SPECIAL ARTICLES

Standardized portrait photography for dental patients

Lewis Claman, DDS, MS, Daniel Patton, BA, RBP, and Robert Rashid, DDS
Coh~mbus, Ohio

Photography is becoming an increasingly important tool in the dental profession. But documentation
of orthodontic or orthognathic treatment with pretreatment and posttreatment photographs can be
misleading if features on one or both photographs are distorted. The dental photographer must be
constantly aware of the importance of standardizing photographic variables when documentation of
change is important. Although total reproducibility may not be practical, the photographer can
establish a reasonably standardized approach to photographing patients. In this article the authors
present the major considerations for frontal and profile facial photographs. Lens selection, camera
position, subject distance, and position are all variables to be understood and controlled if accurate
reproduction is desired. Numerous frontal and lateral photographs were made with head position,
camera position, jaw position, and lens focal length changed to allow assessment of their
contribution to the final picture. Using easily recognized facial landmarks, dental photographers can
standardize frontal and lateral portraits for more consistent comparison. (AMJ ORTHODDENTOFAC
ORTHOP 1990;98:197-205.)

D e n t a l photography incorporates documen- Several recent articles have described methods of

tation of the position of teeth and supporting structures, obtaining facial photographs. Freehe, ~ Gordon and
radiographs, casts, and small objects. This article will Wander,2 and BengeP reviewed general principles of
focus on principles for standardizing frontal and lateral facial photography in which they described the standard
profile photographs of patients. views and gave general principles of head position,
There are several specialties and treatment modal- camera position, and lighting. Williams4 described po-
ities within dentistry for which portraits are essential sitioning and lighting for several features, including the
records. The most obvious need for this type of pho- face, and provided specific anatomic references for head
todocumentation is for patients who will be having position. Larrabee, Maupin, and Sutton5 described
orthodontic treatment, orthognathic surgery, or maxil- methods of photogrammetry, while Farkas, Bryson, and
lofacial prostheses. These photographs are important in Klotz6 used profile analysis.
dental education, in patient education, and in providing The purpose of this article is to help the dental
a legal record of facial features before and after dental photographer understand the effect of several photo-
treatment. graphic principles on the photographic end product and
In many cases, a dentist, and not a formally trained to provide easily reproducible references for standard-
biomedical photographer, performs the photographic izing frontal and lateral profile facial photographs. Al-
procedures. If the practitioner does not follow a rea- though lighting techniques are important, this article
sonably standardized protocol, it is likely that the in- will deal principally with variables inherent in distance,
dividual photographs, as well as the comparison of pho- camera position, and head position.
tographs taken before and after treatment, will fail to
HEAD POSITION
provide an accurate representation of the actual ana-
tomic features and their relative proportions. This dis- Although it is impossible to reproduce photographs
tortion may work in the dentist's favor and show cos- with assured accuracy, it is clinically possible to pro-
metically pleasing changes that never occurred; it may duce consistent results that are useful for comparisons.
work in the opposite way by failing to show improve- Ideal frontal and profile photographs (shown in Figs.
ment that may have actually taken place; or it may even 1A and 2A), along with line drawings (Figs. 1B and
show an apparent worsening of features. In each case, 2B) of these photographs, will be the basis for com-
the documentation would, at best, be legally inadmis- parisons of head position, lens focal length, distance,
sible or, at worst, be damaging to the dentist. and camera position discussed throughout this article.
An understanding of the effect of variables on a
From the Colleges of Dentistry and Veterinary Medicine, The Ohio State photograph requires familiarity with certain anatomic
University.
811113044 references. Although the use of these references does
197
 Am. J. Orthod. Dentofac. Orthop.
198 Claman, Patton, and Rashid September 1990

