How to Increase Patient Acceptance for Cosmetic Dentistry: Cosmetic Imaging With Adobe Photoshop Elements 4.0.

Computer imaging has become an effective marketing strategy for “cosmetic” health practitioners. In dental and plastic surgery practices, cosmetic computer imaging is considered the benchmark in marketing lucrative cosmetic procedures. Several cosmetic imaging systems are available, all at a substantial cost that may range from $1,800 to $5,500. The cost, as well as the learning curve required to become proficient, make these systems impractical for many dental practices. Another consideration is that these systems often utilize a “library” of smiles from which a smile can be selected and superimposed onto the patient’s “before” smile image. Since the selected teeth may not biologically fit in the patient’s mouth, this method can create unrealistic expectations and unhappy patients. It is more prudent to confine the cosmetic imagery to the patient’s own mouth and then edit individual teeth or groups of teeth to provide a more predictable outcome, resulting in happier and more satisfied patients.
An alternative that is available for less than $90, requires less time to master, and still provides outstanding cosmetic imaging is Adobe Photoshop Elements 4.0 (PE). This software is modeled after the professional-grade, industry-standard Adobe Photoshop CS2.1 Many of Photoshop’s best features can be found in PE. PE offers a way to download, organize, store, edit, and print images that can be used to market cosmetic procedures in your practice. PE versions are available for both Mac and PC users. The following article describes some of the uses of PE software in the context of a dental case study.

CASE STUDY

One of the features that PE provides is an image catalog that allows separation of pictures into individually named folders referred to as tags. Once the photos are imported from a camera or a memory card and categorized, individual photos can then be edited. For cosmetic imaging purposes, it is suggested that 3 photographic views be taken to complete these exercises: a close-up frontal, a close-up lateral, and a portrait view. Some patients are reticent about displaying their teeth. However, it is imperative that the photographer get the patient to smile as broadly as possible.
The case study patient presented with discolored anterior teeth with a number of stained class III restorations and was interested in improving her smile. She had unsuccessfully attempted to whiten her teeth with a number of over-the-counter bleaching systems.
Several photographic images were taken. (The beauty of digital photography is that it doesn’t cost anything to take a number of pictures, select the best ones, and delete the rest.) The images were then imported and tagged in the organizer file.

Frontal View Editing

Figure 1. Screen display after the image has been straightened and cropped.

Figure 2. The Zoom (+) tool is used to enlarge the area in the workspace.

Figure 3. Using the Clone Stamp tool and the Brush tool, the discolored restorations are eliminated. The Healing Brush tool is used to remove small dust blemishes.

Figure 4. Screen displays all of the restorations having been removed.

Figure 5. After using the Zoom (+) tool, the incisal edges and embrasure are modified.

Figure 6. The blue arrow shows how the Lasso tool is used to encircle the incisal edge of tooth No. 7.

Figure 7. After a layer is created, the Move tool is placed at one of the small boxes and stretches the incisal edge to lengthen tooth No. 7. The same procedure is performed on tooth No. 10.

Figure 8. Screen displays lengthening of the 2 lateral incisors.

Figure 9. Using the Magnetic Lasso tool, the 6 anterior teeth have been selected.

Figure 10. In the dialogue box select to edit the yellow color and move the saturation slider to the left.

Figure 11. With Master designated, the Lightness slider is moved to the right to increase the brightness of the 6 anterior teeth.

Figure 12. Enlarged area allows you to see clearly areas not selected by the Magnetic Lasso tool. The Brush tool is able to correct these areas.

Figure 13. Screen view of the appearance of 8 veneers.

Figure 14. Screen view of the appearance of 10 veneers.

