DENTAL

OPERATING
MICROSCOPE

DR.AFSAL LATHEEF

 THE FLOW CHART
Þ INTRODUCTION
Þ HISTORY
Þ DENTAL LOUPES
• SINGLE LENS LOUPE
• GALILEIAN LENS LOUPES
• KEPLERIAN LOUPES
• FLIP-UP LOUPES
• FLIP-UP LOUPES
Þ ADVANTAGES OF LOUPES
Þ DISADVANTAGES OF LOUPES
Þ ERGONOMIC CRITERIA FOR LOUPE SELECTION
Þ DENTAL OPERATING MICROSCOPE
Þ CLASSIFICATION
Þ ANATOMY OF DENTAL MICROSCOPE
• THE SUPPORTING STRUCTURE
• THE BODY OF MICROSCOPE
* EYE PIECE
* BINACULORE
* MAGNIFICATION CHANGER
* OBJECTIVE LENS
• THE LIGHT SOURCE
Þ STEPS IN USE OF MAGNIFICATIONS
• WORKING DISTANCE
• WORKING RANGE
• CONVERGENCE ANGLE
• FIELD OF VIEW
• INTERPUPILLARY DISTANCE
• VIEWING ANGLE
• TOTAL MAGNIFICATION
• PARA FOCALIZATION
• BEAM SPLITTER
• DOCUMENTATION
Þ ADVANTAGES OF DENTAL OPERATING MICROSCOPE
• INCREASED VISUALIZATION,
• IMPROVED QUALITY AND PRECISION OF TREATMENT,
• IMPROVED & IDEAL TREATMENT ERGONOMICS
• EASE OF PROPER DIGITAL DOCUMENTATION
• INCREASED COMMUNICATION ABILITY THROUGH INTEGRATED
VIDEO
Þ POSITIONING THE MICROSCOPE
• OPERATOR POSITIONING
• ROUGH POSITIONING OF THE PATIENT
• POSITIONING OF THE MICROSCOPE AND FOCUSING
• ADJUSTMENT OF THE INTER-PUPILLARY DISTANCE
• FINE POSITIONING OF THE PATIENT
• PARFOCAL ADJUSTMENT
• FINE FOCUS ADJUSTMENT
• ASSISTANT SCOPE ADJUSTMENT
Þ ERGONOMICS AND THE MICROSCOPE
Þ FUNDAMENTAL REQUIREMENTS BEFORE USING THE MICROSCOPE:
Þ STERILIZATION
Þ CLINICAL APPLICATIONS
Þ MODERN MICROSCOPIC ENDODONTIC PROCEDURE SEQUENCE
Þ DISADVANTAGE OF MICROSCOPE
Þ RECENT ADVANCES IN ENDODONTIC VISUALIZATION
• ENDOSCOPES
• ORASCOPE
• ENDODONTIC VISUALIZATION SYSTEM
• ZEISS OPMI PROERGO
• MECHANICAL OPTICAL ROTATING ASSEMBLY INTERFACE (MORA
INTERFACE)
• PERIODONTAL ENDOSCOPE
• VARIOSCOPE
Þ CONCLUSION
INTRODUCTION

Þ In clinical dentistry, the human skill and manual dexterity have great
significance.

Þ Visualizing the oral cavity has always been a challenging task for the
dentists.

Þ Earlier radiographs were the only way to see inside a root canal, and
tactile sensation was used to perform endodontic procedures.

Þ Syngcuk Kim stated that "You can only treat what you can see”.
Undoubtedly, the clinician can better evaluate and treat something, if
he or she sees it more clearly and in magnified form.

Þ Size of the image can be enhanced by getting closer to the objects or

by magnification.

Þ Currently, to improve the quality of treatment, the endodontists have

been trying to develop new technologies to achieve success.

Þ Clinical procedure may be carried out successfully with the use of

magnification that ensures precision and, hence, increases the quality
of work.

Þ Presently, Loupes, Dental Operating Microscope, Orascope, Modular

Endoscope system (micro endoscope), Miniature endoscope systems
are the magnification devices used in dentistry.

