| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Features Section |
1 Chesterfield, UK
2 Derby, UK
Correspondence: Unit of Orthodontics, Oral Health and Development, Department of Dental Medicine and Surgery, University of Manchester, UK.
Abstract
This survey was carried out to allow a minimum data set required for intra- and extra-oral photographs to be established. In 1999 a questionnaire was sent to members of the Angle Society of Europe to establish their current clinical practice with regard to extra- and intra-oral photography. The Angle Society was chosen because of their stated commitment to a high standard of record keeping and of clinical care.
Results showed that a full series of extra- and intra-oral photographs were taken both before and after treatment, as well as stage photographs during treatment on many cases. The need for each of these photographs will be discussed in some detail, and recommendations will be made as to what would be considered the Gold standard before, during, and after a course of orthodontic treatment.
Key words: Orthodontics, teaching, active learning
Introduction
It is becoming increasingly important that high quality clinical records are taken as part of a course of orthodontic treatment. Study models tend to be the one record that is consistently taken for orthodontic patients throughout the world. The quality of study models is very variable and unless great care is taken both with the impressions themselves, with the wax registration bite, and with the choice of laboratory, study models can end up offering less clinical information than is ideally required. Clinical photographs, however, can offer at least as much, if not more information provided care is taken when obtaining these photographs.
Clinical Photographic Survey
In order to determine what could be considered the minimum data set for both intra- and extra-oral photographs, we carried out a survey into the use of clinical photography. The Angle Society of Europe was chosen as the body to be approached to seek their opinions on clinical photography because of their commitment to high quality orthodontic records, as well as high quality care. This is a group of orthodontists from 12 European countries who meet on an annual basis to discuss all aspects of orthodontics. One of their aims is to promote educational standards for adequate training in all aspects of modern orthodontics.1
A tick box questionnaire was sent out asking a number of questions about current practice. They were asked the following:
Results of the study
Seventy questionnaires were sent out and within 6 weeks 68 replies were received, which represents a response rate of 96 per cent.
Routine use of photography
An enquiry was made as to when in a normal course of orthodontic treatment photographs were taken. Ninety-eight per cent of the responders take photographs pre- and post-treatment for all their patients (Figure 1).
|
). As far as the intra-oral photographs are concerned, 98 per cent take right buccal, front, and left buccal intra-oral photographs with 70 per cent taking upper and lower occlusal photographs, 90 per cent of these with an occlusal mirror. The overjet photograph was only taken by 4 per cent of the responders and 62 per cent of the responders used buccal mirrors for the buccal shots (Figure 3).
|
|
).
|
).
|
).
|
The orthodontists were asked to estimate what proportion of their total treatment fee could be assigned to the photographs and as one might expect there was a marked variation throughout the European countries. Even within country groups there was sometimes variability of fees for clinical photographs and, therefore, an average fee for each country was assigned.
Fees were recorded in Euros to allow easy comparisons to be made. The lowest fee assignable to photographs was the NHS fee in the UK. The highest fee (Switzerland) was 12 times greater than the lowest (UK). The average fee estimated for orthodontic photography associated with a full course of orthodontic treatment was around 50 Euros (Table 1).
|
From the results obtained in the study a minimum data set for orthodontic photography could be constructed. These are standard extra-oral views comprising full-face view with lips at rest, full face smiling, a three-quarter view, and a lateral profile view.
Some orthodontic treatment can dramatically affect our patient's appearance. Obviously reduction of large overjets or overbites can greatly enhance a patient's smile, as well as improving the relationship between the soft tissues to the upper and lower lips. The full face smiling view is also important because it is this view that we can perhaps most affect as a result of our ministrations.
During normal social intercourse, however, one tends not to engage people in conversation directly from the front. The view we see of most people tends to be slightly off-centre, closer to a three-quarter view, and this view is, therefore, of particular interest. If a three-quarter view is taken with the patient smiling this can be of great benefit in comparing before and after treatment.
The patient's profile can also change during orthodontic treatment, and it is therefore very helpful to have profile views both before and after treatment. Functional appliances can sometimes have a very rapid affect on profile, perhaps introducing lip competence after only a few months treatment. Repeating extra-oral views after a successful course of functional appliance therapy is therefore often useful.
Intra-oral photographs
The front intra-oral photograph details the appearance of the teeth as seen by the patient, the parent, and the general public. Obviously, it is very important to have a quality photograph of the front intra-oral view. This documents both the original malocclusion, and also the hard tissue and soft tissue health pre-treatment.
The buccal intra-oral shots serve a very useful function giving details of the malocclusion. The patient should be told to close in centric relation for this photograph. If taken perpendicular to a tangent of the arch in the premolar/molar area it can offer a great deal of information as to the severity of the malocclusion, the need for treatment, the difficulty of any proposed treatment, and how much anchorage is required.
The upper and lower occlusal views can be used in assessing the space requirement in any particular case. In the absence of study models the photographs can be used to carry out a detailed and accurate space analysis.2 This will allow determination of whether extractions will be required or whether anchorage reinforcement techniques might be necessary.
For high quality occlusal photographs, showing a true plan view of the arch, occlusal mirrors must be used. As seen in the study, the vast majority of responders use occlusal mirrors routinely. One thing that was surprising was that buccal mirrors were used in 60 per cent of cases. In the view of the authors, buccal mirrors fail to offer any significant advantage if the correct retractors have been chosen and are used effectively. The recommendation for the use of retractors and mirrors has been outlined in some detail in a paper by Sandler and Murray.3 Another view that is very occasionally taken is the overjet view. However, this does not really offer any advantages over properly taken intra-oral views.
Discussion
There is a stark contrast between the fact that a full series of both pre- and post-operative photographs are taken almost routinely by the group surveyed, and the situation in the UK, where in the majority of cases only ‘three pre treatment photographs are de rigeur.
The questionnaire also asked for views on taking photographs mid-treatment. Obviously, there is an advantage to having a photographic record of each arch wire that was used. This allows an assessment of the progress achieved to that point and often from a teaching point of view, advantages, or disadvantages of any particular approach can be highlighted on these intra-oral photographs. They are also an invaluable record of the patient's level of oral hygiene throughout treatment if the case ever comes to any form of litigation.
Nine pre-treatment and nine post-treatment images should be considered an absolute minimum for each and every orthodontic patient. In addition to this, any patient who undergoes a comprehensive course of treatment with fixed appliances, photographic details of the appliances at each arch wire change, and at any other important stage would be considered the gold standard. It is envisaged that up to 36 photographs per patient are considered a reasonable number to allow full photographic documentation of the average case. If care is used during recording of images a great deal of information about the case is provided, which will prove to be an invaluable record for patient information, teaching purposes, and in the unlikely case of litigation.
Summary
The need for intra- and extra-oral photographs has been discussed, and the case made for a minimum data set of 18 photographs for each and every orthodontic patient. In addition to this, in treatment photographs at each milestone would be considered a necessity and in the future will become routine.
References
1 Angle Society of Europe Constitution and Bylaws, Edition 2001. www.ASE.com July 2001
2 Kirschen RH, O'Higgins EA, Lee RT. The Royal London Space Planning. AJO-DO 2000; 118: 448–455.
3 Sandler PJ, Murray AM. Recent developments in clinical photography, B J Orthod 1999; 26: 269–274.
Received July 16, 2001; accepted August 28, 2001
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
