The current digital camera we use is the Olympus D320 L (Olympus America, Inc., Melville, N.Y.); it features macro capabilities, auto focus and flash, color LCD screen, TWAIN driver for serial port download, 1024 x 768 resolution, and free Adobe PhotoDeluxe software (Adobe Software, San Jose, Calif.) that is included in the package. (Editor's NOTE 1.) For routine grouping, cropping, printing, compression, storage, and retrieval from hard disk, we use DentoFacial Showcase software (DentoFacial Software, Toronto, Canada). PhotoDeluxe is a simplified version of the professional Adobe PhotoShop imaging software used in many professional film studios. In complex cases involving anticipated facial changes, treatment projections are helpful aids in communication to patient and surgeon. We have found Adobe PhotoDeluxe to be very useful in this process. This technique of image manipulation is not grounded in scientific research or statistics but is an interpolation of manual cephalometric prediction and the facial image. The cephalometric prediction tracing techniques have been described by many authors and are well documented; I find Epker and Fish's 1 text, Dental Deformities, Integrated Orthodontics, and Surgical Correction, to be very helpful. As an example, an adult Class II Division 1 patient with retrognathic profile may not understand the concept of extraction of four first premolars versus extraction of lower premolars with mandibular advancement osteotomy as it relates to facial appearance. Demonstrating the cephalometric tracing prediction and before and after photographs of similar patients may be confusing to the patient. In the past, we would take the patient's pretreatment photographs, cut them with scissors, and reassemble the pieces to represent posttreatment expectations. Now we manipulate the patient's pretreatment digital image (Fig. 1). The digital facial images are taken with two millimetric rulers in the field oriented in the x and y axis. (See editor's enhancements.) These should be close enough to the subject that they remain visible after cropping. It also helps to have an absolutely white background; we use a slave bounce flash to accomplish this. The cephalometric tracing is worked up with dental, bony, and soft tissue posttreatment predictions. Overlaying the original tracing will reveal the two-dimensional changes of the soft tissue chin and lip profile relative to the x and y planes. It is then a simple matter of transferring these alterations to the image. The image can be downloaded from the camera directly to PhotoDeluxe or imported from the hard disk file. In the case of our adult Class II patient for orthognathic treatment, pogonion is moved anteriorly and inferiorly. To do this, trace the mandible with the cursor and use the editing tools to copy and cut the area and paste it in its new position based on the prediction tracing held up to the monitor screen. (Editor's NOTE 2.) The superimposed rulers help if the image cannot be zoomed to fit the tracing precisely. There is no need to worry about edges not lining up at the cut marks or shading discrepancies at this time. Similar alterations are then made to the soft tissue profile according to interpretation from the cephalometric prediction. After gross movements are accomplished, the areas of rough edges, overlapping, and shading are smoothed out with the paint, erase, and smudge tools. The rulers can be erased in the same manner. These refinements can be accomplished over large areas or even one pixel at a time with the zoom-in feature. The changed image is saved, and the original is edited again with prediction tracings used for the nonsurgical treatment option. In this Class II case, little change in pogonion is registered, but maxillary soft tissue drape and upper and lower lip are altered to a retroposition to simulate retraction to Class I. Refinement editing is done as before. The new images can now be printed, incorporated in correspondence, or exported back to Showcase for storage in the patient's image file. Several very sophisticated orthodontic/orthognathic prediction programs are on the market; these are excellent and require less input time. The above procedure is only as accurate as the
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