HISTORY

Þ 1977 - An otolaryngologist (ear, nose, and throat [ENT] Specialist) Dr

Robert Baumann, described the use of microscopes in dentistry


Þ 1981 - The first commercially available dental operating microscope -

Dentiscope, Chayes Virginia Inc. by Apotheker and Jako, the
dentiscope had a single magnification of 8 and dual fiber-optic lights.
Þ September 25, 1982 - Harvard Dental School Boston, offered the first
course in the clinical hands-on use of the dentiscope.

Þ March 1993 - The first symposium on microscopic endodontic surgery

was held at University of Pennsylvania School of Dental Medicine.

Þ 1996 - Proposal that “microscopy training be included in the new

Accreditation Standards for Advanced Specialty Education Programs
in Endodontics” was accepted

Þ In 1999, a DOM was introduced by Gary Carr, that had Galilean optics
and that was ergonomically configured for dentistry, with several
benefits that permitted easy use of the scope for nearly all endodontic
and restorative procedures.

Þ Use of Endoscopy in periapical surgery was described by Bahcall et al

in 1999.

Þ In 1999, Bahcall and Barss first reported the use of orascopic

visualization made up of fiber optic.

Þ To try and quantify the growth of magnification users, the term

“Magnification Continuum” was coined in 2001.

DENTAL LOUPES
Þ Dental loupes are the most common and easily available form of
magnification.

Þ They are basically two monocular microscopes with lenses mounted

side by side and angled inward to focus on the objects.

Þ Magnifying loupes were innovated to address the problem of proximity,

decreased depth of field, and eye strain occasioned by moving closer to
the subject.
Þ Normal range of loupe magnification in dentistry is 2X to 6X.

Þ If Magnification is beyond 5X, loupes tend to become heavy and a

microscope would be a better option.

Loupes are classified in to two:-

A.) According to their different optical construction:

• Single Lens Loupe:

Þ It comprises of simple magnifying lens, which is a diopter and flat
plane.

Þ A single lens system is made up of one object and one convex,

positive, light-converging lens.

Þ An image of object is formed when light travels from the object

and reaches the lens, which then focuses the light from the
object.

Þ The distance of the image of the object from the lens is decided
not only by the quantity of divergence of light that is traveling from
an object but also by the strength of the lens.

Advantages and disadvantages:

Þ The only advantage is that it is the most inexpensive system;

however, it is less desirable because the plastic lenses that are
used are not always optically correct.

Þ Furthermore, the increased image size depends on the proximity

with the object being viewed, which can lead to postural
problems and create stresses and abnormalities in the
musculoskeletal system.

Þ However, they cannot be practically used in dentistry due to size

and weight limitations.
• Galileian Lens Loupes:
Þ It is also known as multi-lens optic system.

Þ An enlarged viewing image is produced with a multiple lens

system which should be at a working distance between 11 and
20 inches.

Þ The Galilean telescope is made up of two lenses; a concave

eyepiece lens and a convex objective lens, in which the eyepiece
lens has greater strength than the objective lens.

Advantages and disadvantages:

Þ In comparison to other compound loupes, these loupes are

economical and are simple to operate having only 2 or 3 lenses
makes these loupes lighter in weight.

Þ However, they create blurry peripheral border of the visual field

because of their limited magnification (2.5- or 3.5- fold).

• Keplerian loupes:

Þ Keplerian also known as Prism loupes are the most

optically advanced type of loupe magnification of present
era.

Þ They are called rooftop or Schmidt prisms as a prism is

fixed at the top of it.

Þ They provide magnifications up to 6x by using refractive

prisms and are actually telescopes with complicated light
paths.

Advantages and disadvantages:

Þ When compared to any other loupes. Prism loupes provide

broader fields of view, wider depths of field and longer working
distance.
 Þ However, they are heavier and more costly due to increased
number of lenses.

B.) On the basis of design


• Flip-up loupes:
Þ The telescope is mounted further away from the eyes
whereas its scope is mounted in front of the lens in a hinge
mechanism, which provides a narrower field of vision.

Þ It has better declination angle (at which the eyes look down
toward the area being worked on) which can be changed
according to the user.

Þ Forward head movement should not exceed 25° more

strain on neck and back muscles occurs if the head is
forwarded further.

Þ The head position becomes neutral if the declination angle

is steeper.

Þ Changing the eye prescription glasses does not require

demounting the scope and it is heavier than TTL loupes.