B \ A J
Fig. 1B. Sketch of ideal head position for frontal view. A, outer
Fig. 1A. Ideal head position and perspective for a frontal view. canthus to superior attachment of the ear (C-SA line); B, inter-
Lens = 105 mm focal length. pupillary line; C, encompassing area (crown to collarbone). The
line from the outer canthus of the eye to the hairline is super-
imposed over the C-SA line and is not specifically labeled in
this diagram.
not provide compensation for anatomic variations such
as facial asymmetry, they assure consistent pretreatment
and posttreatment head position. in frontal and lateral views. 4 Another established
For frontal views, the photographic frame should method for head orientation was termed by Broca in
encompass the crown of the head and clavicle. Distance 1862 as natural head position. Broca defined this po-
is frequently fixed, with the camera and subject at a sition in the following way: "When a man is standing
constant, reproducible distance. This assures consistent and when his visual axis is horizontal, he (his head) is
perspective for all subjects and similar reproduction in the natural position". 8 This has been shown to be a
ratios and subject-to-camera distances. For the dentist reproducible position. 9 Larrabee 5 has used it for facial
who does not need to establish consistent distances and profile analysis. Cooke et al. '° have combined natural
magnifications, encompassing crown to clavicle is a head position with the true horizontal for cephalometric
convenient method of standardizing the portraits in the analysis and have shown a highly reliable method of
adult patient. However, for treatment documentation analyzing craniofacial form. Although natural head po-
over a period of years during growth and development, sition reproducibly relates the patient to the horizontal
it is best to establish a constant distance at one-eighth plane, it does not establish references for the patient
magnification and not rely on encompassing area alone. with respect to the camera; nor does it easily permit
The interpupillary line should be parallel to the hor- photographing the patient in the dental chair or in other
izontal plane. The distance from the outer canthus of nonstanding positions.
the eye to the hairline should be equal on each side. The profile view should also encompass crown to
The line from the outer canthus of the eye to the superior clavicle, and the C-SA line should be parallel to the
attachment of the ear (C-SA line) should also be parallel horizontal plane. There should be a consistent eye-to-
to the horizontal plane. This line, which parallels the nose relationship. For a true lateral profile, this rela-
Frankfort horizontal, is a consistent, practical, clinical tionship is established by making certain that the inner
anatomic reference (Fig. 1). 7 Both lines are used to and outer aspects of one eye are visible, the structures
establish consistent parallelism between the eyes and of the other eye are hidden, and the nose appears to be
the horizontal plane and to prevent tilting of the head more distant than and anterior to the eye (Fig. 2).
Volume 98 Special article 199
Number 3

Fig. 2B. Sketch of ideal head position for lateral view, showing
Fig. 2A. Ideal head position and perspective for a lateral view. outer canthus to superior attachment of ear (A) and encom-
Lens = 105 mm focal length. passing area of crown to collarbone (C).

IB
Fig. 3. Distorted view caused by backward tilt of head. The chin appears prominent, particularly in the
lateral view.
 Am. J. Orthod. Dentofac. Orthop.
200 Claman, Patton, and Rashid September 1990

Fig. 4. Distorted view caused by forward tilt of head. The chin appears to be receded.

the edge of the eyebrow on the other side. 1'2"n This

position compensates for the illusion in a straight profile
that the head is turned away from the lens.
When consistent head position is not reproduced,
distortion of appearance is likely. A backward head tilt
gives a prognathic appearance, particularly in the profile
view (Fig. 3). A forward head tilt gives a retrognathie
appearance (Fig. 4). Head rotation alters the appearance
of symmetry in frontal views (Fig. 5).
CAMERA LENS AND POSITION
Perspective (viewpoint) is determined by the dis-
tance between the subject and the film plane. If the
reproduction ratio is held constant and lenses of dif-
ferent focal lengths are used, the distance from camera
to subject will be determined by the focal length of the
lens. A wide-angle lens requires close subject-to-film
plane distances to fill the field and results in viewpoint
distortion known as barrel distortion, with enlargement
of the chin and nose, elongation in the anteroposterior
dimension, and excessive curvature laterally (Fig.
Fig. 5. Lateral head rotation. The view is not symmetrical. The
6, A). A slight telephoto lens (ideally I00 mm or
distance from outer canthus to hairline is not equal on both 105 nun for 35 mm cameras) provides the best per-
sides, spective (Fig. 1A). An extremely powerful telephoto
lens creates compression-type distortion, with nearer
In profile views, several lateral rotation (side-to- subjects appearing smaller, shortening in the antero-
side) head positions have been recommended. Some posterior dimension, and excessive flattening of fea-
dental photographers recommend that the patient's face tures (Fig. 6, B). The best way to standardize facial
be rotated 3° to 5 ° toward the camera lens, revealing portraits is to keep the focal length of the lens the same
Volume 98 Special article 201
Number 3

Fig. 6. A, Viewpoint distortion caused by a 35 mm wide-angle lens. The camera-to-subject distance

was diminished, causing barrel distortion. B, Viewpoint distortion caused by 300 mm telephoto lens.
The camera-to-subject distance was increased, causing compression distortion.

E
Fig. 7. Distorted view caused by incorrect camera position. A, Camera too high; B, camera too low.
 Am..L Orthod. Dentofac. Orthop.
202 Claman, Patton, and Rashid
September 1990

. . . .

Fig. 8. Three mandibular positions shown in lateral views. Differences between each of the positions
are easily discerned. A, Centric relation; B, centric occlusion; C, extreme protrusive position.

