American Journal of ORTHODONTICS

Volume 74, Number I July, 1978

ORIGINAL ARTICLES

Clinical photography in
orthodontic practice
William F. Stutts, D.D.S.
Dallas, Texas

The equipment used and referred to in this article is a clinical camera which
comprises a 35 mm. camera body with a through-the-lens meter, an automatic bellows, a
180 degree rotating bracket that supports a small strobe light which has the capacity to
produce an exposure guide number of 35 to 40 for a film with an ASA exposure index of
25. The 35 mm. format lens is a 100 mm. short-mount lens. Since a short-mount lens has
no focusing capability, it must be used on a bellows in order to focus the lens. Most
photographs are taken at f/22 at a distance of 9 to 12 inches for intraoral views and f/8 at a
distance of 4.5 to 5 feet for facial view. If the facial photographs are taken at 4.5 feet from
subject to film plane, a 2~ print from a slide will produce quarter-size color prints.’
True macro lenses are available in 100 mm. focal length. There are many items more
delicate and expensive than camera lenses and bellows in an orthodontic office. Minimum
care of the equipment is required. Auxiliary personnel can be instructed in good photo-
graphic technique without concern. When the basic concepts and procedures are tried and
validated, the person taking the photographs will develop the confidence required to
routinely produce clinical photographs of superb quality without apprehension.
The types of cameras that can be used for clinical photography include the Unitek
orthoscan camera, Polaroid cameras, 35 mm. single-lens reflex with 100 mm. macro or
100-105 mm. short-mount lenses on an automatic bellows, and single or twin-lens reflex
cameras which use size 120 film and 150 to 180 mm. lenses (Fig. 1).
The easiest intraoral camera to use is the orthoscan camera. It produces a I : 1 ratio in a
properly oriented perspective (right is right, left is left) of full upper or full lower arches
on Polaroid film only. Polaroid type 107 film yields a 15-second black and white print.
Polaroid 105 film presents a black and white print in 60 seconds, plus a black and white
negative which has to be cleared in sodium sulfite solution, washed, and dried. Polaroid
108 film produces a color print in 60 seconds. The orthoscan camera has a self-contained
erecting prism, light, and lens assembly which has a flat lens table as part of its design.
This lens table is placed over the upper or lower arch. When the shutter is released, a
scanning device photographs a full arch with a 1 : I ratio on the film. The main advantages
of this type of camera are the convenience of seeing the result within a few seconds, ease
of operation, and compact design. There are a number of indications for an orthoscan
002.9416/78/0174-~1$03. IO/O 0 1978 The C. V. Mosby Co. 1
 Am. .I Orrtwd.
Ju/y 1978

Fig. 1. A, Orthoscan camera. B, 100 mm. macro lens with ring-and-point light source. C, 100 mm.
short-mount lens and bellows with rotating point light source.

camera in an orthodontic office: occlusal surface photographs, arch map for indirect arch
wires, follow-up record of varied tooth movements, rapid method of recording tooth
eruption on observation cases, copies for third party, and copies of occlusal surfaces of
models.
The currently available instant film cameras from Kodak and Polaroid are convenient
to use in an orthodontic office. An instant picture can be used for patient identification on
charts, and, it can be used to validate and identify any other photographs taken which must
be sent to a photofinisher to obtain prints or slides. With the exception of the Polaroid 195
series camera, the lenses on these cameras are not of the highest quality. Close-up
attachments do permit facial photographs for identity of patients. However, distortion is
evident.
The most frequently used clinical camera employs a 35 mm. format. The camera body
should be of the single-lens reflex type. Persons with astigmatism should check for
variable and interchangeable view finders so that viewing is easier and clearer. Most 35
mm. single-lens reflex cameras have behind-the-lens meters. Such a meter is not used with
strobe lighting; however, a behind-the-lens meter is useful in copy-stand photography
with photoflood or available light compositions.
Most professional photographers advocate the use of a lens with a long focal length for
superb photographs with good perspective and minimum distortion. The recommendation
Volume 14
Number 1 Clinical photography in orthodontic practice 3

is to use a lens which has a focal length of two to two and one half times the diagonal of
the size of the film used. A 100 to 105 mm. focal length lens satisfies this rule for 35 mm.
film, as the diagonal of 35 mm. film is 45 mm. A 180 mm. focal length lens for 2% format
is also proper as the diagonal of 2% by 2% film is 78 mm. A longer focal length lens also
permits more room to direct the light.2
There are two basic types of lenses for 35 mm. cameras in the 100 to 105 mm. focal
length range. One type is the true 100 mm. macro lens. This lens consists of a helical
focusing mount and can produce a photograph with a ratio of 1 : 1 to infinity with good
results. The other type of telephoto lens is the 100 mm. or 105 mm. short-mount lens. A
short-mount lens has no focusing ability, so a bellows must be attached between the lens
and the camera body. This also permits 1 : 1 to infinity focusing without additional attach-
ments. Either the 100 mm. macro lens or the 100 or 105 mm. short-mount lens/bellows
should have automatic features. This means that the lens will be opened at the widest
aperture while focusing, but the shutter will automatically close or stop down the lens to
the predetermined f stop when the exposure is made.
Intraoral focusing is frequently difficult, especially when mirrors are used. Therefore,
the full aperture of the lens needs to be used when one is focusing and viewing. The lens
must stop down to f/ 16, f/22, or f/32 for balanced exposure to the film and light combina-
tion and for maximum depth of field. Depth of field is a range of sharpness which is one
half in front of and one half behind the area focused on intraorally. In most instances the
total depth of field is only several millimeters. It is therefore necessary to use a small lens
opening or a high f stop (f/ 16 to f/22). A 55 mm. macro lens with a ring light produces
good intraoral views but presents distortion of facial photographs at a 5 foot distance3
(Figs. 1 and 2). The source of light can be an electronic strobe, either combined ring-point
or rotating point. Photoflood lamps (either flood or spotlight type), daylight, and, on
occasion, halogen quartz bulbs are convenient and dependable.
The type of lighting used must be color balanced with the type of color film used (not
applicable if black and white film is used). Manufacturers of light equipment and film state
the specific Kelvin degree requirements for matching light and film.4 Color-compensating
filters can be placed over the lens or more economical color-printing gel filters can be
placed over the light source to adapt and adjust the color hues to the individual’s choice
and preference. Filter gels placed over the light source will change the value of the light to
enhance and correct the color shift so apparent in most color slide materials currently
available. Filter gels are not as color stable as the glass filters, so the gels must be changed
occasionally.
Frequently the color temperature (degrees Kelvin) of strobe lights varies from warm to
cool, so that each light has to be tested and color balanced to the color film used. Two
types of electronic strobe lights are frequently used on clinical cameras. One is a ring light
which has a variable light-intensity adjustment and operates on AC current. The other type
is the small portable strobe light. AC current, batteries, or rechargeable batteries provide
the source of electric power. The small rectangular stobe light is mounted on a bar or on a
180 degree movable bracket at the front of the lens mount and angled slightly toward the
center of the lens. The rotating bracket permits placement of the light in a number of
positions in a 180 degree arc around the lens. This type of lighting is called point or side
lighting. One manufacturer has available a ring light which is attached to the lens, plus a
very accurate but delicate side or point light which moves in a 180 degree arc around the
 Am. J. Orihod.
4 Stutts July 1978

Fig. 2. A, Twin-lens 120 format camera with 180 mm. focal length lens. 8, Full arch taken with
Orthoscan camera.

