involving surgical procedures showing graphical depiction of bone or soft tissue
augmentation. At the other end of the spectrum, some patients are pedantic about every single
detail, and insist on seeing every stage of a procedure, irrespective of how gory this may seem.
Therefore, clinical case studies should be tailored for each patient, respecting his or her wishes
regarding the content of the presentation. As well as gaining informed consent for treatment
after showing various treatment options, together with their advantages and limitations, case
studies are also motivational by emphasising the long‐term benefits of achieving and maintain-
ing good oral health (Figure 10.14). Another issue patients may be unaware of is the importance
of oral health on their general well‐being. For example, the mounting evidence linking perio-
dontitis with cardiovascular diseases, or the mutually destructive nature of diabetes and peri-
odontal health.
Figure 10.14 Pre and post‐

operative split mouth images are
invaluable for showing the
importance of good oral health.
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There is currently a burgeoning trend for digital smile design using various simulation soft-
ware (Figure 10.15). This involves using a pre‐operative intra‐oral image that is imported into
a smile design software, and using various drawing and manipulation tools, a simulation is
created for smile enhancement (McLaren et al. 2013) (Figures 10.16 and 10.17). While these
programmes are useful for communicating treatment possibilities, their limitation is that what
is achievable on a screen monitor may not be reproducible in the mouth. Therefore, a prag-
matic approach is advised; making extravagant claims that may not, or cannot be substantiated
Ovate pontic:
3 mm from CEJ
10 mm 9.5 mm
11 mm
7.8 mm 7.5 mm
8.58 mm
Figure 10.15 Digital smile design.
Figure 10.16 Software simulation:

pre‐operative image of patient with
a ‘gummy smile’.
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Using Image 309
Figure 10.17 Software simulation:

digital simulation showing
aesthetic enhancement of the
smile.
in the clinical environment is committing hara‐kiri. On an optimistic note, most treatment is

successful and immensely satisfying for both the clinician and patient, and offering patients an
electronic slide show or printed portfolio of before and after results does wonders for the repu-
tation of a practice or clinician.
An effective method for communicating with the dental laboratory is with images. This
includes visual prescriptions for diagnostic wax‐ups, articulating study casts, indirect res-
torations, orthodontic appliances, surgical guides, removable denture frameworks, etc.
(Terry et al. 1999; Mahn 2013) A laboratory prescription can incorporate shade analysis, as
well as detailed annotations showing chromatic and characterisation maps for helping the
ceramist recreate these effects in the definitive restoration(s). If the ceramist does not have
access to the patient, a series of images act as a guide for every stage of treatment such as
pre‐operative analysis, intra‐oral mock‐ups, temporarie and try‐in stages, which are inval-
uable for anticipating and correcting problems before delivery of the final prostheses
(Figures 10.18–10.25). This methodology is also crucial for involving patients with treat-
ment, and gaining their approval before proceeding with subsequent stages of therapy. All
images used for laboratory communication should faithfully reproduce the clinical envi-
ronment with fidelity, especially colour rendition for consistency of shade matching.
In many instances a second option is advisable for pathological lesions (Riley et al. 2004), or
for a collaborative interdisciplinary treatment plan. In these circumstances, standardised
images are mandatory, i.e. colour space profiles and metadata should be included for calibra-
tion and identification, respectively. This prevents misdiagnosis, which is essential for arriving
at a correct prescription for the prevailing condition. In addition, images showing pathology
should always include some form of reference for scaling and orientation. This could involve
framing the picture so that adjacent teeth or surrounding oral anatomy are in the field of view,
or reference markers such as periodontal measuring probes or graduated rulers placed next to
suspected lesions for accessing scale. Lastly, annotations and grid lines are useful adjuncts for
orientation (Figures 10.26 and 10.27).
A further use of dental images is liaising with government or insurance‐based healthcare
providers. In some instances, a proposed treatment may require pre‐authorisation, and the
insurance company or health authority may request pre‐operative images for assessing the
validity of the proposed therapy. Also, claims‐processing or disputes are facilitated by forward-
ing pre and post‐operative images regarding a particular item or course of treatment.
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Pre-op - dento-facial (laughter) Pre-op - shade evaluation Pre-op - maximum intercuspation (MI)
Pre-op - protrusive Pre-op - teeth separated Pre-op - right lateral
Crown removal (facial view) Crown removal (occlusal view) Initial temporary with supragingival finish line
Adjusted temporary with Adjusted temporary with Adjusted temporary with

subgingival finish line (MI) subgingival finish line (protrusion) subgingival finish line (left lateral)
Shade evaluation with temporary crown Shade analysis Final preparation: 360° 1.4 mm chamfer (occlusal view)
Final preparation: 360° 1.4 mm chamfer (facial view) Shade evaluation of tooth preparation Shade analysis
Figures 10.18–10.23 Annotated laboratory prescription for replacing a defective crown on the maxillary right
central incisor.
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Frontal: habitat position with temporal crown Frontal: relaxed smile Frontal: exaggerated smile (laughter)
Right oblique: habitat position Right oblique: relaxed smile Right oblique: exaggerated smile (laughter)
Left oblique:
Left oblique: habitat position Left oblique: relaxed smile exaggerated smile (laughter)
Cervical: Vita A2.5

6 mm apical contact area from incisal edge
Inter proximal blue/
grey translucency Body : Vita
A2
A 2.5
A2
Sinuous rounded
line angle Hypocalcified islands
Fracture lines Unique incisal chips/

wear
Incisal blue/grey
translucency
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Figures 10.24 and 10.25 show the

post‐operative result after
replacing the defective crown on
the maxillary right central incisor
with an all‐ceramic e‐max™ crown.
Figure 10.26 A potentially

malignant lesion without
surrounding anatomical landmarks.
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Using Image 313
Figure 10.27 The same image as Figure 10.26, but framed to show surrounding anatomy, grid lines for scaling,
and colour space metadata for colour calibration (blue circle).
Marketing
There is a thin line between marketing and coercion. Ethical marketing is laudable since it
offers a service that the populous may be unaware of, or for seeking a clinician proficient in a
particular treatment modality. However, the distinction between ethical and non‐ethical
marketing is often blurred, and unfortunately, transgression into hyperbole is common. What
constitutes ethical marketing is difficult to define, but blatant statements claiming miracles or
exaggerating treatment outcomes are encroaching on an abyss that is unsurmountable.
Therefore, it is left to the individual or practice to seek guidelines from governing bodies
and indemnity organisations before embarking on a potentially costly and vain marketing
campaign.
The images used for marketing purposes are usually sanitised to show the best ‘view’ or
emphasise positive outcomes of dental treatment. In this respect, they may be construed as
contrived and not clinically ‘honest’, but because their intended use is for promotion and moti-
vation, and hence, a certain degree of latitude or artistic licence is permissible (Figure 10.28).
This should not translate to carte blanche for disguising poor outcomes or hiding defects and
mistakes by flagrant manipulation. Instead, the images should covey an aura, or highlight a
beautiful veneer or composite fillings with appropriate lighting – or, put another way, showing
results in the ‘best possible light’. However, some take a dim view of this form of portrayal as
being deceptive. On the flip side of the coin, the argument is that the purpose of these stylised
images is motivational, and therefore differs from standardised clinical images that serve an
entirely different purpose (Figures 10.29–10.31).
There are two types of marketing, internal (within the practice or institution) and external
(online or print). However, with the advent of mobile devices such as smartphone and tablets,
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Figure 10.28 Marketing images are not always clinically honest, since their purpose is to entice and allure.
Figure 10.29 Images used for

marketing and presentations are
motivational and alluring. The pre‐
operative image shows defective
composite restorations in the
maxillary anterior sextant.
Figure 10.30 Replacement fillings