• Through the lens loupes (TTL):

Þ TTL loupes provide comfort and a wider field of vision as

they are positioned closer to the eyes.

Þ The scope is mounted on the lens.

Þ It is designed specifically for an individual and the angle of

declination is set in the factory where they are made.

Þ Change in eye prescription requires scope to be

demounted to replace the glass.

Þ It is lighter and expensive than flip-up loupes.

ADVANTAGES OF LOUPES:
1. It does not acquire much space, as it is small in size. 


2. No formal training is required as it can be easily 
operated. 


3. Surgeon's position is not restricted. 


4. Neither are they expensive as a microscope is nor do 
they need

higher maintenance. 


DISADVANTAGES OF LOUPES:
1. It does not provide depth perceptions due to lack of Stereoscopic view.

2. With loupes, magnification beyond 5x is uncomfortable on nose or

head due to their large size and increased weight.

3. Head movement makes image unstable.

4. Illumination is less in comparison to microscope.

5. The operating field must be covered by clinician’s eyes: however,

eyestrain, fatigue and changes in vision can be experienced if poorly
fixed loupes are used for longer time.

6. Accessories such as beam splitter, video camera, T.V camera or movie

camera cannot be attached to a loupe to capture the magnified field.

ERGONOMIC CRITERIA FOR LOUPE SELECTION

Considering ergonomic guidelines is imperative when selecting loupes, since
poorly designed or poorly adjusted loupes can cause or worsen pain.

The 3 most significant ergonomic factors to consider when purchasing

loupes are:

• Declination angle: The angle created by the eyes 
being

downwardly-inclined to the work area is called declination angle.
To help operator to attain a comfortable working position with
minimal forward head posture the angle should be steep enough
 (less than 25°). 


• Working distance: The distance between the eyes and the work
area is called working distance. The working range is decreased
in scopes with higher magnification. It is essential to measure the
working distance slightly longer than normal to compensate for
the natural tendency to drift closer to a working area as it gives
an operator a more flexible working range. 


• Frame size/shape: In comparison to smaller oval frames, large

frames that sit low on the cheek will allow lower placement of
the TTL scope. 

DENTAL OPERATING MICROSCOPE
Þ The emergence of Endodontic operating microscope is the most
important development that took place in the field of endodontic.

Þ The microscope not only provides better magnification from 3x up to

30x but also better illumination.

Þ The microscope through its enhanced vision has greatly contributed to

improved surgical as well as conventional endodontic treatment.

Þ The introduction of the microscope includes numerous ergonomic

changes.

Þ Possible reduction in consequent stress for the operator can be

ensured by maintaining the traditional working positions previously
used without the microscope by the clinicians.

Þ The range of working positions is usually from the 9 o’clock to the 12

o’clock position.

Þ Baumann was the first to report the use & benefits of an operating
microscope for conventional endodontics.

CLASSIFICATION:

— Based on Use:
1. surgical microscope
2. examination microscope

• Based on magnification:
1. Lower magnification (2.5x to 8x)
2. Midrange magnification (8x to 14x)
3. Higher range magnification (14x to 30x)

• Based on instalment:
1. Floor type
2. Ceiling mounted
3. Wall mounted
ANATOMY OF DENTAL MICROSCOPE

The operating microscope consists of three basic components.

1. The supporting structure:

Þ The supporting structure should be mounted on the floor, ceiling or wall

to ensure stability of microscope.

Þ Decrease in the distance between the fixation point and the body of
the microscope will increase the stability.

Þ The floor mount is preferable in clinical settings with high ceiling or

distant walls.

2. The body of microscope:

It is the most crucial element and consists of eyepieces, binoculars,

magnification change factor, and the objective lens.

a) Eyepiece:
Þ Magnifying the image is the most 
important function of
the operating 
microscope.

Þ The power of eyepiece determines 
magnification.

Eyepieces are usually available 
in powers of 10x,
12.5x, 16x, and 20x. To 
adjust the accommodation of
the lens of the 
eyes, diopter settings should range from
-5 to +5.15 


b) Binocular:
Þ They are available with straight, inclined or inclinable
tubes with provision to hold the eyepieces.

c) Magnification changer:
Þ It is situated within head of the microscope and is
available as 3, 5 or 6 step manual changer, or a power
zoom changer.
 d) Objective lens:

Þ It is the final optical element, and its focal length

determines the working distance between the
microscope and the surgical field.

