International Journal of Engineering Research & Technology (IJERT)

ISSN: 2278-0181
Vol. 2 Issue 8, August - 2013

Magnification Tools: Surgical Operating Microscope And Magnifying Loupe

In Dental Practice

1. Dr. Ranjana Mohan, Professor and Head, Dept of Periodontology,

Teerthanker Mahaveer Dental College and Research centre, Delhi Road,
Moradabad, U.P., INDIA

2. Dr. Mohan Gundappa, Principal, Professor and Head, Dept of Endodontics,

Teerthanker Mahaveer Dental College and Research centre, Delhi Road, Moradabad,
U.P., INDIA
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 International Journal of Engineering Research & Technology (IJERT)
ISSN: 2278-0181
Vol. 2 Issue 8, August - 2013

 1876- magnification was introduced to

Abstract: dentistry.3
Magnification is an apparent increase in size  Nylen, 1922 – first performed eye surgery
especially by the use of lenses. under a microscope.4,5
History of the Magnification dates back to 1694 when  Barraquer, 1950s- began using microscope
Anton van Leewenhook constructed first compound for corneal surgery.6
lens microscope. Optical magnification has  Jacobsen & Suarez, 1960 – obtained 100%
broadened the horizions of dentistry in general, and patency in suturing 1 mm diameter blood
Periodontology, Restorative dentistry and vessels for anastomosis7
Endodontics in particular. Various magnification  1960s – microsurgery was standard in many
systems used in dentistry include Dental Loupes & specialities such as neurology &
Surgical Operating Microscope. Magnification tools opthamology.8,9

are utilized in routine dental practice for diagnosis, 1970s &1980s - First articles about using a
esthetically demanding prosthetic restorations, microscope in Odontology Dentistry were
routine endodontic procedures, non- surgical published .10-13
periodontal procedures, periodontal plastic  Apotheker & Jako, 1978 – first introduced
microsurgeries, implant dentistry etc for better the microscope to dentistry.
visualization, improved treatment quality and ideal  1986 – microsurgery has been practiced in
treatment ergonomics enhancing motor skills to endodontics.14
improve surgical ability by maintaining the right  1990s - systematic use of surgical
posture. Minimally invasive dental procedures with microscopes started and was applied by the
ease and precision are possible today with the use of different odontological dentistry
magnification in dental practice. specialities15, such as Periodontal Surgery.16
 Carr, 1992- published an article outlining
Key words: Magnification, Dental Loupes, Surgical the use of a surgical microscope during
Microscope, periodontal microsurgery. endodontic procedures14.
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 Shanelec & Tibbetts, 1993 – Presented a
Introduction continuing education course on periodontal
microsurgery at the annual meeting of the
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Visualisation of fine details is enhanced by increasing American Academy of Periodontology.16

the image size of the object. Image size can be
 1994—The first microscopes were
increased by getting closer to the objects or by
routinely used for restorative dentistry.17
magnification. Magnification increases the focal
 1999—The American Association of
length in order to see small objects accurately, which
Endodontists required all endodontic
in turn increases the working distance between the
graduate students to be microscope
eye and the object allowing, extra-ocular muscles to
proficient.17
remain more relaxed and a dentist to maintain normal
 2002—The Academy of Microscope
posture.
Enhanced Dentistry is formed.17
In dental practice, the tissues to manipulate are
 2005—Several dental schools integrate
usually very fine resulting in a situation in which the
microscopes into undergraduate
natural visual capacity reaches its limits. Therefore,
programs.17
the clinical procedure may be performed successfully
with the use of magnification improving precision
and, hence, the quality of work1. Principles of magnification
Two basic types of magnification systems are
Historical background commonly used:
1. Loupes
References to magnification date back to 2,800 years,
2. Surgical microscope
when simple glass meniscus lenses were described in
Egypt.
1) Optical principles of loupes 3,16,18

 Anton van Leeuwenhook, 1694 – Loupes are the most common magnification system
constructed first compound lens used in dentistry. These are fundamentally two
microscope2. monocular microscopes, with side by-side lenses,

