1.1 General

This chapter summarizes the guidelines for the photographic documentation of dentofacial malformations. To ensure that no impressions of the cheek retractor are visible in the subsequent photos, it is advisable to take the facial photos first, followed by the intraoral photos.

1.2 Facial photography

1.2.1 Equipment

In order to enable measurement on the photos after printing, the patient and the photographer must be positioned at the correct distance in order to obtain a true-to-scale printout on DIN A4 (Fig 1-1).

Markings on the floor for the patient’s and the photographer’s chairs ensure that the photographer is always at the same defined distance from the patient. If necessary, markings can be placed for standardized rotations (90/45 degrees) of the patient on the floor and/or on the wall.

A solid color background should be used.

1.2.2 Camera / photographer

The camera should be positioned on a tripod, or photo-grapher positioned on a chair with castors adjustable in height using the feet. This allows the camera to be held at the level of the patient’s head (Fig 1-2), and the photographer’s hands to remain on the camera.

For precise adjustment of half-profile images, the photographer can roll to the side on a circular path without changing his or her posture.

1.2.3 Patient

Position the patient on a height-adjustable swivel chair or chair with a small headrest that does not take up too much space during the exposure.

Large earrings, jewelry, scarves, caps, glasses, etc, should be removed. Long hair should be tied up and tucked behind the ears. Eyes should be open so that the pupils are visible. The patient should sit upright with a straight spine. Shoulders should hang relaxed. Both soles of the feet should be placed completely on the floor.

The head should be kept straight so that the Frankfort horizontal line and interpupillary line are parallel to the floor (except for the frontal image in habitual posture) (Figs 1-3).

There should be sufficient distance to the background to avoid a drop shadow, or a slave flash can be used.

1.2.4 Recording

The entire head with attachment of shoulders should be photographed (caudal, eg, to the suprasternal notch).

For profile pictures, crop the image from the hair at the back rather than the tip of the nose at the front if cropping is required.

Frontal view in habitual posture

The patient should sit down on the chair and hold their head in their individual “natural” posture. The neck and the base of the shoulders are included in this photo, so that the posture can be judged.

It is important to check whether the patient is holding their head at an angle. Referral to an orthopedist may be necessary for assessment of the cervical spine/vertebral column (eg, scoliosis), or clarification of other syndromes (eg, hemifacial microsomia), depending on whether only the face is asymmetrical or if there is an additional scoliosis of the spine.

In the photographic example (Fig 1-3), the patient holds her head slightly tilted to the left and twisted to the right (the left tragus is more visible than the right).

All other frontal views

The eyes should be horizontal, so that the interpupillary line is parallel to floor.

The head should be kept straight (not turned or tilted). Check that both ears can be seen at the same distance, and note that the ears may stick out different amounts.

Frontal view with relaxed lips

This view is shown in Fig 1-4. In addition, here the teeth should be in resting position (let the patient hum “Mmmm” if necessary).

Lips must be relaxed (if necessary, have the patient moisten their lips with the tongue). In the case of lip closure insufficiency, the lips would be open accordingly.

This image is important to measure:

• zygomatic contour

• lip closure insufficiency

• the facial thirds (upper, middle, and lower face)

• the ratio of upper lip length to lower lip length, of lip white to lip red.

The photographic example (Fig 1-5) shows the following:

• Position of the facial thirds:

  • Upper face (UF) = hairline to glabella

  • Midface (MF) = glabella to anterior nasal spine

  • Lower face (LF) = anterior nasal spine to the underside of the chin

  • Target: UF/MF/LF = ⅓:⅓:⅓.

• Measurement of the width of thew oral fissure:

  • Target: not wider than the interpupillary distance.

• Measurement of the width of the nose (= alar base):

  • Target: corresponds to the distance of the median eyelid angles.

Frontal view with slightly open mouth

For this view (Fig 1-6), refer to the frontal view requirements above. The upper lip should be relaxed. Maxillary anterior teeth should be visible up to the incisal edg (if visible with relaxed lips).

This view is important for the following reasons:

• Assessment of the position of the bony maxilla in relation to the upper lip = maxillary anterior tooth show with the upper lip relaxed, to determine the vertical position of the maxilla in relation to the upper lip.

The photographic example (Fig 1-7) shows the following:

• Measurement of the maxillary anterior tooth show

• Target: 3 to 4 mm.

Frontal view smiling

For this view (Fig 1-8), refer to the frontal view requirements above. The patient should smile in a relaxed manner.

This view is important for the following reasons:

• Determination of whether the upper lip on smiling and laughing are different.

• Assessment of the symmetry and height of the anterior dental arch, and whether the dental arch is straight.

• Determination of facial symmetry. The interpupillary line in relation to the facial midline is important for determining the symmetry of the maxilla and mandible and as a basis for postoperative changes in the face.

Identification of the facial midline is demonstrated in the photographic example (Fig 1-9):

• Check that the photo is taken symmetrically: Is the head held turned? Are the ears the same size? Can the tragus be seen to the same extent on both sides? In this case, the patient has tilted her head slightly to the right.

• The interpupillary line can be drawn (between the two pupillary light reflexes): Check that the eyes are at the same level (they could be different eg, in case of hemifacial microsomia or after fractures). Only then can the reconstructed facial midline be used for surgical planning. Alternatively, the median eyelid angles can be used for reconstruction of the facial midline.

• Determination of the facial midline: Determine the midpoint between the pupillary light reflexes and draw down perpendicularly. Alternatively, determine the midpoint between the two median eyelid angles (to be used especially in case of unilateral strabismus) and draw down perpendicularly. Check whether the constructed facial midline is on the glabella/nasal bridge center. If not, is the photo really taken symmetrically (see above)?

• Determination of the lateral deviation to the facial midline of the nose tip, anterior nasal spine, philtrum, center of the maxilla (= approximal contact 11/21 [tooth numbering according to FDI notation]), center of the mandible (= approximal contact 31/41), and chin tip.

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