(100 m m or 105 mm) and have consistent subject-to- the middle of the lens to the eye is parallel to the
camera distances. Ideally, the camera can be mounted horizontal plane (Figs. 1A and 2A). If the camera is
on a tripod and the same distance used each time the too high, the head will appear to have a forward tilt
patient is photographed. (Fig. 7, A). If the camera is too low, the head will
Ideal camera position is one in which a line from appear to have a backward tilt (Fig. 7, B). Centering
Volume 98
Number 3 Special article 203

Fig. 9, A, B. Two mandibular positions shown in frontal view. Differences between the two extremes
are difficult to discern. A, Centric relation; B, extreme protrusive position.

iA ...... ~ i ~°
Fig. 10. Variations in head position mask true changes in jaw position. A, Extreme protrusive position
with a forward head tiff; B, centric relation position with backward head tilt.
 Am. J. Orthod. Dentofac. Orthop.
204 Claman, Patton, and Rashid September 1990

I B
L
Fig. 11. Variations in head position accentuate true changes in mandibular position. A, Extreme
protrusive position with backward head tilt; B, centric relation position with forward head tilt.

the lens between both eyes will result in equal space 10, B). Conversely, actual changes in jaw position can
visible between hairline and outer canthus of the eye be accentuated through nonstandardized photographic
on both sides. techniques. An extreme protrusive jaw position with a
backward head tilt (Fig. 11, A) emphasizes a prognathic
CHANGES IN MANDIBULAR POSITION appearance, whereas a retruded jaw position with a
The orthodontist, the oral surgeon, and the pros- forward head tilt (Fig. 11, B) accentuates a retrognathic
thodontist frequently must show accurate pretreatment appearance.
and posttreatment portrait photographs. To illustrate the
SUMMARY
importance of standardizing photographs and to simu-
late changes in jaw position, vinyl polysiloxane occlusal The dental photographer must be constantly aware
records were made and used to record jaw positions. of the importance of standardizing photographic vari-
Five different occlusal positions from centric relation ables when documentation of change is important. Al-
to past end-to-end (extreme protrusive position) were though total reproducibility may not be practical, the
recorded and photographed in frontal and lateral views. photographer can establish a reasonably standardized
These positions encompassed a range of 7.5 mm. The approach to photographing patients. The documentation
photographs show that, in terms of recording differ- of orthodontic or orthognathic treatment with pretreat-
ences, the lateral view is far more sensitive than the merit and posttreatment photographs can be misleading
frontal view. It is possible to observe differences of as if features on one or both photographs are distorted. In
little as 1.8 nun in the lateral view (Fig. 8), while this article, we have presented the major considerations
differences of as much as 7.5 mm were difficult to for frontal and lateral facial photographs. Numerous
observe in the frontal views (Fig. 9). frontal and lateral photographs were made in which such
When the clinical photographer does not standardize variables as head position, camera position, and lens
distance, head position, and camera position, confusing focal length were changed to allow assessment of their
or misleading photographs are likely to result. An ex- contribution to the final picture. Using easily recognized
treme protrusive position with a forward head tilt (Fig. facial landmarks, the dental photographer can stan-
10, A) is somewhat difficult to distinguish from a re- dardize frontal and lateral portraits for more consistent
truded jaw position with a backward head tilt (Fig. comparisons.
Volume 98
Number 3 Special article 205

REFERENCES 9. BeanLR. KramerJT, Khouw FE. A simplifiedmethod of taking

1. Frehee CL. Dental photography. Funct Orthod 1985;2:34-44. radiographs for cephalometric analysis. J Oral Surg 1970;28:
2. Gordon P and WanderP. Techniquesfor dental photography. Br 675-8.
Dent J 1987;162:307-16. 10. CookeM, Wei S. A summaryfive-factorcephalometricanalysis
3. Bengel W. Standardizationin dental photography. Int Dent J based on natural head posture and the true horizontal. Axl J
1985;35:210-7. ORTHODDENTOFACOR'I-HOP1988;93:213-23.
4. Williams R. Positioning and lighting for patient photography. 11. Stutts W. Clinical photography in orthodontic practice. A.',I J
J Biol Photogr 1985;53:131-43. Oaaalon 1978;74:1-31.
5. Larrabee W, Maupin G, Sutton D.: Profile analysis in facial
plastic surgery. Arch Otolaryngol Head Neck Surg 1985; Reprint requests to:
111:682-7. Dr. Lewis Claman
6. Farkas L, Bryson W, Klotz J. Is photogrammetry of the face Section of Periodonties
reliable? Plast Reconstr Surg 1980;66:346-55. Ohio State University
7. Davidson T. Photography in facial plastic and reconstructive College of Dentistry
surgery. J Biol Photogr 1979;47:59-67. Postle Hall
8. Moorrees CF, Kean MR. Natural head position:a basic consid- 305 West 12th Ave.
eration in the interpretationof cephalometricradi~raphs. Am J Columbus, OH 43210-1241
Physiol Anthropol 1958;16:213-34.

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