Þ The focal length ranges from 100 mm to 400 mm.

Þ A 200 mm focal length permits approximately 20 cm of

working distance, which is generally appropriate for
utilization in endodontics.

Þ A layer of anti- reflective coating ensures absorption of

only a minimum amount of light in order maintain the
illumination of the operative field.

• 175-mm lens focuses at 7 inches 


• 200-mm lens focuses at 8 inches
• 400-mm lens focuses at 16 inches. 


3.The Light Source:

Þ It is one of the key features and responsible for working in operative

fields that are small and deep like the root canal.

Þ Its source is 100watt Xenon halogen bulb, whose intensity is

controlled by rheostat and cooled by a fan.

Þ Illumination and line of sight share the same axis, which means that
light is focused between the eyepieces so that no shadows will be
visible. Galilean optics makes it possible.
STEPS IN USE OF MAGNIFICATIONS

Working distance:

Þ It is the distance measured from the eye lens to the object in vision.

Þ Depending on the individual’s height and length of arms, the WD with

slightly bended arms using microscope increases and ranges between
30 and 45 cm.

Þ At this distance, posture is perfect, ergonomics is greatly improved,

and there is decreased eye strain due to less convergence.

Working range (depth of field):

Þ Range within which the object remains in focus.

Þ The DOF of normal vision ranges from WD to infinity.

Convergence angle:

Þ It is the pivotal angle aligning the two oculars, such that they are
pointing at the identical distance and angle varies with interpupillary
distance (IPD).

Þ Defines the position of extraocular muscles that may result in tension

of the internal and external rectus muscles, which may be an important
source of eye fatigue.

Field of view:

Þ Linear size or angular extent of an object when viewed through the

telescopic system.
Inter-pupillary distance:

Þ It is the key adjustment for the use of any magnification system.

Þ The ideal way to understand your IPD is to focus both the binocular
eyepieces to initially see two images or circles and adjust it to the point,
wherein they merge and become one circle.

Þ That point would be identified as the IPD and used as a permanent

reference for the use of magnifications.

Þ The IPD varies with each individual and forms an important aspect in
the learning curve of use magnifications.

Viewing angle:

Þ It is the position of the binocular optics angled in such a way that it

enables comfortable working position for the operator.

Þ The shallower the angle, the greater the need to tilt the neck to view
the object.

Total Magnification
Parfocalization

Þ Setting the operator specific focus throughout the entire range of

magnification. 


Þ It should be parfocalled once a month to keep it properly focused even
for subtly changing eyesight 


Þ It prevents unnecessary eye fatigue and pain.


Þ In addition, when the microscope is parfocused, accessories 
such as
cameras and auxiliary binoculars are also in focus


Þ To parfocal a microscope, a flat object, such as a dull copper penny is
placed under the microscope and focused at the highest
magnification.


Þ The left/right eye diopter settings are unique to each person and should
be written especially if the microscope is shared 


Beam Splitter

Þ It is in the optical pathway of the microscope as it returns to the

operator’s eyes, thereby supplying light to an accessory such as a
camera or an auxiliary observation tube.

Þ As the beam splitter divides each path of light separately, up to two

accessories can be added. In addition to 50:50 beam splitters, other
configurations are also available.
Documentation

Þ Documentation is an important bene t of using the surgical microscope:

• Video adapter

• Video camera

• Video printer

Purpose of documentation:

1) To communicate with the referring dentist.

2) To educate patients and students.
3) To maintain the required legal documentation of each case.

ADVANTAGES OF DENTAL OPERATING MICROSCOPE

There are five basic advantages in using the DOM and accompanying
documentation systems for an endodontic specialist include:

• Increased visualization,
• Improved Quality and precision of treatment,
• Improved & Ideal treatment Ergonomics
• Ease of proper digital documentation
• Increased communication ability through integrated video

1) Increased Visualization
• Carr reported that the human eye, when unaided by magnification,
has the inherent ability to resolve or distinguish two separate lines
or entities that are at least 200 microns, or 0.2mm, apart . If the lines
are closer together, two separate entities or the objects will appear
as one.

