MAGNIFICATION IN

DENTISTRY

RINI BEHERA
2 ND YEAR PG TRAINEE
CONTENTS
 INTRODUCTION
 HISTORY OF MAGNIFICATION
 OPTICAL DEFINITIONS
 ELEMENTS IMPORTANT FOR CONSIDERATION IN
IMPROVING CLINICAL VISUALIZATION
 CLASSIFICATION OF MAGNIFYING SYSTEMS IN DENTISTRY
-LOUPES
-ENDOSCOPY
-OPERATING MICROSCOPE
 USES OF MAGNIFICATION IN DIFFERENT FIELDS OF
DENTISTRY
  CONCLUSION
INTRODUCTION

“YOU CAN ONLY TREAT WHAT YOU CAN SEE!” - PROF. PROF. SYNGCUK
KIM KIM
Modern dentistry places many stringent demands on the dentist.
A necessary attribute for clinical work is a high level of visual acuity, especially for near vision
and common way to achieve better vision is to move closer to the patient, magnifying the area
of interest.
Two main drawbacks;
• compromised posture, over time, cause muscular and orthopaedic problems.
• presbyopia

Presbyopia is characterized by a progressive loss of accommodation width caused by sclerosis of

the eye lens, increased glare sensitivity and decreased contrast sensitivity.
Presbyopia first occurs around age 40 (Gilbert 1980, Woo & Ing 1988, Pointer 1995,
Eichenberger et al. 2011); often, however, it is only discovered and corrected years later, when it
poses limitations in daily life.
Atchison D. Accommodation and presbyopia. Ophthalmic and Physiological Optics
1995;15:255–272.
Burton J, Bridgman G. Presbyopia and the dentist: the effect of ageing on clinical vision.
International Dental Journal 1990;40:303–312
One possible method to improve clinical vision is to use
magnification
image
or a model.
This is a phenomenon of visually amplifying and availing an
enlarged, exaggerated, intensified view of an object or an
WHY ENHANCED VISION IS NECESSARY IN DENTISTRY??

precision dentistry

The resolving power of the unaided human eye

is only 0.2 mm.
 Restorative dentists, periodontists, endodontists routinely perform procedures requiring
resolution well beyond the 0.2-mm limit of human sight.

 Crown margins, scaling procedures, incisions, root canal location, caries removal, furcation
and perforation repair, post placement or removal, and bone- and soft-tissue grafting
procedures are only a few of the procedures that demand tolerances well beyond the 0.2-mm
limit.
 Clinically, most dental practitioners will not be able to see an open margin smaller than 0.2
mm.

 The film thickness of most crown and bridge cements is 25 mm (0.025 mm), beyond the
resolving power of the naked eye.
The surgical precision can be even achieved manually provided with visual
acuteness, but this could be enhanced multiple times making use of good
magnifying devices.
Microsurgical procedures involving vessels greater than 1.5 mm can safely be
performed with loupes of 3.5x to 4x magnification.
Pieptu D, Luchian S. Loupes-only microsurgery. Microsurgery. 2003;23:181–8.
[PubMed]
(1595)Hans and Zacharias Jansen -Simple (single lens) and compound (two
lenses) microscopes.

(1665) Robert Hooke- Using a compound microscope, coined the word

‘cell’while describing features of plant tissue.

(1674) Anton van Leeuwenhoek- produced single lenses powerful enough to

enable him to observe bacteria 2–3 μm in diameter.

Carl Zeiss, Ernst Abbe, and Otto Schott devoted significant time to develop
the microscope.
 EVOLUTION OF MAGNIFICATION AND
ILLUMINATION IN MEDICINE IN 1921
Dr Carl Nylen of Germany: Monocular microscope for operations to correct
chronic otitis of the ear.
The unit had two magnifications of × 10 and × 15 and a 10 mm diameter view of
the field. This microscope had no illumination.

(1922) the Zeiss Company (Germany) working with Dr Gunnar Holmgren of

Sweden, Introduced a binocular microscope for treating otosclerosis of the
middle ear.
This unit had magnifications of × 8–× 25 with field-of-view diameters of 6–12 mm
.
 (1953)- The formal introduction of the binocular operating microscope took place
when Carl Zeiss introduced the Opton ear microscope

EVOLUTION OF MAGNIFICATION AND

ILLUMINATION IN DENTISTRY
(1876) Dr Edwin Saemisch, a German ophthalmologist, introduced simple binocular loupes to surgery.

(1962) Dr Geza Jako, an otolaryngologist, used the SOM in oral surgical procedures.

(1978) Dr Harvey Apotheker, a dentist from Massachusetts, and Dr Jako began the development of a
microscope specifically designed for dentistry.

(1980) Dr Apotheker coined the term ‘microdentistry’

(1981) The ‘DentiScope’ was manufactured by Chayes-Virginia Inc., USA, and marketed by the
Johnson and Johnson Company.
Dr Gabriele Pecora gave the first presentation on the use of the Dental Operating Microscope (DOM)
in surgical endodontics at the 1990 annual session of the American Association of Endodontists in Las
Vegas, Nevada.