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 International Journal of Engineering Research & Technology (IJERT)
ISSN: 2278-0181
Vol. 2 Issue 8, August - 2013

angled to focus an object. The magnified image that confined to a range determined by the
is formed has stereoscopic properties that are created loupe's characteristics1. The proper depth of
by the use of convergent lens systems. field allows the practitioner to avoid too
Loupes are further classified as: much leaning and any overextension while
(1) Single-lens magnifiers (clip-on, flip-up, jeweller's practicing22. With any brand of loupe the
glasses) and depth of field decreases as the magnification
(2) Multi-lens telescopic loupes. increases.
(1) Single-lens magnifiers (Fig.1) produce the
described diopter magnification that simply adjust the 2. Convergence angle - is the pivotal angle
working distance to a set length. As diopters increase, aligning the two oculars, such that they are
the working distances decrease. A set working pointing at the identical distance and angle.
distance creates difficulty in maintaining focus and, At a defined working distance, the
therefore, may cause neck and back strain from poor convergence angle varies with interpupillary
posture19,20,21. distance. A preset convergence angle as well
as preset interpupillary distance is more user
(2)Telescopic loupes (compound or prism
friendly, since they should not be changed
loupes) (Fig.2) - compound loupes use multiple once correctly positioned. Whereas an
lenses with intervening air spaces which allow an adjustable interpupillary distance allows the
adjustment of magnification, working distance, and loupe to be used by more than one person.25
depth of the field without excessive increase in size 4. Field of view (Width of field) - is the linear
or weight. size or angular extent of an object when
Prism loupes are the most optically advanced type of viewed through the telescopic system 1 or,
loupe magnification, offering improved ergonomic represents the width and height of the area
posture as well as significant advancements in optical the practitioner sees while using the
performance3.They contain Pechan or Schmidt prisms magnification device. The higher the
that lengthen the light path through a series of mirror magnification, the smaller the width of
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reflections within the loupes field.22

Optical features of loupes (Fig.3) 5. Interpupillary distance - depends on the

position of the eyes of each individual and is
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1. Working distance - is measured from the a key adjustment that allows long-term,
eye lens location to the object in vision1, or is routine use of loupes. The ideal setting, as
the distance between the plane of the eye and with binoculars, is to create a single image
the surface being treated.22 Working distance with a slightly oval-shaped viewing area. 1
with slightly bended arms usually ranges
from 30 to 45 cm. At this distance, postural 6. Viewing angle
ergonomics are greatly improved and eye The viewing angle is the angular position of
strain reduced due to lessened eye the optics allowing for comfortable working.
convergence. 23,24 The shallower the angle, the greater the need
to tilt the neck to view the object being
One way to measure it is to ask the clinician worked at. Therefore, loupes for dental
to adjust the second hand on their watch clinicians should have a greater angulation
while holding their arm at midline or heart than loupes designed for industrial workers.
level. It is important that clinician remember The ocular structure of the Designs for
their own working positions, and not match Vision loupe is small and lightweight and is
those prescribed. The correct working physically secured to the lens of the glasses.
should never allow for overextension of the The viewing angle is customized for each
neck, chin, or shoulders. 22 operator and then locked into position by
1. Working range (depth of field) is the range building the magnifier into the lens. The
within which the object remains in focus1 or, ocular structures of Dimension Three loupes
within which one is able to maintain visual are front frame- mounted. These systems
accuracy at the appropriate working offer pivotal angle adjustments that can
distance.22 Normally, eye position and body easily be altered and locked into position
posture vary constantly. Wearing loupes based on the wearer’s comfortable working
changes this geometry, as the body posture posture.25
and position of the extraocular muscles are

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 International Journal of Engineering Research & Technology (IJERT)
ISSN: 2278-0181
Vol. 2 Issue 8, August - 2013

7) Illumination accommodation & refractive error. The eyepieces

magnify the interim image generated in the binocular
Collateral lighting systems may be helpful tubes. Eyepiece selection not only determines the
for higher magnification in the range of 4X magnification, but also the size of the field of view
and more. Loupes with a large field of view corresponding to the loupe spectacles.
will have better illumination and brighter
images than those with narrower fields of
II. Binocular tubes The precise adjustment of the
view. Important considerations in the
inter-pupillary distance is the basic pre-requisite for
selection of an accessory lighting source
the stereoscopic view of the operation area. The
are total weight, quality, and the brightness
binoculars hold the eyepieces. The inter-pupillary
of the light, ease of focusing and directing
distance is set by adjusting the distance between the
the light within the field of view of the
two binocular tubes. Longer the focal length of
magnifiers, and ease of transport between
binoculars, greater is the magnification and narrower
surgeries26.
the field of view. Binoculars can be straight, inclined,
Each surface refraction in a lens results in a or inclinable tubes. Straight tube binoculars have
4% loss in transmitted light due to tubes parallel to the head of the microscope. Inclined
reflection. This could amount to as much as binoculars are orientated so that the tubes are offset at
50% reduction in brightness in telescopic 45 degrees to the head of the microscope. Inclinable
loupes. Anti-reflective coatings have been tubes are adjustable between the straight tube and the
developed to counteract this effect by inclined tube positions and sometimes beyond 90
allowing lenses to transmit light more degrees.
efficiently. The quality of lens coatings
also varies and should be evaluated when III. Magnification changer The magnification
selecting loupes25. changer consists of one cylinder, into which two
Galilean telescope systems with various
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magnification factors are built. The combination of
Optical principles of a surgical the magnification changer with varying objective
lenses and eyepiece yields an increasing
microscope (Fig.4) magnification line when the control is adjusted.
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The surgical microscope is a complicated system of

