Digital Image Management and Manipulation in the Dental Office

Digital images are becoming more and more common in the dental office. With the use of intraoral cameras, digital cameras, and digital radiography equipment, dentistry has advanced into the high-tech arena. One of the issues associated with these images is how they can be most efficiently stored and managed. It would be virtually impossible to print out each image and store it in the patients paper chart. Paper charts already require significant storage space, and this would only add to the challenge of how to keep these images. 

Computer technology is the ideal way to store such images. Several excellent software packages exist so the dental team can easily store and retrieve images as well as create a variety of presentations for patient education or collaboration with dental colleagues (See Table). Many of these software programs also allow for image manipulation to assist in treatment planning and patient/doctor decision-making.

Digital photographs can be acquired through a digital camera and downloaded to the office computer. They also can be captured with an intraoral camera that is attached to the computers video capture card through a standard video connector or USB port. Images captured with a digital camera are generally of higher image quality than the intraoral camera. However, most images captured through an intraoral camera are generally quite acceptable for record-keeping and patient presentation purposes. Extraoral images used in performing digital smile design are best taken with a digital dental camera designed for dental close-up photography.

Figure 1. Digital images should be retrievable based on various categories such as patient name, tooth number, or keyword category.

Storage and retrieval is the basic necessity common to all digital image archiving programs. Various programs will store the captured image as a condensed bitmap image. This image should be saved as an original, not able to be changed. Modified images should automatically be saved with a new name to indicate that it is a modified version of the original. Rather than saving an image solely under a patients name, it is advantageous to tag the image with a variety of categories. In this manner, the image may be retrieved based by patient name, tooth number, or category (Figure 1).

A software program in which the categories can be added is ideal. Categories may include aesthetic onlay, fractured tooth, all-ceramic crowns, gingivitis, etc. Retrieval by category is most useful when the clinician is educating the patient on a particular dental condition and is using certain images to show the patient a similar case. Patients are often most attentive when the dentist is presenting cases that he or she actually did, rather than from a purchased book of images. In effect, digital photography and image management allow the dentist to quickly become the author of his or her personal digital photo album. Simply being able to conveniently store and retrieve digital images is certainly a step toward creating a WOW! Factor in the dental office, but there is much more.

Although these software packages can be used as stand-alone systems, it is ideal to integrate the imaging program with the existing office practice management software. Some practice management software comes bundled with image management capabilities. When the image management system is purchased separately from the practice management software, it is generally referred to as a bridge. Thus, the digital images acquired from the camera or x-ray machine are stored and manipulated, then bridged into an individual computer or the practices local area network. The more advanced systems can integrate with a wide variety of intraoral cameras, twain-compliant scanners, and digital x-ray systems as well as share patient database information with the practice management system. The ideal image management system will demonstrate consistent management of images independent of their source and such flexibility that simultaneous use of devices from different manufacturers can be accomplished. It is essential that the practices particular software and hardware be tested with the imaging software when researching the product for purchase.

Clinical Application

The ease with which a presentation can be created for a particular patient is described as follows.

Figure 2. Image management software allows for addition of text or diagrammatic notations directly on the image itself.	Figure 3. Presentation of a porcelain inlay treatment sequence can be easily created for enhanced patient/doctor communication.

Figure 4. Image management software with prepackaged templates allows for easy development of letters or e-mails.

Suppose a patient presents with a fractured premolar tooth. As the clinician, you might present the option of a porcelain onlay. To most patients, this terminology is relatively meaningless. However, digital imaging software with presentation capabilities enables these dental procedures to be described quite comprehensively. The operator first searches by category images that are related to the treatment being considered. These include but are not limited to fractured tooth, aesthetic restoration, or porcelain onlay. Once the various images are gathered, the operator then begins to develop the presentation. If desired, notations such as text or arrows can be placed on the image (Figure 2). Each image is selected, and the appropriate presentation template screen is selected. The images automatically fall onto the presentation template and can be moved around using a simple drag- and-drop technique. With the images in place, description of the technique can continue with side-by-side sequences of the doctors own work (Figure 3). Even the patients own tooth, which was just captured with the intraoral camera, can be included in the presentation. Presentation software packages also allow for easy development of letters or e-mails (Figure 4).

Cosmetic imaging components in these software programs make it possible for the operator to take a before image and develop an anticipated after photo. Users can manipulate images so a patients teeth can be bleached, a diastema closed, a chipped tooth repaired, amalgams replaced with tooth-colored restorations, or a particular tooth or series of teeth recontoured. Even complete smile makeovers can be simulated on the computer. When used properly, image manipulation can be a convenient treatment planning tool and enhance the opportunity for co-diagnosis. However, the clinician must still be a highly skilled dentist in order to accomplish results similar to those projected by the computer. Certainly, a disclaimer should be included with each manipulated image, stating that this is a simulation only and actual results may vary.

Consider the patient with a large, midline diastema. Both patient and clinician may wonder how the treatment outcome will appear. With a well-constructed imaging program, a computer simulation is easy. The exact technique may vary depending on the functionality of the program and preferences of the operator. For demonstration purposes, the ADSTRA IMAGING program is being used to illustrate this process.