ring light.” If desired, the addition of a ring-point light permits upgrading of other, older
ring lights to a current model, as the adjustable AC power supply is interchangeable with
the earlier ring light models. If cost is a factor or if a rotating mount is not readily available
for the regular rectangular portable strobe light, a fixed mount for the light can be
fabricated without difficulty. A flat bar can be mounted at the bottom of the bellows and
extended beneath and to either side of the lens. The bar should have a shoe mount on
either side of the bar in order that the light can be changed from one side of the lens to the
opposite side. A more primitive arrangement has the light mounted on only one side of
and even with the lens. The entire camera is turned over in order that the light can be on
the side of the lens desired for photographing different intraoral areas. The inconvenience
of some slides being returned upside down is offset by the solidarity of the light attach-
ment and standardized procedures in clinical photography. If required, a rotating light
bracket can be added at any time desired.6
It is rarely necessary to have a point light on the lens axis in a position other than to the
left (9 o’clock) or to the right (3 o’clock) of the lens. Facial photographs are taken with the
camera in the vertical format, with the light in the position which places the shadow
behind the head. If a ring light is used, no rotation of the light is required unless the point
light which rotates around the ring light assembly is used.
Some authors have varying opinions about the difference in the theory of ring light and
point or side light illumination. The combination ring-point light is a versatile lighting
concept under the exacting control of the operator. The main differences are that ring
lights illuminate cavity areas evenly, without shadows, but point lights provide better
modeling or form by creating shadows. Different areas of a ring light can be marked with
Volume 74
Number I Clinical photography in orthodontic practice 5

Fig. 3. A, Copy stand with models supported on glass to control shadows. B, Camera with 100 mm.
short-mount lens, lens shade, and bellows.

aluminum or black opaque slide-binding tape to produce more directional lighting if

desired.7
Photoflood lamps have a definite place in clinical photography. Usually No. 1 or No. 2
3400 degree or 3200 degree Kelvin photoflood lamps are used for illumination in copying.
If photoflood lamps are used, the correct color film balanced for tungsten light or
filters over the lens must be used. One of the disadvantages of photoflood lamps is that a
lot of heat is produced. Photoflood bulbs have a short life and loss of proper color
temperature occurs rapidly with aging of the bulb.
Reflector flood lamps are useful when black and white or radiographic duplicating film
SO 185 is used. There is less heat and longer bulb life. When such lamps are used with
color film, added filtration is needed to correct the color balance. Test exposures must be
made and calibrated for color balance if regular reflector flood lamps are used with any
color film. Usually, the manufacturer’s notice that is packaged with each roll of film is
accurate and reliable.
In some climates, daylight or sunlight is useful for illumination in copying procedures.
Although care must be taken to prevent the light from flaring into the lens, a lens hood will
usually prevent this.
The halogen quartz light source can be color corrected and has a long life. Halogen
lights are currently readily available as small portable movie lights. Such a lamp can be
bounced off a ceiling or used in an umbrella for directing a soft, even illumination to the
 Am. J. Orthod.
6 Srurrs July 1978

Fig. 4. A, Black-light fluorescent tubes beneath white plastic for illumination in duplicating radiographs.
B, White card at 4.5 degrees with strobe light illumination to direct a bounce-light effect up through white
plastic for copying radiographs and tracings.

facial features. If an umbrella lighting system with a movie light shining into the umbrella
is used, the effect of the light can be seen and adjusted to produce the desired lighting
effect in facial photography. Halogen quartz light bounced off a white ceiling is not
distracting and permits the effect of the light to be viewed before exposure. Two halogen
lamps can be used for copy-stand illumination, although the amount of heat produced is a
disadvantage.

Film selection8
The following films are available:
A. 35 mm. black and white
1. Panatomic-X (negative)
2. Plux-X Pan (negative)
3. Radiographic duplicating SO- 185 (positive)
4. Direct Panchromatic 5246 (positive)
Volume 74
Number I Clinicul photography in orthodontic practice 7

B. Size 120 black and white

1. Panatomic-X (negative)
2. Plus-X Pan (negative)
C. 35 mm. color
1. Kodachrome 25 (positive), daylight or strobe
2. Kodachrome 64 (positive), daylight or strobe
3. Ektachrome 200 (positive), daylight or strobe
4. Ektachrome 160 (positive), tungsten illumination
5. Ektachrome 50 (positive), tungsten illumination
6. Ektachrome 64 (positive), tungsten illumination
7. Vericolor II type S (negative), daylight or strobe
8. Kodacolor 400
D. Size 120 color
1. Ektachrome 200 (positive), daylight or strobe
2. Ektachrome 50 (positive), tungsten illumination
3. Ektachrome 64 (positive) daylight or strobe
4. Vericolor II type S (negative), daylight or strobe
5. Kodacolor 400
E. Instant
I . Polaroid color 108, ASA 75
2. Polaroid 107, ASA 3000
3. Polaroid 105, ASA 75 (produces black and white print plus same-size
black and white negative)
4. Kodak instant color
Black and white film can be used to great advantage in orthodontic clinical photogra-
phy. Photographs of plaster casts made on black and white positive film can be projected
as slides similar to color slides. Photographs of flat copy can be made on negative or
positive black and white film. The use of a copy stand with the ability to see the effect of
the lighting is a realistic way to photograph plaster casts. Photographs of plaster casts can
be placed on the patient’s work card. This eliminates handling of the actual casts.
Since most publishers require black and white prints, the technique of making black
and white prints from color slides will be presented. Black and white film, either Plus-X or
Panatomic-X, is placed in the 35 mm. camera. A slide-copying attachment is placed on
the bellows rack. The color slide is cleaned with a camel hair brush and placed in position
with the emulsion (dull) side of the color slide toward the light source. The lens is focused
and the exposure is determined. The light source can be any of the types discussed
previously. If sunlight or tungsten lights are used, the behind-the-lens meter reading is
taken with the lens in the stopped-down position. The exposures are bracketed one f stop
on either side of the exposure meter determination. If strobe light is selected for illumina-
tion, a test roll with varying distances from the strobe illumination to the 35 mm. color
slide will be required. Once this is determined, a fixed distance permits standardization of
the exposure procedure (Fig. 5).
Another method of making black and white negatives from color slides is to use a slide
copy attachment. This is a tube which is usually nonadjustable, although adjustable tubes
are available. The lens is built into the tube so that the camera body holds the entire
apparatus. The cleaned color slide is placed in the slide carrier with the emulsion side
 Am. J. Orthd.
July 1978

Fig. 5. A, Slide-copying attachment using sunlight for light source. B, Print made from black and white
negative copied from a color slide.

facing the lens-tube assembly. The strobe light is placed at varying distances or a meter
reading is taken using other sources of light.3
In either of the two above-mentioned slide-duplication procedures, the black and white
negative, when processed by fine-grain developing procedures, may exhibit too much
contrast. If Panatomic-X film is used, an ASA index of 25 instead of the manufacturer’s
rating of ASA 32 can be used. The control of the contrast can be varied by intentional
overexposure of the film and underdevelopment of the negative. Either of these techniques
yields a black and white negative of a color slide. The black and white negatives are
contact printed on a sheet of photographic print paper. The contact sheet will show twenty
or thirty-six prints on one piece of paper. Cropping instructions can be drawn on the prints
with black wax pencil. The negatives are then printed conventionally by the enlargement
process to the required size on resin-coated paper which gives a glossy finish.
Many photofinishers will make a 4 by 5 inch black and white negative from a 35 mm.
color slide. The procedure requires that the color slide be placed in an enlarger with the
emulsion side down. The image is focused on a 4 by 5 inch film pack loaded with 4 by 5
inch sheet film. In effect, the 35 mm. color slide is enlarged to 4 by 5 inches on a black
and white negative. After the 4 by 5 inch negative is processed, the negative can be
contact printed to produce a 4 by 5 inch black and white print, or the 4 by 5 inch negative
can be enlarged conventionally to a black and white glossy print of the desired size. A roll
Volume 74
Number I Clinical photography in orthodontic practice 9