after contouring, but before
polishing.
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Using Image 315
Figure 10.31 Post‐operative image

after polishing the composite
restorations. The key light was
positioned on the left side of the
patient to encourage specular
reflections for conveying vitality,
and showing the fillings in their
‘best possible light’.
this distinction is somewhat obsolete. The traditional choice of media is printed stationery,
branded gifts, brochures and leaflets. The electronic media are digital picture frames, laptop or
tablet presentations, e‐brochures, e‐mails, social media, websites and blogs. Hence, even com-
pared to a few decades ago, the scope for dissemination is immense.
Although the conventional printed methods are somewhat antiquated, a well‐designed prac-
tice brochure showing high‐quality before and after shots still carries weight; tactile sense
hasn’t totally surrendered to the virtual era. Nevertheless, the order of the day is embracing
new technology. All the information compiled in a brochure is converted into a digital form as
an e‐brochure PDF file, and attached to targeted e‐mails to existing or potential new patients.
There are several marketing companies offering e‐mail addresses of specific socio‐economic
groups in any given locality. Also, the marketing material can be uploaded to various hosting
domains such as Facebook, Twitter, Instagram, Flickr, Google, WhatsApp, LinkedIn, Viber,
Baidu Tieba and so on.
Whereas in the past building a website involved engaging a web designing agency at consid-
erable cost and time, now even a novice can build a professional‐looking and interactive site in
a few days at almost no cost (Figure 10.32). Online web designing companies such as WordPress®
have revolutionised and simplified building websites. Most of these companies offer a free
starter pack, plus the option to upgrade by purchasing specific templates, 24/7 online help and
hosting services for ensuring the integrity of the site for a relatively modest fee. Besides listing
practice details, a website is probably the best way of showcasing treatment outcomes, practice
or clinician(s) achievements, which can regularly be updated with blogs and posts. Another
feature of interactive websites is allowing visitors to respond to the content of the site. This
instant feedback is ideal for gauging the ‘thumbs‐up’ or ‘thumbs‐down’, and making changes in
order to increase web traffic. Finally, the password‐protected statistical analysis is useful for
tracking visitor numbers and for assessing the success (or failure) of a website.
Education
The last use of dental images is the education realm that expounds self, patient, staff and pro-
fessional learning. The protagonist on this list is the clinician, who benefits the most by learn-
ing from failures and critiquing his or her own work. This is essential since without clinical
self‐deprecation there is little possibility for improving clinical skills and foreseeing and miti-
gating mistakes.
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Figure 10.32 An interactive and professional looking website can be created within days, with little or no cost.
The images for educational purposes should ‘talk to the audience’ by effusing vitality and
spark. Furthermore, they should inspire and motivate the delegates rather than causing tedium
and boredom. This is not to say that the images should be frivolously altered with pyrotechnic
effects that neither add to the understanding of a particular technique, nor enhance the mes-
sage being delivered. Instead, the photographer should concentrate on using photographic
techniques for producing pictures that captivate the audience and secure their attention. There
are several methods for achieving these objectives. For example, composing pictures using the
rule of thirds, converging lines, or thinking outside the box for capturing views that are unusual
and interesting (Figures 10.33 and 10.34). Other methods include unidirectional lighting for
enhancing texture and depth, lighting from various angles to create specular reflections
Figure 10.33 Unusual images

captivate the audience and
enhance the learning process, such
as this image showing placement
of the last incremental enamel layer
of composite for restoring a Class IV
cavity.
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Using Image 317
Figure 10.34 Remnants of cement

following removal of orthodontic
brackets can be detected by
scratching the labial surface with a
dental probe.
Figure 10.35 Unidirectional

lighting creates shadows that
convey depth, while specular
reflections confer vitality.
(Figure 10.35), and illuminating only a few teeth or a particular part of the oral cavity. Also, the
picture should be framed to include only relevant items, extreme magnification for highlight-
ing a particular anatomical feature (Figures 10.36–10.41), adding annotations (Figures 10.42–
10.45), or selective focusing on items of interest and blurring the background. If a series of
images are showing a particular technique, a simple approach is association, i.e. placing instru-
ments or materials adjacent to the teeth or soft tissues to add relevance (Figures 10.46 and
10.47), especially if these are an integral part of the procedure (Figures 10.48–10.60). To add
credence to a lecture, it is always beneficial to show the longevity of a particular restoration or
procedure (Signori 2018) (Figures 10.61–10.63). Finally, a striking effect is using colour for
visual impact, e.g. selectively isolating a coloured item for emphasis, while making the remain-
der of the picture black and white (Figure 10.64).
Staff training and education conveys a sense of belonging and unity, making everyone feel
that they are part of a team. It also informs staff members about dental procedures so they are
fully conversant with various treatment modalities, and can relay this information to patients
who may be apprehensive about the therapy they are about to embark upon. Another benefit
is updating colleagues with the latest clinical techniques and legislative changes for smooth
running of a practice or institution. Also, clinical appraisal is particularly relevant if an office
has a dedicated treatment coordinator who is responsible for discussing treatment options
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Figure 10.36 Framing only a few teeth allows the

viewer to concentrate on the relevant technique being
shown. Pre‐operative view of a failing mandibular left
first molar.
Figure 10.37 Atraumatic extraction with intact buccal

and lingual alveolar plates.
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Using Image 319
Figure 10.38 Immediate implant placement and

simultaneous augmentation with bovine xenograft.
Figure 10.39 Immediate screw retained acrylic crown.
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Figure 10.40 Osseointegration after six month healing.
Figure 10.41 Definitive porcelain fused to metal screw

retained crown.
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Using Image 321
Figure 10.42 Adding annotations

is extremely useful for teaching,
such as a chromatic map for these
complex composite restorations in
the mandibular central incisors:
pre‐operative status showing
defective and stained restorations
with a median diastema.
Figure 10.43 A chromatic map detailing incremental layering and characterisations.
with patients, and counselling them about the importance of diet and home oral hygiene
procedures.
The next education endeavour involves clinical research, lecturing, publishing and present-
ing at dental conferences. Besides the obvious egotistical self‐gratification of having your name
in print, the spin‐off is adding kudos for a clinician or practice that reassures patients they are
receiving state‐of‐the‐art dentistry. Although academia is not for everyone, it is still worth-
while meticulously documenting clinical cases for sharing with colleagues on an informal basis.
In an academic environment, use of dental photography can inspire creativity for both under-
graduate and postgraduate students (Siegle 2012). Furthermore, many prospective and
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Figure 10.44 Tooth preparation.
Figure 10.45 Post‐operative result.
Figure 10.46 Placing a probe in

this photograph shows the extent
of bone loss encircling the root of
the maxillary right canine.
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Using Image 323
Figure 10.47 A curette being used

to remove excised soft tissue after
gingivectomy during an aesthetic
crown lengthening procedure.
Figure 10.48 Incorporating instruments and materials

in a series of images showing a clinical technique aids
the learning process: pre‐operative defective filling in
the maxillary right first molar.
retrospective studies rely on photographic documentation for monitoring changes in treat-

ment outcomes over time, and ascertaining survival and success rates. The use of simulation
software for intentionally altering images is useful for epidemiological survey studies, espe-
cially relating to aesthetic dentistry (Ker et al. 2008). If images are to be sent to publishing
houses, it is prudent to read the author guidelines for ensuring the correct file format, size and
dimensions. Also, if large TIFF files are required by the publishers, it is better to use applica-
tions such as Dropbox® for transmitting the files, rather than waiting hours for e‐mail attach-
ments to upload.
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Figure 10.49 After removing the filling, a matrix band is

secured with an interdental wooden wedge.
Figure 10.50 Bulk‐fill composite being introduced into

