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 documentation of the position of teeth and supporting structures,

radiographs, casts, and small objects. This article will
focus on principles for standardizing frontal and lateral
profile photographs of patients.
There are several specialties and treatment modalities within dentistry for which portraits are essential
records. The most obvious need for this type of photodocumentation is for patients who will be having
orthodontic treatment, orthognathic surgery, or maxillofacial prostheses. These photographs are important in
dental education, in patient education, and in providing
a legal record of facial features before and after dental
treatment.
In many cases, a dentist, and not a formally trained
biomedical photographer, performs the photographic
procedures. If the practitioner does not follow a reasonably standardized protocol, it is likely that the individual photographs, as well as the comparison of photographs taken before and after treatment, will fail to
provide an accurate representation of the actual anatomic features and their relative proportions. This distortion may work in the dentist's favor and show cosmetically pleasing changes that never occurred; it may
work in the opposite way by failing to show improvement that may have actually taken place; or it may even
show an apparent worsening of features. In each case,
the documentation would, at best, be legally inadmissible or, at worst, be damaging to the dentist.
From the Colleges of Dentistry and Veterinary Medicine, The Ohio State
University.
811113044

Several recent articles have described methods of

obtaining facial photographs. Freehe, ~ Gordon and
Wander,2 and BengeP reviewed general principles of
facial photography in which they described the standard
views and gave general principles of head position,
camera position, and lighting. Williams4 described positioning and lighting for several features, including the
face, and provided specific anatomic references for head
position. Larrabee, Maupin, and Sutton5 described
methods of photogrammetry, while Farkas, Bryson, and
Klotz6 used profile analysis.
The purpose of this article is to help the dental
photographer understand the effect of several photographic principles on the photographic end product and
to provide easily reproducible references for standardizing frontal and lateral profile facial photographs. Although lighting techniques are important, this article
will deal principally with variables inherent in distance,
camera position, and head position.
HEAD POSITION
Although it is impossible to reproduce photographs
with assured accuracy, it is clinically possible to produce consistent results that are useful for comparisons.
Ideal frontal and profile photographs (shown in Figs.
1A and 2A), along with line drawings (Figs. 1B and
2B) of these photographs, will be the basis for comparisons of head position, lens focal length, distance,
and camera position discussed throughout this article.
An understanding of the effect of variables on a
photograph requires familiarity with certain anatomic
references. Although the use of these references does
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Claman, Patton, and Rashid

B
Fig. 1A. Ideal head position and perspective for a frontal view.
Lens = 105 mm focal length.

not provide compensation for anatomic variations such

as facial asymmetry, they assure consistent pretreatment
and posttreatment head position.
For frontal views, the photographic frame should
encompass the crown of the head and clavicle. Distance
is frequently fixed, with the camera and subject at a
constant, reproducible distance. This assures consistent
perspective for all subjects and similar reproduction
ratios and subject-to-camera distances. For the dentist
who does not need to establish consistent distances and
magnifications, encompassing crown to clavicle is a
convenient method of standardizing the portraits in the
adult patient. However, for treatment documentation
over a period of years during growth and development,
it is best to establish a constant distance at one-eighth
magnification and not rely on encompassing area alone.
The interpupillary line should be parallel to the horizontal plane. The distance from the outer canthus of
the eye to the hairline should be equal on each side.
The line from the outer canthus of the eye to the superior
attachment of the ear (C-SA line) should also be parallel
to the horizontal plane. This line, which parallels the
Frankfort horizontal, is a consistent, practical, clinical
anatomic reference (Fig. 1). 7 Both lines are used to
establish consistent parallelism between the eyes and
the horizontal plane and to prevent tilting of the head

Fig. 1B. Sketch of ideal head position for frontal view. A, outer
canthus to superior attachment of the ear (C-SA line); B, interpupillary line; C, encompassing area (crown to collarbone). The
line from the outer canthus of the eye to the hairline is superimposed over the C-SA line and is not specifically labeled in
this diagram.

in frontal and lateral views. 4 Another established

method for head orientation was termed by Broca in
1862 as natural head position. Broca defined this position in the following way: "When a man is standing
and when his visual axis is horizontal, he (his head) is
in the natural position". 8 This has been shown to be a
reproducible position. 9 Larrabee 5 has used it for facial
profile analysis. Cooke et al. ' have combined natural
head position with the true horizontal for cephalometric
analysis and have shown a highly reliable method of
analyzing craniofacial form. Although natural head position reproducibly relates the patient to the horizontal
plane, it does not establish references for the patient
with respect to the camera; nor does it easily permit
photographing the patient in the dental chair or in other
nonstanding positions.
The profile view should also encompass crown to
clavicle, and the C-SA line should be parallel to the
horizontal plane. There should be a consistent eye-tonose relationship. For a true lateral profile, this relationship is established by making certain that the inner
and outer aspects of one eye are visible, the structures
of the other eye are hidden, and the nose appears to be
more distant than and anterior to the eye (Fig. 2).

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Fig. 2A. Ideal head position and perspective for a lateral view.
Lens = 105 mm focal length.

Fig. 2B. Sketch of ideal head position for lateral view, showing
outer canthus to superior attachment of ear (A) and encompassing 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.