• Most people cannot refocus at distances closer than 10 to 12 cm.

As the eye-subject distance (i.e. focal length) decreases, the eyes
 must converge, creating eyestrain.

• Furthermore, as one ages, the ability to focus at closer distances is

compromised, caused by the lens of the eye losing flexibility with
age (presbyopia).

• As the focal distance decreases, depth of field also decreases.

Considering the problem of the uncomfortable proximity of the
practitioner’s face to the patient, moving closer to the patient is not
a satisfactory solution for increasing a clinician’s resolution.

• Illumination is a critical component in increasing visualization.

• Most microscopes are equipped with an integrated coaxial light

source that allows for unobstructed, shadow-free illumination of the
operating field which allows for significantly improved visualization.

2) Improved Quality and precision of treatment

• The visual information provided by the operating microscope is, in

fact, not indicative of the magnification that is being employed.

• The actual amount of visual information is the area under the scope
and is therefore the number of horizontal pixels multiplied by the
number of vertical pixels.

• A microscope at 10× magnification provides 25 times the

information compared to that obtained through the use of entry-level
loupes (2×) and over 10 times that of 3× power loupes.

• As magnification increases, the depth and diameter of the field-of-

view of the operating field decrease.

• There is an increased demand at higher magnification for improved

control of the micromotor muscles and joints (fingers and wrists) that
can require stabilization of the gross motor joints (elbow and
shoulder) with microendodontist’ chairs
• Shanelec and Tibbets[1998] reported that clinician, working without
magnification, can make movements that were 1–2 mm at a time.
At 20× magnification, the refinement in movements can be as little
as 10–20 microns at a time.

• It is useful therefore to note that the limitation to precision of

treatment is not in the hands but in the eyes.

• Baldissara et al. [1998] showed that the experienced clinician with

a sharp, new explorer can determine marginal gaps of around 36
microns with a tactile sense. Thus, it can be assumed that when
magnification is greater than 6× powers, the reliance on an explorer
and tactile means of inspection significantly decreases.

• The precision of treatment studies by Leknius and Geissberger,

[1995] as well as by Zaugg et al. [2004] demonstrated that as
magnification is incorporated, procedural errors decrease
significantly.

3) Improved & Ideal treatment Ergonomics

• DOM improved ergonomics is realized on many levels, the most

obvious being improved posture.

• With microscope, the clinician is able to practice while looking

straight ahead without having to either bend forward in an effort to
see better (causing lower back pain), or raise the patient horizontally
in order to bring the oral cavity closer to the clinician (causing neck
pain). The microscope allows for 100% of the retina to be focused
on the site

• By operating in a more upright, neutral and balanced posture, the

endodontist is less likely to experience strain, tension or fatigue of
neck of lower back muscles.

• Ergonomics is also improved during digital documentation because

intra-operative images can be captured very efficiently by the
assistant without interrupting treatment.
4) Ease of Proper Digital Documentation Capabilities

• With the optional addition of a beam-splitting device, one is able to

capture digital photos and record real-time video at multiple
magnifications, by integrating various types of digital recording
devices, such as an SLR and/or video camera and saved in hard
drives and mini DV tapes or directly to DVD.

• Digital documentation capabilities enable the clinician to efficiently

capture and share with patients what is seen during an examination
pre-operatively, intra-operatively and post-operatively and stored in
patients chart.

• This is especially useful when unforeseen problems are

encountered. This can leads to greater rates of case acceptance,
increasing patient’s level of trust and confidence.

• The usage of documentation for medico-legal, insurance, patient

communication, and lecturing purposes, as well as for
communication with staff or colleagues, is also impressive.

5) Increased Ability to Communicate through Integrated Video

• Adding video to the microscope have found useful in providing

information both to patients and to auxiliaries

• The live video can be transferred from the scope to an LCD projector
and transmitted onto a screen for the audience to see, or be
captured on tape or hard drive and shared with colleagues at high
magnification allowing greater learning experience.
POSITIONING THE MICROSCOPE
The introduction of the operating microscope in a dental office requires
significant forethought, planning, and an understanding of the required
ergonomic skills necessary to use the microscope efficiently.