the cavity following etching and application of a
dentine bonding agent.
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Using Image 325
Figure 10.51 A craving instrument for sculpting the

composite.
Figure 10.52 Post‐operative result.
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Figure 10.53 Incorporating

instruments and materials in a
series of images showing a clinical
technique aids the learning
process: pre‐operative status
showing profound tooth surface
loss associated with both the
maxillary and mandibular teeth
(intra‐oral fontal view).
Figure 10.54 Pre‐operative dento‐

facial frontal view showing
compromised anterior dental
aesthetics.
Figure 10.55 Pre‐operative dento‐

facial right oblique view showing
compromised anterior dental
aesthetics. Notice that the patient’s
left cheek and background are out
of focus to concentrate on the
anterior teeth.
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Using Image 327
Figure 10.56 Intra‐oral acrylic

mock‐ups for the maxillary incisors
fabricated from a diagnostic wax‐up.
Figure 10.57 Intra‐oral acrylic

mock‐ups ‘luted’ with a glycerine
water soluble try‐in paste.
Figure 10.58 Intra‐oral frontal view

of mock‐ups in‐situ after removing
excess try‐in paste.
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Figure 10.59 Dento‐facial frontal
view of mock‐ups in‐situ
photographed with unidirectional
lighting to emphasise highlights
and shadows.
Figure 10.60 Dento‐facial right

oblique view of mock‐ups in‐situ.
Notice that the patient’s left cheek
and background are out of focus to
concentrate on the anterior teeth
(similar to Figure 10.55).
Figure 10.61 Monitoring the longevity of restorations adds

credence to a presentation: pre‐operative defective
amalgam restorations in the maxillary left first and second
molars.
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Using Image 329
Figure 10.62 Immediate post‐operative replacement of

amalgams with resin‐based composite (RBC) restorations.
Figure 10.63 Resin‐based composite (RBC) 14 years

later.
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Figure 10.64 Selective colour

isolation for emphasising the use of
a wooden [pink] wedge for
transiently separating the teeth
during a composite build‐up for
ensuring a tight contact area
between the maxillary central
incisors.
Figure 10.65 The most popular presentation programmes are PowerPoint and Keynote.
Preparing a lecture for conferences requires using presentation software. The most widely
used applications are PowerPoint™ or Keynote™, which are both relatively easy to use and
require minimum or no training for basic features (Figure 10.65). An important issue before
starting is setting the correct aspect ratio of the presentation, which should correspond with
the projector at the venue. Also, the aspect ratio determines whether the images require crop-
ping to accommodate the chosen ratio. For example, some popular aspect ratios are 4 : 3, or
widescreen 16 : 9, but some conferences or projectors require different ratios, and it is worth
checking beforehand to ensure that the presentation is compatible with a particular projector.
Besides the aspect ratio, the native resolution of the auditorium projector, e.g. 720p, 1080p or 4K,
also influences the dimensions of the presentation. The second issue is using relatively small files,
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References 331
Figure 10.66 Thank you!
preferably JPEGs rather than TIFFs, so that the upload and transition time between slides is
quicker. Preparing a presentation is time‐consuming depending on the vision of the lecturer.
However, images supplemented by line drawings and synoptic text are accomplished relatively
easily. On the other hand, if the intention is incorporating videos, audio, sophisticated transi-
tions and animation effects, the task is far more demanding, and some training, as well as
patience, is necessary for creating memorable visual impact – Thank you! (Figure 10.66).
References
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Boye, U., Pretty, I.A., Tickle, M. et al. (2013). Comparison of caries detection methods using
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(4): 285–289.
Signori, C. (2018). Journal of Dentistry 71: 54–60.
Terry, D.A., Moreno, C., Geller, W. et al. (1999). The importance of laboratory communication in
modern dental practice: stone models without faces. Pract. Periodont. Aesthet. Dent. 11:
1125–1132.
Wander, P. and Gordon, P. (1987). Specific applications of dental photography. Br. Dent. J. 162 (10):
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Index
Note: Bold page numbers indicate Figures and Italic page numbers indicate Tables.
1 aesthetic experience 45
1080p 330 aesthetics 21, 90, 108, 232
16 bit 7, 15, 19, 102, 120, 256, 257, 261–265, AF. See auto‐focus
264, 268, 269, 271, 303, 332 ala‐tragus line (plane) 79, 84, 99, 154, 159,
See also bit depth 161, 233
18% neutral density grey card 63, 67, 106, See also Camper’s plane
109, 158, 188, 209, 265 albums 302
See also grey card algorithms 94, 220
aluminium foil 181, 184, 187, 189
3 ambient light 48–50, 63, 138, 150, 158, 198
32 bit 272 analogue to digital converter (A–D
See also bit depth converter) 6
35 mm cameras 91 Anglepoise lamp 184, 187, 189
3D‐printed models 175, 189, 193, 198 Angle’s relatrionships 113, 240, 241
3D‐printed surgical guides 175, 193 animation 331
anisotropic 203
4
annotations 230, 233–235, 234, 235, 255, 309,
4K 7, 330
317, 321
See also cine film
anonymity 42
8 anterior guidance 175, 239
8‐bit 7, 15, 256, 257, 261, 262, 265, 269, 303 anti‐alias filter 7, 12
See also bit depth Apple (Mac) 150, 230, 256, 257, 259, 302
APS (advanced photo system) sensors 6, 7,
a 11, 19, 54, 56, 57, 62
absolute colour 92, 93, 221, 224 archiving 93, 254, 255, 256, 258, 295,
academic environment 321 296, 303
achromatic 190, 224 artefacts 89, 93, 257, 260, 286
acutance 288 articulators 175
Adobe 7, 67, 220, 230, 255, 256, 259, 262, 263, artistic 47, 137, 140, 248, 257, 313
264, 300, 302, 303 artistic licence 248, 313
Adobe RGB (red, green, blue) 7, 67, 220, 262, aspect ratio 67, 159, 277, 280, 281, 283, 284,
263, 264, 300, 303 295, 330
aesthetic dentistry 4, 17, 42, 67, 69, 106, asymmetrical lighting 50, 52, 53, 184
306, 323 attached gingivae 89