(1999)Gary Carr: Introduced a DOM that had Galilean optics and that was ergonomically configured
for dentistry, with several advantages that allowed for easy use of the scope for nearly all endodontic
and restorative procedures
OPTICALDEFINITIONS
 Working Distance: The distance measured from the
dentist’s eye to the treatment field being viewed.

 Depth of Field: Depth of Field is the area of an image that

is in focus and extends in front of and behind the object .
 The greater the magnification (how big the subject
appears) the smaller the Depth of Field.


Field of view : The area that is visible through Optical magnification. This represents
the width and height of the area ,the operator sees while using the magnification
device.
Viewing angle/Declination angle:
This is the degree where the eyes of
the operator are declined to view the
area being treated.
angles range from 15

Declination degrees to
44 degrees .
 angle at which a lens is set to a horizontal reference line drawn from
the superior auricular crevice to the bridge of the nose and will
determine the sight line.
 When operating, the greater the angle with respect to this line, the
greater the neck tilt necessary to view the object.
Pupillary distance (PD) or interpupillary distance (IPD)
is the distance measured in millimeters between the centers of the pupils of the
eyes.
different from person to person and also depends on whether they are looking at
near objects or far away.
Because instruments such as binoculars and microscopes can be used by
different people, the distance between the eye pieces is usually made adjustable
to account for IPD.
Measuring pupillary distance

 Monocular PD can be measured during an eye test

 accurate measurement can usually be determined by an ECP during an eye
examination. This is normally done with a small millimeter ruler referred
to as a "PD stick" or with a corneal reflex pupillometer, which is a machine
calibrated to help the optical professional more accurately measure the
pupillary distance.
 There are also mobile phone and web apps that can measure one's pupillary
distance.
Several elements are important for consideration in
improving clinical visualization.

Included are factors such as

Stereopsis Magnification range Depth of field Resolving power Working
distance Spherical and chromatic distortion (ie, aberration) Ergonomics
Eyestrain Head and neck fatigue Cost
(1)Stereopsis: Stereopsis vision where in two separate images from two
eyes are successfully combined in to one image in the brain. Also called
as 3-dimensional perception .

(2)Magnification range: Magnification is ability to produce enlarged images of

object.
The Maximum magnification of human eye is .068 cm also called as 1X
magnification . So the image size can be increased by using lenses for
magnification.

(3)Depth of field : It is the range of a depth that a specimen is acceptable

in focus. Depth of Field is basically how much of the object under the
microscope can actually be viewed.
(4)Resolving power: The resolving power of a microscope determines the
degree of details that is visible. The resolving power of normal human eye
is 200 micron.
Object separated by less then this distance appears as single Object.
Dentists can increase their resolving ability without using any
supplemental device by simply moving closer to the object of observation.
This movement is accomplished in dentistry by raising the patient up in
the dental chair to be closer to the operator or by the operator bending
down to be closer to the patient.
Resolving power can be increased by using lenses for magnification .
Resolving power also enhanced by using the shorter wavelength Light for
illumination.

(5)Working distance :The nearest point that the eye can accurately focus on
exceeds ideal working distance.
Working distance of Microscope is inversely proportional to the Magnification.
(6) Spherical and chromatic distortion (i.e., aberration) : type of
distortion in which there is failure of a lens to focus all colors to same
point.
(7)Eyestrain:
operating microscopes possess the additional benefit of Galileian Optics, focus at infinity
and send parallel beams of light to each eye. With parallel light, the operator’s eyes are
at rest, as though looking off into the distance, permitting performance of
timeconsuming procedures without inducing eye fatigue, like we have if we are working
with the naked eye at a small distance from the patient requiring convergent optics.

Eye strain or Eye Fatigue are major problem for microscope users if they have poor vision
and if user don't know the correct position to use it .

Fig. 8. Galilean optics. Parallel

optics enables the observer to
focus at infinity, relieving
eyestrain.
CLASSIFICATION
There are four magnification systems used in dentistry:

1) simple magnifying glasses in spectacle frames

2) hinged magnifiers that can be attached to either spectacle frames or worn attached
to a headband
3) multiple lens systems commonly referred to as loupes or surgical telescopes.
 

4) the
operating microscope
 LOUPES
Loupestwo mono-ocular
microscopes with lenses mounted
side by side and angled inward
(convergent optics) to focus on an
object. magnification >, depth of
field <.
smaller the field of view, the
shallower the depth of field.
Note-
For a loupe of magnification ×2, the
depth of field is approx 5 in [12.5 cm]
for a loupe of magnification ×3.25, it
is 2 in [6 cm];
for a loupe of magnification ×4.5 it is
1 in [2.5 cm]
 CLASSIFICATION
Loupes are classified by the optical method by which they produce magnification.

3 types of binocular magnifying loupes:

(1) a diopter, flat-plane, single lens loupe

(2) a surgical telescope with a Galilean system configuration (2-lens system)

(3) a surgical telescope with a Keplerian system configuration (prism roof

design that folds the path of light).
DIOPTER SYSTEM (SINGLE LENS LOUPE)

 diopter system relies on a simple magnifying lens.

