facial photography for the orthodontic office

Founded in 1915

American Journal of ORTHODONTICS and DENTOFACIAL ORTHOPEDICS

Volume 11l Number 5 May 1997

Copyright © 1997 by the American Association o f Orthodontists

SPECIAL ARTICLE

Facial photography for the orthodontic office

George Meredith, MD Great Bend, Kan.

I t is becoming increasingly apparent to Table I. Standards plastic surgeons and otolaryngologists who d o maxillofacial and facial plastic surgery that stan- Fiew Framing Point of focus

dardized, high-quality preoperat ive, and postop- AP Horizontal Lashes

erative facial photographs are essential for suc- RT oblique Horizontal Nasal dorsum cessful tracking of their patients. 1,2 Clinical LToblique Horizontal Nasal dorsum

evaluation of surgical techniques, in a longitudinal RT lateral Horizontal Nasal dorsum fashion, depends on accurate operative notes and RT lateral (animated) Horizontal Nasal dorsum on clear, meaningful preoperat ive and postopera- LT lateral Horizontal Nasal dorsum tive photographs. 3,4

Intraoral photographs taken in the orthodon- tist's office are gradually improving in quality. Un- fortunately, facial photography in these same offices is, sometimes, less than the best possible.

Faulty techniques 3'4 in the or thodont ic office that are responsible for less than optimal pretreatment and pos t t rea tment photography results include:

• Positioning the patient too close to the background. 3 (Fig. 1 shows an efficient office photography room.)

• Background of wrong color. 5,6 A flat blue- green background is the best (Fig. 2).

• No left and right flood/flash umbrella used for soft facial illumination. 3,4

• Single frontal flash producing harsh facial wash and shadow zones.

• Use of the wrong camera. The Olympus, Mi- nolta, Canon, or Nikon 35 mm, single lens reflex cameras (SLR) are really logical choices today (Fig. 3).

• Wrong lens: 28 or 55 mm lenses are totally inadequate when compared with the 105 mm (facial portrait) macrolens (Fig. 3).

• Use of the wrong film. The best choice is 35

Reprint requests to: Dr. George Meredith, 2318 Washington, Great Bend, KS 67530. Am J Orthod Dentofac Orthop 1997;111:463-70. Copyright © 1997 by the American Association of Orthodontists. 0889-5406/97/$5.00 + 0 8/1/78426

mm color print film (Kodacolor, ASA 100, Fig. 4). Poor patient head positioning. 7-9 (Fig. 2 shows proper positioning.) Disparity between the level of the camera lens and the patient's face. Subject or photographer can stand on a stool (8 inch lift) to compensate for any photographer-subject height disparity. Use of battery-powered flash h e a d s Y '6 The cycle time in battery-powered flash units is too long. Conversely, use of a l l 0 V AC flash unit (Fig. 5), such as the Norman or the Multiblitz Minilight, allows the flash to recycle to full charge in 1 second. Valuable office time is not lost and, more importantly, photographs are not shot with a partially charged unit.

MATERIALS AND METHODS

To obtain the highest quality photographs, the photographer must:

• Have consistent lighting exposure, focal length, and poses.

• Use the Frankfort horizontal line on lateral facial photographs. 7,9

• Use l l0V AC flash/flood units (Fig. 6). • Use a Synch cord between the camera body and one

of the l l0V AC flash/flood units. The other unit will trigger at the speed of light (almost) and simulta-

463

464 Meredith American Journal of Orthodontics' and Dentofacial Orthopedics May 1997

Fig. 1. Note flat blue-green (painted) wallboard background, Hunter-Douglas Dwette Eclipal "total darkness" window shade, and 8-inch lift. Note optional indirect Lite Disc Reflector to provide soft light from below, directly to chin and front of face.

Fig. 2. Office photographer and subject, both standing. Base view. Patient's previous photographs should be reviewed and should be on counter behind photographer. Camera synch cord is attached to closest Multiblitz Minilight. Subject is 21/2 feet from background and 5 feet from back of camera.

neously flash. This gives a balanced soft flood/flash lighting effect on both sides.

• If the photography room is narrow, use wall mounted flash/flood units (Fig. 6). If the room is wide, then tripods should be used to mount the flash/flood units (Fig. 7).

• Be sure that the patient is properly framed and crisply focused.

• Assure standards for view, framing, and point of focus (Figs. 8 to 14). 6 (See Table I.)