Figure 5. ADSTRA Imaging software being used to simulate digitally a diastema closure. The mesial surface of one of the teeth is selected.

Figure 6. A duplicate image of the mesial surface being dragged over to the maxillary central incisor. Once positioned, this image can be dropped into place.

Figure 7. A second image is pasted on the work surface and digitally flipped to create a mirror image. This new image is then dragged to abut the adjacent maxillary central incisor.

Figure 8. After the copied images are rotated and adjusted for minor size discrepancies, a smudge tool allows the demarcated areas to be blended.

Figure 9. Presentation of a digitally simulated diastema closure showing both intraoral and extraoral views.

The pretreatment image is selected for the work area, and the mesial third of one of the teeth is selected, preferably the tooth with the straighter mesial line angle (Figure 5). A duplicate of this area is created using the copy-and-paste command. The duplicate image is then moved over the mesial portion of the tooth using a drag- and-drop technique (Figure 6). Minor changes in width, height, or rotation may be necessary to fit the digital tooth piece in an aesthetic position. The same procedure can be applied to the adjacent tooth, but an even easier technique exists. A second duplicate image created in the previous copy process is again pasted on the work area. Using the mirroring button, a reverse or mirror image is created (Figure 7). This image can then be dragged over the digitally untreated tooth, and the same process of rotation and resizing applied. Slight aesthetic touch-ups may be applied with the programs coloring tools. Finally, there may be a noticeable demarcation between the original image and the pasted image. Using a smudge tool, this area can be blended to make the perceived addition virtually unnoticeable (Figure 8). As the operator becomes more skilled with the program, intraoral and extraoral images can be modified and presented in less than 10 minutes (Figure 9).

Figure 10. Simulated smile makeovers with cosmetic imaging software from DENTALEYE 3.

In certain clinical situations, the dentist may wish to modify the patients complete smile. Here is where a smile makeover/cosmetic imaging feature can come in handy. Some programs will allow the operator to remove digitally a patients existing teeth and replace them with more ideal dentitions with varying aesthetic contours. This allows the patient to see numerous what if situations and helps guide the dentist to develop a particular treatment plan (Figure 10). It remains up to the dentist how this smile makeover will be accomplished. Can it be done with veneers or full-coverage restorations, or will orthodontics or periodontal plastic surgery be required? These are questions that need to be considered. A computer cannot decide this for younot yet anyway! A highly trained and technically skilled clinician is of utmost importance in achieving the anticipated results again, if patients are given these simulated images, it is best to attach a disclaimer stating that the photographs are for planning purposes only and are not a guarantee of treatment; actual results may vary. Several smile libraries, compiled by expert clinicians, are commercially available. However, the simplicity of digital photography allows dentists to compile their own personal libraries using existing patients and treated cases.

There is a bit of controversy associated with imaging makeovers. It has been suggested that the best way to show a prospective patient what is possible is through a presentation of the dentists similar past cases. In this manner, the dentist builds patient confidence that he or she has treated this clinical situation in the past with successful outcomes. There are no simulated smiles available for comparison. As a result, unrealistically high expectations by the patient are reduced. As was demonstrated earlier, digital imaging software is an ideal presentation tool to achieve this end as well.

Imaging programs are not all alike and are not cheap. They are not the same as photo editors for home computing. Choosing a software package often represents a significant investment in time and money. Involve staff members in the decision-making process.  Trial versions of the software, which are fully functional, are usually available. Put the program to use in your office. Find out if the cost of help and training beyond the very basics is included in the purchase price. Test to see how well the software package integrates with the offices practice management system. Consider how you will be storing and backing up these images.

CONCLUSION

Digital photography is another way to make dental practice fun. These images can enhance communication with patients, staff, and colleagues. Digital images improve our treatment planning and record-keeping abilities. They are also a great way to showcase and assess our clinical abilities. Image management software puts this complete package together.

Additional Reading

Benjamin SD. Digital imaging: a picture is worth a thousand words. Pract Proced Aesthet Dent. 2003;15(6):494-496.

Emmott L. Digital cosmetic imaging: tips and tools to keep you and your patients smiling. Dent Prod Rep. 2002;May:38-45.

Gane D. Image management in dentistry. J Calif Dent Assoc. 2001;29(10):759-763.

Goldstein MB. Digital photography in your dental practice. The whys, hows, and wherefores. Dent Today. 2003;22(4):98-101.

Maher R. Digital dental magic. Dent Econ. 2003;May:78-80.

Schleyer TK, Spallek H, Bartling WC, et al. The technologically well-equipped dental office. J Am Dent Assoc. 2003;134(1):30-41.

Acknowledgements 

The author would like to recognize Lori Paulson of American Dental Cooperative and Viviana Bardea of ADSTRA Systems,  for use of the ADSTRA Imaging software; also Imagin Systems Corporation and Anders Berggren of DentalEye AB for use of the DENTALEYE 3 software.

Dr. Rada is in private practice in LaGrange, Ill, where his focus is on restorative and aesthetic dentistry and dentistry for special-needs patients. He also is a clinical assistant professor in the Department of Oral Medicine and Diagnostic Sciences at the University of Illinois College of Dentistry, where he teaches in the general practice residency clinic and dental Informatics course. He can be reached at (708) 482-3636.