Proper positioning, for the clinician, patient, and assistant is absolutely

necessary. Most problems in using a microscope in a clinical setting are
related either to positioning errors or lack of ergonomic skills on the part of
the clinician.

It is possible to work at the microscope in complete comfort with little or no

muscle tension if proper ergonomic guidelines are followed.

In chronological order, the preparation of the microscope involves the

following maneuvers:

1. Operator positioning
2. Rough positioning of the patient
3. Positioning of the microscope and focusing
4. Adjustment of the inter-pupillary distance
5. Fine positioning of the patient
6. Parfocal adjustment
7. Fine focus adjustment
8. Assistant scope adjustment

1) Operator positioning

• The correct operator position for nearly all endodontic procedures is

directly behind the patient at the 11 or 12 O’clock position.

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

• The operator forearms should lie comfortably on the armrest of the

operator’s chair and his or her feet should be placed flat on the floor.

• The back should be in a neutral position, erect, perpendicular to the

floor, with the natural lordosis of the back being supported by the
 lumbar support of the chair, with the eyepiece inclined so that the head
and neck can be held at an angle that can be comfortably be sustained.

• This position is maintained regardless of the arch or quadrant being

worked on.

• It is the patient who is moved to accommodate this position. After the

patient has been positioned correctly, the arm rests 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.

• A common problem in establishing proper posture in microscopic

dentistry results from chair headrests that position the patient’s head
too far from the doctor’s waist. Such positioning will result in the doctor
having to bend forward from the waist.

• Holding this position for long periods results in muscle fatigue and
muscle splinting, with resultant pain and chronic injury. Most dental
chairs that have too long a headrest are best modified by simply
removing the headrest and placing a soft pillow in its place.

• Both Global Surgical Corp. and Zeiss have adapters which solves the
problem of the caudally placed patient or the doctor with expanded
girth.

2) ROUGH POSITIONING OF THE PATIENT

• The patient is placed in the Trendelenberg position and the chair is
raised until the patient is in focus.

• The main advantage of the Zeiss Pro-Ergo microscope is that the

patient height can be varied to fit the most comfortable position
because the focal length of the microscope can be optically changed
simple by activating the zoom control.

• This ability to easily change the focal length of the lens makes patient
positioning to the ideal height possible on nearly all patients.
3) POSITIONING OF THE MICROSCOPE AND FINE FOCUS

• After turning on the light of the microscope, the microscope should be

maneuvered so that the circle of light shines on the working area.

• Knowing the focal length of the objective lens, 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.

• During this maneuver, the fine focus device of the objective lens should
be in an intermediate position in order to allow a wide range (20 mm)
during the fine focusing of the operative field.

• 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.

4) ADJUSTMENT OF THE INTERPUPILLARY DISTANCE

• Looking through the binocular, each eye sees a small circle of light.
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.

• With some microscopes, this maneuver is made moving a knob located

on the binocular. Adjustable rubber cups extend from the ends of the
eyepieces.

• 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.

5) FINE POSITIONING OF THE PATIENT


• Now it is necessary to make little movements with the back of the

dental chair, in order to position the patient in the definitive position.
• With this in mind, one should take into consideration that in nonsurgical
endodontics 100% of the work at the microscope is done in indirect
vision through the mirror.

• Therefore, the definitive position of the patient depends on the angle

that the light of the microscope has to make in order to illuminate the
root canal where the clinician is working.

• The root canal of the tooth to be treated must be positioned at 90° to

the light beam, while the mirror is at 45° angle.

• Therefore, to work in a maxillary root canal the patient should be

horizontal, parallel to the floor to work in mandibular root canal the
patient should be in “Trendelenburg” position, which means with the
head slightly lowered to the pelvis.

6) PARFOCAL ADJUSTMENT

• 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.

• In fact, it is mandatory that when the working area is in focus for the
operator, it is also in focus for the assistant, for the video camera or for
the still camera.

7) FINE FOCUS ADJUSTMENT

• The dental chair, which should have its back thin enough to allow the
operator to position his or her legs underneath.

• 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
millimeters 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.

8) 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.