IV. Objective lens The focal length of the objective
lenses that allows stereoscopic vision at a
lens determines the operating distance between the
magnification of approximately 4-40X with an
lens and the surgical field. Variety of objective lenses
excellent illumination of the working area. The light
is available with focal lengths ranging from 100 to
beams fall parallel onto the retinas of the observer so
400 mm. A 175-mm lens focuses at about 7 inches, a
that no eye convergence is necessary and the demand
200-mm lens focuses at about 8 inches and a 400 mm
on the lateral rectus muscles is minimal.
lens focuses at about 16 inches.
The advantages and four areas to be discussed are: 27
A typical microscope package could be one with
12.5X eyepieces, 125-mm straight or inclinable tube
1. Magnification. binoculars, a power zoom magnification changer, and
2. Illumination. an objective lens of 200 mm. This package would
3. Documentation. allow a clinician to operate comfortably about 8
4. Accessories. inches from the patient and in the magnification
1) Magnification range of about 3 X to 26 X.29
Magnification is determined by the power of the V. Lighting unit Optimal illumination is necessary
eyepiece, the focal length of the binoculars, the with high magnifications. Light source is a 10-watt
magnification changer factor, and the focal length of xenon halogen bulb providing a whiter light than
the objective lens. conventional bulbs due to their higher colour
temperature. As halogen lamps emit a considerable
The optical unit includes the following components28 portion of their radiation within the infrared part of
(Fig.5) the spectrum, microscopes are equipped with ―cold-
light‖ mirrors to keep this radiation from the
I. Eyepieces Available in powers of 6.3X, 10X, operation area. An alternative to the halogen light is
12.5X, l6X and 20X. For periodontal purposes the xenon lamp that functions up to ten times longer
generally 5X to 12 X suffices. Eyepiece diopter than the halogen lamp. The light has daylight
settings range from -5 to +5 and are used to adjust for

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 International Journal of Engineering Research & Technology (IJERT)
ISSN: 2278-0181
Vol. 2 Issue 8, August - 2013

characteristics with even a whiter colour and delivers esthetic restorative treatments. Due to shady
a brighter, more authentic image with more contrast.1 illumination by the operatory lamp, any outcome
oriented dentist reaches limits even with high
2) Illumination27 magnifying loupe. With the introduction of dental
Light intensity is controlled by a rheostat and cooled microscope there has been significant increase in
by a fan. Light is then reflected through a condensing success rate.
lens to a series of prisms and through the objective
lens to the surgical field. After the light reaches the In all areas of Endodontics from exposure of
surgical field, it is reflected back through the access cavity and preparation to three dimensional
objective lens, magnification changer lenses, obturation and postendodontic management,
binoculars and exit to the eyes as two separate beams microscope provides major advantages over working
of light. The separation of the light beams is what without appropriate magnification.
produces the stereoscopic effect that allows the
clinician to see depth of field. Surgical microscope Magnification tools such as magnifying
uses coaxial fiber-optic illumination producing an loupe and especially surgical operating microscope
adjustable, bright, uniformly illuminated, shadow- are useful in dentistry for various purposes such as
free, circular spot of light that is parallel to the optical diagnosis of subgingival deposits, microfractures,
viewing axis. longitudinal fractures, defective margin fit of
3) Documentation 27 restorations etc that are often overlooked clinically.
Photo and cine adapters provide the necessary focal Magnification is often necessary to study root canal
length so that the cameras record an image with the anatomy and the root surface in endodontics.
same magnification and field of view as seen by the Diagnosis of second mesiobuccal root canal of
operator. As the 35mm camera gets only half the maxillary molar, extra root canal, C-shaped canals etc
available light and due to the relative insensitivity of are extremely easy and accurate with the help of
color photographic film, it is usually necessary to microscope leading to successful management of the
supplement the microscope’s lighting system by
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case. Use of microscope is the best option for
adding a strobe over the objective lens. Strobe is a detection of perforations, localization of broken
device used to produce regular flashes of light. endodontic instruments in root canals, where
Videotape is an extremely sensitive format and does visualization is the major problem. In general
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not need supplemental light. magnification can be set to between 4X and 24X
Video printers can be connected to a thereby expanding the diagnostic options due to
videocassette recorder or the video camera on the better lighting and sight. Repair of perforations can
microscope. A microcomputer inside the video be done more accurately and reliably using variable
printer automatically analyzes the image, and prints and adjustable magnifications with shadow free light
are created in 70 seconds by a high density due to a coaxial radiating light source. Prognosis for
sublimation dye. Video prints can be used for patient major preservation of tooth structure without any
education, medico-legal documentation, or reports to major loss is the reality with surgical operating
referring dentists and insurance companies. microscope.
4) Accessories 27
Pistol grips can be attached to the bottom of Current digital visualization technology has
the head of the microscope to facilitate movement advanced significantly in recent years. Dental
during surgery. Observation ports can be added to the microscope can offer integrated, efficient solution for
microscope by a beam splitter and can be helpful in daily practice and documentation. When coupled
teaching situations. Auxiliary monocular or with the appropriate capture devices, microscope
articulating binoculars can also be added and used by becomes an instrument for the projection and
a dental assistant. Another accessory used to facilitate recording of clinical procedure in more streamlined
an assistant’s viewing is the liquid crystal display and efficient manner.
screen. It is possible to record videos or take still
images since it provides adaptable and integrated For non-surgical periodontal therapy, vast
mounting options for video camera or digital and array of modern instruments and equipments such as
SLR cameras. microultrasonics, Endoscope, LASERS are available
to achieve a biologically acceptable root surface. The
Magnifying optical systems have become an study was undertaken by the author to evaluate the
integral part of restorative dentistry. It has a wide effectiveness of scaling and root planing (SRP) under
scope for the permanent functional and various different magnifications using Magnifying Loupe [X