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334 Index
auto‐focus (AF) 16, 18, 67, 158, 160, 162, card reader 25, 257
163, 166, 188 cascading menus 4, 260, 299
AWB (automatic white balance) 16, 63, 106, cataloguing 257, 258, 260, 295, 302, 305
109, 160, 162, 163 catch lights 22, 23, 144, 145
See also white balance CBCT (cone beam computed tomography)
178, 230, 303, 306
b CCD (charged coupled device) 6
back‐up 258, 297 ceiling mounts 155
backdrops 23, 25, 153, 156, 170, 182, 185, centric relation 239
187, 188 CF (compact flash) card 25
background(s) 13, 14, 23, 28, 29, 52, 58, 69, cheek retractors 20, 27, 28, 30, 33, 39, 41,
70, 88, 91, 106, 109, 116, 137, 138, 139, 91, 93, 94, 101, 104, 109, 111, 113, 115,
148, 149, 151, 153, 154, 155, 156, 158, 159, 275, 285
160, 162, 163, 167, 168, 170–172, 173, children 39, 94, 150, 166, 306
175, 178, 181, 182, 183, 187, 188, 189, 190, chromatic distribution (mapping) 48, 224,
191, 192, 193, 195, 196, 198, 199, 209, 227, 228, 234, 309, 321
215, 216, 223, 317, 326, 328 CIE L*a*b* 221, 256,
balance 83, 87, 88 cine film 7
Bayer pattern 6, 9 circle of confusion 9, 53
beam splitter 246 clinical portraiture 50, 67, 91, 102, 137, 138,
bellows 18 152, 154, 155, 156, 158, 160, 162, 163,
bilateral illumination 20, 22, 50 164, 173, 184
bilateral negative spaces 106, 109 clinical self‐deprecation 315
biofilm 31, 93, 213, 214 clinical setting (environment) 33, 154
bit depth 7, 9, 15, 92, 254, 256, 257, 261, 263, clipped 148, 265, 269
265, 268, 270, 271, 299, 303 cloning 286
black and white 6, 8, 13, 34, 223, 224, 226, 317 cloud storage 257, 258, 297
black lights. See UV lamps CMOS (complementary metal oxide
bleaching. See tooth whitening semiconductor) 6
blogs 260, 315 CMYK (cyan, magenta, yellow, key) 6, 8, 256,
Blu‐Tack 181 258, 261–263, 264, 300, 303
bokeh 195, 196, 199 co‐diagnosis 300
brightness 6, 223, 224, 227, 253, 261, 265, colorimeters 221, 254
269, 270, 272, 287 ColorSync 299
brilliance 265, 270 colour 5, 6, 7, 8–11, 15, 16, 18, 20, 21, 23, 27,
broad light 145, 146 48, 59, 62, 65, 69, 83, 85, 89, 93, 100, 101,
buccal corridor 91, 109, 113 106, 138, 153, 167, 170, 171, 181, 182, 183,
burnt out. See clipped 187, 188, 190, 191, 192, 193, 194, 212,
216, 219, 288, 302, 311, 319; 221, 223, 224,
c 225, 227, 237, 256, 261–263, 265, 270,
calibration 93, 223, 224, 230, 253, 254, 286, 288, 300, 303, 313, 317, 330
265, 313 colour accuracy 16, 219, 265
cameras settings 57, 59, 68, 89, 99, 106, 109, colour balance 85, 253
116, 116, 129, 129, 158, 188, 209 colour calibration 93, 223, 224, 253, 254,
Camper’s plane 79, 84, 93, 99, 154, 233 265, 313
canine guidance 239, 240 colour casts 15, 16, 62, 63, 89, 184, 220, 268
capture 6, 9, 15, 17, 30, 31, 40, 45, 46, 62, 64, colour filters 6, 9, 216, 288
77, 84, 93, 94, 116, 220, 253, 254, 257, 258, colour consistency 219, 220, 253, 265, 309
261, 280, 288, 295, 299, 300 colour contrast 170, 182, 215
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Index 335
colour distribution 48, 224, 227, 265 d