film back can be used much like a film pack if a smaller film format is desired, that is, 120.
Polaroid 105 print and negative film can also be used by projecting the slide onto the film
pack in the darkroom, replacing the film pack in a Polaroid camera, and carrying out the
conventional Polaroid technique for development. This method yields a semiglossy 3% by
4% inch black and white print, plus the same-size negative which must have the jellylike
developing chemicals cleared from it by rinsing in a 12 percent solution of sodium sulfite.
After clearing in the sulfite solution, the negative is washed and dried in the same manner
as a radiograph. The resulting negative can be contact printed or placed in an enlarger to
have projection prints made on glossy paper.
The direct method of obtaining black and white prints is to use black and white film for
the photographic exposures instead of a color film. If Panatomic-X is used with an ASA
index of 25, the exposures with the clinical camera are made with the same exposure data
as required for color film with an ASA index of 25.
If color-correction gels have been placed over the strobe light, or if any glass filters
have been placed over the lens, they should be removed when Panatomic-X (ASA 25) is
used to obtain the various views. In the event black and white plus color photographs are
desired, another camera body made by the same manufacturer can be used. The extra
camera body is loaded with black and white film. It takes only a few moments to remove
the lens and light filters and change camera bodies. Use of two camera bodies and one
lens-light assembly provides many advantages. There is some comfort in having an extra
camera body available if one of the mechanisms in the camera body fails and has to be sent
for repair.
With the current mobility of the patient population and the growing trend toward third
party benefits in orthodontics, additional requirements are placed on the orthodontist to
keep copies of patient records for professional and legal protection. Records can be lost or
misplaced in transit when material is sent to a third party or when a case is transferred.
Radiographs can be copied on color-positive or color-negative material or on black
and white film. A copy-stand technique can be standardized so that accurate photographic
copies of material to be sent out or retained as office copies can be obtained.
Radiographs are duplicated by placing the radiograph on an opal or frosted glass. Two
L-shaped pieces of mat board are adjusted to block out any extraneous light which comes
from below the frosted glass or plastic. A neater arrangement uses a regular cut-out mat
with openings ?J’S inch smaller than the area to be copied. The light source can be strobe,
fluorescent, or tungsten. The exposure using tungsten illumination is determined by read-
ing the through-the-lens light meter on a clinical camera at the stopped-down lens posi-
tion. Specific filters for balancing the type of light should be used for color film.
Although any 3.5 mm. film can be used for this copying procedure, a film made
especially for radiograph duplication is available in preloaded cassettes from Eastman
Kodak Company. The film is classified as SO 185 radiographic duplication film. The
instructions provided with the film are complete. There is no specific exposure index. The
recommended illumination is obtained by using black-light fluorescent bulbs. Contrast of
the duplicate radiograph in 35 mm. format can be enhanced by an additional exposure to
white light. Long exposure times of from 3 to 20 seconds are required. Small f stops
(wider lens openings) are used. The roll of SO 185 film is readily developed in con-
ventional dental x-ray chemicals. Individual 35 mm. x-ray duplicates can be mounted in
 Am. J. Orthod.
10 stutts July 1978

glass slide mounts to prevent buckling of the slides and projected much the same as
regular color slides. SO 185 film is the same type of duplication film that is currently used
to duplicate full-mouth radiographs, panoramic surveys, head films, and wrist films.
Radiographic duplicating film is available in sizes ranging from 8 by 10 inches to 5 by
I2 inches. One-to-one size black and white positive slides can be made from 35 mm. color
slides by placing the color slides in contact with a piece of duplicating film in the
appropriately sized contact printing frame and exposing the sandwich of slides and dup-
licating tilm to a regular x-ray illuminator. Black-light fluorescent bulbs yield a truer
duplicate. The exposure for head film duplication is usually 12 seconds at 3 feet, using an
illuminator with 32 watts of white fluorescent light. Although placing the emulsion side of
the slide to the emulsion side of the duplicating film and developing is done under
safelight conditions, the exposure can be made under white-light conditions. After expo-
sure of the duplicating film, regular x-ray processing chemistry procedures provide an
accurate duplicate radiograph. Duplicating boxes using black light and accurate timers are
readily available and deliver consistent results” (Fig. 4).
Direct Panchromatic 5246 positive film can be used to make contact prints of a black
and white negative and ultimately provide a positive black and white slide for projection.
If a positive black and white slide is desired, a simpler method is to use Panatomic-X film
and have it developed in reversal chemistry. Instead of a black and white negative, a black
and white positive is produced.
Size 120 films that are useful in orthodontics are Plus-X for black and white and
Vericolor II for color prints of full-face and profile views. There is little indication for 2%
inch color slides.

instant films
Polaroid provides two useful black and white film formats-type 107 for prints and
type 105 for prints plus a black and white negative. Polaroid color prints can be enlarged
as prints or reproduced by Polaroid Corporation into 35 mm. slides for projection. For 35
mm. slides, color photographs can be copied with the clinical camera. Eastman Kodak
Company now has color instant film available.
As Kodak Kodachrome II film is no longer available, it has become necessary to use
Kodacolor II negative material, Vericolor II type S negative material, Kodachrome 25,
Kodachrome 64, or Extachrome-X. If enough film of the same manufacturer’s emulsion
number with a long expiration date is purchased, one roll can be tested in order that the
proper filtration can be determined. Kodachrome 25 usually requires a CC 10 green to CC
10 yellow filter gel over the light. Kodachrome 64 requires a CC 20 yellow, plus a 0.4
neutral density filter over the light source which has a guide number of 40. A 1A filter is
placed over the lens. The amount and type of filtration can vary with the brand of strobe
light. 2. 8, 10
Ektachrome 64 requires a neutral density filter of 0.4 over the light to reduce the
intensity and sometimes an 80A or 80B filter over the lens. Neutral density filters can be
eliminated if the strobe light has the capability of being moved back from the lens or
partially masked with photographic black opaque tape to reduce the intensity. The purpose
of a neutral density filter is to reduce the intensity of the light so that f stop settings for
maximum depth of field (f/ 16 to f/22) are still applicable for ASA 64 film. The ring-point
light combination has a variable dial to adjust the intensity of the light. The purpose of the
Volume 14
Number I Clinical photography in orthodontic practice 11

Fig. 6. Four photographs demonstrating use of pretreatment and posttreatment plaster casts. Before-
and after-treatment views taken together on one frame of 35 mm. film.

color-correction filters is to change the color temperature of the light source to better
balance the light and the film for a more accurate color rendition. When a color film is
properly exposed to a balanced light, the density, clarity, contrast, crispness, and detail
are dramatically improved. If large amounts of film are purchased, the film should be
stored in a refrigerator. Film stored in a refrigerator remains inert; however, it should be at
room temperature before it is used.
In order that one batch of film can be calibrated, one roll of film is exposed without
color filtration, using varying distances and f stops. A written notation should be made of
each frame exposed.
After the film is processed, mounted, and returned, the slides are placed on a color-
corrected viewbox or viewed by sunlight reflected on the white side of a Kodak Gray
Card. The different hues and colors of color-printing filter gels are rapidly passed over the
slide. When the eye perceives the desired color, that specific colored filter gel is cut and
taped over the strobe light source. The color-correction gel will balance the color of the
strobe light to the film. The addition of filtration to a strobe light source sounds more
complicated than it is. The procedure can be done in less time than it takes to write about it
explicitly.2, ”
One of the best ways to determine the effects of light is to spend some time taking
photographs with the use of a copy stand. The type. direction. and intensity of illumina-
tion are some of the critical factors in good photographic technique. The control and
choice of the type of light can be determined by copy-stand photography. It is difficult to
hold a fairly heavy camera with one hand and a strobe light off the camera with the other
hand. Although acceptable photographs of dental casts can be obtained with one strobe
and a white reflector, the use of two light sources enhances the modeling, pattern, form,
and shape of the object being photographed. Delegation of a specific photographic proce-
dure is routine. Using the proper equipment, a person taking the varied photographic
 Am. .I. Orthod.
Julv 1978

