If you want to properly diagnose and present cosmetic cases then you will absolutely, positively need to invest in a decent camera. I’ll write more on that subject at a later date, but for now let’s focus on what you’re going to do with the darn thing once you get it. I keep my camera handy and have trained my assistant to help me take these critical photos quickly. Here’s what I shoot and why:
(1) Rest
This one is usually missed. Although not always essential for diagnosis in most cases, a resting shot can still give you some good information about the patient’s shape and position of the lips. Additionally you can look for signs of excessive or diminished vertical dimension of occlusion (VDO). If the patient has a VDO that is too high you may notice lip incompetence; the inability to have the lips meet without straining the facial muscles. This can also be a result of a normal VDO but with excessive protrusion of the teeth. If the VDO is diminished you may notice angular chelitis or even a “squished” appearance to the lips.
(2) Normal Smile
Ask the patient to smile and see what you get. It is not uncommon for someone seeking cosmetic dentistry to conceal their smile in some way. They may feel uncomfortable and smile sheepishly; this is an important psychological clue! Check for the balance of the smile. Does the patient reveal more teeth on one side? If so, explain to the patient that this will not be corrected with cosmetic dentistry.
(3) Exaggerated Smile
This patient has an average smile line showing just the tips of the papilla.
This is often the most important picture to take. I ask the patient to show as much tooth and gum as possible while still closed. This is where we can determine the patient’s smile line. If the gingival heights of contour can be seen then we must take their esthetics into account. Esthetic crown lengthening and reshaping must at least be considered if discrepancies are noted.
If teeth are to be replaced with implants and the patient demonstrates a high smile line, then we must be aware of any potential need to prosthetically mimic the soft tissue with acrylic, porcelain, or composite. This is tricky and is always better achieved with sift tissue grafting. It’s important to figure this out early on!
Also look for the patients buccal corridor display. Many patients are oblivious of whether or not their teeth fill the buccal corridor, but some are acutely aware of it.
(4) Retracted Frontal
With retractors in place, take a full frontal shot. This will help you see all of the details without the lips getting in the way. This is a good shot to appreciate symmetries, facial and dental midlines, and relative tooth position and morphology.
Only with retraction can we appreciate the several cosmetic and occlusal factors at play in this case.
(5) And (6) Left and Right Side
These photos can be taken with a mirror or just with a retractor. Using a mirror will allow you to see details of the posterior dentition that would otherwise be invisible.
A right lateral shot. Notice that although the mirror reveals more posterior detail, it will also reverse the image.
(7) and (8) Upper and Lower Occlusal
A good occlusal shot will help you appreciate bucco-lingual tooth position. If you are considering orthodontic help then this photo is essential. An occlusal picture will also tell you the shape of the patient’s arch. Square arches behave differently than tapering ovoid ones, which I’ll discuss in another post.
The extent of crowding of the mandibular teeth is best appreciated from the occlusal view.
Additional Shots
We can take a picture of a patient at rest with their teeth apart. This can give me some information about the incisal edge display at rest, which is sometimes helpful.
We can also take a full facial and full lateral profile shot to appreciate the patient’s smile in relation to their full facial esthetics. Again, this is not always necessary in my opinion. It can be helpful in full reconstructions, assessing VDO, and orthodontic analysis.
Finally, it can be useful to take a retracted frontal shot with shade tabs held next to the teeth of interest. I routinely do this when fabricating restorations to give my lab critical information on final shade hue, value, and chroma as well as tooth characterizations.