Article
Clinical photography involving a series of extra-oral and intra-oral views plays an indispensable role in contemporary orthodontic diagnosis, treatment planning and case documentation. However, in certain clinical situations, additional views clearly documenting specific dentofacial attributes of malocclusions are called for.
The aim of this article is to propose adjunctive photographic views, and describe modifications of existing intra-oral and extra-oral views, particularly in patients presenting with specific malocclusions, such as Class III malocclusions, cleft anomalies and dentofacial asymmetries. The merits of taking additional clinical photographs are also discussed by using case examples.
With recommended camera settings, proper background and lighting conditions, properly oriented supplementary views helped capture clinically useful information pertaining to various dental and facial components, including attributes of profile smile and aesthetics. Depending on the case at hand, series of standardized adjunctive photographic views may prove invaluable in visual description of varied clinical attributes of malocclusions and jaw deformities.
With increasing emphasis on smile aesthetics and facial harmony in the recent past, digital clinical photography has become an indispensable component of orthodontic diagnosis and treatment planning. Digital photography aids in evaluation of craniofacial and dental relationships, assessment of soft-tissue profile, treatment planning, and medico-legal documentation.1
A series of extra-oral and intra-oral photographic views are recommended in clinical orthodontic practice. The routinely used standardized extra-oral photographic views include frontal full face, full face with posed smile, right profile (and left profile in cases of facial asymmetry), and three-quarter profile.1 Submental view, taken with patient's head in hyperextended position (about 45 degrees), and superior view, taken with patient's head in hyperflexion (about 45 degrees) are helpful in assessing symmetry and projection of the anterior cranial vault, orbital areas and cheeks. Nasal and cheek deformities can be assessed in submental and superior views, respectively.2 A three-quarter view is another optional photograph. Standard intra-oral photographic views include frontal, right and left lateral, and maxillary and mandibular occlusal views.1
However, in a few specific cases, the above views do not suffice and some additional photographic projections may be required to document the case fully. This article intends to present a few adjunctive views which can help in illustrating various attributes in specific dentofacial anomalies, such as scissors bite, cleft cases, facial asymmetry, etc. The indications and merits of taking additional clinical photographs are also described.
Procedure
A Nikon D5000 SLR camera with automatic through-the-lens (TTL) metering was used for taking high-quality supplementary extra-oral and intra-oral photographic views in different clinical situations and with standardized camera settings. Standardization was achieved by marking the lens barrel with reproduction ratios and setting it to a constant magnification factor. The following are the proposed adjunctive and modified photographic views:
a) Frontal smile view for patients with dentofacial asymmetries
Patients with facial asymmetry tend to exhibit compensatory head posturing due to which the head is tilted slightly to the right or left in an attempt to mask the effect of asymmetry.2 Therefore, prior to making an objective photographic examination, the clinician should deliberately orient the patient's head to correct any compensatory head posture.
Additionally, frontal photographs of unstrained posed smile should be taken in the patient's natural head position, as determined by the patient's visual axis. The patient's head is stabilized in the cephalostat, with ear rods positioned directly in front of the tragus, lightly touching the skin, and thus establishing bilateral head support in the transverse plane.3 The whole of the patient's face should be clearly visible. Ensuring parallelism of the inter-pupillary line is vital for accurate orientation of photographic view (Figures 1a, b).
b) Smile in profile view
Contemporary orthodontic diagnosis includes the frontal assessment of maxillary incisor display at rest and during smile. However, additionally viewing the maxillary incisors in profile would help in assessing the effect of changing the anteroposterior position of the maxilla or maxillary incisors in relation to forehead and other external facial structures.4 Therefore, evaluating smile attractiveness in the natural head position relative to labiolingual inclination and anteroposterior position of maxillary incisors should be an integral part of a complete orthodontic diagnosis (Figures 2a, b). A contrasted colour background is preferred for taking a smiling profile photograph.
c) Intra-oral anterolateral view
In malocclusions with sagittal discrepancies, an intra-oral anterolateral view captured at the height of occlusal plane may help in assessment of not only the anteroposterior relationship of maxillary and mandibular anterior teeth to each other, but also the crown inclinations and root contours of the anterior teeth with respect to the basal arches (Figure 3). Properly oriented intra-oral anterolateral views may also aid in assessment of the effects of last treatment care, and supplement the mid-treatment lateral cephalograms taken for assessment of upper incisor torque, especially during camouflage treatment of cleft lip and palate cases (Figures 4a, b).
In bilateral cleft lip and palate patients presenting with mobility of protrusive premaxillary segment, the conventional intra-oral lateral view may not accurately document the actual overjet due to the displacement of the premaxillary segment during soft tissue retraction (Figure 5a). In such cases, a close-up intra-oral anterolateral view provides necessary information regarding the correct amount of overjet and inclination of prolabium (alveolar process of premaxilla) without any displacement of the premaxillary segment (Figure 5b). Also, the views taken from both right and left sides can help clearly demonstrate the functional mandibular shift in edge-to-edge incisor relationship in centric relation during diagnosis and treatment planning for Class III malocclusions (Figures 6a, b). For obtaining adequate depth of field in intra-oral anterolateral view, the camera should be focused on the distal surface of the lateral incisor.
d) Modified intra-oral frontal views
Apart from the routine intra-oral frontal view (Figure 7a) taken at the height of the occlusal plane, an intra-oral frontal-superior view, taken from above eye level, helps in accurate depiction of asymmetric overjet in patients with dentofacial asymmetries (Figure 7b).
Similarly, in addition to a routine intra-oral frontal view (Figure 8a), a frontal-submental view taken from below eye level aids in clear visualization of the cusp-fossa relationship in cases of problems in transverse plane, such as scissors bite (Figure 8b).
Properly oriented supplementary views help document and gain original clinically useful information pertaining to various dental and facial components, including attributes of profile smile aesthetics. The additional information provided by the supplementary views aids the orthodontist in diagnosis and formulation of the best possible treatment plan for each patient, and monitoring any changes during subsequent follow-ups.
Discussion
Depending on the case at hand, supplementary views, in addition to the routinely used photographic views, help to overcome the inherent deficiencies in the documentation of patient-specific dento-alveolar and facial attributes at the initiation of treatment and during midtreatment. Any pre-existing clinical condition can be recorded accurately, and the aesthetic and functional impact of the treatment plan can be accurately visualized in most malocclusions. Moreover, these views may help enhance the learning experience for postgraduate trainees.
Superior quality photographs should be free of saliva and bubbles. Good quality cheek retractors and mirrors are essential for consistent photographs. All the above-mentioned views are typically taken with a direct approach. Standardization of all views should be achieved in terms of maintaining consistent subject-to-camera distance, same focal length of the lens, same magnification factor, perspective, lighting and background. Colour standardization helps ensure same colour and hue of all images. While taking extra-oral views, smooth and patternless background, clearly delineating and enhancing the images of all skin colours, is preferred. Additionally, appropriate multisource lighting, preferably with diffusion, is suggested to minimize shadowing. Backlighting also helps eliminate the casting of background shadows.5 Above all, use of a digital, single-lens, reflex camera, controlled exposure settings and through-the-lens metering helps achieve good quality clinical photographs.
Conclusion
Depending on the case at hand, a series of standardized adjunctive photographic views may prove invaluable in providing additional information about various clinical attributes of malocclusions and jaw deformities.