Traditionally, orthodontic pretreatment and post- t reatment photographs have used a vertical format. Or- thodontists must be aware of this and standardize their photographic records accordingly. The reader is directed to the work by Stutts, 1° as well as t h e A B O Handbook, H

American Journal of Orthodontics and Dentofacial Orthopedics Mered i th 465 Volume 111, No. 5

Fig. 3. Minolta X-9 SLR 35 mm camera with Vivitar Series I 105 mm macrolens.

Fig. 4. Kodak Gold ASA-100 35 mm film. Film should be stored in cool place. Some professional photogra- phers refrigerate their film.

Fig. 5. 110V AC Multiblitz Minilight has ring-type, highly durable flash bulb and smaller centrally located, less durable, bulb for floodlighting. Silver-lined umbrella has been removed for this photograph.

that specifically outline the "official position" of the American Board of Orthodontics regarding facial photography. Nevertheless, it must also be noted that there is a strong movement in related specialties, notably otolaryngology and plastic surgery, toward the use of a horizontal format (exclusively). In addition, the photographer must:

• Include more than just right lateral and frontal (AP) views--left and right oblique views and a base view should also be included.

• Insure optimal patient positioning.

• Insure correct lighting. • Avoid parallax distortion.

Previous photographs must be reviewed, 3,12 just before taking follow-up photographs, so that consistent postoperative or posttreatment photographs can be ob- tained. Most plastic surgery and otolaryngology scientific program directors not only insist on a horizontal slide format but also insist on a (fully loaded) Kodak Carousel 80-unit slide tray.

Kodacolor ASA 100 provides excellent color quality prints. Prints are stored on the patient 's chart and

466 Meredith American Journal of Orthodontics and Dentofacial Orthopedics May 1997

Fig. 6. Photographer holding 35 mm SLR Minolta X-9 camera with attached Vivitar Series 1105 mm macrolens. Lateral view. Note left and right side wall-mounted Multiblitz Minilight 200 flood/flash units with umbrellas for soft indirect lighting. Patient's previous photographs should be reviewed and should be on counter behind photographer. Note PC (synch) cord going from camera to one of minilights.

Fig. 7. Frontal projection in wider rooms, Multiblitz Minilights should be mounted on tripods. In so doing, extreme angles in flash presentation can be avoided.

negatives are stored elsewhere in a secure, fireproof box (in case of fire or theft, or other loss). Slides for scientific presentation can be easily made from color print negatives. Conversely, color prints made from film for slides requires the use of an intranegative. The increased cost and loss of

crispness are both important factors to consider if slides have to be subsequently converted to prints for orifice use, use in the operatory, use in the operating room, or use in scientific publications. Alternatively, if it is known that these particular photographs are going to be used for a live scientific presen-

American Journal of Orthodontics and Dentofacial Orthopedics Mered i th 467 Volume 111, No. 5

Fig. 8. Frontal view. Note that patient is properly aligned with regard to Frankfort horizontal line.

Fig. 9. Base view. Include all of chin and small area of neck. Interpupillary line should be horizontal. Photographer should correct any habitual head tiring that subject may have.

tation, then it is easier and less expensive, in these cases, to use Kodachrome 64 film for color slides.

There should be at least 21/2 feet between the back of the subject's head and the rear wall to prevent shadows. A flat nonglare blue-green or medium green background provides for good color prints. Regardless of the back-

ground color used, it must be consistent from year to year. High-quality color prints are perfectly acceptable for publication (even though they may be published in black and white, to reduce costs). It is important to aim the flood/flash umbrella or (Photofex) soft box (Multiblitz Minilite 200) dual flash boxes accurately at the patient. A


Fig. 10. Lateral view. Chin and about 40% of neck should show. Use Frankfort horizontal line to be sure that head is level.

Fig. 11. Oblique view. Use Frankford horizontal plane. (Horizontal line through tragus and through infraorbital rim). Make sure that about half of opposite upper lid eyelashes show. All of far side pupil should not show.

small electronic portable flashlight (pointer) taped to the umbrella rod and aimed at the patient facilitates this.

Central facial distortion is produced with 50 or 55 mm 6 and is even more obvious when a 28 mm lens is used. The best option is the 105 mm facial portrait macrolens. Physicians and dentists interview patients in their office at distances of 3 to 5 feet. The 105 mm macrolens allows the pho tographer to frame the head and neck from 5 feet without parallax problems. To do the same with a 55 mm lens would require that the photographer be just

15 inches away from the subject. Central facial distortion, a product of the standard 55 mm lens, is even worse at 15 inches.

