Contents

Introduction .. 1
Why Dental Photography . 1
What is Photography 2
Light Properties 3
Basic Colors . 4
Basic Tools .. 6
Camera .. 6
Lenses 8
Minimal Allowed Distance (MAD) .. 9
Light Source .. 12
Assisting Tools . 14
Retractors .. 14
Photographic mirrors 14
Backgrounds 17
Optical Image Quality 18
Sharpness . 18
Depth of field .. 18
Brightness 20
Contrast 21
Factors Controlling Light Exposure ......................... 22
Color Balance .. 24
Technical Image Quality 25
Magnification .. 25
Working Distance 26
Camera-object relation .................... 27
Digital Photography .. 30
Which Digital Camera .. 31
Comparison between digital and analogue photography . 36
Different Camera Modes .................. 36
Errors and Solutions . 37
Recent application of photography ................... 41
Copying photographs ................... 42
Copying radiographs 42
Archiving recorded image 44
Required shots for different dental specialties 45
Definitions 46
Photographic hints 48

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Introduction
Registration of past man activities and knowledge enabled us to know a lot
about previous ancient civilizations and will allow future generations to
know about us. Drawing was the only way for visual registration in the
ancient civilizations, but it was replaced gradually by photography as its
more easily saved, reproduced and shared.

It was claimed that one picture worse more than 1000 words, so,
visual media now are so impressing and effective in not only registration,
but also in decision making and taking. Lot of activity fields are
photography-dependant for various purposes. The medical field isnt an
exception of this, and particularly dentistry as it deals mostly with visual
aspects of the personal representation. Medical photography is a science
dealing with producing high standard photographs to record the medical
procedures for a variety of purposes.

Photography term comes from the two Greek words: photos which
means light and graphos which means drawing.

Why Dental Photography/?

As a general rule, any invasive and/or irreversible procedure should be

registered and recorded before starting the procedure by photographs.

Two main aspects dictate using photographs in the dental field:

1- Legal aspect: for the dentist to protect him (her) self if the patient
claims an error occurred or there was a technical mistake made by the
dentist. The only proof to deny or prove this; is preoperative recording
including photographs. Patient may not be satisfied of the dental
treatment as the patient can not remember the preoperative conditions
(shape, esthetics, morphology,..), but presence of preoperative
recoding will help understanding the condition. Another legal point is
the ownership and copyright of the produced image.

2- Medical aspect: which may include the following purposes:

a. Documentation
i. Diagnosis (Fig 1-a)

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 ii. Follow up (Fig 1-b)
iii. Contribution to building data base
iv. Illustration (educational and research purposes).

(a) (b)
Fig (1): (a) diagnosis, (b) follow up.

b. Communication
i. With patients (patient education).
ii. With colleagues (for presentations, knowledge sharing).
iii. Consultation (now through the internet video conference,
we can make remote consultation)

c. Marketing and skill development

i. For personal presentations of available services in the
dental care clinics, equipments, facilities, ..
ii. To evaluate self skill development and future
enhancements.

What is Photography?
Photography is simply a simulation of the human vision process, the
camera system is an imitation of the visual apparatus including lens, image
receptor (retina of the eye, photographic film, or digital receptor) (Fig 2).

(a) (b)
Fig (2): Cross section of the human eye (a) and in camera (b)

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 So, photography is the process through which we can record an image
for a certain object on light sensitive receptor, processing data, record it, and
retrieve it when needed. To understand concepts of photography, some light
properties should be known as photography is receiving the light reflected
from any object.

Some light properties

1- Light is composed of seven colors with different wave lengths
forming the visible light spectrum (fig. 3). (Basic and complementary
colors will be explained later)

Fig (3): The light spectrum

2- The objects color depends on its ability absorb the whole spectrum
except one (or a combination) of a certain wave length producing the
objects color.

3- Light travels in straight lines

4- Reflection: light is completely reflected when strikes a reflective

surface (a mirror). As shown in figure 5, the reflected image on the
mirror is inversed (horizontally) (a), and that the angle of incidence
equals the angle of reflection (b). (applied in intraoral photography)

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 (a) (b)
Fig (5): The reflected image on a mirror (a), and relation between incident and reflected ray (b).

5- Deflection: which means deviation of the light from its straight course
due to passing through two different media (air and water or air and
glass) (fig 6). This phenomenon is the base on which a lens can collect
light beam when passing from air to glass of the lens at a certain point.

(a) (b)
Fig (6): The deflection property when light passes through two different media, air and water (a),
and air and glass (b)

What are the basic colors?

There has been an old debate about basic colors. People working in art field
considered a basic color is that color that can not be obtained from other
colors, so they considered basic colors are Red, Blue and Yellow. There
were several objections to this hypothesis as:
A- It was found that those colors can be obtained from mix of certain
shades of other colors.

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 B- This hypothesis could not explain the relation between basic and
complementary colors (will be explained later).
On the other hand scientists considered the basic colors are: Red, Blue and
Green (not yellow). They have 2 basic facts according to which they
claimed the basic colors:
The first is that the receptors in the retina in the human eye can only see red,
blue and green colors (with unlimited combinations).
Additionally, practical application of considering a green color as one of the
basic colors is that balance between basic and complementary colors.
Simply, each basic color when added to other specific complementary color
will result in obtaining gray color (which is the mid-shade between black
and white which are considered neutral colors).

Principal Red Blue Green

+ + +
Complementary Cyan Yellow Magenta
= = =
Balanced Shade Gray Gray Gray

NB: Obtaining pure gray color in the image means all other colors are
balanced to natural colors as in real (which has important indication in
image interpretation).

The second fact is an optic phenomenon; mixing the three basic colors in
equal proportions and received on a black board will produce a white spot
(Fig 4A) and mixing complementary colors in equal proportions and
received on a white board will produce black spot (Fig 4B) (which will not
happen if the yellow color is considered a basic color). (Note that
combination of such colors will produce the two neutral colors, white
[mixing basic colors] and black [mixing complementary colors])

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 A B
Fig 4: A mixing basic colors gives white spot, while in B mixing complementary
colors produce black spot.

Needed tools
For production of high quality dental images, special tools are needed to
achieve such goal. Two types of tools are needed:
I- Basic (principle) tools:
A) Camera (optical or digital)
B) Special accessories including lens, close up tools (extension
tubes or close up lenses).
C) Light Source (natural, artificial, continuous or snap)

II- Assisting tools, including cheek and lip retractors, photographic

mirrors and photographic background.

