The basic tenet of Facially Generated Treatment Planning is that we always begin the treatment planning process with the maxillary front teeth. Dr. Frank Spear says, “problems, frustrations and concerns around treatment planning occur because teeth are in the wrong position.”

If treatment planning begins with the correct positioning of the front teeth, a more structured a systematic planning process will evolve and an appropriate restorative outcome can be expected.

Photography is a key component to the FGTP planning process. The strategic photographic series of images aids the restorative dentist in evaluation and determination of Airway, Esthetics, Function, Structure and Biology as they relate to the individual circumstances presented by the patient. These parameters provide reference and guidance in planning the appearance and relationship of the teeth. It is imperative that this basic series of images are captured so as to provide a comprehensive assessment of patient condition.

The photographic series recommended is deigned to provide reference and guidance in executing treatment planning decisions. The accuracy and detail of the images are essential. Distorted, improperly angled or inadvertently rotated photos can lead to misinterpretation and subsequent inappropriate treatment recommendations.

Due to these circumstances, it becomes necessary to add images to the photographic series to verify the patient's condition at hand.

Photographic strategy for restoration of the maxillary front teeth

I utilize treatment planning guides for a step-by-step outline in my cases. These guides systemize the planning, so all parameters have been assessed and evaluated.

The planning process is “top-down.” This means that Airway, Esthetics, Function, Structure and Biology are evaluated in that specific order. Treatment, on the other hand, proceeds from the bottom up: Biology, Structure, Function, Esthetics, Airway. Proper tooth position is the critical ingredient for success.

One of the main considerations in evaluating maxillary anterior tooth position is the facial/palatal inclination. The aspect of tooth angulation can significantly affect all areas of treatment. Proper evaluation is critical in the treatment decision making process.

Lateral teeth apart with tooth angulation lines.

Figure 1 is part of the standard photographic series. One of the key features of this image is to analyze and visualize the amount of tooth cuspal wear of both anterior and posterior teeth. Additionally, the relationship of the incisal plane and the occlusal plane may be evaluated.

We understand that the correct relationship is that both incisal and occlusal plane are coincident. These are just two observations that arise from these lateral photographic images. But a critical observation that must be assessed is the angulation of the maxillary anterior teeth. All components of AEFSB can be affected by improper tooth angulation. Awareness and definition of this positioning is paramount.

Many times, in my own treatment planning process, I find difficulty in using this lateral photographic image to make a conclusive assessment of the maxillary tooth angulation. Sometimes it is challenging to accurately determine tooth angulation, since I do not have reference to horizon or the facial plane.

For this reason, I have intentionally added an extra photograph to my standard treatment planning imaging series. This “angulation pearl” provides for definitive evaluation and judgement as to tooth positioning within the patients face.

Lateral head image of patient.

In the standard series of photographs, it is recommended to capture 18 images. Participants in the FGTP workshop are provided EFSB PowerPoint and Keynote templates that specifically designate the recommended images.

Of these 18 photographs, 16 images are intraoral views, while four images are extra-oral, or portrait actualizations. As discussed previously, proper tooth position, within the patients face, is the critical aspect of FGTP. It is the patients face and smile that dictates attractiveness and appropriateness of tooth position.

The lateral portrait image of the patient smiling can be a telling image for lip support and buccal corridor extension. As much as this image may be utilized for tooth angulation evaluation, there are three reasons I find this image challenging for definitive tooth position assessment:

Reason 1: As much as I like the fact that the patient's face (relative to horizon) may be evaluated, assessing the maxillary tooth angulation is difficult because the distance of the camera to the patient's face. This extended range makes the teeth meniscal.

Reason 2: When attempting to communicate with a patient about tooth inclination using this lateral face photograph, the patient may be distracted by other features captured within this image. Things such as moles, acne, facial hair, etc. may deter from the conversation.

Reason 3: To increase tooth size, I could crop and expand this image to highlight only the maxillary tooth smile. However, the less cropping and photographic alteration I need to do, the more efficient I can be with my patient interaction during the photographic tour of their mouth.

Close-up of patient smiling, showing nose-to-chin proximity.

My alternative solution to image-cropping is to capture a lateral “close-up:” nose-to-chin view of the patient smiling. This image provides adequate and specific detail of the maxillary tooth angulation. It contributes to patient focus on the front teeth as this situation is discussed during the photographic review tour.

I find this additional image very simple to capture and provides a detailed representation of tooth position to the incisal/occlusal plane.

Retro-inclination, normal inclination and proclination.

I hope you find this “photographic angulation pearl” a valuable resource in evaluating and discussing tooth position with your patient treatment planning conversations.

Jeffrey Bonk, D.D.S., is a member of Spear Resident Faculty.


Commenter's Profile Image John P.
March 29th, 2021
I would like to see the borders of the photo moved laterally so that we can see the ala tragus line as well, (for other purposes).