PATIENT CONFIDENTIALITY

Medical photographs are essential to planning the diagnosis and t rea tment of pat ients with aberrant dentofacial development . Photographs are also essential for pat ient and professional instructional purposes.

American Journal of Orthodontics and Dentofacial Orthopedics Meredith 469 Volume 111, No. 5

Fig. 12. Another oblique view, showing about half of subject's pupil, most of her upper lashes, and none of her lower lashes. Also, note how use of soft, indirect flash brings out this patient's delicate flesh tones, pouting lips, and long eyelashes.

Fig. 13. A, Hairstyle can distract from facial analysis. B, Hair should be pulled back, in a ponytail, if necessary. This allows for auricular analysis and for relationship between tragus and infraorbital rim to be evaluated. Same applies to hair down over forehead. Compare Fig. 11 with Fig. 13.


Nevertheless, patients have a right to their privacy. Photographs taken in the operat ing room, in the operatory, and in the office photography room should be taken only with t h e patient 's written permission. The same goes for the use in scientific and, especially, lay publications or television broadcasts. Fur thermore , it is simply good medi- cine to ask patients for verbal, as well as written permission, before the use of these photographs for any instructional purposes.

CONCLUSIONS

Use of a hand-held, single lens reflex 35 mm camera, with 110V indirect flood/flash units, significantly improves patient photographic records. The use of a 105 mm macrolens allows proper facial framing at an ideal 5 foot distance. Kodacolor 35 mm film for prints (ASA 100) will provide high quality working color photographs for the office, operatory, laboratory, and operating room.

Color prints should be filed on the patient's chart and the negatives stored elsewhere (as a backup). Slides can be easily made from color negatives, but not vice versa. Standardization of facial framing and timely review of the previous photographs, makes for organized, consistent photographic records. An adequately sized (at least 9 × 11 foot) room, specifically dedicated for facial photography, as well as office personnel specifically trained in the standardization of facial photographs, makes for the best possible results. Finally, the patient's wishes for privacy should be respected. Most patients are agreeable to share

their photographs with professional personnel in interre- lated specialties, and even with the public. Nevertheless, patients should be consulted before such use.

I extend my sincere appreciation to professional photographer Dale Riggs, Riggs Camera, Great Bend, Kan., for his technical assistance and for his photographs of the photography room, camera, lens, flash units, and photography office assistant. I also express my appreciation to Michelle Doll, RN, for consistent high quality in-office patient photography.

REFERENCES

1. Larrabee WF, Maupin G, Sutton D. Profile analysis in facial plastic surgery. Arch Otolaryngol 1985;111:682-7.

2. Morello DC, Converse JM, Allen D. Making uniform photographic records in plastic surgery. Plast Reconstr Surg 1977;59:366.

3. Dickason WL, Hann De. Pitfalls of comparative photography in plastic and reconstructive surgery. Plast Reconstr Surg 1976;58:166.

4. Gomey M. Malpractice. In: Courtiss EH, editor. Aesthetic surgery: trouble, how to avoid it and how to treat it. St Louis: Mosby, 1978:180.

5. Daniel RK, Hodgson J, Lambros VS. Rhinoplasty: the light reflexes. Plast Reconstr Surg 1990;85:859.

6. Daniel RK. Reference points and guidelines for facial, dentofacial, and nasal photographs. In: Daniel RK, editor. Aesthetic plastic surgery. Boston: Little, Brown & Co., 1984:83-98.

7. Butow KW. A lateral cephalometric analysis for aesthetic--orthognathic treat- ment. J Maxillofac Surg 1984;12:201-7.

8. Zarem HA. Standards of photography. Plast Reconstr Surg 1984;74:137. 9. Zide G, McCarthy J. Cephalometric analysis. Plast Reconstr Surg 1981;68:816-23,

961-8. 10. Stutts WF. Clinical photography in orthodontic practice. Am J Orthod 1978;74:1-

31. 11. American Board of Orthodontics. Instructions for candidates. Am Board Orthod

1990:A1-AS0. 12. Chappel JG, Stephenson KL. Photographic misrepresentation. Plast Reconstr Surg

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facial photography for the orthodontic office

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