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 International Journal of Engineering Research & Technology (IJERT)
ISSN: 2278-0181
Vol. 2 Issue 8, August - 2013

4.5] and Surgical Operating Microscope. [2.5X – instruments are resistant to distortion from repeated
12.5X] It was proved from the analysis of results that use and sterilization, non-magnetized and are lighter
magnification tools significantly enhance the efficacy than the stainless steel instruments.
of supra gingival and sub gingival scaling and root
planing. Suturing in Microsurgery 30-33

Key to aesthetic and functional success as well as Suturing is a critical factor in success of surgical
predictability is the selection of a minimally dental treatment. Suture materials and techniques
traumatic approach which not only depends on have evolved to the point that sutures are designed
surgeon’s dexterity, but also on the perception of the and developed for specific procedures. The criteria
human eye. Therefore, the use of magnification necessary for the successful use of suture materials
systems is essential to appropriately performing are dependent on the surgical procedure to be
microsurgical techniques. There are various performed and the factors necessary to successfully
applications of magnification in surgical close the wound in a manner that promotes optimum
periodontics. healing. Ideally, the incisions should be almost
invisible and closed with precisely placed, small
Microsurgery represents amplification of universally sutures with minimal tissue damage and bleeding.
recognized surgical principles in which gentle
handling of soft and hard tissue and extremely Advantages and Disadvantages OF
accurate wound closure made possible through Magnification
magnification, allowing for well planned and
precisely executed surgical procedures.18
The magnification recommended for
surgical interventions ranges from 2.5-20x.3, 12 In
Requirement of special instruments while periodontal microsurgery, magnifications of 4-5X for
working under magnification loupes and 10-20X for microscopes appear to be
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ideal depending on the kind of intervention. Loupes
Working with magnification tools requires specially have the advantage over the microscope in that they
designed instruments to keep fingers from getting in reduce technique sensitivity, expense, and learning
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the way such as micro mirrors, micro explorers, phase. The lighting of the operation field is often
micro restorative and endodontic instruments and insufficient and that may limit magnifications more
hand spreaders instead of finger spreaders, rotary than 4.5X. A clinician using loupes for magnification
files instead of hand files in the field of Endodontics receives the ergonomic benefits of an increased
and minimally invasive restorative dentistry. working distance from the viewing object as well as
increased visual acuity. Loupes allow maintaining
Proper instrumentation is fundamental for less than 20 degrees of neck flexion. Working in
microsurgical intervention. As the instruments are postures with greater than 20 degree of neck flexion
primarily manipulated by the thumb, index and has been associated with increased neck pain34.
middle finger, their handles should be round, yet However, increased magnification with loupes results
provide traction so that finely controlled rotating in increased weight of the lenses, and reduced
movements can be executed. The most commonly stability of the field of vision. The surgical
used precision grip in microsurgery is the pen grip microscope guarantees a more ergonomic working
which gives greater stability than any other hand grip. posture35, optimal lighting of the operation area, and
The instruments should be approximately 18 cm long freely selectable magnification levels - The
and lie on the saddle between the operator's thumb microsurgical triad2. Because microscopes are
and the index finger; they should be slightly top- external to the body, clinicians who use them are not
heavy to facilitate accurate handling. In order to affected by the weight of the instrument or the
avoid an unfavorable metallic glare under the light of challenge of maintaining a stabilized field of vision.
the microscope, the instruments often have a These advantages are countered by increased
coloured coating surface. The weight of each expenses of the equipment and an extended learning
instrument should not exceed 15-20 g (0.15-0.20 N) phase for the surgeon and his assistant. In order to
in order to avoid hand and arm muscle fatigue. visualize lingual or palatal sites that are difficult to
Working tips of microsurgical instruments are access, the microscope must have sufficient
smaller than the regular instruments. Needle holders maneuverability. Restricted area of vision, loss of
and tissue forceps are made of titanium to provide depth of field as magnification increases, and loss of
consistent manipulation of the tissues. Such