PE has two editing modes: Quick Fix and Standard Edit modes. The Quick Fix mode has basic photo-editing capabilities and can be used for correcting minor details such as lighting, contrast, and color, but does not possess the tools needed for image creation. The Standard Edit mode has a variety of editing tools and is the designated workspace in which cosmetic imaging will be completed.
After selecting the best frontal view in the organizer file, the image is opened in the standard editing mode. All editing should be approached systematically: fix the picture, correct the individual teeth, and then “make” the smile. Editing tools are found in the left column of the editing screen. Usually the first tools used are the Crop and Straightening tools. Regardless of the angle at which the image was taken, the Straightening tool can correct the vertical and horizontal vectors of the image. Then the Crop tool can eliminate any undesired parts of the image (Figure 1). Once the image is aligned properly and cropped, the editing/imaging process begins.
It is always easier to edit magnified images. Select the Zoom (+) tool and place it in the center of the image. Left-click several times to enlarge the image (Figure 2). In this case, the discolored class III restorations are changed to the shade of the adjacent tooth structure. Several different tools can be used to accomplish this. One is the Clone Stamp tool, which is very effective in creating color changes. It allows you to paint parts of images over other parts and is mostly used for repairs and retouching.2 The cursor is moved to the desired area of the tooth to duplicate. Holding down the Alt key and left-clicking, the paint color is selected. The cursor is then moved over the discolored restoration, and either by clicking over one area at a time or by clicking and holding, the cursor acts as a brush and paints the new color over the area. In the Options bar, the size of the brush can be changed as well as the degree of opacity. All of the discolored restorations are changed to the adjacent tooth color, which essentially eliminates the fillings.
The Brush tool can also be used to change the color of an area. After selecting the Brush tool from the toolbox in the left column, the size of the brush can be chosen in the Options bar. Again, place the cursor in the desired color area and Alt-click to select the color. Then, while holding down the left-click button, brush over the discolored restorations and change the color.
The Healing Brush tool can also be used to mask the discolored restorations. The tool uses the color of the adjacent pixels and places them over the discolored area. This tool is not always consistent in the color choice. The Healing Brush, however, is an excellent tool to remove spot blemishes (Figure 3).
Using the Brush tool, the incisal edges and incisal embrasure of the central incisors are corrected. Select the size and type of brush. The color is chosen by aligning the cursor at the incisal edge and Alt-clicking. As the corrections are made, the opacity level is adjusted to create a blending effect (Figures 4 and 5).
The next exercise is to lengthen the lateral incisors. The following steps can also be used to close diastemas. Select the Lasso tool from the toolbox. This tool has 3 versions: the Lasso, the Magnetic Lasso, and the Polygonal Lasso. The border of the selected area can be softened by changing the “feathering” value in the Options bar. Changing the value to 2 or 3 pixels will make the border of the selected area less abrupt. Place the cursor slightly above the incisal edge and while holding down the left-click, draw a line around the entire incisal edge of tooth No. 7 and return to the starting point. The line of the circle will appear as “marching ants” to signify the selected area (Figure 6).
The next step is to create a layer. This is accomplished by clicking on Layer in the Menu bar. In the drop-down dialogue box select New ‘ Layer via Copy or use the shortcut Control + J. This will create a layer in the Layer Palette on the right side of the screen. From the toolbox, select the Move tool. A rectangular box is displayed with small boxes at the corners and in the middle between the corners. The cursor can be placed at any of the small boxes. While holding down the left-click, the selected area can be dragged to increase the length (Figure 7). In the Options bar, click on the check symbol to save the addition. Before proceeding to the left lateral incisor, go to Layers ‘ Flatten Image to remove the layer. Repeat the same steps to lengthen tooth No. 10, then Flatten Image (Figure 8).
There are several ways to create the cosmetic effect of placing laminate veneers. One way is to use the Magnetic Lasso tool and encircle the teeth that will be affected. The beauty of this technique is that one can create different images to show patients what their teeth would look like if 6, 8, or even 10 veneers were completed. This would depend on how many teeth are visible in the smile display. That is why an image of the patient’s broadest smile is critical when obtaining the original images.
To begin, create a starting point in an area of high contrast. For example, place the first set point on the incisal edge where there is a definite color difference between the edge of the tooth and the background. The Magnetic Lasso can distinguish be-tween the different colors of the pixels. The amount of contrast and the width of pixels can be adjusted in the Options bar. Using the Magnetic Lasso tool, draw a circle around the desired teeth. For example, include the 6 anterior teeth for the first selection (Figure 9). When the cursor meets the original set point, the selected area is designated by the “marching ants.” In the Menu bar, click Enhance ‘ Adjust Color ‘ Adjust Hue/Saturation. A dialogue box appears with an Edit pop-up menu. Click on the “down” arrow and select Yellows from the menu (Figure 10). Move the Saturation slider control to the left to remove the yellow from the teeth. After the yellow is removed from the teeth, change Yellow in the Edit pop-up menu to Blue. Decrease the saturation level by moving the slider to the left. Now change from Blue in the Edit pop-up menu to Master. Drag the Lightness slider control to the right to the desired level of brightness, then click OK (Figure 11).3 Use the Zoom (+) to enlarge the image and check around the gingival margins and edges of the teeth for any areas that were not included. If you need to add areas, select the Brush tool and fix these areas by Alt-clicking the brighter tooth color adjacent to the unaffected areas (Figure 12).
The new cosmetic image can now be saved. In the Menu bar, click File ‘ Save As, and a Save As dialogue menu appears. Select a file where the image will be stored and select JPEG as the format. Label the image as “6 veneers.” Click OK, and the image is now saved. The next step is to create the appearance of veneering not only the 6 anterior teeth but also the first bicuspids. Click on File ‘ Open and select the image that was just created, “6 veneers.” After the image appears, select the Lasso tool and encircle one of the bicuspids. Then, in the Options bar, click on the “add to selection” option and encircle the contralateral bicuspid. Choose the Enhance menu and repeat the same steps in eliminating the yellow and blue and increasing the lightness (Figure 13). Now save this image in the same file but labeled as “8 veneers.” If the 2nd bicuspids are visible in the smile display, then the same process can be repeated and saved as “10 veneers” (Figure 14). This gives the patient the opportunity to view the effect of the different treatment options. In most cases, the patient desires the full smile effect.
In situations where the bicuspids still have a gray appearance from large amalgams, the teeth can be “tweaked” using the Dodge tool. In the toolbox, select the Dodge tool, which is one of the tools in the Sponge tool category. In the Options bar the brush size and type can be selected. The type of brush can have a sharp or diffused border. The color range and exposure percentage can also be selected. The color range includes shadows, highlights, and mid tones. The exposure percentage is similar to the level of opacity, and the selection is based on the situation. Experiment with these different settings to arrive at the desired effect.