 The degree of magnification is usually measured in diopters.

 One diopter (D) means that a ray of light that would be focused at infinity
would now be focused at 1 meter (100 cm or 40 in).

 A lens with 2 D designation would focus light at 50 cm (19 in); a 5 D lens would
focus light at 20 cm (8 in)

 Confusion occurs when a diopter single-lens magnifying system is described as

5 D. This designation does not mean ×5 power (ie, 5 times the image size).
Rather, it signifies that the focusing distance between the eye and the object is
 20 cm (<8 in),with an increased image size of approximate magnification ×2 (2
times actual size).
Advantage -the most inexpensive system.

Disadvantage-
less desirable because the plastic lenses that it uses are not always optically
correct.
the increased image size depends on being closer to the viewed object,
compromise posture and create stresses and abnormalities in the
musculoskeletal system.
Weller N, Niemczyk S, Kim S. The incidence and position of the canal
isthmus: part 1. The mesiobuccal root of the maxillary first molar. J
Endod 1995;21(7): 380–3.
MULTIPLE LENS SYSTEM

The surgical telescope of either Galileian or Keplarian design produce

an enlarged viewing image with a multiple lens system positioned at
a working distance between 11 and 20 inches (28-51 cm).

The most used and suggested working distance is between 11 and 15 inches
(28-38 cm).
Galilean loupe:
 most common type of loupe in dentistry
 typical conical shape.
 optical system consists of a
combination of convex and
concave lenses, the working
distance of which can be
adjusted to the given
ergonomic needs.
 the magnification factor is
physically limited to 2.5×, it is
possible to reach a higher
magnification of up to 4.5×,
albeit with optical
compromises (limited field of
vision, blurring around the
edges).
Keplerian (prismatic) loupes
 characterized by their
cylindrical shape.
 consist of a complex convex optic system of lenses and prisms.
 This system allows various magnifications and working distances.
 the passage of light is lengthened through a series of internal reflections via a
Schmidt prism/rooftop
 The preferred range of magnification in dentistry is between 3.5× and 6×, in
order to minimize the influence of the limited depth of focus.
 The considerable optical
advantage over Galilean loupes is
offset by greater weight and
higher price.
 The lenses of both types can be
mounted on to the spectacle
frame or embedded in the
spectacle lens .
 Adjustable frame-mounted loupes give the clinician the ability to adjust
the interpupillary distance individually, together with the convergence,
horizontal and, in some cases, declination angulations.
Laser Loupes
Designed for clinicians that perform laser procedures, this loupe combines eye
protection and magnification into a single lightweight product.

A virtually clear glass filter is built into the telescope, while a tinted polycarbonate
filter is baked onto the carrier lens.
Visual acuity is heavily influenced by illumination.
An improvement to using dental loupes is obtained when a fiberoptic headlamp
system is added to the visual armamentarium.
Surgical headlamps have a much shorter working distance (13 in or 35 cm) and
use fiberoptic cables to transmit light, thereby reducing heat to minimal levels.
Another advantage is that the fiberoptic cable is attached to the doctor’s headband
so that any head movement moves the light accordingly.
Surgical headlamps can increase light levels up to 4 times that of conventional
dental lights.
ENDOSCOPY
Endoscopy is a surgical procedure whereby a long tube is inserted into the
body usually through a small incision. used for diagnostic, examination, and
surgical procedures in many medical fields.
Goss and Bosanquet reported that Ohnishi first used the endoscope in
dentistry to perform an arthroscopic procedure of the temporomandibular
joint in 1975.
 Detsch et al. (1979) first used the endoscope in endodontics to diagnose dental
fractures.

Held et al. and Shulman & Leung (1996) reported the first use of the endoscope
in surgical and non-surgical endodontics.

Bahcall et al. (1999) presented an endoscopic technique for endodontic surgery.

The endoscopic system consists of a telescope with a camera head, a light source, and
a monitor for viewing.
The traditional endoscope used in medical procedures consists of rigid glass rods and
can be used in apical surgery and non-surgical endodontics.

 A 2.7 mm lens diameter, a 70° angulation and a 3 cm long rod-lens are

recommended for surgical endodontic visualization.
 A 4 mm lens diameter, a 30° angulation, a 4 cm long rod-lens are recommended
for non-surgical visualization through an occlusal access opening.

 Flexible fiberoptic orascope recommended for intracanal visualization, has a .8

mm tip diameter, 0° lens, and a working portion that is 15 mm in length.
Bahcall J , Barss J. Orascopic visualization technique for conventional and surgical
endodontics. Int Endod J 2003: 36: 441–447.