ERGONOMICS AND THE MICROSCOPE

The Law of Ergonomics:

Þ 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:

1) Class I motion: moving only the fingers 


2) Class II motion: moving only the fingers and wrists 

3) Class III motion: movement originating from the elbow 

4) Class IV motion: movement originating from the shoulder 

5) Class V motion: movement that involves twisting or bending
at the waist 


FUNDAMENTAL REQUIREMENTS BEFORE USING THE

MICROSCOPE:

• Vision: Front surface quality mirror which is silvered on the surface of

glass should be used for having best quality undistorted reflected
images.

• Lightening: Inbuilt light source is present in the microscope, if

necessary an auxiliary light can be used perpendicular to the long axis
of the tooth at the level of pulp chamber.
 • Patient compliance: Even the slightest movement of patient’s head
can affect the field of vision. For optimal view through microscope, u-
shaped inflatable pillow should be provided.
• Cooperation from dental assistance: dental assistance can also be
helpful in increasing the efficiency of clinician. The dental assistance
should be adequately trained for use microscope.

• Rubber dam placement: This is necessary as direct viewing with

microscope is difficult. For absorbing reflected light & to accentuate
tooth structure, blue or green dam sheet is recommended

• Mouth mirror placement: should be placed slightly away from the

tooth, if placed close to the tooth it will make difficulties while using
endodontics instruments.

• Indirect view & patient’s head position: Mirror should be placed at

45 degrees to the microscope. For indirect viewing patient’s head
should be positioned such that it forms 90-degree angle. Between the
binocular & the
• maxillary arch.

• Instruments: Use of micro instrument such as micro-opener, micro

mirrors, micro explorers, micro restorative and endodontic instruments
and hand spreaders instead of finger spreaders, rotary files instead of
hand files. In order to avoid an unfavorable metallic glare under the
light of the microscope, the instruments often have a colored coating
surface. The instruments should be approximately 18 cm long. The
weight of each instrument should not exceed 15-20 g (0.15-0.20 N) in
order to avoid hand and arm muscle fatigue.

STERILIZATION:

• Parts of microscope such as the rubber caps, sleeves & handgrip can
be sterilized in autoclave at 134º C for 10 minutes.

• Other non-serializable parts can be cleaned using a moist cloth.

• Any residue can be wiped off using a mixture of 50% ethyl alcohol +
50% distilled water + a dash of household dish-washing liquid.
CLINICAL APPLICATIONS 

Þ In clinical diagnosis
• Cracks and microfracture
• Locating the canal orifices
• Managing calcifying canals
• Intracanal medicament
• Obturation of root canal
• Retrieval of broken instruments

Þ In non-surgical treatment:
• Removal of post

• Perforation errors
• Final examination of the canal preparation

Þ In surgical treatment:
• Isthumus identification and preparation
• Retro preparation

• Osteotomy (précised and small – 5 mm)
• Curettage
• Apicectomy
• Inspection of the resected root surface
• Detect apical perforation
• Apical preparation
• Retro filling
• Examination of surgical site
• Post-operative healing

Þ In conservative dentistry:
• Caries detection 

• Coronal preparation 

• Impression quality 

• Evaluating the restoration under surface 

• Restoration delivery and polish 

• Bonded restoration
MODERN MICROSCOPIC ENDODONTIC PROCEDURE
SEQUENCE
1) The diagnosis indicates that endodontic treatment is needed and tooth is
anesthetized.

2) Following placement of the rubber dam, access is made. The microscope

is not needed for this step, although some clinicians may prefer to use it.

3) Using the microscope at low to mid magnification, the pulp chamber is

thoroughly prepared using a Buc tip size 2 for inspection.

4) Under high magnification (16x-24x), the floor of the chamber is examined

for additional canals because more than 50% of molar teeth have a forth
canal.

5) After the canal entrance is identified, the microscope is not needed until a
later stage. The apex is negotiated with a size 10 K file and is then
enlarged with size 15 or 20 files.

6) Gates –Glidden burs are used in reverse order to enlarge the coronal half
or two thirds using the crown down techniques.

7) An apex locater is used to determine the canal length at this stage.

8) NiTi rotary instruments now employed to prepare the remaining one half
or one third of the apical canal in the crown down technique. The final
apical preparation of the master apical file is done by hand instruments
and light Speed, depending on the original canal width or estimate of
working width.

9) The microscope is used to check the preparation and to check again for
additional canals.