I- Basic (principle) tools

A) Camera:
i. Viewfinder cameras: which are not suitable for dental photography which,
as it can not produce the required magnification because its lens is fixed to
the camera body and can not be changed (Fig 5, left) and its responsible for
what is know as parallax (Fig 5, right).

What is parallax?
Its the difference between what the eye can see through the viewfinder lens
and what the film will record through the camera lens. This phenomenon is
more noticed in close up photography (Fig 6).

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Fig (5): Range finder camera (left), and parallax phenomenon (right).

ii. SLR cameras: which represents the Single Lens Reflex technique, where
the lens is interchangeable according to the required assignment (Fig 6,left).
The right figure shows a cross section in the SLR cameras explaining how
the image is transferred to the view finder through one lens which is
interchangeable through a pentaprism on the top of the camera body.

Fig (6): SLR camera (left) and schematic diagram (right).

1) The lens
2) Reflecting mirror (45 on the horizontal plane)
3) Sutter screen (when opens, its exposes the film to the light passing through the lens). The
speed of the shutter screen to open and close (shutter speed) controls the amount of light

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 strikes the film in combination with the lens aperture (when using a continuous light
source), which be discussed later
4) Film
5) Condenser
6) Condenser (intensifies light beam to pentaprism)
7) Pentaprism (reflecting light to the view finder).
8) View finder eye piece (can see precisely what the film is going to record).

When the release button is pushed, the reflecting mirror turns upward, the
shutter screen is opened and the film is exposed to light.

B. Special accessories
i. Lenses
A lens is a special apparatus that collects light beam in a specific point
to form a sharp image in a certain area called focus point.

Focus point: is the point at which the sharpest image of an object is formed.

Focal length: is the distance between the center of the lens and the focus
point when the lens is set at infinity (dotted arrow) (Fig 7).

A: the object A: the objects image at the focus

Fig (7): The proper focusing of the object (A) in the focus point (A) (left) and when the object
(B) in the wrong focus (B) (right). CC denoting the circle of confusion which is the
difference between the supposed focal point and virtual focus at (B) resulting in blurred
image.

If the object moves from point A to point B (right side of the figure), and the
position of the lens and the film are fixed, the sharpest image of the object in
position B is formed at the point B behind the focal point. The image
formed at the film plane will be blurred (pre-focus image). The cc is an
imaginary circle known as the circle of confusion which represents the
difference between the actual image position and the proposed sharpest
image position. Increasing the difference between two positions will
increase the circle of confusion, leads to more blurred image.

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Minimal Allowed Distance (MAD):
It is the minimum distance at which a lens can form a sharp image at
the focus point. Getting closer to the object beyond this limit will produce a
blurred image. This distance is recorded on the lens body and it differs from
one focal length of the lens to another. This distance is greater by increasing
the focal length of the lens, e.g the focal length of a lens is 50 mm and the
minimal allowed distance is 40 cm, in a lens with 100 mm focal length, the
minimal allowed distance will be 65 cm, i.e if we use a lens with a focal
length 100 mm, we can not get closer than 65 cm (Fig 8) unless we use
additional accessories (a lens with macro option or adding close up lens to
the original lens).

Fig (8): Minimal allowed distance of lenses with different focal lengths.

As the visible light spectrum contains seven colors with different wave
lengths; each wave length has a different deflecting angle when passing
though the lens producing different focus points for each wave length which
is known as aberration.

Aberration: is defined as the failure of a lens to bring all the wave lengths of
a light beam to an exact same focus (Fig 9).

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Fig (9): Red wave length has a different focusing point than blue one.

Introducing the achromatic lens solved this problem partially as this lens
consisting of two or more elements, usually made of crown glass and flint
glass. This lens has been corrected for aberration in that it has the same focal
point with respect to two different colors (red and blue) (Fig 9A).

Apochromatic lens, similar to the achromatic lens, this lens corrects for
three colors (red, blue and green) (Fig 9B), greatly reducing the blur caused
by the colors uncorrected by the achromatic lens. Thats why lens prices
vary greatly according to its ability of aberration correction.

Fig (9A): Achromatic lens with a coat to correct Fig (9B): Apochromatic lens with 2 coats to
blue wave length deviation correct blue and green wave length deviation

Types of lenses (according to the focal length)

Camera lenses are classified according to its focal length into:
I- Prime lens: has a fixed and single focal length that cant be changed.
II- Zoom lens: has a changeable focal length (more than focal length in
the same body).

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Prime lenses can be classified into:
a- Standard lens: which its focal length is between 45-55 mm (which has
the same angle of vision of the human eye).
b- Wide Angle lens: where the focal length is less than 45 mm.
c- Telephoto lenses: where the focal length is larger than 55 mm.

Zoom lens: with more than one focal length in the same body. Those lenses
may be either wide-wide, wide-standard, standard-telephoto, telephoto-
telephoto or wide-telephoto zoom lenses.
The smaller the focal length (wide angle lens) (left side), the smaller the
object size (the larger the angle of view) and vice versa (Fig 10).

Fig (10): The effect of focal length of the lens on the object size, wide angle lens (left), and
telephoto lens (right).

The camera lens has 2 calibrations, one for the distance adjustments (in the
manual distance adjustment cameras), and the other for aperture adjustments.
The aperture of the lens is the diameter of the opening that permits light to
pass through it to the film when the shutter screen opens. Its calibration
starts from 1.4 (sometimes 1.2), 2, 2.8, 4, 5.6, 8, 11, 16, 22, 32 and is
represented as f/number or f-stop. This f-stop is calculated by dividing the
focal length of the lens by the diameter of the opening. If the shutter speed
and light conditions are constant, one f-stop gives half the amount of light
the previous f-stop gives (f/8 gives half the light f/5.6 gives), while it gives
double the light amount the next f-stop gives (f/8 gives double light the f/16
gives), so the bigger the number, the lesser the light allowed to passes to the
film (Fig 11).

