More Than a Snapshot

According to a 2023 Inside Dentistry survey, the majority of dentists only send full-face photography to the laboratory on less than 25% of their esthetic or complex cases.¹ Meanwhile, a high-quality camera costs only about $2,000, which pales in comparison to the $150,000 that many dentists are willing to spend on CBCT scanners. Even the latest smartphones are equipped with good enough cameras to be useful in dental photography. So why are they not being used? Why are dentists so willing to invest heavily in capturing information about the inside of the mouth, while showing so little concern for the outside? Addressing these questions and actively convincing dentists to utilize photography to its fullest extent on their cases should be a priority for almost any dental laboratory. "I cannot imagine working on complex cases without photography," says prosthodontist Bernadette Sawa, DDS, who also works with the primary author of this article. "Investing in a quality camera should be standard." Despite all of the CAD/CAM technology available today, the laboratory's understanding of a patient's facial dimensions, tooth position, pink and white concepts, and more still come down to photography, so our ability to fabricate the best possible restorations for each case hinges on that.

Five to 10 years ago, nothing other than a high-quality digital single-lens reflex (DSLR) camera was sufficient for taking good dental photography. The quality of the image is important because of various elements, including color, detail, and surface texture. Although a high-end DSLR camera still will capture those elements better than anything else, the newest smartphones and smartphone attachments have cameras that come close—and are better than nothing for dental teams. Still, lighting and size are the most important factors, and while smartphones can take amazing photographs of a lot of things, they do not have lighting control—which involves the angulation of where the light comes from—to see colors, texture, and other details adequately. In addition, smartphones can take high-resolution photographs in the range of 1 MB, but the capture of information just cannot match a quality camera.

That said, merely purchasing the right equipment is not enough. Understanding that equipment is the key. If you read a book and seven words on each page are beyond your vocabulary, the book carries no value for you. A camera is similar. If you simply pick up a camera and start shooting, and the colors are not set correctly or the light angulation is less than ideal, you need to be able to recognize that.

Another important element of photography technique is the value of what we see in head position and facial features: this includes the patient's natural head position vertically and horizontally, the esthetic plane, and the patient's true lip dynamics, as over time patients develop an acquired smile when they are uncomfortable with their own smile. These factors are critical to know in order to reproduce or create the esthetics that we are looking for on a particular patient's face.

In the grand scheme of modern practice ownership, a high-quality camera is a miniscule investment, and the time it takes to photograph the patient is relatively minor as well. The biggest challenge, Finkel says, is the steep learning curve. "There is no easy shortcut," he says. "A CBCT scanner just requires the pressing of a few buttons. Photography is an art that requires commitment. It took me probably 5 years to get really comfortable using a camera. It can be intimidating, but photography is something that cannot be simplified very much. You just need to learn it. You need to understand flash, exposure, F-stop, color temperature, and so much more. Many dentists do not see the value in investing the time it takes to get really good."

Adding to that challenge is the fact that high-level photography is not easily accessible. It is not taught much in dental school or in dental continuing education courses. "In school, they did not teach us to look at photographs and evaluate facial dimensions, build a plane of occlusion to the lips, etc," Sawa says. "It took a ceramist to make me see the details of the tooth that we are trying to match."

Many of today's dental photography courses, meanwhile, often focus on artistic photographs—"Picture the strawberry in the mouth or glitter lipstick," Finkel says—more so than laboratory communication. "There is a big trend of using massive soft box lights," Finkel says. "Those photographs may look nice, but there is so much light and reflection hitting the teeth that it can obscure the important details for the dental team." At the same time, that trend may further intimidate dentists if they mistakenly believe they need a full studio in order to photograph at a high level. "You need that if you want to take a photograph for the cover of a magazine, but not to take the right photographs to send to the laboratory," Finkel says.

The best way laboratories can convince their dentists to take high-quality photographs is to walk the walk before talking the talk. Buy a camera and start photographing your own work in the laboratory. Photograph the person sitting next to you. As you get more comfortable, go to a nearby dentist's office and take pictures for one or two cases, so you can start to see your own work in before and after shots. "Dental photography started in the laboratory world, so ceramists are probably the best people to teach dentists how to do it," Finkel says.