The term orascopy describes the use of either the rigid rod-lens endoscope or
the flexible orascope in the oral cavity.
Endodontic Visualization System (EVS) (JEDMED Instrument Company, St
Louis, MO, USA) incorporates both endoscopy and orascopy into one unit.
Endodontic visualization system utilizing a fixed rod lens for apical surgery.
Clinicians who use orascopic technology appreciate the fact that it has
a non-fixed field of focus, which allows visualization of the treatment
field at various angles and distances without losing focus and depth
of field.
Disadvantage
Critics of this form of magnification point out that the images viewed
are two-dimensional and too restrictive to be useful when compared
with the stereoscopic images provided with loupes or microscopes.
OPERATING MICROSCOPE
WHY OPERATING MICROSCOPE ??
This represents a view that is approximately magnified 2x, similar to 2x
loupes. Can you readily identify any major issues with the mandibular left
second molar (image flipped for clarity)?
This photo represents approximately what is seen under
6x magnification. The vertical fracture on the lingual of
the left second molar is clearly visible.
 Improved magnification

 Improves ergonomics

 Reduced eye fatigue/strain

 Improved lighting

 Documentation, education and communication

Improved magnification: Dental microscopes provide a range of
magnification from 2.6-16x with the average microscope dentist operating
at an 8x magnification (compared to 2.5-4.5x magnification for most loupe
users).
This enhanced magnification can improve accuracy of tooth preparations
and margins, allow for more conservative treatment, and can be kinder and
gentler to adjacent teeth/restorations as well as the supporting soft tissues.
Higher magnification provides enhanced visibility in all aspects of dentistry

Improves ergonomics: It forces you to sit upright in your chair with improved
posture reducing strain on your neck and back.
Reduced eye fatigue/strain:
The technology of loupes utilizes “converging vision” due to the short working
distance, can cause eye fatigue and strain. The higher magnification lens and
distance from the operating field allows parallel vision of the working field,
thereby reducing the strain and fatigue on the eyes.

Improved lighting: The built-in light sources on the microscopes today are
halogen, xenon or LED. They allow amazing visibility and admission of light
to areas in the mouth that are otherwise difficult to see.
Documentation, education and communication:
When paired with a monitor and /or camera, the microscope becomes
an excellent way to document treatment as well as communicate with
patients or other dentists can also be a good way to educate auxiliary
staff.
HISTORY
Apotheker introduced the dental OM in 1981.
Apotheker H. A microscope for use in dentistry. J Microsurg
1981;3(1):7–10.

MARKET FAILURE-
 poorly configured and ergonomically difficult to use.
 capable of only 1 magnification (×8) positioned
 on a floor stand and poorly balanced, had only straight binoculars, and had a
fixed focal length of 250 mm
 used angled illumination instead of confocal illumination.
Howard Selden was the first endodontist to publish an article on the use of the
OM in endodontics.
Selden HS. The role of a dental operating microscope in improved nonsurgical
treatment of ‘‘calcified’’ canals. Oral Surg Oral Med Oral Pathol
1989;68(1):93–8.

(1999) Gary Carr- introduced an OM with Galilean optics and was

ergonomically configured for dentistry, with several advantages that allowed
for easy use of the scope for nearly all endodontic and restorative procedures.
This OM had a magnification changer that allowed for 5 discrete
magnifications (magnification ×3.5–× 30), had a stable mounting on either
the wall or ceiling, had angled binoculars allowing for sit-down dentistry,
and was configured with adapters for an assistant’s scope and video or
35mm cameras.
Carr GB. Common errors in periradicular surgery. Endod Rep 1993;8(1):12–
8.
Carr GB. Microscopes in endodontics. J Calif Dent Assoc 1992;20(11):55–61.
 used a confocal illumination module so that the light path was in the
same optical path as the visual path, and this arrangement gave far
superior illumination than the angled light path of the earlier scope.
 use of the OM requires advanced training
1995- the American Association of Endodontists formally
recommended to the Commission on Dental Accreditation of the
American Dental Association that microscopy training be included in
the new Accreditation Standards for Advanced Specialty Education
Programs in Endodontics.

At the commission’s meeting in January 1996, the proposal was

agreed on, and in January 1997, the new standards, making
microscopy training mandatory, became effective.
Selden HS. The dental-operating microscope and its slow acceptance. J
Endod 2002;28(3):206–7.
ANATOMY OF OM
The operating microscope
consists of three primary
components:

(1)The supporting structure

(2)The body of the

microscope

(3) The light source

The Supporting Structure
 essential for microscope stablility in operation, yet remain maneuverable
 with ease and precision.

 can be mounted on the floor, ceiling, or wall.

 the distance between the fixation point and the body of the microscope is
decreased, the stability of the set up is increased.

 clinical settings with high ceilings or distant walls, the floor mount is
preferable even in that ceiling mount is most preferable.
FLOOR MOUNT MODEL
 CELING MOUNT MODEL