colour fidelity 63, 85, 216, 219, 253, 309 DAM (digital asset magagement) 306
colour overlay 265 daylight 16, 21, 48, 49, 58, 63, 137, 138,
colour rendering index. See CRI 150, 155
colour rendition 89, 92, 93, 94, 99, 100, See also photographic daylight
216, 220, 258, 309 default settings 67, 68, 260, 263, 288, 289
colour space(s) 6, 7, 67, 92, 94, 106, 220, delegation 17, 32, 40, 286, 300
254, 256, 258, 260–263, 264, 299, 300, 303, dental armamentarium 3, 33, 45, 85, 88, 89,
309, 313 94, 101
colour swatches 224 dental cast(s) 175, 182, 184, 186, 189, 190,
colour temperature 16, 48, 63, 64, 65, 138, 306, 309
139, 140, 155, 219, 220, 256 dental laboratory 41, 175, 181, 236, 309
coloured gel(s). See gel(s) dental laboratory prescription 231–237,
colour transitions 20, 227, 261 310–312
communication 3, 41, 44, 84, 93, 137, 175, dental midline 79, 99, 103, 107, 109, 113, 230,
219, 221, 230, 255, 295, 300, 301, 303, 306, dental mirror 28–30, 31, 32, 39, 41, 67, 93,
307, 309 113, 114, 115, 116, 117, 118, 119, 121,
compact camera 4, 5, 12, 19, 54 122, 127, 128, 182, 184, 246
compact flashes 17, 19, 20, 22, 24, 25, 39, 40, dental records 94, 102, 258, 295, 297, 302,
50, 67, 155, 183, 184, 189, 192, 197, 216 303, 306
compliance. See patient compliance dental syringe 31, 101, 109, 111, 113–115,
composition 4, 31, 39, 41, 48, 53, 57, 69–92, 118, 121, 127, 128
93, 94, 99, 102, 103, 107, 109, 110, 116, dento‐facial. See extra‐oral
116, 117–122, 128, 129, 137, 153, 158, 159, dento‐facial compositions 93, 99, 102, 103,
172, 175, 178, 182, 184, 188, 190, 193, 209, 107, 159
223, 280 dento‐legal 16, 242, 260, 295, 306
compression 254, 255, 256, 299, 303 dentogingival 99, 204, 212
computers 230, 247, 256, 295 depth of field (DoF) 52, 54–57, 56, 67, 93,
condensation 30, 31, 41, 93, 114, 128, 286 106, 158, 211, 247
confidentiality 99, 154, 258, 297, 301 diagnostic wax‐up 175, 178, 186, 230, 231,
consent 41, 42, 102, 154, 157, 300, 307 309, 327
continuous illumination (lights) 20, 22, 137, diagonal lines 69, 81, 86, 188
153, 181, 184, 189, 211, 215 diagonals. See diagonal lines
contrast 9, 48, 50, 69, 70, 71, 72, 140, 227, DICOM (digital imaging & communication in
253, 265, 270, 275, 276, 288, 289 medicine) 303
contrasters 27, 28, 29, 30, 32, 41, 58, 67, 93 diffusers 21, 22, 25, 40, 106, 109, 148, 149, 220
contre‐jour effect. See rim light digital assets management. See DAM
conversion rings 18 digital dental workflow 301, 303
CPD (capture, process, display) triad 45, 46, digital shade analysis 221, 224–226, 234
220, 253 display monitor 9, 33, 63, 84, 93, 220, 253,
cranio‐maxillio‐facial 157 258, 262, 265, 270, 289, 295
CRI (colour rendering index) 219, 220 DNG (digitl negative graphic) 7, 67, 106, 109,
crop factor 11, 19, 53, 91 158, 188, 209
cropping (crop or cropped) 12, 31, 69, 70, 73, documentation 4, 31, 32, 40, 41, 84, 88, 89, 90,
74, 75, 77, 78, 80–82, 93, 123, 128, 257, 92, 94, 102, 128, 175, 184, 189, 203, 221,
260, 273, 275, 277, 279, 280, 284, 285 230, 236, 237, 242, 246, 259, 295, 306, 323
cross‐infection 17, 31, 32, 33, 34, 35, 41, 99 DoF. See depth of field
curve of Spee 109, 113, 119, 233 dolly 24, 155
curve of Wilson 109, 119, 223 dominance 63, 69, 188
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336 Index
DR, See dynamic range exposure 6, 7, 13, 15, 17, 18, 20, 22, 23, 29, 57,
drapes 32 58–62, 67, 85, 89, 93, 106, 109, 128, 129,
drawing software 227, 228, 230, 234, 254, 155, 158, 167, 181, 184, 188, 205, 209, 211,
258, 260, 295, 303, 331 215, 223, 227, 256–258, 260, 265, 268, 269,
Dropbox 323 271–274, 286, 287
dry field. See field of view bracketed 271
dSLR (digital single lens reflex) 4, 5, 6, 7, 12, pushed 268, 269
18, 19, 20, 25, 62, 221, 246 exposure modes 6, 7, 67
dust 6, 7, 13, 14, 15, 18, 32, 256, 257, 260, exposure value (EV) 62
285, 286 exposure warnings 265, 271–273
dynamic range (DR) 7, 9, 59, 60, 62, 247, 254, extension tubes 18
265, 266, 270, 271, 276 extra‐oral 4, 50, 58, 67, 68, 85, 91, 93, 99,
102–106, 108, 109, 119, 157, 184, 215,
e 285, 292
e‐brochure 258, 303, 315
e‐mail(s) 230, 255, 256, 258, 303, 307, 315, 323 f
e‐marketing 258, 296, 303 f‐stop 7, 53, 55, 56, 59, 61–63, 67, 93, 116,
editing 6, 9, 14, 15, 25, 29, 31, 59, 62, 64, 73, 119, 129, 198, 209, 223, 265, 269,
77, 93, 94, 128, 223, 246, 253–261, 263, 270, 287
264, 265, 269, 286, 289, 292, 295, 299, 300, facial enhancement 4, 42, 157
302, 303, 305 facial midline 79, 84, 93, 99, 103, 107,
editing software 6, 15, 25, 29, 31, 59, 62, 64, 154, 230
77, 93, 94, 223, 246, 253–261, 269, 289, factory default 68, 289
292, 295, 299, 300, 302, 303, 305 feminine shots 141, 142, 145
EDP (essential dental portfolio) 32, 101–123, Fibonacci spiral 69, 74, 76–79, 82
126, 128, 156, 157, 159, 184, 203, 207, 236, fibre‐optic 21, 182, 184, 211, 213–216, 218
239, 280, 284, 285 field of view (FoV) 28, 30, 41, 85, 91, 93, 103,
education 41, 65, 88, 258, 295, 306, 106, 109, 110, 113, 116, 116, 117, 119,
315–317, 321 120, 122, 128, 129, 129, 158, 159, 160,
elderly 39, 94 162, 163, 180, 181, 188, 208, 209, 242,
elective dental procedures 3, 42, 306 280, 309
enlargement 123, 125, 227, 277 figure‐ground 70, 71, 148, 153, 178, 182,
epidemiological survey studies 323 188, 190
EPP (essentail portrait portfolio) 32, 101, 102, file format(s) 6, 67, 89, 93, 106, 109, 158, 188,
156–165, 184, 203, 274, 284 209, 254, 255, 256, 258, 260, 261, 295, 297,
EPS (encapsulated post script) 254, 255 299, 300, 301, 303, 306, 323
equipment settings 32, 33, 45, 85, 88, 89, 93, fill light(s) 49, 50–52, 104, 106, 109, 137, 138,
99, 101, 128, 158, 186, 189, 203, 253 139, 150, 151, 153, 155, 156, 158, 167,
essential dental portfolio. See EDP 168–172, 184, 185, 187, 188, 189,
essential portrait portfolio. See EPP 191–193, 196, 197, 200, 203, 208, 217
ethics 94 film 6, 7, 18, 61, 62, 91, 253
EV. See exposure value flash card (drive) 257
EXIF (exchangeable image file format) See also CF card, SD card
300, 303 flash ratio 50, 52, 104, 109, 158, 184, 188, 207,
export 25, 257, 258, 292, 295, 299–302, 303, 208, 209, 210
304, 306 flash(es) 5, 7, 16–25, 29, 32–34, 39–41,
export presets 258, 299 48–52, 58, 59, 63, 64, 67, 89, 93, 99, 104,
export recipes 258, 295, 299, 301, 303, 306 105, 106, 109, 111, 118, 127, 129, 137, 138,
exporting files 301, 304 141, 145, 147, 148, 150, 151, 153–156, 158,
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Index 337
160–163, 167, 168, 170, 171, 181–200, gingival stippling 89, 184, 205, 208, 213,
203, 207–210, 215–218, 220, 223, 257, 300 290, 291
bilateral 19, 20, 22, 52, 104, 106, 109, 111, glamour shots 50, 137, 156
183, 188, 189 glare. See specular reflections
built‐in 19 glitches 258
compact flashes 17, 19, 20, 22, 24, 25, Golden Proportion 73, 81, 188
39, 40, 50, 67, 155, 183, 184, 187, 191, goniochromism 205, 212, 219
192, 195, 196, 197, 199, 207, 208, Google 230, 256, 259, 307, 315
216–218, 257 GPS (global positioning system) 6, 7, 67, 300
flash guide number. See guide number grainy 13, 14, 58
flash intensity 19–22, 29, 48, 50, 52, 58, 59, graphics card 257
64, 67, 93, 104, 106, 109, 129, 138, 147, grey card 21, 63, 64, 65, 67, 94, 106, 109, 158,
150, 153, 158, 167, 168, 188, 198, 208, 182, 188, 209, 220, 223, 224, 265
209, 215 See also 18% neutral density grey card
monolights 22, 23 greyscale 62, 224, 261, 266
pack and head 22 group function 239, 240
ring flash 19, 20, 21, 23, 25, 50, 52, 99, 104, GUI (graphic user interface) 259
105, 106, 109, 111, 118, 127, 129, 141, 145, guide number (flash) 19, 20, 21, 22, 58
183, 184, 189, 207, 208, 209, 210, 223
slave flash photography 17, 155 h
studio flashes 17, 19, 22, 23, 24, 25, 33, 50, habitual lip position 102, 103, 106, 107,
59, 67, 138, 150, 151, 153–155, 156, 158, 120, 227
160, 162, 163, 167, 168, 183, 197 hand‐held camera 17, 18, 20, 21, 23, 39, 105,
synchronisation 5, 7, 18, 23, 58, 67, 106, 106, 109, 111, 116, 118, 119, 129, 154, 158,
109, 158, 188, 209 184, 186, 188, 209
flipped. See laterally inverted hands‐free 23, 32, 39, 181
fluorescence 16, 25, 175, 208, 209, 211, 214, hands‐on session xiv
215, 217, 219 hard drives 254, 258, 295
fluorescent tubes 20, 63, 188 hard lighting 48, 49, 148, 149, 167, 203, 208,
focus stacking 56, 247 210–213
focusing rail (stage) 17, 24, 25, 39, 106, 109, hardware 4, 39, 53, 62, 89, 92, 123, 125, 128,
116, 119, 129, 158, 188, 209 220, 253, 261, 270, 287, 297
focusing screens 13 HDR (high dynamic range) 62, 247, 271
fogging 30, 31, 93, 128 health and safety 32, 33, 41, 99
folders 295, 302, 305 high key image 50, 150, 151, 265
fontal view 157, 274, 326 highlights 20, 21, 48, 49, 52, 59, 105, 138, 147,
Fovean X3 6, 9 148, 156, 184, 185, 186, 189, 193, 204, 265,
Frankfort plane 79, 84, 93, 99, 154 266, 269–274, 328
free gingival margin 30, 66, 89, 184, 185, 205, HIPAA (health insurance portability &
212, 213 accountability act) 258, 297, 307
histogram 57, 59, 60, 61, 93, 106, 109, 158,
g 188, 209, 261, 263, 265, 266–268, 270,
gagging reflex 41, 85 271–274
gamut 262, 263, 264 HMI (hydrargyrum medium‐arc iodine)
gel(s) 22, 48, 84, 138, 150, 170, 171, 182, 199, 184, 188
215, 216, 217 honesty 94
generic bench image set‐up 185, 187 honeycomb grid 22, 148, 150, 167, 168,
generic image file format 254 170, 171
generic studio portrait 167, 168 horizon 93, 99, 101, 273
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338 Index
hot‐shoe 5, 7, 17, 19, 23, 155 ISO (international standards organisation 5,