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 International Journal of Engineering Research & Technology (IJERT)
ISSN: 2278-0181
Vol. 2 Issue 8, August - 2013

visual reference points, are some of the drawbacks of 3. Shanelec D : Opticals principals of loupes.
magnification. California Dental Association Journal 1992;
20(11):25-32.
Loupes and Surgical microscope both allow clinician
to perform tasks not possible without improved visual 4. Dohlmen GF. Carl OL of Nylen & the birth
acuity; however, loupes cannot be compared to the of the otomicroscope and microsurgery.
comfort, versatility, illumination, and visual acuity Arch Otolaryngol 1969; 90: 813-817.
offered by the microscope. Dental microscope makes 5. Daniel RK. Microsurgery: through the
it possible for the surgeon to sit in an ergonomically looking glass. N Engl J Med 1979; 300:
correct, relaxed and upright position during the 1251-1258.
treatment. A magnified microscopic image is worth
more than the thousand words. 6. Barraquer JI. The history of the microscope
in ocular surgery. J Microsurg 1980; 1: 288-
299.
7. Lee S, Frank DH, Choi SY. Historical
Infection Control 36 review of small and microvascular vessel
surgery. An Plast Surg. 1983; 11: 53-62.
Magnifying loupes collect debris from many
procedures. Infection control is difficult at best. 8. Lenkius C, Geissberger M. The effect of
Ideally, all areas of the loupe should be disinfected magnification on the performance of fixed
with a high-level disinfectant after each patient. prosthodontic procedures. J Calif Dent
Disinfecting with ethyl alcohol solution is Assoc 1995; 23:66-70.
recommended. The telescopes are disinfected with 9. Serafin D. Microsurgery: Past, present &
alcohol ( Isopropyl Alcohol 70% by volume).If the future. Plast Reconstr Surg 1980; 66:781-
lenses are water resistant, products such as Lysol 785.
Disinfectant Spray (Reckitt Benckiser Professional,
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Wayne, N.J.) may be sprayed into a gauze sponge 10. Baumann RR. How may the dentists benefit
and used to wipe the frames and lenses before the from the operating microscope?
procedure. Quintessence Int 1977; 5:17-8.
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11. Ducamin JP, Boussens J. Surgical

Conclusion microscope in dentistry. Rev Odonto
estomatol.1979;8:293-8.
Use of magnification tools such as surgical operating
microscope and magnifying loupe in dentistry not 12. Apotheker H. Jako GJ. A microscope for use
only improves the quality of care provided to in dentistry. J Microsurj 1981; 3: 7-10.
patients, but also expands the range of treatments that
can be offered. Various benefits of magnification are
magnified image, brilliant illumination, better 13. Donoff RB, Guralnick W. The application of
posture, improved comfort, increasing precision, microneurosurgery to oral- neurological
improved dental care, and additional treatment problems. J Oral Maxillofac Surgery 1982;
options improving profitability. New era of micro 40:156-9.
dentistry, micro endodontics and micro suturing for 14. Carr GB. Microscopes in Endodontics. J
various microsurgical procedures in dentistry is Calif Dent Assoc 1992; 20:55-61.
gaining popularity with magnification tools.
15. Pecora G, Andreane S. Use dental operating
microscope in endodontic surgery. Oral
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Vol. 2 Issue 8, August - 2013

Figure1. Simple Loupe

Figure 5. Components of a surgical microscope

Figure 2. Prism Loupe

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Figure 3.The principal optical features of loupe

Figure 4. Comparison of vision enhancement with

loupes and a microscope.

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