I have been a practicing dentist since 1979, specializing in aesthetic and re-storative dentistry, especially complex reconstruction, TMJ problems, and cosmetics. Like most areas of dentistry, this field is part science and part art.
For everything from porcelain veneers and implants to partial dentures, I need to analyze scrupulously every visual detail to ensure that the end result is precisely correct in terms of shape, size, and color. Of course, I also must communicate accurately with dental labs so that patients are satisfied with the end result.
Digital imaging technologies have become essential to my work with each patient, from planning and design to final treatment. Thanks to digital imaging, patient planning and treatment is more advanced and precise than ever. Instead of relying solely on x-rays, plaster casts, and written notes, I can communicate visually with dental labs and patients. The result is more precise treatments—and more satisfied patients.
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| Figure 1. The patient presented with diastemas following orthodontic treatment. |
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| Figure 2. Natural smile with orthodontically corrected occlusion. |
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| Figure 3. Close-up view of new veneers in centric occlusion. |
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| Figure 4. Close-up view of new veneers with teeth slightly apart. |
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| Figure 5. Natural smile of new veneers taken from a high angle |
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| Figure 6. Natural smile of new veneers taken from straight-on view. |
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| Figure 7. Mock-up using Photoshop to close diastemas. |
THE MOVE TO DIGITAL IMAGING
I first began using traditional imaging techniques to document patients’ baseline conditions and communicate with labs. Unfortunately, I usually had to wait days for the film to be developed, resulting in delays while patients waited for treatment.
As soon as it became practical, I made the switch to digital imaging. Today, I use a digital camera to take a dozen images of each patient before treatment begins. By capturing images from several different angles, I have a wealth of documentation that I can use to show the patient before-and-after photographs detailing the effectiveness of a treatment.
I also use the baseline images to plan and visualize each treatment. I download the images from my digital camera via a Macintosh PowerBook computer via the office network to an image server in my office. With Adobe Photoshop software I manipulate the images—whitening, shortening, lengthening, or widening the teeth, for example. Using this approach, I can gain an understanding in advance of what I will encounter when I actually begin work on the patient.
WHY USE ADOBE PHOTOSHOP?
I prefer Photoshop because it allows me to respect the root position of the teeth. Certain other software would allow me to unrealistically move teeth around at will during visualization, often producing results that are technically not achievable. Patients may be enthused by the images I show them, but when the day comes for actually cementing the crown or the veneers, the end result looks nothing like what I proposed. Photoshop, on the other hand, provides a reliable foundation upon which to apply a cosmetic treatment. The end result is therefore more predictable, and patients are more satisfied with the final treatment.
Benefits for Dentists and Patients
The integration of digital imaging and Photoshop can greatly benefit you and your patients. It’s a great sales tool for cosmetic dentists because patients can see how their smile will look before they pay a cent for treatment.
We all want to show the highest quality images to patients, something that was previously easier using film. By using Photoshop, I have found that I can easily adjust images to adjust image brightness and make them easy for patients to view on screen.
Digital imaging also benefits patients by putting them at ease and preparing them psychologically for a major change in their appearance. Using digital imaging technology, I can determine which treatments will most improve the patient’s smile before I begin treatment. I can also reduce risk, because I can use images to obtain patient approval before proceeding with treatment.
EASY PHOTOSHOP TIPS
You may think that Photoshop is too complicated and difficult to use. While it is true the program is incredibly feature-rich, there are just a few simple techniques you need to know to make it work for you in your practice.
First, keep in mind that it provides a number of safety-net features that let you learn and experiment without penalty. One useful feature is layers, a means of editing images or portions of images while leaving the original image intact. You can always start by copying the image that you plan to edit onto a separate layer. Then you can manipulate the copied layer, whitening, shortening, or performing other proposed changes to the teeth. You can also select portions of an image—specific teeth or parts of the gumline, for example—and place them on a separate layer if you need to.
Layers are also a valuable means of communicating with patients. You can put a before image on one layer and an after image on another layer. By toggling back and forth, you can show the patient the effect of a proposed treatment.
Once you have copied the image onto a new layer, Photoshop offers a number of brushes and paint tools that let you easily extend, shrink, and otherwise paint on top of a patient’s existing teeth to help visualize treatments. You can also draw a new smile by creating a path in Photoshop and then filling it in.
If you don’t like what you see once you start editing an image, you can always use the history palette, a feature that lets you revert back to previous image versions. Layers and the history palette are extremely beneficial, whether you are just starting to learn the program, or whether you are already experienced.
All of these techniques are relatively simple to learn and use. They do take practice, but the results are much more predictable. You can use a standard computer mouse for drawing in Photoshop as I do, but you may find it easier to draw using a graphics tablet.
RICH VISUAL COMMUNICATION
In my practice, once I have planned the treatment, I show the images to patients to obtain their approval to proceed. After the client ap-proves the treatment plan, I select key images using the File Browser in Photoshop and send them to a dental lab by e-mail and via CD. I have created an action in the program that automates the process of sizing images for sending via e-mail. This saves a lot of time. I usually send about 20 images, and resizing each one manually might take 30 seconds each. Actions are easy to set up and probably save me 10 to 20 minutes each time I send photos to a lab.
The images edited or mani-pulated give the lab a better idea of the patient’s personality and provide more detail about the color of the patient’s skin, the shape of the face, and the position of the teeth in relation to the lips. None of this is conveyed using a standard plaster cast. By providing precise visual images coupled with written instructions, the lab achieves more accurate results.
I’ve found that my patients are more satisfied with the end results because of the rich visual communication that I’m able to achieve using Photoshop throughout the planning and treatment pro-cesses. The images also serve as a reminder. Like many dentists, I’m sure you’ve discovered that patients quickly forget how they looked prior to treatment. In addition to using this software for communication during treatment, I create bound booklets for each patient showcasing before-and-after images as a marketing tool and a reminder of how the patient’s new smile has improved his or her overall appearance.
CLINICAL EXAMPLE
Figures 1 through 7 demon-strate the clinical use of digital imaging as discussed in this article. In this case, the patient presented with post-orthodontic diastemas of her maxillary anterior teeth. She was unhappy with the results of orthodontics and wanted to have diastemas closed. Ideally, she would have re-quired 6 veneers, but we were able to get a good result (and a happy patient) with 4 veneers on the laterals and central incisors.
CONCLUSION
If you’re waiting on the sidelines, now is the time to try digital imaging. It has greatly enhanced my practice, and the same may be true for you. As dentists, we are healthcare practitioners, but we can also have a profound impact on our patients’ visual appearances. By applying the highest quality tools for visual communication, we can enhance our practices, help the labs that we rely on, and most important, greatly improve patient care.
Dr. Martinez has a practice in Albuquerque, NM, emphasizing complex reconstruction, TMJ problems, and cosmetics. He is active in several dental study clubs that promote excellence and help build skills in new and existing techniques. He can be reached at (505) 881-7337.