hyperfocal distance 53, 54, 93, 106 7, 13, 14, 19, 22, 57, 58, 67, 93, 103, 106,
109, 110, 116, 120, 122, 158, 160, 162,
i 163, 188, 198, 200, 209, 288
ICC (international colour consortium) 89, 93,
220, 256, 299, 303 j
image content 69, 70, 72, 256 JPEG (joint photographic experts group)
image data storage 25, 67, 254, 255, 295, 7, 93, 254, 255, 256, 258, 260, 300, 303,
297, 302 304, 331
image dimension(s) 6, 91, 193, 227, 284, 295,
306, 323, 330 k
image noise 9, 13, 14, 260, 288, 292 Kelvins (K) 7, 16, 48, 63, 67, 106, 109, 138,
image quality 3–6, 12–15, 18–20, 41, 48, 56, 155, 158, 160–163, 219
59, 61, 62, 64, 67, 81, 88, 123, 125, 128, keratinised gingiva 89, 227
138, 220, 246, 253–255, 257, 260, 269, 270, key light 49–52, 104, 106, 109, 137, 138,
272, 274, 292, 303 139, 140, 144, 150–153, 155, 158, 167,
image stabilisation 18 168–172, 184, 185, 187, 188, 189, 190,
imaging chain 220, 253, 289, 295 191, 192, 193, 195–200, 203, 204, 207,
imaging software 59, 62, 69, 77, 80, 93, 94, 208, 211, 213, 216, 217, 315
113, 116, 128, 159, 220, 221, 224, 253–260, kinetic imagery 81
263, 264, 265, 272, 277, 280, 288, 289, 292,
297, 303, 306 l
implantology 34–38, 157 landscape orienation 18, 79, 93, 159, 159,
improvised set‐up 181, 182, 184 247, 277
in‐camera processing 94, 260, 288, 289 lateral views 29, 102, 113, 116, 122, 127
incisal edge(s) 29, 85, 89, 109, 115, 119, laterally inverted (flipped) 113, 116, 246,
120, 122, 126, 175, 177, 178, 184, 190, 275, 279
192, 193, 198, 204, 205, 209, 212, 213, laughter 102, 103, 105, 106, 107, 108, 120,
214, 215, 216, 224, 227, 236, 280, 124, 125, 310, 311
290–292, 311 layers (in imaging software) 257, 260
incisal embrasures 107, 184, 185, 227, 231 LCD (liquid crystal display) 6, 7, 58, 59, 72,
incisal halos 184, 205, 213, 228 265, 289
incisal lobes 184, 185, 204, 205 leading lines 69, 79, 81, 82, 188
incisal plane 79, 85, 99, 101, 107, 109, 154, learning curve 3, 247, 256, 259
159, 172, 230, 232, 273, 274 lecturing 41, 88, 94, 153, 247, 248, 295, 296,
intended use 41, 45, 62, 84, 88, 184, 186, 321, 330, 331
248, 254, 255, 260, 286, 289, 292, 295, LED (light emitting diode) 20, 21, 182, 188, 215
296, 300, 313 lens axis 19, 64, 88, 99, 113, 114, 116, 117,
inter‐commisure 99 121, 154, 158, 188, 188, 193, 194, 223
inter‐pupillary line 79, 84, 93, 99, 154, lens correction 260
159, 230 lenses 13, 17–22, 54, 56, 216, 285
internet 47, 93, 94, 254, 257, 265, 297, 301 adapters 18
interpolation 277, 288 Apo (apochomatic) 18
interproximal translucencies 29, 205 ASPH (aspherical) 18
intra‐oral mirrors. See dental mirrors focal length 7, 17–20, 53, 54, 56, 57, 88, 91
intra‐oral scanners (IOS) 221 macro lenses 17, 18, 54, 56
inversely square law 147 prime lenses 17
IPTC (international press telecommunications zooms 17, 18
council) 300, 301, 303 light meter 25, 155, 265
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Index 339
limited mouth opening 94, 117, 128 memory card(s) 255, 257
lines angles 48, 184 See also SD card
lint‐free cloths 28, 32, 286 menton 91, 92, 103, 104, 105, 106
litigation 3, 41, 230, 306 metadata 93, 295, 299, 300, 301, 303,
local adjustments 257, 260, 286, 287 309, 313
lossless compression 254 metamerism 219
lossy compression 254, 255 MI (maximum intercuspation) 102, 107, 109,
low key image 50, 150, 152, 265 113, 239, 240
luminosity 263, 265, 268 micromorphology 204
lustre 50, 205, 207, 212 Microsoft 230, 256, 259
LUT (look up tables) 257, 258, 260, 299 midtones 59, 60, 265, 266, 270, 274
LZW (Lempel, Ziv, Welch) mode 254 mirror 13, 20, 27, 28–30, 31, 32, 39, 41, 67,
93, 102, 113, 114–119, 121, 122, 126, 127,
m 128, 129, 182, 184, 185, 246, 275, 285
Macintosh 253 mirrorless cameras 4
macro stage. See focusing rail (stage) modelling lights 22, 153
macro studio. See still life table Moiré 67, 260
macrophotography 4, 16, 17, 53, 58, 175, monochromatic 182
181, 247 monopods 24
magnification 17, 18, 24, 53, 70, 88, 91, 92, 93, mRGB (medical red, green, blue) 262
106, 109, 116, 119, 126, 127, 129, 158, mucogingival junction 30, 91, 109, 110,
160–163, 188, 208, 209, 212, 227, 242, 116, 285
274, 287, 317 mug shots 3
magnification factor. See magnification
magnification ratio. See magnification n
malpractice 306 naming convention(s) 295, 297, 298, 301
mamelons 20, 65, 89, 184, 205, 216, 228, 236 naso‐labial angle 230
mandibular arch(es) 91, 102, 109, 113, 116, native resolution 330
117, 119, 126, 127, 128, 129, 175, 184, 213, negligence 306
233, 321 noise reduction 260
mandibular lip 31, 81, 85, 99, 102, 107, 109, non‐clinical portraits 67, 137, 154, 166, 167,
119, 172, 237, 238 171, 248
manipulation 15, 27, 42, 255–258, 260, 261, non‐clinical setting 33, 67, 154
286, 295, 299, 308, 313 non‐keratinised 89
manual focus 7, 17, 24, 25, 67, 106, 109, 158,
160–163, 188, 209 o
mapping 224, 227, 228 Obies. See catch lights
marketing 3, 31, 41, 47, 50, 88, 99, 128, 152, oblique view 120, 121, 123, 158, 159, 161,
153, 171, 184, 242, 248, 257, 258, 260, 295, 164, 165, 166, 239, 240, 241, 326, 328
296, 303, 306, 313, 314, 315 off‐centre 72
masculinity 145 office stationery 295
maxillary arch 28, 31, 48, 69, 91, 102, 109, online training 4, 258
113, 116, 117, 119, 126, 127, 129, 129, 173, opalescence 208, 209, 211, 214, 215, 216, 219
175, 184, 207, 213, 230, 233 operating microscope 246
maximum intercuspation. See MI operator 16, 20, 32, 33, 39, 84, 85, 89, 93, 94,
metering 5, 6, 7, 17, 20, 23, 29, 58, 59, 63, 128, 284
67, 89, 106, 109, 155, 158, 188, 205, 209, optical axis 64, 221, 223, 224
265, 269 optional compositions 117, 119, 122, 128
megapixel(s) 5 oral medicine 88, 217
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340 Index
orientation 89, 93, 99, 101, 159, 246, 256, 257, posterisation 261, 262, 263, 271
260, 273, 274, 284, 309 practice brochure 315
orthodontics 4, 42, 88, 106, 157, 165, 175, 236 prescription. See dental laboratory prescription
output location 295, 301 presentation(s) 40, 63, 255, 256, 258, 303,
overbite 233 307, 314, 315, 328, 330, 331
overjet 227, 230, 233, 241 presets 68, 258, 260, 289, 290, 299
printing houses 258, 295, 296, 299
p processing 25, 31, 62, 64, 65, 69, 77, 84, 93,
papillon lighting 141, 142, 143, 145 94, 220, 223, 224, 227, 247, 253–255, 257,
pathology 40, 42, 215, 286, 292, 309, 312, 313 260, 261, 284, 287, 288, 289, 295, 299,
patient compliance 48, 85, 94 300, 309
PDF (portable document file) 230, 254, 255, processing workflow 220, 260
256, 315 profile view 93, 120, 121, 123, 157, 158, 159,
peadodontics 157 164, 165
perikymata 89, 204, 205, 212, 213 projection shadows 153, 155, 181, 190, 191,
periodontal bioforms 89, 205 193, 194
periodontal biotypes 89, 205 projector 9, 65, 86, 222, 291, 332
periodontics 88, 106, 157, 303 prosthodontics 4, 159
persona 14, 31, 59, 106, 137, 150, 260 publishing 43, 90, 96, 130, 244, 257, 260, 297,
perspectives 109, 122, 126–128, 129, 230 301, 323, 325
Perspex 181, 182, 185, 188, 193, 194–197
Phi grid 69, 73, 74–76, 81 q
philtrum 103 quadrant(s) 27, 122, 123, 125, 126,
phonetic analysis 236, 238, 239 127–130, 129
photodocumentation 4, 32, 102, 128, 175, 203
photographic mirrors. See dental mirrors r
photographic daylight 16, 48, 53, 155 radiographs 40, 94, 292, 297, 306
Photoshop 256–260 rangefinder camera (rangefinders) 4, 5
pixellation 42, 227 RAW file format 6, 7, 67, 106, 109, 110, 116,
pixel(s) 6, 7, 8, 9, 12, 18, 125, 277, 279, 280, 120, 122, 129, 158, 160–163, 188, 209,
281, 283, 284, 288, 303 254, 255, 256, 258, 260, 261
plaster cast(s) 175, 178, 189, 190, 192 reclined 33, 99
plug‐ins 77, 257, 258, 299, 306 red eye 153, 257
PNG (portable network graphic) 254, 255, reference marker(s) 41, 227, 229, 309
257, 300, 303 reflection(s) 22, 23, 113, 144, 145, 193,
PoF (point of focus) 53, 54, 57, 103, 106, 109, 203, 219
110, 116, 119, 120, 122, 129, 158, 159, See also specular reflections
160, 161, 162–164, 188, 209, 247 reflective umbrellas 22, 145, 148
PoV (point of view) 104, 105, 112, 114, 115, reflector(s) 21, 22, 23, 25, 32, 41, 48, 49, 52,
119, 121 138, 139, 140, 145, 148, 150, 151, 152,
polarising filter 25, 223, 224 155, 156, 167, 168–172, 181, 182, 184,
portraiture 4, 17, 18, 22, 23, 24, 25, 33, 48, 50, 185, 187, 189, 191, 192, 196, 197, 198,
57, 59, 67, 68, 77, 91, 102, 137, 138, 140, 200, 203, 204, 205, 207, 208, 209, 210,
141, 147, 148, 150, 152, 154–156, 159, 211, 213
160–164, 166, 167, 173, 183, 184 bowl reflector 148, 150, 151, 152, 155, 156,
positioning 6, 7, 23, 39, 41, 59, 67, 69, 72, 84, 167, 168–172
89, 93, 99, 103, 123, 151, 153, 175, 194, umbrellas 22, 145, 148, 150, 154, 156, 158
203, 207, 236, 240, 242, 253, 284 refraction 219
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Index 341
relaxed smile 81, 102, 103, 105, 106, 107, 108, medium format 6, 11, 19, 62
120, 124, 125, 157, 159, 164, 165, 172, 311 sizes 9, 11, 13, 91
Rembrandt lighting 141, 144, 145, 148, 167 separated teeth 102, 107, 109, 122, 125, 240,
remote shutter release 7, 17, 25, 32, 181 241, 310
resolution 9, 12, 13, 18, 56, 58, 64, 65, 66, sextant(s) 27, 28, 53, 54, 69, 83, 103, 122, 123,
67, 89, 92, 123, 125, 255, 268, 288, 299, 125, 126, 197, 198, 207, 224, 240, 314
303, 330 shade analysis (evaluation) 40, 42, 63, 99, 209,
rest position. See habitual lip position 221, 223, 224–226, 234, 236, 299, 309, 310
restorative dentistry 31, 65, 157, 216 shadowless illumination 52
RGB (red, green, blue) 6, 7, 8, 9–11, 16, 67, See also uniform illumination
220, 256, 261, 262, 263, 264, 265, 266, shadows 20, 21, 48, 49, 50, 52, 59, 100, 101,
299, 300, 303 105, 138, 140, 141, 147, 148, 149, 150, 153,
rhinion 91, 92, 103, 158, 159 155, 156, 171, 181, 184, 185, 187, 189, 190,
rich media assets 295, 301 191, 193, 194, 203, 204, 205, 265, 266,
Rickett’s E‐plane 230, 233 269, 270, 287, 317, 328
rim flash. See rim light sharpening 260, 287, 288, 289–291, 292,
rim light 147, 148, 170, 171 299, 303
ring flashes 19, 20, 21, 23, 25, 50, 52, 99, 104, sharpness 53, 286, 287, 288, 289
106, 109, 111, 145, 183, 184, 189, 209, 223 short light 145, 146
rubber dam 30, 31, 134, 221 shutter 6, 7, 17, 18, 22, 23, 25, 32, 33, 57, 58,
rule of direction 69, 81, 83, 86, 87 59, 67, 93, 106, 109, 138, 155, 158, 181,
rule of thirds 69, 72–75, 81, 188, 316 188, 189, 198, 209, 211
wireless 7, 17, 21, 23, 155, 184, 187, 188,
s 189, 191, 192, 195–197, 199, 216, 217
safety glasses 33, 211, 215 shutter speed(s) 6, 7, 18, 22, 23, 57–59, 67,
saturation 224, 265, 270 93, 106, 109, 138, 155, 158, 188, 189, 198,
scale calibration 230 209, 211
scaling 17, 88, 91, 227, 273, 274, 277, 299, silhouette 186, 193
309, 313 skin tones 144, 154, 155, 289
See aslo magnification smartphone(s) 4, 5, 7, 23, 32, 94, 247, 295, 313
SD (secure digital) card 7, 25, 67 smile design 69, 157, 175, 227, 230, 303, 308
seamless surface 185 smile line 105, 106, 119, 171, 173, 230, 308,
seamless transition 178, 193, 261, 263 309, 311
seated upright 93, 99, 103, 104, 105, 111, 154 social media 41, 255, 256, 258, 295, 296,
seductive compositions 153 303, 315
selective focusing 69, 70, 71, 182, 188, 317 soft box(es) 22, 23, 24, 48, 145, 148, 149, 150,
sensor 5, 6, 7, 9, 12, 13–15, 17–19, 23, 32, 53, 151, 154, 155, 156, 158, 167, 168, 172
54, 56, 57, 58, 62, 64, 88, 91, 106, 109, 119, soft lighting 21, 48, 49, 50, 148, 149, 150, 167,
127, 129, 158, 188, 209, 264, 270, 271, 276, 203, 208, 210–213
280, 285, 288 soft proofing 258
sensor cleaning 6, 7, 13, 14, 15, 32, 285, 286 software:
APS (advanced photo system) 54, 56, 57, 62 dedicated dental 297, 302, 306
APS‐C (advanced photo system type‐c) 6, drawing 227, 228, 230, 234, 254, 258, 259,
7, 11, 19 303, 308
APS‐H (advanced photo system type‐h) management 258, 260, 295, 297, 301–306
6, 11 manipulation 15, 42, 220, 255, 258, 260,
full‐frame 6, 7, 11, 18, 19, 53, 54, 62, 91, 261, 286, 295, 299, 308
106, 109, 119, 129, 158, 188, 209 open‐source software 256, 259
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342 Index
software (cont’d) three‐dimensional imagery 20, 22, 48, 52, 53,