Fig. 7. A, Right-side profile. B, Left-side profile. C, Frontal. D, Smiling. Umbrella light source with slave
strobe light on a white background.

views can follow a minimum of instructions and routinely produce highly acceptable
photographs.
Although a number of different types of cameras, films, and film formats have been
presented in this article, it is not necessary that any specific camera be used for clinical
photography. There is no one universal system. The eye is very flexible; therefore,
different persons properly agree or disagree on color density, hue, composition, and
lighting.
The size of the film to be used depends upon the size of the camera used. The choice of
instant film is determined by the desire for black and white or color prints available within
seconds after the exposure. Most photographs in black and white can be taken in either 35
mm. or 120 sizes, using Panatomic-X to obtain a negative. By the process of enlarging, a
black and white print will be obtained. Radiographic duplicating film SO- 185 delivers a
positive black and white photograph which can be projected. A versatile color film used in
35 mm. or 120 format is Vericolor II type S, which yields a negative. Color slides, color
prints, and black and white prints can be produced from a Vericolor II type S negative.
Volume 74
Number I Clinical photography in orthodontic practice 13

Fig. 8. A, Patient‘s right-side profile. B, Left-side profile. C, Frontal view. Umbrella and slave light on
background used in A, B, and C. D, Note more contrast and shadow behind the head with srru& lioht
on camera on left side of lens. Slave strobe was used on background also.

Kodachrome 25, Kodachrome 64, or Ektachrome 64 is usually used for intraoral clinical
photographs. Ektachrome SO is used for copy-stand procedures with photoflood or
tungsten illumination.
Photographs of the profile and the full face are usually taken at 4% to 5 feet from the
subject. These photographs may be taken with 35 mm. or I20 film. The size of the image
on the film, using a 35 mm. format and a 100 mm. focal length macrolens or short-mount
lens and bellows, will be larger than the image on the I20 film when used with a standard
X0 mm. focal length lens in a 120 twin-lens reflex camera if the distance from the subject
to the film is the same for both cameras. This means that if a larger image is desired on 120
film than the image obtained with the standard 120 format 80 mm. focal length lens at 5
feet, a longer focal length lens must be used to prevent distortion of the facial features.
Interchangeable lenses for some twin-lens and single-lens 120 cameras are available. One
of the main advantages of 120 film is that twelve 2% by 2% inch photographs are obtained
from one roll of film.
The twelve-exposure 120 size usually offers a faster turn-around time than the twenty
 Am. J. Orrhd.
14 StrtttJ July 1978

or thirty-six exposure 35 mm. film. Ideally, use of long focal length lenses on 35 mm. and
120 format cameras provides a better perspective with less distortion of facial photographs
and more distance for illumination. If an interchangeable-lens I20 camera is not available,
superb enlargements can be made from 35 mm. facial photographs taken with a clinical
camera that has a 100 mm. lens. If an additional 35 mm. camera body is loaded with color
negative film, the lens and bellows can be changed from one camera body to the other.
Color prints are easier to show to parents than color slides and do not require a projector
for viewing.
Although the side-mounted strobe light on a clinical camera provides good illumina-
tion, better lighting is provided for facial photography when the light from a separate
strobe light is bounced off a silver- or gold-lined umbrella placed at an angle to and nearly
at the top of an g-foot wall (Fig. 7). This arrangement reflects light onto the subject. If one
camera is used and umbrella lighting is desired, the cord from the camera-mounted strobe
light is disconnected from the X terminal on the camera body. The connecting cord from
the umbrella strobe is connected to the X terminal of the camera body, the f stop on the
camera is adjusted, the camera is focused for the distance desired, and the exposure is
made. This type of lighting prevents the red eye seen when an on-the-camera strobe is
used for full-face photographs. A slave light is used to illuminate the background and
gives the effect of separation of the subject from the background (Fig. 8).
If the camera is loaded with color slide film, color prints can be obtained from the
slides. However, the current process of printing a color photograph directly from a slide
does not yield as good a color print as printing color photographs from color negative film.

Custom photographic laboratory services

Most orthodontists neither desire nor have the time to accommodate film-processing
procedures in their offices. One of the greatest aids to the orthodontist who desires full use
of clinical photographic potential is the use of custom photofinishing laboratories. Some
of these custom photographic facilities are involved in black and white photographic
processing and finishing only. Other custom laboratories limit their service to color
processing and finishing. Use of certain photographic facilities permits the orthodontist
interested in clinical photography to produce superior intraoral photographs and color
facial portraits of professional status.
If a clinician desires to protect slides from projector heat, dust, scratches, and possible
loss of the material, it is a common procedure for certain color photographic laboratories
to duplicate color slides. Many benefits other than secure master slides are evident. A slide
that is too dense or underexposed can frequently be corrected for density. Titles of
identification can be imprinted on the slide or the slide mount. Subtle color correction is
possible, so that a more pleasing color will be obtained. The original slide can be cropped
or enlarged when it is duplicated. Enlargement of the main area of interest improves the
quality of a slide presentation, since extraneous noses, fingers, cheeks, retractors, lips,
labels, etc. can be cropped out of the corrected duplicate slide.i2
Careful composition of photographs will eliminate superfluous and distracting areas of
the slides. However, in the event older slides are part of a slide library, these can be
upgraded with a high degree of accuracy and acceptance not only by the presenter but also
especially by the audience.i2
Slides can be duplicated in the office with Ektachrome duplicating film 5038. This film
:_ . . :,-l-1- : .- 1. nn
_L P
.Y_/1 .,L ,,,d ,,,uai LL iudcxi iuto cassettes. A simpler procedure is to
Volume 74
Number 1 Clinical photography in orthodontic practice 15

Fig. ,9. A, fwo lights at 45 degrees to casts. 8 &WI 3, f%Wast tungsten iilurnination using a &mm ling
lighi : directton and a light at 45 degrees. D, One light directly over camera lens. E, Two lights at 45
rees.

mar-k on the slide mount the desired corrections and let a commercial color finishi
labt oratory provide the duplication service for a fair nominal fee.r3
At the American Association of Orthodontists’ annual session in Dallas, Texas, in
Ma: y, 1965, I presented a table clinic which showed the concept of using an 8 by 10 ir tch
colt )r print together with an accompanying typed sheet of information explaining Ithe
 Am. J. Orthad.
16 Stutts July 1978

Fig. 10. A, Strobe light rotated to left of lens. Note frenectomy scar. 6, Strobe light to right of lens. C,
Strobe light to lefl of lens. Note gingival stripping. D, Upper mirror view with light at 12 o’clock to the
lens.