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Fig (11): Range of f-stop in a standard lens

The aperture value controls the amount of light strikes the film in
combination with the shutter speed (when using continuous light) and in
combination with the object-lens distance and flash guide number (when
using snap light), assuming the film sensitivity is constant. The number
written in the following formula 1:1.4, f = 55mm, means that the maximum
aperture of this lens is 1.4 while its focal length is 55mm. Zoom lenses may
have two number indicating the maximum aperture (the smaller number
indicates the maximum aperture at the smaller focal length and the other
indicating the maximum aperture at the larger focal length) as follows: 1:
2.8~4 f = 35~85mm. This means that the focal length of this zoom lens
ranges from 35 mm (wide) to 85 mm (tele) and the maximum aperture at 35
mm = 2.8 while at 85 mm = 4 (Fig 12).

Fig (12): Data on the lens identifying maximum aperture and focal length

2. Light Source
Light source is one of the most important factors affecting the image quality
as it may affect brightness, contrast and hue of the image.

Light sources are classified according to either its nature or duration.

I) According to nature:
i) Natural light: which include the day light exposure, whether direct
or indirect (shaded areas) (Fig 13 left)

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 ii) Artificial light: which may be tungsten or florescent light source,
(Fig 13 right).

Fig (13): Natural (day) light (left) artificial (right)

II) According to duration:
i) Continuous light which is either natural or artificial
ii) Snap light: flash light. Flashes may be mounted in a top or side
position (Fig 14, left), but this gives an ugly shadow to the obtained image
(Fig 14 right). The ring flash which is mounted on the lens (Fig 15 left) will
produce shadowless image by equalizing amount of light from all directions
(Fig 15 right). Its very useful in close up and dental photography.

Fig (14): Top position flash unit (left), and resulted ugly shadow (right)

Fig (15): Ring flash unit (left), and shadowless image (right).

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Assisting tools:
1) Retractors: using cheek and lip retractors expose the intra-oral
target area clearly to be photographed (fig 16 a, b and c). Plastic
retractors (c) are superior to metal ones (d) to avoid light
reflection.
NB: Metal retractors were used in the past as they could be sterilized and
autoclaved but recently plastic retractors are made of autoclavable materials.

a b

c d
Fig (16): Semi-circular self-retained plastic retractor (a, b and c), metal retractor (d) may
create unaccepted reflection that may affect final image.

2) Photographic mirrors: specially designed mirrors to assist

photographing certain areas that are not clearly photographed
directly. They are either metal or glass mirrors. Glass mirrors
being cheaper, but sometimes it produces what is known as
ghost image (second image), as two surfaces are reflecting the
image, the silver coating of the glass (rear surfaced mirror), and
the glass surface itself which partially reflects the image (fig 17
left and fig 18). In addition to be cheaper, glass mirrors can be

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 precisely customized with different sizes as needed by each
operator. Metal mirrors on the other hand, gives a single
reflection as only one surface will reflect the image (front-
surfaced mirror, fig 17, right) its durable, easy sterilized,
thinner (will not annoy the patient).

GI = ghost image PI = Primary image

Fig (17): Occlusal and side mirror shapes (left). Primary and ghost images in glass and
metal mirrors (middle and right).

Fig (18): Intraoral occlusal photograph of maxillary dental implant with ghost image of
the implant (arrow)

Occlusal and lateral mirrors:

Occlusal mirrors are trapezoid in shape, used for photography of occlusal
surfaces of upper and/or lower arches (fig 19), while lateral mirrors are
nearly rectangular in shape and are useful for photography of side views of
the teeth (opened or in occlusion) (fig 20), and also may be useful for lingual
photography. The mirror (occlusal or lateral) should be placed 45 (fig 19,
20), to both the object (to obtain proper viewing of the object) and camera to

15
avoid reflection. It should be noted that mirror image is reversed
(horizontally), i.e. the right side appears as left and vice versa (this can be
easily corrected now by photo editing software).

(A) (B) (C)

(A) (B) (C)

Fig (19): Intraoral mirror(occlusal mirror above, side lateral mirror, below): (A)
schematic diagram for 45 angle, (B) clinical view and (C) the resulted image.

Perfect presentation of certain clinical situations can only be achieved by

using intraoral photographic mirrors (Fig 20).

Fig (20): showing lateral (side view of maxilla teeth), left direct (without the mirror),
right using intraoral mirror showing perfect presentation of the available space for the
implant and good evaluation of the neighboring teeth alignment.

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 3) Background: its the surface behind the object to be
photographed, it should fulfill 4 main criteria:
- Suitable color for the object (sufficient contrast).
- Being non reflective.
- Composed only of one color.
- Flat with no texture.

Any failure to choose the proper background may affect the optical quality
of the image or would disturb the person who watches it (Fig 21).

(A) Bad background color (wrong) (B) Multiple background color (wrong)

(C) Reflective background (wrong) (D) Proper Background

Fig (21): Effect of background on the image quality.

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Image quality:
The photographed image in the dental field (as well as all fields) should
fulfill certain quality criteria to be accepted

A) Optical image quality.

B) Technical image quality (photographic conditions and photographer
performance).

A) Optical image quality includes the application of optical basic concepts to

produced images with high quality. This includes:
- Sharpness.
- Sufficient depth of field (depth of focus).
- Brightness and contrast.
- Color balance (hue).

- Sharpness:
As previously mentioned a sharp image means formation of the objects
image through the lens in the focus point. A sharp image means that the
image components are sharply defined from each other and that a point or a
line in the object is represented by a point or a line in the image (fig 22).
Precise adjustment of the distance scale permits a sharp image quality. But
why some produced images are blurred and out of focus although nearly all
available digital cameras (compact or DSLR) have an auto-focus adjustment
system? This will be discussed later.

Fig (22): Blurred image (left) (unaccepted) and sharp image (right).

- Depth of field (depth of focus) DOF:

Is the portion of the scene that is in focus or it is the area in which all objects,
located at different distances from the camera, appear in focus (Fig 23).

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Four factors may influence the degree of depth of field (DOF):
(a) The focal length of the lens.
(b) The distance of the object from the lens.
(c) The aperture and
(d) Focal plane (plane at which the distance scale is adjusted).

Additional factor may be the distance between elements in the foreground

and elements in the background of the frame.

Fig (23): Effect of depth of field (focus) on image quality.

1- The bigger the focal length of the lens (telephoto lenses), the narrower the
DOF, and similarly, the closer the object (close up or macro photography),
the narrower the DOF.
2- The smaller the aperture, the bigger the DOF (fig 24).

Fig (24): Effect of aperture on DOF (left), and distance between objects close and far
from the camera (right).