photo‐editing (processing) 6, 25, 29, 31, 62, 57, 105, 141, 145, 148, 153, 184, 184, 204,
64, 65, 69, 77, 84, 93, 94, 220, 223, 224, 208, 272
227, 247, 253–258, 259, 260–256, 269, 271, thumbs‐down 315
272, 274, 277, 280, 286, 288–290, 292, 295, thumbs‐up 315
299, 300, 309 TIFF (tagged image file format) 93, 254, 255,
simulation(s) 308, 309, 323 256, 258, 260, 300, 303, 304, 323, 331
smile design 230, 303, 308, 309 tip of the chin. See menton
spectrophotometers 221 tooth wear 109, 184, 190, 204, 205
specular reflections 27, 48, 140, 148, 192, 203, tooth whitening 3, 217, 236
205, 211–213, 221, 223, 224, 225, 315, touch screen 6, 7, 257
316, 317 trained eye 64, 66
sphere of Monson 109, 119, 233 transillumination 213, 214, 215, 216, 246
sRGB (standard red, green, blue) 7, 67, 220, transitions 20, 48, 49, 148, 227, 261
262, 263, 264, 299, 300, 303 translucency 20, 70, 71, 89, 205, 216, 234,
staff training 40, 41, 317 236, 311
standardisation 69, 84, 88, 89, 93, 99, 102, transmission 204, 219, 256
137, 154, 159, 220, 242, 262, 280 treatment coordinator 317
static electricity 285 tripod(s) 6, 7, 17, 23, 24, 25, 39, 40, 93, 104,
sterno‐clavicular joint 158, 159, 160, 106, 109, 111, 116, 119, 129, 154, 155, 158,
162, 163 181, 184, 188, 198, 209, 211, 215
still life 57, 73, 175, 184 trismus. See limited mouth opening
still life table 181 TTL (through‐the‐lens) metering 5, 17, 20,
stop‐motion images. See stroboscopic effect 23, 29, 53, 58, 67, 89, 103, 106, 109, 110,
storage device(s) 6, 254, 258, 295, 297 116, 120, 122, 129, 155, 158, 160, 162,
Strobo. See stroboscopic effect 163, 188, 205, 209
stroboscopic effect 196, 198, 200, 201 tungsten lamps 20
studio flashes 17, 18, 22, 23, 24, 25, 33, 50, 67, two‐dimensional imagery 21, 53, 141, 142,
138, 151, 153, 154, 155, 156, 158, 160, 208, 210
162, 163, 167, 168, 183, 197
submental oblique view 166, 239, 240, 241 u
submental vertical view 165 uniform illumination 20, 50, 52, 53, 127, 184,
sunlight 18, 63, 137, 147, 167 193, 194, 208, 210
supine position 33, 93, 99, 127, 128 unilateral (unidirectional) illumination 204,
surgery 44, 90, 108, 167, 219, 235 209, 317
surgical procedures 17, 23, 30, 32–34, 34–38, USB (universal serial bus) 7, 253, 257
88, 178, 242–245, 286, 307, 309 user presets 68, 258, 260
symmetry 69 UV (ultra‐violet) lamps 18, 25, 27, 182, 184,
synæsthesia 45, 46, 69 188, 209, 211, 214, 215, 216, 217, 218
synoptic text 331 UV (ultra‐violet) filter 18
t v
tablets 4, 23, 94, 257, 295, 313, 315 vacuum stents 175, 193
tele‐consultations 45 variants 299
templates 41, 258, 315 Velcro 172, 181
tethering 257 vertical dimension of occlusion (VDO)
texture 5, 20, 48, 89, 138, 154, 182, 183, 184, 175, 227
188, 190, 203, 205, 208, 212, 272, 316 video 6, 7, 22, 246, 247, 258, 260, 331
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Index 343
vignetting 193 white balance (WB) 5, 7, 16, 63, 64–67, 89,