WALL MOUNT MODEL

The Body of Microscope Most important part it contains the lenses and prisms
responsible of magnification
and stereopsis.
The body of the microscope is
made of following components
(1)Eyepieces,
(2)Binoculars, (3)Magnification
changer factor
(4)The objective lens.
EyePiece :
available in powers of 10x, 12.5x, 16x,
and 20x. commonly used are 10x and
12.5x.
end of each eyepiece has a rubber cup
that can be turned down for clinicians
who wear eyeglasses. have adjustable
diopter settings.
Diopter settings range from -5 to +5
and are used to adjust for
accommodation, which is the ability to
focus the lens of the eyes.
DIOPTER SETTINGS
1. Set the dioptric correction for both the eyepieces to be “0” 2.
Select the lowest magnification and focus on the flat specimen.
3. Select the highest and read just the sharpness
4. Select again the lowest magnification and do not look in to the eyepieces
5. Carry out the steps 6 to 8 for each objective individually
6. Rotate the eyepiece in the counterclockwise “+” direction as far as it will
go in the “+5 diopter settings”
7. Look in to the eyepiece
8. Slowly rotate the eyepiece individually in the”-”direction until the eyes sees
the object sharply imaged.
9. Select the highest magnification and refocus if necessary
THE BINOCULARS: contain the eyepieces and allow the adjustment of the
interpupillary distance.
aligned manually or with a small knob until the two divergent circles of light
combine to effect a single focus.
Once the diopter setting and interpupillary distance adjustments have been
made, they should not have to be changed until the microscope is used by a
surgeon with different optical requirements.
Binoculars are available with 3 different kind of tubes i.e
(1) Straight: orientated so that the tubes are parallel to the head of the
microscope. They are generally used in otology and are not well suited for
dentistry.
(2) Inclined: fixed at a 45° angle to the line of sight of the microscope.
(3) Inclinable tubes: The inclinable tubes are adjustable through a range of
angles of 0 – 210 degrees depending on the brand. and allow the clinician to
always establish a very comfortable working position. Even if more
expensive, the inclinable binocular is always to be preferred.
The Magnification Charger Factor :
available as 3-, 5-, or 6-step manual changers, or a power-zoom changer.
located within the head of the microscope.
consist of lenses that are mounted on a turret that is connected to a
dial located on the side of the microscope. The magnification is altered
by rotating the dial.
A power zoom changer is a series of lenses that move back and forth on
a focusing ring to give a wide range of magnification factors.
The advantage of the power zoom changers is that they avoid the
momentary visual disruption or jump that occurs with manual step
changers as the clinician rotates the turret and progresses up or down
in magnification.
The disadvantages : the excursion from the minimum to the
maximum magnification is quite slow, while it is must faster with the
manual step changers; the number of lenses is much higher compared
 to the manual step changers, and this means a greater absorption of
light; power zoom changer are much more expensive.
The objective lens.: The objective lens is the final optical element, and its focal
length determines the working distance
between the microscope and the surgical field.
The range of focal length varies from 100 mm
to 400 mm.
Note- A 200 mm focal length allows
approximately 20 cm (8 inches) of working
distance, which is generally adequate for
utilisation in endodontics.
The objective lens, all have several layers of an
anti-reflective coating on both surfaces, which
reduces return light loss from normally 2% per
lens surface to only 0.5% per lens surface.
The fine focus can be done manually using the device integrated in the
objective lens, or rotating a fine focus knob, which raises the entire body of the
microscope, or by an electric foot control.
Total Magnification of Microscope • The total magnification (TM) of a
microscope depends on the combination of the four variables:
1) focal length of binocular (FLB);
2) focal length of objective lens (FLOL);
3) eyepiece power (EP);
4) magnification factor of the changer (MF).
5) The total magnification can be represented by the following formula:

TM = (FLB/FLOL) x EP x MF

For example: Binocular focal length = 125 mm

 Objective lens focal length = 250 mm Eyepiece magnification = 10x
Magnification factor = 0.5

TOTAL MAGNIFICATION = 125/250 x 10 x 0.5 = 2.5x

Body Tube Optics:
Body tube have a no of lenses and prisms to convey the light
from the fiber optic cable to the patient via objective lens
and to the operator from the patient with the desired level
of magnification.

Beam Splitter: (Optional)

A beam splitter is an optical device that splits a beam of light in two. It is integrated between
binoculars and objective lens. It splits the light beam which is being transferred from objective
lens to binoculars and supplies the light to an accessory such as camera or an auxiliary
observation tube.
Most commonly used beam splitter is 20:80.