3- Focal Plane: there is an optical phenomenon, 1/3 of the area to be

photographed in front of, and 2/3 behind the focal plane lie in the
focus area (fig 25). So, when photographing frontal view of occlusion,

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 if the focal plane is adjusted at the level of central incisor, an area in
front of this focal plane will lie in focus, although there is no object to
be photographed occupying this area, while the area behind this plane
will not extend to include the first molar which is needed to be in
sharp focus (gray area, left image). Readjusting the focal plane to be
at the level of the canine or first premolar will help including the areas
in front and behind this plane in a sharp focus (right image, gray area).
So in dental photography we need to capture images for small objects so we
have to use telephoto lenses with close up (macrophotography) which
greatly decreases the depth of focus. This can be compensated by using
small lens aperture and shift the focal plane slightly posterior (Fig 25).

Fig (25): Effect of position of focal plane on depth of field (gray area).

- Brightness and contrast: brightness is affected by proper light exposure

while contrast is affected by processing of the film.

- Brightness
Its the amount of light being reflected off a subject or surface, and
representing the lightness value from black {0} to white {255} (Fig 26).

0 255
Fig (26): The brightness scale from 0-255 (applied in color and black and white mode).

Proper film exposure will result in a well illuminated image (proper

brightness), while increasing film exposure results in a more bright image
(all color tones are more bright). On the other hand, decreasing the film
exposure will produce darker image (Fig 27, left middle and right
respectively). In other words, increasing brightness of an image means

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adding the same amount of light to all image components and dark image
means decreasing same amount of light from all image components.

Normal Lighter Darker

Fig (27): Different grades of image brightness.

- Contrast
Contrast in general is the ability to distinguish differences. In photographic
field it can be defined as the difference between the dark and light areas in a
photo. The greater the difference, the higher the contrast (Fig 28). The bright
areas become brighter and the dark areas become darker.

Normal contrast High Low

Fig (28): Different grades of image contrast.

Brightness and contrast can be adjusted by photo-editing software within

limits

NB Brightness is related on film exposure to light, while contrast is related

to film processing.

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Factors controlling amount of light exposure:
I- Using continuous light: two factors control light exposure
supposing film sensitivity and light intensity are constant:
A) Aperture: f-stop or f/number, which was previously
mentioned and calibrated as 1.2, 2, 2.8, 4, 5.6, 8, 11, 16, 22, 32
and represents the diameter of lens opening (fig 29). The
smaller the diameter of the lens opening, the lesser the amount
of light is passed (dark image) and the bigger the diameter of
the lens opening, the greater the amount of light that can pass
(bright image).

Narrow aperture Wide aperture

Fig (29): Small f-stop [16] (narrow opening), (left) and wide f-stop [4], (wide opening
right).

B) Shutter speed: which represents the duration the shutter screen

remains opened (time). It is calibrated in a fraction of a second
(1/value) starting from 1second, 1/2, 1/4, 1/8, 1/15,
1/30, .1/2000 of a second (Fig 30 left). If the shutter speed
is too slow (30 or slower), the image may be blurred due to
shaked camera and not due to wrong distance adjustment which
leads to double or even triple image of the object (Fig 30, right).

Fig (30): Shutter speed scale (left), image resulted from slow shutter speed (right).

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In a constant light intensity and same film sensitivity, it is a reversible
relation between f-stop (diameter of the lens opening) and shutter speed
(duration of opening the shutter), so to maintain the same amount of light
exposure, if we increase the lens diameter (more light is allowed),
necessitates compensation to reduce this increase by using higher shutter
speed (decrease duration).

A fixed amount of light (Z) can be obtained from different combinations of

f-stop and shutter speed, that is to say:
Z (fixed amount of light exposure) can be obtained from combination of f/11
and shutter speed 1/125 and the same (Z) light exposure can be obtained
from a combination of f/16 (smaller diameter) and shutter speed 1/60 (longer
duration) assuming the light power and film sensitivity are constant.
Selecting specific combination depends on the photographic target (object to
be photographed) whether it is still or moving (will be discussed later).

NB: Intraoral photographs (still objects) needs close up position of the

camera and telephoto lens (macrophotography), so the depth of focus will be
shallow and critical, so compensation of light change should be by adjusting
the aperture on the expense of shutter speed which increases depth of focus.
On the other hand photographing moving objects dictates increasing shutter
speed on the expense of aperture value to obtain fixed object in the image.

II- Using snap light (flash): three factors affect the amount of light
received by the film:
A) F-stop (aperture) which is directly related to distance.
B) Distance: as increasing the distance between light source (flash)
and the object, decreases the amount of light reflected from the
object (the light is distributed over a larger area), which needs
compensation by increasing the f-stop (fig 30).
C) The power of the flash (guide number), the greater the guide
number, the greater the light intensity and hence the bigger the
distance it can cover. The appropriate f-stop to the distance can
be calculated by dividing the guide number of the flash by the
distance (this is performed automatically in advanced camera
systems).

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NB: It is important to notify here that shutter speed has no effect on the
amount of light received by the film when using snap light source as the
flash releases the light in a speed much greater than any available shutter
speed (flash can reach a release speed of 1/30,000 of a second). On the other
hand, shutter speed may affect the image in other way if it is not
synchronized with the light release from the flash, i.e., the flash should
release the light when the shutter screen is fully opened. Synchronization
failure may produce a partially illuminated image (only part of the image is
illuminated), this is solved now in modern cameras.

Fig (30): Relation between distance and aperture to control light exposure.

- Color balance:
Color balance means producing an image with the same natural colors
of the object. Using artificial light source without correction will add
unwanted hue to the image. The hue is the predominant wave length (color)
in the image (certain color of the light spectrum). Tungsten light source
(dental unit spot light) will add yellowish hue to the image, while fluorescent
light source may add greenish hue (fig 31). In the past, correction of color
balance was done in the printing lab using special filters for corrections
(depending on understanding basic and complementary colors). Now, this
procedure can be performed using photo editing software of the computers.
As mentioned before, good knowledge of basic and complementary colors
will help correcting this problem.

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 (A) (B) (C)
Fig (31): A Normal (natural) colors, B yellowish hue (when using tungsten light) and
C greenish hue (when using fluorescent light).

NB: Obtaining natural colors of the object in the image is important as colors have some
indications describing the clinical situations for example inflamed gingival is reddish in
color which should be presented as it is in the real situation.