photograph. The photographs and the typed information are compiled in regular photo-
graphic albums. The possibilities for training and instruction of patients, parents, and
auxiliary personnel are without limits. Many advantages accrue from this type of visual
instruction. No special area is required, and no projectors, earphones, or cassettes are
indicated. The material can be easily and rapidly deleted or added to. The response from
the patient who looks at a color photograph and reads the typed information while sitting
in the dental chair has been very favorable.
Minimum time is involved on the part of the staff, since all that is required is the
choice of the proper album or section of an album to show a patient a specific procedure.
Auxiliary personnel appreciate the availability of a picture and a typed legend when they
are reviewing or learning some of the many procedures required in the contemporary
orthodontic office.
Use of this type of instructional book eliminates a lot of “busy work” involved in
moving patients, winding film strips, AV cartridges, and cassettes. Upgrading some types
of audio-visual material is a constant endeavor. Often it is not possible to change existing
film strips or conventional audio-visual materials. Upgrading a photograph and typed
sheet is not difficult and permits a current professional approach to this greatly overlooked
area of continued education of patients, parents, and auxiliaries. Sometimes the desired
program is not available commercially.‘3 (Fig. 20.)
If the simple, yet most effective, photographic album does not completely fill the
requirements of some offices, many fine audio-visual sequences are available from private
companies. If an orthodontist has or can develop good photographic technique, a slide-
Volume 74
Number I C’linitul photngruphy in orthodontic practice 17

tape sequence can be produced in the individual office. The primary intent is to develop
the theme of the sequence. One should write the audio portion, take photographs to
illustrate the written material, place the slides in proper order, and, in one’s own voice,
record the written script on the type of cassette recorder which allows placing a pulse on
the tape which will cause the projector to automatically advance silently as it records. A
good start for an in-office slide-tape sequence can begin with laboratory procedures, such
as construction of a plaster cast, or with procedures for taking a head or wrist film. This
first approach to self-contained, in-office audio-visual slide-tape sequences gives the
operator the opportunity to determine the basic effectiveness of such a program. A frank
critique of the program among the staff can verify the need of or appeal to this type of
learning concept. Although Super 8 sound film can be edited and transferred to television
tape, most office procedures can be learned and reviewed easier and with less expenditure
of time, money, and space by using a photographic album as described previously or by
using a slide-tape sequence.
One of the continuing problems in orthodontics is lack of proper oral hygiene. A
photographic print can be used to specifically but properly call abrupt attention to this
dilemma. If a patient fails to follow instructions in proper oral hygiene, an easy way to
communicate with the general dentist or pedodontist and the parent is to take a photograph
showing the poor oral hygiene condition as the patient presents for treatment. After the
slide is returned, two small color prints are made. One print is sent to the dental referral
source and one print is sent to the parent with a brief note of explanation regarding the
need for improvement in the area of concern. Usually the parent and the dentist will
telephone the orthodontist a day or so after receiving the print and express concern about
the poor oral hygiene of the patient. Often the problem disappears, as all of the persons
involved can see the problem and mutually resolve the difficulty. A specific record
becomes part of the case history.
At the completion of orthodontic treatment, a smiling 8 by 10 inch color portrait sent
to the parents with a letter has more impact than small copies of before- and after-
treatment pictures. Any photograph carries a stronger thrust when properly mounted and
set off by a colored mat. A gallery of similar smiling photographs, framed and placed in
the office, will be readily accepted by the patient’s peers. Written permission from the
patient and parent should be obtained before public display of such portraits.
After a number of years in practice, most orthodontists have a vast amount of record
material (plaster casts, radiographs, copies of correspondence, etc.). It is practical to copy
the records which have accumulated over the years on 35 mm. film. Black and white film
is the film of choice. All the material is placed in the same direction on a copy board and
exposures are made in sequence. Each of the two copy board lights is placed at 45 degrees
to the subject. The exposure is determined by reading the behind-the-lens meter with the
lens stopped down. A written record permits fairly rapid location of the frame number on
the negative in the event retrieval is required. The black and white negatives should be
developed and returned uncut so that thirty-six different exposures of record material can
be placed on one roll of film. The individual frames can be viewed with a magnifying
glass or hand viewer. If necessary. black and white prints can be made to recover the
material previously photographed. Accurate photographic technique will permit remote
storage of the actual records, but at the same time an accurate copy is available in the
office. The amount of physical space required for filing is reduced. The technique for this
 Am J. Orthod.
July 1918

Fig. 11. A, Lower mirror-view lens set at f/22. B, Close-up of lips and chin area in profile. C, Tongue
thrust. D, Light to left of lens.

procedure is photographic copying. It is a routine procedure for most auxiliary personnel

to learn to copy patient record material on 35 mm. black and white film, using two lights
on a sturdy copy board and a good clinical camera. If more sophistication is desired,
microfische equipment is available commercially; this permits an even greater conserva-
tion in storage requirements. Microfilm procedures are available from companies on a
contract or per-piece basis. Microfilm and microfische readers are required for viewing the
material. If microfilm or a similar format is to be used, care in the selection of viewers and
the format requires inquiry from publishers, since more and more journal, textbook, and
magazine publishers have their printed material available in microfilm or microfische. The
medium of microfilm using photographic techniques will continue to increase and become
more available as the cost of postage, storage, indexing, and availability of past issues of
journals becomes more dear.i4* ‘,;

Title slides
When a lecture is illustrated with slides, the lecturer often does not know the size of
the room or the distance from the projector to the screen. Most audiences are not able to
read charts, graphs, and title slides because too much material is placed on the screen in a
font that is too small. Kodak Publication S-30 provides accurate information for determin-
ing the size of lettering and the number of words to be placed on a slide to improve
legibility and visibility. If a color gel is placed over black printing on white paper and a
photograph is made through this gel, using Ektachrome type B film, a color title slide can
be made with various colored letters or different-colored backgrounds. The color can be
controlled by the choice of the color gel that is placed over the typed or drawn material. If
Volume 74
Number I Clinical photography in orthodontic practice 19

Pig. 12. A, Occlusal mirror view at f/22. 8, Buccal mirror view at f/22. Focus on mirror with strobe light
on the same side of the lens as the mirror. C, Cropped and enlarged view of the buccal mirror view. D,
Strobe light reflected into umbrella for facial photography. Photographs in Figs. 10 to 12 are not of the
same patient but are presented to show a number of lighting arrangements and angles of view.

white letters on a blue background are desired in the title slide, Ektachrome type B film
should be used to take the photograph. An orange-colored gel obtained from a stage
lighting company may be placed over the printed material which has been sized and
calibrated for best visibility and readability. When the film is processed, C-22 or reversal
chemistry processing should be requested. I6 The services of a custom photographic color
laboratory are usually required to obtain the desired developing process.
Filters designed for black and white film can be placed over the camera lens to obtain a
colored slide of printed material. The original black print on white paper will be returned
with the hue and color of the filter placed over the lens as the background color with black
printing.
Different-colored title slides can also be made by typing the information desired on
pastel-colored paper with a colored carbon ribbon. Kodachrome 25 or 64 Ektachrome 64
will record the subtle colors with no change in film processing.
The choice of film used to photograph plaster casts is determined by the need to
provide black and white glossy prints or color slides for projection. Black and white direct
positive film will produce a projection slide in black and white. Orthodontic casts are
usually white, so there is no requirement that the photographs be in color.
Plaster casts can be photographed by the same procedures as these used in intraoral
photography. If strobe illumination and color positive film are used, one higher f stop is
required since the models are white. If a constant source of light is used the lens should be
opened up two stops.
 Am. J. Orthod.
July 1978

Fig. 13. A, Photograph taken more perpendicularly to the occlusal plane than 6. C, Cheek retractors of
the direct-bonding type are satisfactory in deflection of the lips. D, Note modeling created by point light
source.