Its main role is in documentation. can be single sided or

double sided.
In double sided beam splitter one can be used for camera
for still photography and other side for video camera for
video documentation and live display or an be used for
attachment of other eyepiece for assistant.
LCD screens can also be attached with the video camera
and screen mounted on the ceiling so the patient can also
see ongoing treatment. When viewing the LCD screen, the
assistant sees without having to take his eyes away from the
operating field.
The Light Source
Two light source systems are commonly available:
(1)halogen light
(2)xenon light.
The halogen light - frequently does not provide enough illumination for quality
documentation especially at higher powers. used very less nowadays. yellow in
colour.
The xenon light - is much more powerful and provides a brighter light at about
5,000° Kelvin approximating day light.
In both cases the light intensity is controlled by a rheostat and cooled by a fan.
After the light reaches the surgical field, it is reflected back through the objective
lens, through the magnification changer lenses, and through the binoculars and
then exits to the eyes as two separate beams of light.
The separation of the light beams is what produces the stereoscopic effect that
allows the clinician to see depth of field
Metal Halide: White in colour but short life, about 6,000 to 15,000 Hrs.
LED: Most commonly used. White in colour. It has long life, about 50,000 Hrs
Accessories
 Some microscopes are built with fixed components and don’t allow the insertion of any
accessories.
 Some others can be personalized with
accessories like the assistant scope and
documentation tools, like a 35-mm and a
video camera.
 The video camera can be connected to a
monitor, a videotape recorder, and a video
printer.
 The monitor can be used not only to motivate
the patient, but mainly to the second surgical
assistant, who can follow the surgical
procedure and give to the operator the right
instruments at the right moment.
 Other important accessories are the eyepiece
with the reticle and the assistant scope.
 An eyepiece with a reticle field can be
substituted for a conventional eyepiece and
can prove an invaluable aid for alignment
during videotaping and 35 mm photography.
 Very useful is the assistant scope which allows the assistant to “assist” the operator during the
entire procedure

LAWS OF ERGONOMICS
An understanding of efficient workflow using an OM entails
knowledge of the basics of ergonomic motion. Ergonomic
motion is divided into 5 classes of motion:
Class I motion: moving only the fingers.
Class II motion: moving only the fingers and wrists .
Class III motion: movement originating from the elbow
Class IV motion: movement originating from the shoulder
Class V motion: movement that involves twisting or bending at
the waist.
1. Class I motion: moving only the fingers (Fig. 9)
Class II motion: moving only the fingers and wrists (Fig. 10)
Class III motion: movement originating from the elbow (Fig. 11)
Class IV motion: movement originating from the shoulder (Fig. 12)
POSITIONING THE MICROSCOPE
The preparation of the OM involves the following maneuvers:

(1) Operator positioning

(2) Rough positioning of the patient
(3) Positioning of the OM and focusing
(4) Adjustment of the interpupillary distance
(5) Fine Focus positioning
(6) Parfocal adjustment
(7) Fine focus adjustment
(8) Assistant scope adjustment.
 OPERATOR POSITIONING
 The correct operator position –directly behind the patient, at the 11- or 12-o’clock
position.

 9-o’clock position may seem more comfortable when first learning to use an OM,
but as greater skills are acquired, changing to other positions rarely serves any
purpose.

 The operator should adjust the seating position so that the hips are 90º to the floor,
the knees are 90º to the hips, and the forearms are 90º to the upper arms.

Michaelides PL. Use of the operating microscope in dentistry. J Calif Dent Assoc
1996;24(6):45–50.
 The operator’s forearms should lie comfortably on the armrest of the operator’s
chair, and feet should be placed flat on the floor.
 The back should be in a neutral position, erect and perpendicular to the
floor, with the natural lordosis of the back being supported by the lumbar
support of the chair.

 The eyepiece is inclined so that the head and neck are held at an angle that
can be comfortably sustained. This position is maintained regardless of the
arch or quadrant being worked on.

 The patient is moved to accommodate this position. After the patient has
been positioned correctly, the armrests of the doctor’s and assistant’s chairs
are adjusted so that the hands can be comfortably placed at the level of the
patient’s mouth.
 The trapezius, sternocleidomastoid, and erector spinae muscles of the neck
and back are completely at rest in this position.
ELBOW SUPPORT
 Elbow support for doctor and assistant is mandatory to allow the necessary fine
motor skills under constant magnification and muscular comfort throughout the
day.

ROUGH POSITIONING OF PATIENT

The patient is placed in the Trendelenberg position and the chair is
raised until the patient is in focus, which means with the head slightly
lowered to the pelvis .
POSITIONING OF MICROSCOPE
AND FOCUSING
 After turning on the light of the microscope, the microscope
should be maneuvered so that the circle of light shines on the
working area.
 The operator moves the body of the microscope approximately to
the working distance and then, looking through the eyepiece,
moves the microscope up and down until the working area comes
into focus.

 The inclinable eyepiece is now adjusted so that the operator’s head

and spine can maintain a comfortable position with the working
area in focus.

ADJUSTMENT OF INTERPUPILLRAY
DISTANCE
 The interpupillary distance should be now adjusted by taking the
two halves of the binocular head of the microscope , and moving
them apart and then together, until the two circles are combined
and only one illuminated circle is seen.
 Those who wear glasses should have the cups in the lowered
position and those who work without glasses should work with the
cups in the raised position.