Technical image quality (photographic conditions)

This section of image quality depends on a good understanding of the basic
photographic knowledge and the ability to apply it in a right way. Recent
photographic equipments solved most of the problems of optical image
quality as auto-focus techniques, auto-exposure metering systems, color
balance, so most of the errors now may occur regarding the technical
prospective depending on the skill, performance and experience of the
photographer.

Achieving such criteria depends not only how to see the object but also on
how properly to visualize the surrounding circumstances as proper retraction
of the lips, proper angle of the camera to the target which is summarized as
frame construction which means what should be included in the frame?,
how big the object should be?, camera-to-object angle, and the ability to
reproduce these conditions in serial photographs either in one session as
surgical procedures or in successive sessions as follow up of a procedure.
Controlling these conditions will permit the photographer not only to
produce a high quality photographs, but also will be able to ensure
reproducibility of those conditions. Standardization of such conditions is the
key of high quality image production. This standardization will include:
1- Magnification (reproduction ratio)
2- Working Distance
3- Camera-Object relation (vertical and horizontal)

1- Magnification (reproduction ratio): means how much the object will fill
the frame. Failure to obtain proper magnification will result either in too
small (fig 32 left) or too big (fig 32 right) object image, which will
consequently results in loss of details. This may be due to improper distance
(too far or too close), or wrong selection of the proper lens).

25
Fig (32): Undesired details are included in the left image (too far distance), while the
molar area was not included in the right image. Both images are not accepted.

2- Working distance: a sufficient working distance should be maintained to

avoid certain errors. Working too close to the object while using side or top
mount flash will produce huge ugly shadows (if ring flash isnt available).
This will increase shadow size (fig 33).

Fig (33): Too close camera with side light source will result in bigger shadow.

Dimensional distortion is another problem occurs when using too close

distance with wide angle lens (fig 34, left), which can be avoided by using
telephoto lens and slight increase the distance between the camera and the
object (fig 34, right).

Fig (34): Distorted proportions

due to too close distance with
wide angle lens (left), same
patient with proper proportions
(right), when using tele-photo
lens.

26
3- Camera-object relation:
If a ring flash is not available and a side or top mounted flash is to be used, a
simple hint is so useful to avoid unaccepted shadow. As a rule, a shadow
occurs opposite to the light source direction. So, when photographing the
right or left profile of a patient, if the light source comes from the side of the
patients ear, the shadow will appear in front of the patients forehead and
nose, complicating the proper evaluation of the profile of the patient (fig 35,
left). To overcome this problem, simply place the light source at the nasal
side directing the shadow behind the patients head (away from the target
area fig 35 right).

Fig (35): Changing the light

source direction will
eliminate the undesired
shadow (left), giving clear
details (right).

27
Camera-object orientation
Vertical and horizontal camera orientation affects the final outcome of the
image quality. For example, when photographing the intra oral frontal view
of occlusion, the camera should be parallel to occlusal plane (fig 36 a). If the
camera is too downward or too upward oriented, the image will give false
presentation of the real clinical situation (fig 36 b and c).

(a)

(b)

(C)

Fig (36): Well oriented horizontal plane (a), too downward camera position (b) and too
high upward camera position (c).

28
When capturing extra oral photographs, it should be kept in mind that the
inter-pupillary line should be parallel to a horizontal plane (lower border of
the frame), or the produced image will be unsatisfactory (tilted) (fig 37).

Fig (37): Adjusting the horizontal plane to be parallel to the inter-pupillary line.

So before pressing the release button (before photographing), lot of points

should be kept in mind simultaneously:
- Proper magnification adjustment.
- Framing the object properly (what is in and what is out.
- Sharp focusing on the most important point of the object.
- Proper orientation.
- Edges of the mirrors as well as fingers holding them should not be
visible.
- Avoid fogging formation on the mirror surface by either warming
the mirror surface, or instructing the patient to expire the air
through the nose.

Standardization of the photographic conditions, will not only help to produce

high quality photographs, but will also help for proper reproducibility of the
photographs after a period of time, enabling dentists, to evaluate the
treatment outcome as well as their own performance (Fig 38).

29
Fig (38): Standardized photographic conditions resulted in standardized photographs over
a period of time. Left picture shows a patient with extracted maxillary central
incisor. Right picture shows the same patient after insertion of removable partial
denture. Note that the magnification and camera orientation are nearly the same.

Digital photography
Digital photography is electronically capturing and producing images using
a charge-couple device (CCD) which is the light-sensitive image device
within most modern cameras, containing hundreds of thousands of photo-
sites (pixels) that convert light energy into electronic signals. The more the
number of these pixels; the more the data stored on the sensor and
consequently more stored fine details producing high image quality. This is
how image is stored on the electronic sensor to be retrieved later, transferred
to the computer or printed.

One of the most important advantages of digital photography is previewing

the captured images helped to detect any errors, replacing defective images
by proper ones after correction and adjustment, but still the basic knowledge
is needed to properly evaluate the image and realize whether it is meeting
the needed quality criteria or not. Every device has its abilities and limits, so,
understanding these abilities and limits of the device and working within
those limits and abilities is more important than earning a highly
sophisticated device with shallow knowledge about the basic principals of
photography.

Digital photography follows the same rules of conventional (optical)

photography techniques and concepts with more advanced assisting
technologies including automated exposure metering systems and auto-
focusing techniques. As in conventional cameras, range finder and SLR
digital cameras are available. The advantage of back screen (Fig 39, left) in

30
range finder digital cameras over rang finder optical cameras, is that it
solved the problem of parallax, as this back screen shows exactly what the
sensor will receive. In addition, built-in zoom lenses and several program
modes facilitated the use of cheaper range finder digital cameras in some
dental photography situations. Still, SLR digital cameras have the advantage
of wide variety of interchangeable lenses with the facility of using different
light sources (ring flash, or light system).

Fig (39): Range-finder digital camera with back screen (left) and DSLR digital camera
(right).

What to look for in a digital camera? (Which Digital Camera?)

1- Mega-pixel: the greater the mega-pixel, the higher the image quality.
The pixel is that smallest part of the receiver that can record light as
electronic signals in the charged-couple device (sensor) of the digital
camera. Greater megapixel values will record more data and hence
resulting in a better image quality (Fig 40 left) than lesser megapixel
value which will result in more noise (Fig 40 right) (cameras with
more megapixel value will be more expensive).