In order that all views of the model will be the same size, the camera can be focused on
the larger of the two casts, that is, upper or lower. Once the entire cast chosen is seen in its
entirety in the camera view finder, the ratio is noted and the bellows fixed at the deter-
mined distance with the clamping attachment on the bellows. If the entire camera is
moved in or out to focus, each of the views of the model will be the same size ratio. If the
model views are taken at the same ratio, the viewer’s or reader’s eye does not have to
adjust from one size of picture to another. In publications, usually four views will suffice:
left view from the buccal aspect incorporating the central incisor to the most distal aspect
of the model, right view from the buccal incorporating the central incisor to the most distal
aspect of the model, full upper occlusal, and full lower occlusal. An anterior view permits
checking of midline and overbite relationships.
One strobe light on a clinical camera will provide satisfactory photographs in a
minimum of time and with few accessories. A piece of dark paper is laid over a table and
curved up a wall. The paper does not have to be very large, since the area to be photo-
graphed is small. The model can be turned with the buccal aspect parallel to the edge of
the table. Depth of field is greatly improved since the area taken is viewed straight toward
the buccal surfaces of the teeth. After one side is taken, the model is rotated to the
opposite side and the light is changed to the opposite side of the lens. The entire occlusal
view, upper and lower, can be taken with the vertical format so that the light can be on top
of the lens at a 12 o’clock position to the lens when viewing. Once the ratio size is
Volume 14
Number I Clinical photography in orthodontic practice 21

Fig. 14. A, Same as D in Fig. 13, except focused on upper right premolar. B, Direct view of upper right
impacted canine. C, Compare with D. Note upper frenum, depth of field, and modeling in both C and D.

determined, the model or tripod is moved for proper focus instead of refocusing the
camera. This keeps all views the same size.
If more precise photographs are required, whether in black and white or color, the
most effective way is to use a copy stand and place the models on a piece of glass
suspended 10 to 12 inches above the copy board. The type of illumination is determined
by the type of film used. Color film may require filters placed over the lens to balance the
film to the light source.4
As most orthodontic casts are approximately the same size, a standard procedure for
lighting can be determined with a few trial exposures. If photoflood lamps in reflectors are
used on a copy stand, the effect of the light is immediately apparent. Modeling, texture,
and depth can be attained by slight changes in the direction and intensity of the lights. If
the lights are at 45 degrees to the area illuminated, one light will cancel the shadows
created by the other. The shadows of the light will be projected through the glass support
on the copy board and will not be seen on the final photograph. This effect frequently
provides separation and depth to the photograph. Colored paper can be placed on the copy
board if desired. A more dramatic and realistic photograph of orthodontic casts can be
obtained if one light is placed almost parallel to and at the height of the area being
photographed while the other light is moved to an angle greater than 45 degrees. This type
of lighting produces detailed form and texture to the cast. The viewfinder in the camera
will show the effect of a low-angle or skimming light source. Shadows are controlled by
changing the higher placed light. 17, I8 If photoflood lights are used, the exposures are
determined by the behind-the-lens meter in the camera. (One should open the lens one to
 Am. J. Orrhmi.
July 1978

Fig. 15. A, Upper mirror view with light at 12 o’clock and focused on upper premolar. B, C, and D, Note
detail in recession and crazing of enamel. They are direct views at f/22. Observe difference in depth of
field and perspective obtained by moving the area of focus to the left premolar in B and C.

one and one-half stops more than the meter reading or decrease shutter speed.) If a
daylight-balanced film (Kodachrome 25 or 64) is used, a filter must be used over the
camera lens to balance the light and film. Extachrome 50 tungsten color film is balanced
for photoflood light and will not require a filter.
Once the desired lighting effect has been determined by the use of photoflood illumi-
nation, strobe lights can be substituted for the two photoflood lights. One strobe is
connected to the camera by a long cord, and the other strobe light is controlled by a slave
unit on the strobe.
A tripod and two light stands can be used to create the same lighting effect as that
obtained when a copy stand is used. The casts are placed on black velour paper on a table,
and the required views are taken by rotating the cast. The benefits of using a copy stand or
tripod and two lights far outweigh the time required to understand the actual mechanics of
learning the procedure of copying. A cable release should be used to prevent movement
and vibration when a tripod or copy stand is used (Figs. 3, 6, and 9).
Taking photographs of radiographs is similar to the procedure of taking photographs of
plaster casts. The difference is that a % by 1I by 14 inch flashed opal glass or YI by 11 by
14 inch white plastic sheet is placed over the supports IO inches off the copy stand board
instead of the plain glass. Black opaque tape or mat board is used to block out extraneous
light that comes from beneath. Incandescent for Plus-X film and black-light fluorescent
light for SO 185 film is placed beneath the opal glass to illuminate the radiograph from
beneath the glass. A strobe light can be used for the light source by placing it under the
Volume 14
Number 1 Clinical photography in orthodontic practice 23

Fig. 16. Photographs of same patient. A, Note roundness and modeling of teeth produced by controlled
shadows developed by a point light source. These are direct buccal views focused approximately
perpendicularly to occlusal plane. B, Note detail in tissues and depth of field obtained when focused on
upper right first premolar with lens set at f/32. C, Focus was on upper left canine with lens at f/22.
Notice difference in sharpness in incisor area compared to A. D, Occlusal mirror view with lens at f/22.

opal glass or by aiming the strobe at a white card angled 45 degrees to the glass and copy
board 9, 13, 17

The film of choice for taking photographs of a radiograph is Plus-X, if prints are
desired, or SO 185, if a positive slide is required. A properly exposed SO 185 slide can be
projected when mounted in a 2 by 2 inch glass slide mount. The visual image received by
the viewer will be accepted as if the original radiograph were projected. It is very difficult
to obtain acceptable color slides of radiographs.

Facial photographs
If instant film is to be used, an accurate and convenient camera for facial views can be
assembled from a 4 by 5 inch view camera which has a long focal length lens and the
appropriate Polaroid film pack back. The optics of the lens are excellent and the advantage
of an instant print is evident.
The use of a 120 camera and film has the distinct advantage of providing twelve 2% by
2% exposures per roll. This allows the prints of four patients (front, profile, and smiling of
each facial series) to be obtained rather rapidly. A portrait type of print is produced with
good perspective and minimum distortion at a distance of 5 feet from subject to film when
a 180 mm. long focal length lens is used. If a millimeter ruler is held by the patient, the
custom photofinisher can print the photograph life size by enlarging the print to match the
 Am. J. Orthod.
24 Stutts July 1978

Fig. 17. A, Direct buccal view showing effect obtained by using only one lip and cheek retractor. B,
Effect obtained in using two lip retractors, even though only one side is to be taken. C, Anterior lip
retraction is not as effective as in D.

millimeter gauge. Much diagnostic information can be gained from life-size photographs.
Consultation with patient and parents is enhanced, as muscle activity is most apparent and
facial growth predictions can be drawn on acetate overlay film.
If quarter-size prints are required, a photofinisher can reproduce these from 35 mm.
color slides taken at 4% feet by making a 2~ color print from the slide. The 120 film for
facial photography can be black and white (Professional Plus-X) or color (Vericolor II).
Vericolor II is a negative film which is returned as a color print. However, slides can be
made from Vericolor II by having the negative printed on Kodak Ektacolor print film
4109. Black and white prints can be made on Kodak Panalure paper. If office space is
available, the use of a 120 camera provides a photographic facility which permits a fixed
lighting and seating arrangement that yields photographs of a standardized portrait quality.
A colored mat board, a sheet of paper, or a window shade can be placed on a wall. The
color of the background is a matter of personal preference. If in doubt, the white side of
any colored mat board can be used as a start. If the patient is placed 3 or 4 feet from the
wall, shadows created from the light can be projected out of the area of view. An effective
lighting setup requires another small strobe light connected to a slave or remote unit and
aimed at the background. The slave light will be synchronized to the strobe light con-
nected to the camera. A background light provides separation of the patient from the
background.
The camera is mounted on a focusing rail which is attached to a stand or tripod. The
camera is adjusted vertically until the viewer is at the patient’s eye level. The ratio is
determined and the camera is focused on the patient’s eyes. A strobe light is mounted on a
Volume 74
Number 1 Clinical photography in orthodontic practice 25

Fig. 18. A, A vestibular lip retractor, such as the Swain retractor, will reflect the lower lip and improve an
occlusal mirror photograph. 9, The focus was on the upper right premolar. The point light was to the
right of the lens. Observe the depth of field and perspective obtained at f/22. C, Sometimes the use of
two cheek retractors is uncomfortable for the patient. Compare C with a closer field of focus in D. Lips
can be cropped out of the field of view by focusing closer to the object.