PARFOCALADJUSTMENT
The eyepieces should now be individually adjusted so that the focused view of
the working area will stay sharp as the magnification setting is changed. This
process is called parfocaling, and it is important to perform it correctly
especially when the assistant scope or the documentation accessories are
mounted on the microscope.
These are the steps to follow for the parfocal adjustment:
1) Position the microscope above a flat, stationary surface.
2) Using a pen or pencil, make an “X” on a piece of white paper to serve as
a focus target and place it within the illumination field of the microscope.
3) Set both the eyepiece diopter settings to “0”.
FINE FOCUS ADJUSTMENT
Installing an operating microscope should also be considered a new
ergonomic organisation in the dental office. This should also include
the dental chair, which should have its back thin enough to allow the
operator to position his or her legs underneath.
In fact, the fine focus and even more, changing the focused area from
one plane to another dipper inside the root canal, is made lifting just
a few millimetres the entire back of the dental chair with the
operator’s knee .

This way, working inside a root canal, the area in focus can be
changed from the orifice level to the deepest point of the canal itself
without using the hands and without moving the hands from the
working area.
(A) Small movement of the chair to the left (note that patient’s head is tilted a little
to the left). (B) If necessary, the patient’s head is moved slightly to the right to
compensate chair movement (note that the OM was not touched at any time).
ASSISTANT SCOPE ADJUSTMENT
Once the clinician has
completed all the above
mentioned procedures, the
dental assistant will
perform the same
adjustments on the binocular
and on the eyepieces,
obviously without changing
the
position of the microscope
OPERATORY DESIGN PRINCIPLE
 There is an ergonomic flow to using an OM efficiently, and careful operatory design is
critical in enabling this flow.

 One of the main reasons clinicians struggle with using the OM for all procedures is that the
ergonomic design of the operatory prohibits it.

 The organizing design principle using the OM in the dental operatory should revolve around
an ergonomic principle called CIRCLE OF INFLUENCE .

 The principle posits that all instruments and equipment needed for a procedure are within
reach of either the clinician or the assistant,(that all necessary equipment and supplies
needed by both the doctor and assistant are within an arm’s reach of either), requiring no
more than a class IV motion, and that most endodontic procedures are performed with class
I or class II motions only.
 The circle of influence design takes into consideration the 3 participants of the dental team:
doctor, assistant, and patient. Maximum ergonomics, efficiency, and comfort for all
members are achieved with this office design.

Examples of traditional operatory designs with large side cabinets, sinks, and
so forth. A design such as this makes efficient OM use problematic.
The circle of influence design takes into consideration the 3 participants of
the dental team: doctor, assistant, and patient. Maximum ergonomics,
efficiency, and comfort for all members are achieved with this office design.
 The circle of influence principle can be implemented into private practice (A) and
in the academic environment (B) (Einstein Medical Center, Philadelphia, PA,
USA).
Therefore, the circle of influence design principle places the OM at the center
of the operatory design, and all the ergonomic movements necessary to work
with this technology are centered within those circles.
• In nonsurgical endodontics, most procedures are made using indirect
vision via a mirror, most of the time the mirror is positioned far away from
the tooth, even outside the mouth, on the cheek, just to make room for the
instruments or handpieces.
• In some instances, the operator’s view is improved by using a buccal
photographic mirror instead of a mouth mirror. Buccal photographic mirror
provides a broader viewing area.

USES OF OM IN ENDODONTICS
Use of Microscopes in Endodontics: General
• locating hidden canals that have been obstructed by calcifications and reduced in size;
• removing materials such as solid obturation materials (silver points and carrier-based materials),
posts or separated instruments;
• removing canal obstructions;
• assisting in access preparation to avoid unnecessary destruction of mineralized tissue,
• repairing biological and iatrogenic perforations;
• locating cracks and fractures that are neither visible to the naked eye nor palpable with anendodontic
explorer; and
• facilitating all aspects of endodontic surgery, particularly in root-end resection and placement of
retrofilling material.

Additional benefits of the OM include the facilitation of enhanced photographic documentation and
improved positioning ergonomics for the operator.

SOM enables the endodontist to access the marginal integrity of restorations and
to detect cracks or fractures.
Also an efficacious method in detecting radicular cracks.
In numerous cases, the width of a crack is merely that of an hairline and would
go unnoticed.in addition ,utilization of the SOM allows a video print to be
recorded and presented to the patient and referring clinician.

Microfracture detected under the microscope

(A) and the same tooth after extraction
(B). Arrows identify the fracture line.
High-magnification inspection of caries below crown margin (courtesy Dr. Francesco
Maggiore, Aschaffenburg, Germany).
 NON SURGICAL ENDODONTICS
 Identifies calcified canals and additional hidden canals with ease.
 Following the introduction of the microscope to the Graduate Endodontic
Program at the University of Pennsylvania in 1992, it has been found that nearly
an astounding 50% of all molars (maxillary and mandibular) have a fourth
canal, more than 30% of all premolars have a third canal, and close to 25% of
all anterior teeth have two canals.
 Pulp stones can be easily detected and eliminated
 Routine identification of second mesiobuccal canal of maxillary first and second
molar..

When the maxillary first molars were

considered separately, the frequency of MB2 canal
detection for the microscope, dental loupes, and no
magnification groups was
71.1%,62.5%,and17.2%,respectively.
Burhley et al.Magnification and Locating MB2 Canals Vol. 28, No. 4, April
2002 .
RETREATMENT
Procedures such as bypassing a ledge,removing a broken instrument or
repairing a perforation have become more reliable.