Fig (40): Effect of megapixel value

on image quality. Larger megapixel
value (left with 14 MP) gives
better image and less noise than the
smaller megapixel value (right with
6 MP.

2- Sensor size: CCD (sensor) has different sizes even in the same brand
name company (Fig 41 left) which is opposite to analogue cameras

31
 using films as image receiver which has a standardized size measuring
24 X 36 mm (Fig 41right). The bigger the sensor size, the bigger the
pixel size (even with the same amount of pixels) which enhances the
image quality by reducing the noise around the main signal. So, if we
have two digital cameras having the same number of pixels but
Camera A with sensor size X will produce better image quality
than another camera B with sensor size 1/2 X (Fig 42).

Fig (41): Different sizes of digital camera sensors (left) and standardized full frame film
size (right)

Fig (42): Showing effect of sensor

size on the image quality. Full
frame sensor (left) gives better
image than smaller sensor size
with high noise (right)

3- In range finder digital cameras, optical zoom option is available. It

is the ability of the built-in zoom lens to actually magnify the image
of the object. SLR digital cameras depend on the focal length of the
interchangeable lenses to needed proper close up magnification. In
range finder digital cameras, optical zoom is more important than
digital zoom as the former is acting by real magnification while the

32
 latter acts by enlarging a small area of the image and consequently it
will affect the image quality. To explain this, if we use digital zoom
on a camera with 8 mega-pixel to get a double magnification, the
processor of the camera will use only 4 mega-pixel to stretch the
image over the area that was recorded over the whole 8 mega-pixel, so,
digital zoom enlarges a small part of the image and stretches it over a
bigger area, but will not magnify the image of the object (Fig 43).
Optical zoom option is expressed as X and the power is expressed
in number, i.e., [3X] optical zoom means the lens can give
magnification 3 folds from the same distance.

(a) (b) (c)

Fig (43): Small object image captured by wide angle lens (a), cropped and stretched
image with increased noise (b), and an actual magnification (c).

4- Macro photography option: it is the ability of the lens to get closer

to the target object (small minimal allowed distance).
a. In compact digital cameras, it depends on the optical zoom of
the lens and macro option of the camera.
b. In SLR cameras it depends on the focal length of the lens and
whether it has a built in macro ability or using additional close
up lenses (threaded in front of the lens)

Technical Hint: Conflict between telephoto lens and macro option(Fig 40)
As mentioned before the minimum allowed distance (MAD) increases by
increasing the focal length of a lens but the maximum allowed distance is at
infinity. Macro option of a lens has a minimum and maximum allowed
distance, so there may be a shared range of focusing distances between the
minimum allowed distance of the lens at normal setting and the maximum
allowed distance of macro option. Increasing the focal length of lens at the

33
normal setting decreases this zone, and higher focal length may result in a
0 zone preventing focusing adjustment when using high focal length with
macro option (Fig 44).

Fig (44): Conflict between normal focusing setting and macro option setting.

Hand grip: too compact digital cameras (Fig 45 A) (usually range finder
type) are not the best choice for dental photography as being too light and
compact may give the chance for slipping or changing the frame
composition adjusted by the photographer specially with beginners who
have no experience, leading to disappointing results regardless a proper
sharpness and lighting (brightness and contrast). Compact digital cameras
with pop-up flashes as a light source (Fig 41B), are not recommended as
they will produce unpleasant shadow due to relative far position of flash unit
from the camera lens. If a compact digital camera is to be used, a camera
design with a good hand grip and near flash unit to the lens is recommended
for better controlling camera handling and reducing shadow size (fig 41C).

A B C
Fig (45): Slim body and pop-up flash position compact digital cameras are not the best
choice (A & B), while digital cameras with hand grip and close flash unit to the
lens are superior (C).

34
It is important to note that we are not talking about different commercial
names, but, about the camera body design regardless the manufacturers
company.

NB: For digital cameras it is advisable to use the original lithium battery
(rechargeable) supplied with the camera, or if the camera uses the AA size
batteries, it is recommended by most camera manufacturers to use
rechargeable batteries as it is the best for protecting the electric circuits from
electric shocks. Do not recharge non-rechargeable batteries as leakage may
occur damaging the internal parts of the camera. Keep your camera away
from dust, fluids and deposits to protect it from damage. If the camera is not
going to be used for more than 1-2 weeks, it is advisable to remove the
batteries.

35
Comparison between analogue (optical) and digital photography
Item Analogue Digital
Image Registration On film On CCD (electronic)
Image Processing Chemical Electronic
Image Retrieval Print on sensitive paper - On Camera Screen
- On Computer Screen
- Print on sensitive paper
- Print on normal paper
Preview Not Available Available
Image quality Depends on grain size Depends on pixel number
Compact cameras
Parallax Present Absent (by back screen)
Macro Absent Present
Optical Zoom Absent Present

Different program modes in the digital cameras and its meanings

Symbol Meaning
This option automatically select the desired program from the listed
modules according to the situation..
Program This option enables the camera to fully adjust the light exposure regardless
the combination between shutter aped and f-stop
Av This represents Aperture value, indicating that the photographer selects the
aperture value and the camera selects the relative proper shutter speed.
Tv (S) This represents time value where the photographer selects the shutter speed
and the camera selects the relative proper aperture.
M Full manual control the light exposure adjustment.
MF Represents adjusting the focusing manually (manual focus)
AF Represents adjusting the focus automatically (auto focus)
Still photography mode
Macro photography option (close up, intra-oral)

Photographing portrait

Photographing moving objects (sports, wildlife, kids, with shutter speed).

For landscape photography (small aperture for large depth of field).

Night mode photography, when the background is dark, or just night lights,
the mode uses slow shutter speed and the flash lighten the faces.
Video mode

Viewing the captured saved images

36
 To erase unwanted saved images. A dialogue box appears to confirm that
the selected image is intended to be deleted.

ISO This option is included in the camera menu represents the calibration of
sensor sensitivity to the light which determines the amount of light
exposure needed to capture an image with accepted brightness. Its
graduated as 80, 100, 200, 400, 800, 1600. The higher the ISO, the more
sensitive sensor to light (needs less amount of light to produce proper
brightness and contrast and is called fast film).