Lateral View Editing

Figure 15. After removing stained restorations and lengthening the lateral incisors, the 6 anterior teeth are “veneered.”

Figure 16. Screen view of 8 veneers.

Figure 17. Screen view of 10 veneers.

The advantage of using this view is that it allows patients to see their smile up close at an angle that they are not accustomed to seeing. Many times a patient will present for a consultation with the preset notion of needing only 6 veneers. This is often the patient who also wants to go from an A-3 to an A-0 shade. The patient is not aware of the dramatic contrast between the canine teeth and the first bicuspids. As clinicians, we try to sway them to include more teeth in their cosmetic makeover, knowing that it will result in a more natural appearance. Often, the patient is thinking about the cost and not the value of the treatment. Showing the patient a lateral view of completing 8 veneers, or even 10, as opposed to 6 is a very effective communication tool. It should be explained that this is the view from which most people see them.
To complete the cosmetic imaging in the lateral view image, the same sequence of tools and exercises can be used as previously described for the frontal view. Again, it must be emphasized that the more tooth display that is seen in the image, the more helpful it is to the patient in evaluating the cosmetic effects (Figures 15 to 17).

Portrait View Editing

In the portrait view, the teeth will, of course, be smaller. Once the image is imported into the workspace, click on the Zoom tool in the toolbox. Make sure the Zoom (+) mode is active. Move the Zoom tool over the smile area and left-click until the smile is enlarged. At this point, the same tools that were used for the 2 previous exercises can be used again. Because of the size, the cosmetic imagery does not have to be as detailed. To check the effects, on the Option bar click Zoom (-) to bring the image back to the normal size. If more changes are necessary, then enlarge the image again using the Zoom (+) tool. Once satisfied with the changes, click File ‘ Save As and save the image with the title “after portrait.”