photographic umbrella which has a silver lining. The umbrella is placed at the top of an
8-foot wall and at an angle to the ceiling so that shadows are placed out of range on the
camera lens. A strobe light cord is connected to the X terminal of the camera.
For full-face views, the patient is instructed to close his mouth and, according to the
desire of the operator, have the lips in contact or relaxed. When the exposure is made, the
remote slave-operated strobe light will fire at the same time as the umbrella strobe light.
For the profile view, the patient is turned to the left and/or the right side. The camera lens
is not refocused, but the camera is moved along the focusing rail. This procedure obtains
frontal and profile photographs of the same size.
A true photographic profile based on the curvature of the lens of a camera and the
focusing ability of the viewer’s eye usually requires that the eyebrow farthest from the
camera be just barely visible. A smiling photograph can be taken in a three-quarter pose.
The patient leans slightly forward toward the camera. The patient’s body should be at an
angle to the camera and the face should be turned to face the lens. If this photograph is
taken last, it is usually an easy procedure to obtain a natural smiling expression, since
head films and impressions were taken previously. If the effect of fill light, main light,
background light, and hair light is desired, the rule in portraiture is to use the main light to
determine the exposure and to illuminate the side of the face away from the lens with the
main light. The fill light acts to reduce the shadows created by the main light. The
background light creates separation of the subject and background, and a hair light of
 Am. J. Orthod.
26 Srutts July 1918

Fig. 19. A, Anterior view showing good tissue rendition, midline relationship, diastema with frenum, and
irritation of papilla on upper right lateral incisor. Lens set at f/22. 6, Focused farther back to include the
molars. Lens at f/22. C, Photograph to show midline. Note improper lip retraction. D, Disposable
spoons used as lip retractors in small mouths when photographs of anterior teeth only are desired. E
and F, Types of photographs that can be made for staff training.

small dimension and intensity adds sparkle to the hair and aids in recording the shape of
the head.ls
Excellent facial and profile photographs can be obtained with bounce-light proce-
dures. Strobe light bounced from a silver umbrella is soft, even, not offensive, and,
together with a background light, will create simple but effective light ratios for facial
photography. If the full-face and profile photographs are taken with the patient in the
cephalostat, the light that is near the camera should be placed in such a position that the
shadows of the head are directed to the back of the head rather than alongside the nose and
chin. A white mat board can be placed over the cassette to provide a subtle background.
Illumination of this background can be provided by a remote slave strobe light pointing to
Vohle 74
Number I Clinical photography in orthodontic practice 27

Fig. 20. A, The angle of view in A shows the midline discrepancy, but it does not show the upper right
canine position as clearly as B. A better view of the canine was obtained by focusing more toward the
posterior area of the mouth. B does not show the midline discrepancy as well as A. C, Area as seen by
using disposable spoons as lip retractors. A, B, and C are views of the same patient.

the mat card; it should be remembered that the angle of incidence of light equals the angle
of reflectance.20 (Fig. 12.)
Strobe lights with remote sensors which attach to the camera permit placement of the
light in any desired position. The sensor reads the amount of light emitted from the strobe
light and provides the proper amount of light for a correct exposure, regardless of whether
the light is bounced from an umbrella or from the ceiling.
Additional reading in portrait lighting techniques encourages definitive lighting con-
cepts using a main light, fill light, background light, and occasionally a hair light. Using
the camera on a tripod with a cable release and an off-the-camera light will produce
standard facial photographs in any desired format.20’ 21
Photographs of highly reflective objects are not commonly made in clinical orthodon-
tic photography. If necessary, the technique of tent lighting is appropriate. A small round
or rectangular support is made larger than the object photographed. The frame is covered
with white diffusing fiberglass, thin white paper, or cheesecloth. The lights are directed on
the covering so that the light from two sides of the tent is evenly distributed inside the tent
onto the object being photographed. This type of lighting creates soft, even illumination
without shadows or reflection. If the object to be photographed is placed inside the tent
and supported on glass, the object will have a floating-in-air effect when the final photo-
graphic result is obtained. Colored paper of choice can be placed below the suspended
glass. Diffusing fiberglass placed over the light sources can also soften the lighting effect
and reduce, but not eliminate, glare and reflection on a shiny object. Polarizing filters
 Am. .I. Orrhod.
28 Stutts Julv 1918

placed over the light source and a polarizing filter placed over the lens permit exacting
control of reflectionsI

Cheek retraction
Cheek retractors are of three types: semicircular plastic, flat U-shaped plastic, and
wire. Front-surface mirrors of varying sizes or highly polished metal mirrors are used for
occlusal and buccal views. Disposable plastic spoons are effective as tongue depressors.
When warmed and shaped to go over the lower anterior teeth, stabilization of the tongue is
definite and comfortable. If anterior views of the anterior teeth in occlusion are required,
plastic spoons can be used with ease to retract the upper and lower lips, especially in
patients with small lips.
The main difficulty in cheek retraction is in determining the direction of pressure of the
retractors. Cheek retractors made of plastic can be modified and adjusted for mouths of
various sizes. As a rule, cheek retractors should be held by the patient in a direction
perpendicular to the occlusal plane, rather than being pulled back toward the ears. A
metal-wire cheek retractor can be used when mirrors are used for buccal views.22 The area
should be photographed at a distance that permits cropping of the area to eliminate lips,
nose, areas of mirrors, and other distracting objects. Mirror views of buccal surfaces will
be reversed and need to be turned when projected. If the area of interest can be taken
without a mirror, focusing will be less of a problem. Saliva should be removed from teeth
and tissues, and clean mirrors which have been warmed may need to have air blown upon
them to remove condensation. The alignment of the camera should be parallel with the
occlusal plane. For a buccal view, the area to focus on is usually in the premolar region.‘”
There should be no hesitation in bracketing exposures of the same area. Although not
frequently used, tripods with a horizontal bar can be very conveniently used over a dental
chair to support a clinical camera if difficulty is encountered in keeping the occlusal plane
parallel in the view finder of the camera.

Intraoral photographs
As specific and detailed instructions are available in the current literature,’ only a
summary of intraoral technique will be presented here. After determining that there is film
in the camera, as well as the type of film, and ascertaining that the lens and viewfinder are
clean and the strobe ready light is lit, the person taking the photographs can be certain that
specific views can be obtained, if the f stop and shutter speed are correct (Figs. 10 through
20).
After the ratio is determined, the bellows is clamped to prevent the lens from changing
position. If a direct buccal view is taken, the light is placed on the same side of the lens as
the area to be taken; that is, if the patient’s right side is taken, the light is on the right side
of the lens when one is viewing the area.
If mirrors are used for buccal views, the light is placed on the same side of the lens as
the mirror; that is, if the patient’s right side is taken, the light is on the left side of the lens
as viewed through the view finder. Anterior views are taken with the light on either side of
the lens (either the 9 o’clock or the 3 o’clock position). For direct buccal views, the largest
cheek retractor that is comfortable is used. If a mirror view is taken, a wire retractor is
used on the side with the front-surface glass mirror. With any mirror view, the opposite
cheek is retracted with a plastic retractor.
Volume 14
Number I Clinical photography in orthodontic practice 29

Occlusal views are taken with the aid of a mirror. The mirror is placed to the distal of
the area of interest. Plastic cheek retractors are used on both sides of the mouth, and the
head is tipped back for ease in focusing. Another pair of hands is helpful to position the
mirrors when occlusal views are taken in order that the procedure will not be lengthy. If
the ratio desired is determined, any of the views taken will be of the same size, since the
entire camera is moved to focus rather than the lens being focused with each exposure.
Placing the light at a low angle in a skimming position improves form and texture of raised
objects, such as mucoceles or tumors. The light is removed from the camera and held at
the same level as the lens, but at a lower angle to the subject. This type of lighting creates
definite modeling so that the photograph will show more texture and form of the object
being photographed (Figs. 10, 12 and IS).‘* 17, 23

