Photographic records: without standardisation a before-and-after proves nothing

Photographic documentation in orthodontics serves three distinct purposes: diagnostic, communication with the patient, and medicolegal. All three require the same thing, namely images that are comparable over time.

Comparable means standardised. Two photographs taken at different distances, with different lighting and different framing do not permit a change to be assessed: they show two situations that cannot be compared.

The complete orthodontic set comprises extraoral views frontal at rest, frontal smiling and in profile, plus intraoral frontal, right and left lateral, and upper and lower occlusal views.

The minimum equipment is a camera with a macro lens and a ring flash or twin flash. The ring flash gives uniform, flat illumination, convenient for intraorals; twin flashes give more depth.

A phone is not adequate for clinical records, not for resolution but for the lack of control over focal distance and exposure, which are precisely what needs standardising.

Settings should be fixed and noted. Same magnification ratio, same aperture, same distance: only then is the review photograph comparable with the initial one.

For intraorals, retractors must be used as a pair and pulled symmetrically. One retractor pulled harder than the other produces an image suggesting an asymmetry that does not exist.

Mirrors must be warmed to prevent fogging, and the resulting image must be mirrored during filing, otherwise right and left appear reversed.

For extraorals, head position is the critical variable. The photograph is taken with the patient in natural head position, not with the Frankfort plane parallel to the ground.

The difference is substantial: natural position is reproducible and corresponds to how the patient presents in life, whereas a position forced onto an anatomical plane varies with the operator.

Medicolegal value is the function one appreciates only when it is needed. Complete initial records demonstrate the starting situation, and in the event of a dispute they are the most solid evidence available.

Documenting pre-existing conditions — recessions, restorations, white lesions already present, asymmetries — protects against their later attribution to orthodontic treatment.

In summary: standardising distance, exposure and position is what makes photographs useful, retractors must be pulled symmetrically, natural head position is more reproducible than a forced one, and complete initial records have a value discovered at the worst moment.