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Am. J. Orthod. Dentofac. Orthop.

September 1990

1
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

Fig. 5. Lateral head rotation. The view is not symmetrical. The

distance from outer canthus to hairline is not equal on both

sides,

In profile views, several lateral rotation (side-toside) head positions have been recommended. Some
dental photographers recommend that the patient's face
be rotated 3 to 5 toward the camera lens, revealing

Perspective (viewpoint) is determined by the distance between the subject and the film plane. If the
reproduction ratio is held constant and lenses of different 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.
6, A). A slight telephoto lens (ideally I00 mm or
105 nun for 35 mm cameras) provides the best perspective (Fig. 1A). An extremely powerful telephoto
lens creates compression-type distortion, with nearer
subjects appearing smaller, shortening in the anteroposterior dimension, and excessive flattening of features (Fig. 6, B). The best way to standardize facial
portraits is to keep the focal length of the lens the same

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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.

201

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Claman, Patton, and Rashid

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-tocamera distances. Ideally, the camera can be mounted
on a tripod and the same distance used each time the
patient is photographed.
Ideal camera position is one in which a line from

the middle of the lens to the eye is parallel to the

horizontal plane (Figs. 1A and 2A). If the camera is
too high, the head will appear to have a forward tilt
(Fig. 7, A). If the camera is too low, the head will
appear to have a backward tilt (Fig. 7, B). Centering

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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.

203

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Am. J. Orthod. Dentofac. Orthop.

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Claman, Patton, and Rashid

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

visible between hairline and outer canthus of the eye
on both sides.
CHANGES IN MANDIBULAR POSITION

The orthodontist, the oral surgeon, and the prosthodontist frequently must show accurate pretreatment
and posttreatment portrait photographs. To illustrate the
importance of standardizing photographs and to simulate changes in jaw position, vinyl polysiloxane occlusal
records were made and used to record jaw positions.
Five different occlusal positions from centric relation
to past end-to-end (extreme protrusive position) were
recorded and photographed in frontal and lateral views.
These positions encompassed a range of 7.5 mm. The
photographs show that, in terms of recording differences, the lateral view is far more sensitive than the
frontal view. It is possible to observe differences of as
little as 1.8 nun in the lateral view (Fig. 8), while
differences of as much as 7.5 mm were difficult to
observe in the frontal views (Fig. 9).
When the clinical photographer does not standardize
distance, head position, and camera position, confusing
or misleading photographs are likely to result. An extreme protrusive position with a forward head tilt (Fig.
10, A) is somewhat difficult to distinguish from a retruded jaw position with a backward head tilt (Fig.

10, B). Conversely, actual changes in jaw position can

be accentuated through nonstandardized photographic
techniques. An extreme protrusive jaw position with a
backward head tilt (Fig. 11, A) emphasizes a prognathic
appearance, whereas a retruded jaw position with a
forward head tilt (Fig. 11, B) accentuates a retrognathic
appearance.
SUMMARY

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. The documentation
of orthodontic or orthognathic treatment with pretreatmerit and posttreatment photographs can be misleading
if features on one or both photographs are distorted. In
this article, we have presented the major considerations
for frontal and lateral facial photographs. Numerous
frontal and lateral photographs were made in which such
variables as head position, camera position, and lens
focal length were changed to allow assessment of their
contribution to the final picture. Using easily recognized
facial landmarks, the dental photographer can standardize frontal and lateral portraits for more consistent
comparisons.

Volume 98
Number 3

Special article

REFERENCES
1. Frehee CL. Dental photography. Funct Orthod 1985;2:34-44.
2. Gordon P and WanderP. Techniquesfor dental photography. Br
Dent J 1987;162:307-16.
3. Bengel W. Standardizationin dental photography. Int Dent J
1985;35:210-7.
4. Williams R. Positioning and lighting for patient photography.
J Biol Photogr 1985;53:131-43.
5. Larrabee W, Maupin G, Sutton D.: Profile analysis in facial
plastic surgery. Arch Otolaryngol Head Neck Surg 1985;
111:682-7.
6. Farkas L, Bryson W, Klotz J. Is photogrammetry of the face
reliable? Plast Reconstr Surg 1980;66:346-55.
7. Davidson T. Photography in facial plastic and reconstructive
surgery. J Biol Photogr 1979;47:59-67.
8. Moorrees CF, Kean MR. Natural head position:a basic consideration in the interpretationof cephalometricradi~raphs. Am J
Physiol Anthropol 1958;16:213-34.

205

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

radiographs for cephalometric analysis. J Oral Surg 1970;28:
675-8.
10. CookeM, Wei S. A summaryfive-factorcephalometricanalysis
based on natural head posture and the true horizontal. Axl J
ORTHODDENTOFACOR'I-HOP1988;93:213-23.
11. Stutts W. Clinical photography in orthodontic practice. A.',I J
Oaaalon 1978;74:1-31.
Reprint requests to:

Dr. Lewis Claman

Section of Periodonties
Ohio State University
College of Dentistry
Postle Hall
305 West 12th Ave.
Columbus, OH 43210-1241

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