Separated instrument
in second mesio-buccal
canal of left maxillary first
molar (arrow).
Situation after uncovering
of fragment with ultrasonic
tips and debris removal.
SURGICAL ENDODONTICS

Introduction of SOM and ultrasonic tips for root end preparation are the two
main reasons for change.
Periapical curretage is facilitiated since bone margins can be scrutinized for
completeness of tissue removal.
One recent prospective study demonstrated that the success rates of endodontic
surgery performed under SOM employed the microsurgical technique and the
appropriate cement (eg superEBA,Bosworth,skokie,IL). A success rate of
96.8% with an average healing of 7.2 months was observed.
(Rubinstein R, Kim S. Results of 94 endodontic microsurgeries using super EBA
retrofill .J Endodont 1996;22:188.)
High-magnification inspection of resected root surface of left maxillary lateral
incisor using a micro mirror.
Note leakage of previous root filling stained with
methylene blue.
PERIODONTICS
 The incisions and flap reflections are accurate.
 permits butt joint-approximation of the flap,
mandatory for the healing and regeneration.
 The principles of microsurgery can be applied
effectively in various wide-ranging surgical
periodontal procedures including resective
procedures, combined resective/periodontal
microsurgery, and regenerative procedures,
extractions and ridge preservation procedures,
sinus augmentation and repairs, biopsy, and
larger soft tissue grafting.

 The idea of minimal invasiveness could be achieved by using microsurgical instruments

with the aid of magnification which help the surgeon to make very small cuts just enough
to expose and gain access to the operating spot
Shanelec D, Tibbets L. A perspective on the future
of periodontal microsurgery. Periodontology 2000,
1996;11:58-64.

PROSTHODONTICS

Leknius C, Geissberger M. The effect of magnification on the performance of fixed prosthodontic

procedures. J Calif dent Assoc 1995;23:66-70.
The dental students using devices like low-magnification telescopic loupes made very less errors in
preparation design and laboratory processing. The errors by these students were reduced to half
while compared with another set of control group students who were not using magnification
devices.
The study also showed that the microscopes are extremely
useful during the try-in and seating appointments.

The magnification devices proved to be beneficial even to

laboratory technicians who could trim the stone dies with
utmost precision and improve the quality of prosthesis
with the aid of microscopes

ORAL SURGERY
A clearer and magnified view is particularly important
in all surgical procedures for treating impacted teeth,
and in particular for mucogingival surgical
procedures to increase the width of attached gingiva by harvesting soft tissue grafts.

The injuries and lesions to the sensitive nerves of the mouth area are surgically treated in a
better way using microscopes.
Labanc JP, Van Bowen RW. Surgical management of inferior alveolar nerve injuries. Oral
Maxillofac Surg Clin North Am 1992;4:425-37
During lower molar and premolar level oral surgical
treatment, or during the surgery of third molars, if
appropriate care is not taken about the lingual flap,
then the lingual nerve and the lower dental nerves
are prone to injury. This could be well avoided by
adopting microsurgery assisted by high end
magnification.

ORTHODONTICS
The orthodontists are now using a magnification eyewear along with
smaller bracket systems, lingual appliances, self-ligating systems and
ceramics. The standard of patient care will be well improved if superior
magnification devices with better ergonomics are put in place.

Juggins KJ. Current Products and Practice The Bigger The Better:can
magnification aid orthodontic clinical practice? Am J Orthod
2006;33:62-6.
Recently the use of new technique in orthodontic microsurgery
piezosurgical bone cuts and monocortical tooth dislocation showed good
dental repositioning in a shorter time with a decrease in treatment time
by 65-70%.
Bertossi D, Vercellotti T, Podesta A, Nocini PF. Orthodontic
microsurgery for dental repositioning in dental
malpositions. J oral maxillofac surg 2001;69:747-
53.

IMPLANT DENTISTRY
The specialized branch of implant dentistry is
an emergent segment with ample space for
improvisation. The microscopic magnification
systems can be suitably incorporated in all
levels of implant treatment. The age of painful
and traumatic tooth loss, never-ending replacement of a continuously
deteriorating anterior tooth, etc., will be taken over by the new age
microsurgical procedures assisted with cutting edge magnification
instruments.
Shourie V, Raisinghani J, Jain S, Todkar R.
Microsurgery in Periodontics: A Review.
Universal Research Journal of Dentistry
2011;1:19-24.

CONCLUSION
The operating microscope has revolutionised the specialty of endodontics. The
increased magnification and the coaxial illumination have enhanced the
treatment possibilities in non-surgical and surgical endodontics.

Treatment modalities that were not possible in the past have become reliable
and predictable with help of OP. As today we cannot imagine a dental office
without the X-ray machine, in the same way we can state that the day is not
far away when dentistry will be entirely and diffusely performed under the
operating microscope. All endodontic graduate programs are now teaching
its use as part of their curriculum.