The benefits of photography in the laboratory extend beyond simply convincing a dentist to do it as well. Every crown looks good overfired in a technician's hand. Every time a restoration is built up or stained in and out of the oven, the technician holds it and thinks it looks really good. On the model, the shape looks right. While the ultimate test is seeing it in the patient's mouth and within their face, a simple photograph of a buildup or a contour can show so many little details that you might otherwise have missed. When a case is finished, before glazing and finalizing it, consider just taking a few pictures and putting it on a big screen. It is amazing what pops out at you that you thought was perfect on that little model.

Once the laboratory is ready to talk to dentists about photography, the key is to simply reinforce the value. An argument can be made that a dentist cannot run a successful practice without it. Even for dentures, at least knowing what the patient's face and smile look like is so important. The dentist should be reminded that they can save chair time if the laboratory is not needing to make bite rims and set planes of denture teeth six times before getting it right. "Shade photography is a major part of the communication between dentist and laboratory," Finkel says, "but a camera can be used for so much more than that. We use it to analyze the case from full-face, dentofacial, and dental perspectives. I take a full set at the beginning, a full set of the proposed treatment plan with the try-in, a full set on the day we prepare and temporize, and even a full set on cementation because we are always self-assessing our work to do better the next time."

The financial aspect should be noted as well. Even if a laboratory provides free remakes, the additional chair time that those remakes require hurts the practice's bottom line. "Nobody wants to have remakes," Sawa says. "Photography is the most helpful way to communicate because a picture really is worth 1000 words. We spend so much time writing detailed prescriptions, meanwhile, one quality picture is able to define the most precise details, such as incisal length, cant in planes or midline, and chroma and value."

Finkel notes that dentists also should be reminded of other benefits of photography, including medical-legal documentation, patient education, and marketing. "If you are doing good work, but you cannot take good photographs, nobody will know what you can do," Finkel says.

Sawa suggests inviting dentists to workshops, training sessions, and lunch-and-learns. She says showing other dentists' cases in high-level photographs can help as well. "Ideally, dental schools would teach more photography," Sawa says, "but until that happens, every new dentist should be learning from laboratories. It is a big deal and helps us become better dentists."

Many of the major dental associations, such as the American Academy of Cosmetic Dentistry (AACD) and American Academy of Esthetic Dentistry (AAED) have their own standard protocols for photography, and similarly, every dental laboratory should have its own. This can be a sheet detailing the 12 to 16 photographs you need for every diagnostic case and what angles you want them taken at, along with some information about color, lip dynamics, etc. For newer dentists, a supplementary sheet going into some further detail may be a good idea.

Recommendations for positioning of the patient are important. Having the patient sitting up or standing against a wall, instead of on their back in the dental chair, creates a more rested position. Some patients have a tendency to tilt their heads for the camera, so dentists should be advised to be cognizant of head position. In addition, if the patient's bite causes the view of the mandibular incisal plane to be obstructed by the maxillary teeth, that becomes a missing piece of information that could require another try-in.

It should also be noted that shade tabs, in a good photography system, are merely a reference for value and chroma. Many dentists pick a shade and put that tab there to support their request of that shade, but laboratories should not be reluctant to select the final shade themselves, using the tab as a reference.

The information that photography provides is useful for every case—and critical for many. But obtaining and evaluating it is a constant fight. Even though photographs should be enough to provide the highest-quality restorative work—as long as you know how to get the right ones—video can also be a helpful tool for the laboratory. A video can be equivalent to about 30 photographs, and a dentist can film for 10 to 20 seconds and capture every bit of information that is needed.

"The dentist and laboratory need to be talking about value, chroma, hue, texture, translucency, opalescence, and all of the other visual ingredients that go into a smile," Finkel says, "and the camera is our second set of eyes to have that conversation."

The result will be better patient outcomes, which, of course, is a shared goal of the entire restorative team. "I did not know what a huge difference photography would make in the quality of the dentistry I deliver until I learned about it at a high level," Sawa says. "Through multiple hands-on CE courses and communication with my laboratory technician, I have perfected my photography skills. Investing in a great DSLR or mirrorless camera should be the priority for every dentist."

1. Mazda J. Trends in dentistry 2023. Inside Dentistry. 2023;19(12):12-21.