Finishing Tips

Figure 18. The “before” image is resized to 30%.

Figure 19. The “before” image is moved onto the “after” image. The new image is then printed for the patient.

It is highly recommended that the patient leave with a picture in hand to take home. Many times the patient wishes to discuss the treatment plan with a spouse or significant other. The before-and-after cosmetic images showing the different treatment options can be printed using 4x6 photographic paper. Another effective version is to put a small “before” picture in one of the “after” pictures using 8.5x11 photographic paper. This can be done several different ways.
One way to create an image within an image is to open the “before” image of the frontal view, which will be the image that goes inside the “after” image. Then open the image showing 6, 8, or 10 veneers. In the Options bar on the right side, click on Tile or Cascade Windows so both images are on the screen. The first or “before” image will have to be made smaller, otherwise it will occupy the same amount of space and cover the “after” image. A small portion of the “before” image can be selected with the Rectangular Marquee tool from the toolbox. A box can be placed in the desired area of the “before” image. Change to the Move tool from the toolbox and place the tool over the selected area. While holding down the left-click, drag the selected area to the “after” image and situate it. Then release the left-click.
Another option is to click Control+A on the “before” image. This will select the entire image. Go to the Menu bar and select Image ‘ Resize ‘ Image Size. In the Document Size dialogue box, change the display from pixels to percentage. Change the size to 30% and click on the Resample box. Click OK, and the image will be reduced to 30% (Figure 18). Click on the Move tool and move the smaller “before” image to the larger “after” image and place it in the desired location (Figure 19).
After creating the image within an image it can be saved by File ‘ Save As, then the image is named as “before and after” as a JPEG file. The image can then be printed on 8.5x11 photographic paper and given to the patient at the consultation appointment.

Consultation

Depending on the experience and speed of the clinician with PE, the imaging can be completed as the patient watches. New users of the PE program who desire extra time to complete the cosmetic changes can reschedule the patient for a subsequent appointment. If the patient is to return for a consultation appointment, it may be desirable to have taken diagnostic models in which a mock-up can be created either by the clinician or by a laboratory technician, so the patient can hold a 3-dimensional model in his or her hand. Patient acceptance may be more successful when he or she can show family and friends before-and-after photographs and/or models of the proposed treatment plan.

CONCLUSION

Computer technology is a powerful device that can be used as an effective communication tool in dentistry. For less than $90, the Adobe Photoshop Elements program can increase patient acceptance by allowing the patient to view realistic treatment scenarios. Patients can take home before-and-after photographs in portrait and close-up versions that will usually have a positive impact on their decision to proceed with the treatment.


References

1. McClelland D. Photoshop Elements 3 for Windows One-on-One. Sebastopol, Calif: Deke Press; 2005:3.
2. Grossman R. Fun with Photoshop Elements 4: Foto Fakery for Everyone. Indianapolis, Ind: Sams Publishing; 2006:41.
3. Kelby S. The Photoshop Elements 3 Book for Digital Photographers. Berkeley, Calif: New Riders/Peachpit Press; 2005:236-239.


Dr. Helvey is a Master in the AGD and is an adjunct associate professor at Virginia Commonwealth University School of Dentistry, where he teaches cosmetic dentistry with emphasis on laminate veneers in the AEGD residency program. He is also a laboratory technician, which has aided in the development of his laminate veneer techniques. Presently, he serves on the Editorial Board of Practical Procedures and Aesthetic Dentistry. Dr. Helvey has published peer-reviewed articles relevant to clinical and laboratory techniques in the Journal of Prosthetic Dentistry, Practical Procedures and Aesthetic Dentistry, The Compendium, Contemporary Esthetics and Restorative Practice, Dental Dialogue, and Dentistry Today. He has lectured nationally and internationally, and maintains a private practice in Middleburg, Va, emphasizing restorative aesthetic dentistry. Dr. Helvey teaches a full-day, hands-on course mastering the techniques (and many others) that are described in this article. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .



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