Error and Solutions

Error Solution
Blurred image Adjust focus and retake

Shallow depth of focus Adjust focal plane and retake

Fogging (cold mirror) Warm the mirror and retake

Extremely bright Retake (dont adjust on computer)

37
Extremely dark Retake (dont adjust by computer)

Reflective background Change background and retake

Small target (wrong lens) Use telephoto lens and retake

Dimensional distortion (too close Use telephoto lens and increase the distance
to the object with wide angle lens)

38
Head tilting (vertical or horizontal) Adjust interpupillary line and retake

Shadow (wrong light direction) Change light source direction

Light

Improper retraction Use proper retractor and retake

Uncentralized target (central incisor) Centralize the target and retake

39
The next table summarizes some errors in the resulted image, its causes and
how to correct or avoid

Error Cause Action to correct

Blurred image* - Wrong distance adjustment - Retake picture, avoid the
- Working beyond auto-focus limits cause of the error
Shallow depth - Too wide aperture - Retake picture, avoid the
of field* - Improper focal plane cause of the error
Too bright - Over exposure ( in the manual mode) - Can be adjusted in a photo-
- Working beyond exposure meter limits editing computer software
(within limits)
- Retake if too bright
Too dark - Under exposure ( in the manual mode) - Can be adjusted in a photo-
- Working beyond exposure meter limits editing computer software
- Reflective background (within limits)
- Retake, change background
Too Small - Too far camera-object distance - Retake (dont crop)
object - Using wide angle lens
Abnormal hue - Artificial light (tungsten, florescent) - Adjusted using a photo-
- Improper adjustment of color mode editing computer software
Distorted - Using wide angle in a very close - Retake
proportions* distance
Ugly shadow - Using side or top mounted flash - Retake and avoid the cause
on the target - Wrong light direction (use ring flash, or change
area* light source direction)
Ill defined - Improper background color or nature - Retake, change the
object from (reflective) background
background*
Un-centralized - Bad frame composition - Cropping using photo-
object. editing software
Items with (*) sign means it can not be corrected and should be repeated.

40
Recent application of photography:
Dental pictures can be used as a measuring tool in different purposes when a
reference tool is included in the picture. A color matching of prosthetic
restoration can be assisted by using an intraoral photograph with a shade
guide included in the picture (fig 46). Dental photographs may be also used
in smile assessment researches when a ruler is included in the picture as a
reference to normalize measurements from the image (fig 47).

Fig (46): Using photographs as a measuring tool with color reference included in the picture. Color
matching for a dental restoration, numerical values of the selected shade appears on the color picker option
of the software (right).

Fig (47): Linear reference included in the image to calculate the magnification or reduction factor.

41
Converting Old Analogue Stuff into Digital format:
A) Converting Old Printed Pictures:
Sometimes, a digital camera can be used as a faster and easier alternative of
a flat bed scanner for copying old printed photographs or papers. The same
basic photographic knowledge is applied with some modifications. When
copying photographs, dont use the flash unit as a light source as it will
produce annoying shadow spoiling the picture details (fig 48, left). Instead
use day light or artificial light with color correction for such procedure for
better image quality (fig 43, right).

Fig (47): Left, copying pictures using flash unit with distorting reflection, right same
picture copied using balanced light source.

B) Converting Old Radiographs:

Recent techniques of radiograph production enables a digital copy of a
radiograph whether conventional, CT, MRI or any other form, but
sometimes if we have old radiographs that have no digital copy which needs
to be digitized. A digital camera may be an accepted alternative for highly
sophisticated expensive x-ray scanners for digitization of old radiographs
(the radiograph film plate size may exceed the size of the scanning window
size of the scanner). Copying radiographic films using digital cameras
depends on the use of available light (as radiographic film viewer). Opposite
to object photography, radiographs needs the light source to be behind the
radiograph passing through it to be photographed (transmitted light), so flash
light is not the suitable light source as it will not record data from the
radiograph but will be reflected from the acetate base of the radiograph
giving disturbing reflections (fig 48 left). As the light source may not be
sufficient, the shutter speed may be so slow (30 or slower); depending on the
brightness of the radiograph, the camera should be as stable as possible.
Holding the camera in hands may lead to blurred image due to shacked
camera during photography and slow shutter speed (fig 48 right), so its
advisable that the camera should be mounted on a tripod or on a copying

42
stand (fig 49 left) to avoid such error to produce a high quality image of the
x-ray film (fig 49 right) .

Fig (48): Copying radiographs using flash unit leads to reflection (left) or using
extremely low shutter speed results in blurred image due to camera shake (right).

Fig (49): Copying stand (left) and perfect resulted image (right)

43
Archiving the recorded images
Although computers helped a lot in proper archiving and retrieving the
images in a very easy way, standardization of work steps will make the
image transfer procedure easier. To separate between patients pictures
recorded on the digital camera, its worthy to photograph a paper recording
the needed data about the patient including the name, date, diagnosis type of
treatment, stage of treatment (preoperative, postoperative or during) before
starting photographing the patient. Then, in a customized folder, the
patients pictures should be saved, giving sufficient data for easier search
and retrieve (Fig 50).

Fig (46): Customized folder, including all patients photographs.

N.B.: A backup file is needed to ensure a rescue copy to avoid data

loss if any error occurs in the storage unit of the computer.

44
Required photographs in different dental fields

As previously mentioned, any invasive procedure should be photographed

preoperatively, and postoperatively. Required photographs differ according
to the dental specialty.

1- Oral Surgery
A- Osteotomy operations
i- Extra-oral shots
- Frontal face - Frontal smiling
- Lateral profile (right and left) - 45 profile (right and left)

ii- Intra-oral shots

- Occlusion (frontal) - Occlusal views (upper and lower arches)
- Occlusion (side view), right and left. - Maximal opening

B- Fracture
i- Extra-oral shots
- Frontal face - Lateral profile (right and left).
- 45 profile (right and left)*

ii- Intra-oral shots

- Occlusion (frontal) - Occlusal view (affected arch only)
- Occlusion (side view), right and left. - Maximal opening
- Protrusive position - Lateral excursion (right and left)*.

C- TMJ
- As in fracture cases.

D- Miscellaneous

2- Orthodontics
- As in oral surgery for patients undergoing osteotomy operations

3- Fixed prosthetics
A) Intra-oral
- Occlusion (frontal) - Occlusal view (affected arch only)
- Occlusion (side view), right and left.