Slide filing
As a large library of slides continues to grow, retrieval of slides can become compli-
cated. One way of cataloging slides is to use a cross-index system. Each slide can be
numbered sequentially and classified by intent and reason for taking the photograph. The
patient’s name and date can be placed on the slide mount. For each patient a card can be
placed in alphabetical order on 4 by 6 inch cards in a file kept expressly for photographs.
The number and classification are recorded on each patient’s card. On additional 4 by 6
inch cards, the classification of the types of information desired is recorded. Any slide
number appropriate to this classification is written by the sequential slide number on this
card. All the slides for any patient can be located by number under each patient’s name.
Any category can be located by retrieval of the slides when sequential numbers are also
indexed on the 4 by 6 inch category cards. Slides should be stored in wood or metal
stackable slide trays with individual spaces for slides. As slides are removed for review or
appraisal, the numbers of the slides removed are recorded on an “out” card. The storage
cabinets offer protection from dust, and a visual scanning locates any empty spaces in the
slide trays at a glance. Master slides can be placed in plastic guides and filed in a
three-ring notebook.2”

Summary
An effort has been made to encourage improved clinical photography. Contemporary
and readily available photographic publications are included in the reference list at the end
of this article. Those interested are encouraged to obtain copies for their personal libraries.
Advantages and uses of a copy stand have been shown. Methods of obtaining black and
white negatives from color slides have been described. The use of a 35 mm. copy
technique has been expanded to encourage copying of older case histories, transfer rec-
ords, and third-party requests, Duplication of radiographs using Kodak SO 185 film has
been described. The concept of 8 by 10 inch color photographs, together with a typed
description of the information to be learned, have been explained. These areas include
parent, patient, and staff instruction and encourage the in-office fabrication of slide-tape
sequences.
The advantages of slide duplication have been covered. Correction of color, density,
cropping, and primarily the safety factor of using duplicate slides to prevent loss or
damage of slides frequently used by clinicians has been presented. Techniques for making
color slides or black and white prints of plaster casts have been explained. The techniques
 Am. J. Orrhod.
30 Stutts July 1978

showed lighting concepts to obtain modeling, form, and texture together with procedures
to control shadows on casts.
A lighting system for facial photographs using light reflected into an umbrella has been
presented. This type of light is flattering and prevents the red eyes produced when the light
source is close to the lens. Patients should not look at an on-the-camera strobe light but at
a point away from the light. Use of a slave strobe light has been discussed in order that the
backgrounds for facial photographs could be illuminated.“’
The difficulties experienced in the color balance of certain films has been described.
One way to improve the color of photographs taken with Kodachrome 25 and Koda-
chrome 64 film by adding color-correction filter gels has been stated.
An attempt has been made to encourage the use of either life-size or 8 by 10 inch facial
photographs for more detailed diagnosis and consultation. Muscle activity is more readily
visible on larger prints and is a valid requirement in orthognathic surgical procedures. The
convenience of using prints for parent consultation and diagnosis has been described. One
of the advantages of prints is that a projector is not required and the ambient light in a
room does not have to be lowered.
In the past, most clinical cameras were adaptations of regular photographic equip-
ment. Currently, there are a number of detailed and technical articles on photographic
techniques and types of equipment which can consistently produce dependable slides or
prints. Before- and after-treatment photographs have been unique in the practice of or-
thodontics for many years. The availability of improved camera bodies, exposure meters,
strobe lights, and longer focal length lenses with a better definition of what makes a good
clinical photograph has created another sphere in orthodontic history and record produc-
tion.
It is hoped that this article will stimulate those who desire better clinical photographs
to search the literature and to take the time to produce, in a consistent manner, superior
clinical photographs, irrespective of film format.
One of the thrusts of this article has been to encourage orthodontists to spend some
time reading the theory of films, lenses, filters, and basic photographic techniques. The
availability of photographic equipment of a hiqh quality, together with the understanding
of a few concepts, will deliver credible photographs for the orthodontist and his staff. This
knowledge can provide pleasure and service to the orthodontist, his colleagues, and the
patients he treats. If custom photographic laboratories are used, a more specific channel of
communication is afforded each party in order that a finished slide or print will please
those involved.
Particular appreciation is extended to Clifford Freeheat the University of Washington in Seattle.
Mr. Freehe has been a driving force for excellence in clinical photography. He has developed
procedures, concepts, and equipment that fulfill the highest goals of clinical photography. Gratitude
is also expressed to Mr. Lester Dine who, for many years, has providedequally excellent equipment
for industrial and scientific photography.

REFERENCES
I. Freehe, C. L.: Clinical dental photography, Clin. Dentistry 1: I-50, 1976.
2. Carlson, E., Meisel Photochrome: Personal communication.
3. Rothschild, N.: Leica Manual No. IS, Dobbs Ferry, N. Y., 1973, Morgan & Morgan, pp. 253-273.
4. Smith, R.: The Tiffin practical filter manual, Garden City, N. Y., 1975, Amphoto, pp. l-93.
5. Dine, Lester, Inc., 2080 Jericho Turnpike, New Hyde Park, N. Y.: Personal communication.
Volume 74
Number I Clinical photography in orthodontic practice 31

6. Stutts, W.: Patient photography, AA0 Audio-Visual Library, pp. 220-270, 1969.
7. Hetherington. W., and Freehe, C.: Single lens reflex cameras in dental photography, Dent. Clin. North Am.
12: 699-729, 1968.
8. Kodak Color Films: E-77, DS2-DS26, 36, 1975.
9. Eastman Kodak Company: Copying radiographs, M-3-24, Rochester, N. Y., 1975.
IO. Freehe, C., University of Washington: Personal communication. 1976.
I I. Hurtgen. T.: Biomedical photography, Kodak publication N-19, Rochester, N. Y., 1976, Eastman Kodak
Company, pp. 60-86.
12. Meisel Photochrome, P.O. Box 6067, Dallas, Texas.
13. Rothschild, N.: Making slide duplicates, titles and film strips, Garden City, N. Y., 1973, Amphoto, pp.
I l-157.
14. Eastman Kodak Company: Copying, M-I, l-32, Rochester, N. Y., 1974.
15. Eastman Kodak Company: Microfilm products. A- 1583, l-33, Rochester, N. Y ., 1974.
16. Eastman Kodak Company: Planning and producing slide programs, S-3, 34-59, Rochester, N. Y., 1975.
17. Croy, 0. R.: How to use your camera close-up, London, 1961, Focal Press, Ltd., pp. 102-140.
18. Adams, A.: Basic photo No. 5, artificial light, Dobbs Ferry, N. Y., 1968, Morgan & Morgan, pp. 9-23.
19. Feininger, A.: Total picture control, Garden City, N. Y., 1972, Amphoto, pp. 176244.
20. Eastman Kodak Company: Professional portrait techniques, O-4, l-68, Rochester, N. Y., 1973.
21. Mason, R.: Basic lighting techniques, Life Library of Photography, New York, 1970, Time Life Books, pp.
181-201.
22. Freehe, C. L.: Dental retractors, Dent, Clin. North Am. 12: 731-740, 1968.
23. Strohlein, A.: The management of 35 mm. medical slides, New York, 1975, United Business Publications,
Inc., pp. 6-84.

7912 Spring Valley Rd. (75240)

The best time for moving the Teeth is in youth while the jaws have an adapting disposition,
for, after a certain time they do not readily suit themselves to the irregularity of the teeth.
This we feel plainly to be the case when we compare the loss of a Tooth at the age of fifteen
years, and at that of thirty or forty. In the first case, we find that the two neighboring Teeth
approach one another, in every part alike, till they are close; but in the second, the distance
in the jaw, between the two neighboring Teeth remains the same, while the bodies will in a
final degree incline one toward another for lack of support. (Hunter, John, F.R.S.: Natural
History of the Human Teeth-Explaining Their Structure, Use, Formation, Growth, and
Diseases, London, 1771, J. Johnson, No. 72 Church Yard, p.76.)