visual acuity 53 93, 106, 109, 158, 184, 188, 209, 220, 223,
visual impact 144, 173, 183, 248, 317, 331 257, 258, 260, 265
visual weight 69, 83, 188 See also AWB
visually perceivable threshold 220 widescreen 330
Vita 3D 221 WiFi (IEEE 802.11x or wireless fidelity)
Vita Classical 221, 223, 224 ‑6, 7, 297
Windows (Microsoft) 253, 257
w
web‐publishing 254, 255, 256, 258, 295, x
300, 303 x‐jack 7, 17, 23
website(s) 41, 255, 256, 289, 299, 315, 316 XMP (extensible metadata platform) 299, 300
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Essentials of Dental Photography

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Library of Congress Cataloging‐in‐Publication Data

Cover Design: Wiley

Set in 10/12pt Warnock by SPi Global, Pondicherry, India

Section 1 Equipment and Concepts 1

2 Dental Armamentarium and Clinical Considerations 27

3 Technical Concepts and Settings 45

Section 2 Photographic Set‐ups 97

5 Extra‐Oral and Intra‐Oral Images 99

Profile Portrait 168

7 Bench Images 175

8 Special Applications 203

Section 3 Processing Images 251

9 Processing Images 253

Colour Spaces 262

10 Exporting, Managing and Using Images 295

Original French text

The most frequently asked questions about dental photography are:

‘Which equipment do I need?’

The aim of this opening module is to provide answers to these questions.

Essentials of Dental Photography, First Edition. Irfan Ahmad.

Figure 1.1 Different types of camera systems.

Specification Must have Wish list

Sensor size minimum Advanced full‐frame (36 mm × 24 mm),

Additive RGB Subtractive CMY

Fovean X3® sensor Bayer pattern

Figure 1.5 Red channel colouration.

Figure 1.6 Green channel colouration.

Figure 1.7 Blue channel colouration.

Lens image circle matching a full frame sensor

Full frame (1.0x)

Sensor Speed or ISO

ISO 100 ISO 400 ISO 800

Dirty sensor with dust particles Clean sensor

16 bit/colour (channel) 8 bit/colour (channel)

Colour (Bit) Depth

1000 K 2500 K 3200 K 4000 K 5500 K 6500 K 10000 K

Remote Shutter Release

Figure 1.18 Ring flashes produce lacklustre, bland two‐dimensional images.

Figure 1.21 Examples of studio flashes for portraiture.

Figure 1.22 Tripod‐mounted camera, compact flashes and focusing rail.

Table 1.2 Budget photographic equipment for dental photographya

Item Cost (US$)

dSLR camera body 500

­Other Photographic Items

Dental Armamentarium and Clinical Considerations

Photographic Mirrors and Contrasters

Essentials of Dental Photography, First Edition. Irfan Ahmad.

Figure 2.1 Selection of cheek retractors of various configurations and sizes.

Figure 2.4 Contrasters are made of metal with a black

Without contraster With contraster

Figure 2.7 Draped photographic equipment as part of cross‐infection control.

Figure 2.11 Suturing.

Figure 2.12 Five week healing.

Figure 2.13 Radiopaque surgical

Figure 2.14 Flapless osteotomy.

Figure 2.15 Guides for ascertaining

Figure 2.16 8 1/2 week healing

Other Photographic Items

Every Picture Tells a Story

hotodocumentation, standardisation is mandatory, and the guidelines below are intended to