4- Implantology
A- Intra-oral
- Occlusion (frontal) - Occlusal view (affected arch only)
- Occlusion (side view), right and left.

5- Miscellaneous

45
Definitions
Aberration: failure to collect light beam in he same focus. [p 9]

Achromatic lens: a lens that can collect red and blue wave lengths in the same focus
point. [p 10]

Aperture: diameter of lens opening allowing light to pass through. [p 11]

Apochromatic lens: a lens that can collect red and blue and green wave lengths in the
same focus point. [p 10]

ASA: A number set by the American Standards Assoc., which is placed on film stock to
measure sensitivity to light. (not used now)

Basic colors: Red, Blue, Green (identified by visual receptors of the eye) [p 4]

Brightness: amount of light reflected b the object. [p 20]

Complementary colors: Cyan, Yellow, Magenta (colors opposite to basic colors). [p 5]

Contrast: difference between dark and light areas of the image. [p 21]

Deflection: deviation of light beam from its straight course when passing in two different
media (air and water or air and camera lens). [p 4]

Depth of field (DOF): part of the image lying in sharp focus. [p 18]

Digital photography: it is electronically capturing and producing images using a charge-

couple device (CCD). [p 30]

DIN: DIN, an acronym for the German Deutsches Institut fr Normung (German
Industrial Standard), found 1917 (German measure for film sensitivity).

Flash guide number: light intensity produced by a flash unit. [p 12]

Focal Length: the distance between focus point and center of the lens when the distance
scale is set at infinity ().[p 8]

Focal plane: the point at which the distance scale is adjusted. [p 19]

Focus point: the point at which the sharpest image is formed. [p 8]

Ghost image: secondary image produced by a rear-surface glass mirror. [p 14]

Hue (color balance): the most dominant wave length (color) in an image. [p 24]

46
ISO: Used for film sensitivity calibration in all digital cameras established by
International Standards Organization. [37]

Lens: Special apparatus which collects light in the focus point. [p 8]

Macro photography: The ability to get closer to the target object. [p 33]

Optical image quality: image quality related to optical bases. [p 18]

Optical zoom: ability of a zoom lens in a digital camera to actually magnify the target
object. [p 32]

Parallax: difference between two views of two lenses (range finder cameras) [p 6]

Photography: comes from the two Greek words: photos which means light and
graphos which means drawing. [p 1]

Pixel: the smallest unit in the CCD than can register data. [p 30]

Primary image: the image reflected by the reflecting surface of a mirror. [p 15]

Prime lens: is the lens that has a fixed focal length. [p 10]

Ring flash: circular flash unit mounted by screw in the lens. [p 13]

Sharpness: well defined boundaries of the image components. [p 18]

Shutter speed: time the shutter screen remains open to expose the film. [p 22]

SLR camera: Single Lens Reflex camera. [p 7]

Standard lens: a lens with focal length of 45-55 mm (has the same angle of vision of the
human eye). [p 10]

Technical image quality: image quality related to the skill of the photographer. [p 18, 25]

Tele-photo lens: a lens with focal length greater than 55 m (has narrower angle of vision
than the standard lens). [p 10]

Wide angle lens: a lens with focal length smaller than 45 mm (has wider angle of vision
than the standard lens). [p 10]

Zoom lens: a lens with interchangeable focal length. [p 10]

47
Some hints and tips
- Obtaining pure gray color in the image means all other colors are
balanced to natural colors as in real (which has important
indication in image interpretation).
- Metal retractors were used in the past as they could be sterilized
and autoclaved but recently plastic retractors are made of
autoclavable materials.
- Brightness is related on film exposure to light, while contrast is
related to film processing.
- Intraoral photographs (still objects) needs close up position of the
camera and telephoto lens (macrophotography), so the depth of
focus will be shallow and critical, so compensation of light change
should be by adjusting the aperture on the expense of shutter speed
which increases depth of focus. On the other hand photographing
moving objects dictates increasing shutter speed on the expense of
aperture value to obtain fixed object in the image.
- It is important to notify here that shutter speed has no effect on the
amount of light received by the film when using snap light source
as the flash releases the light in a speed much greater than any
available shutter speed (flash can reach a release speed of 1/30,000
of a second). On the other hand, shutter speed may affect the image
in other way if it is not synchronized with the light release from the
flash, i.e., the flash should release the light when the shutter screen
is fully opened. Synchronization failure may produce a partially
illuminated image (only part of the image is illuminated).
- Obtaining natural colors of the object in the image is important as
colors have some indications describing the clinical situations for
example the image of an inflamed gingival should have reddish
hue to simulate the natural situation.
- For digital cameras it is advisable to use the original lithium
battery (rechargeable) supplied with the camera, or if the camera
uses the AA size batteries, it is recommended by most camera
manufacturers to use rechargeable batteries as it is the best for
protecting the electric circuits from electric shocks. Do not
recharge non-rechargeable batteries as leakage may occur
damaging the internal parts of the camera. Keep your camera away
from dust, fluids and deposits to protect it from damage. If the
camera is not going to be used for more than 1-2 weeks, it is
advisable to remove the batteries.

48
- Warming the intraoral photographic mirrors will help avoiding
fogging (specially in cold weather), but dont overheat the metal
mirrors (warm it from the rear surface not the glazed front surface).
- Dont use wide angle lens with close up photography as it will
cause dimensional distortion (elongation of the middle third and
compression of the peripheral 2/3).
- Reflective background may not only disturb the vision, but may
also lead to dark image (as it may disturb the function of the
exposure metering system).
- Blurred image may be due to incorrect focus adjustment, but may
also occur even with autofocusing system if the working distance
is beyond the autofocusing system limits.
- Blurred image may also occur when using continuous light source
if the shutter speed is too slow (less than 1/125) specially, if the
camera isnt mounted on a tripod.
- When photographing highly reflective objects (metal partial
denture base, orthodontic brackets, metallic hand instruments,)
a light system composed of indirect light sources is better than
using single flash unit as a light source, even if it is a ring flash (it
may make produce highly reflective surface of the reflective
objects)

49
Practical Dental Photography

Prepared by
Dr. Ahmad S. Hashem
Director of Practical Dental Photography

e-mail: ahmadhashem41@yhoo.com

Facebook group
Dental Photography
https://www.facebook.com/groups/dentalphotography/

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