10) A master gutta percha cone is selected, the canal length and solid “tug
back” is assured.

11) After obturation microscope is used again for final check. Finally, the canal
is filled with temporary cements.
DISADVANTAGES OF MICROSCOPES

Þ The instrument occupies lot of space and is difficult to carry.

Þ Training regarding its parts and usage is a must before surgery is

attempted on a patient. Also, the surgeon’s position is restricted.

Þ With higher magnification, the field of view and depth of focus is

reduced.
Þ The equipment is very expensive and requires proper and regular
maintenance.

RECENT ADVANCES IN ENDODONTIC VISUALIZATION

ENDOSCOPES

Þ The term endoscopy is derived from the Greek language and is literally
translated as endon (within) and skopion (to see), hence the meaning,
“to see within.”

Þ Early endoscopists such as Hippocrates in 377 BC used primitive tube-

like instruments for endoscopy.

Þ With major advances in the field of medicine, a breakthrough in optical

quality was achieved in 1960 by an English physician, Hopkins, who
created a rod lens series that led to important advancements in the
field of view, magnification, and focal length of the endoscope,
resulting in a clearer image.

Þ The field of endoscopy has expanded further with the introduction of

the dental endoscope. The use of rod-lens endoscope in endodontics
was first reported in literature in 1979.

Þ It was helpful in diagnosing dental fractures.

Þ The traditional endoscope used in medical procedures consists of rigid
glass rods and can be used in apical surgery and non-surgical
endodontics.
 Þ The flexible and semi-flexible endoscopes can be very valuable
addition to the armamentarium.

Þ The endoscope is flexible due to special nitinol coating.

Þ The optical part which is 0.9 mm of diameter, is a piece of equipment

that enables the practitioner a magnification of up to 20X with clear
picture with wide angle.

Þ The rod-lens endoscope provides clinicians greater magnification,

greater clarity as compared to the microscopes and the loupes and the
non-fixed field of vision.

Þ The Modular endoscope system (Sialotechnology Ltd., Ashkelon,

Israel) being based on modern technology of microendoscopes is used
in small channel organs (salivary gland ductal system, tear canals) and
is designed to enable the practitioner to work inside the root canal with
magnification and instrument access.

The system includes three parts:

• endoscopic compact system
• optical part that includes ocular part and the endoscope, and
• handpiece with a disposable part.

Uses of DENTAL ENDOSCOPE

Diagnosis: The dental endoscope viewing system (Dental View) is currently

available as a diagnostic and therapeutic adjunct to the restorative dentist,
endodontist, periodontist, oral pathologist, oral surgeon, otolaryngologist,
and dental hygienist.

Enhances Visualization: This dental endoscopic viewing system provides

high magnification (24X to 50X) and a light source via a fiber-optic
illumination that allows to detect new carious lesion, recurrent caries,
inadequate restorations in proximal boxes or class V restorations, intrafurcal
fractures, anatomic aberrations, (e.g, a palatal groove on maxillary lateral
incisors), residual crown and bridge cement, oral pathologic lesions, and root
fractures/perforations.
Trans illumination: In cases of tooth infraction, the endoscope can provide
trans illumination as a diagnostic aid. As a fiber optic light source, it is an
excellent tool for fracture detection as light may refract along fracture line.

Apical Surgery: The surgical procedure is performed under the inspection

of the endoscope with intermittent irrigation of isotonic saline and suction.
The curvature of the hand-piece enables the practitioner to visualize the
hidden parts of the cavity preparation, and to inspect for cracks and root
fractures in the apical retrograde preparation.

Endoscopic Observations during Endodontic Treatment: The

endoscopic observation and treatment usually leads to detection and
removal of the remaining dental pulp tissue following cleaning and shaping
of the root canal walls. Lateral canals and microscopic root cracks are usually
detected with high accuracy, providing better intraoperative judgment and
facilitating adequate treatment.

ORASCOPE

Þ The recently introduced flexible fiberoptic orascope is recommended

for intracanal visualization, has a .8mm tip diameter, 0º lens, and a
working portion that is 15mm in length.

Þ The term orascopy describes the use of either the rigid rod-lens
endoscope or the flexible orascope in the oral cavity.

Þ Orascopic endodontics is the use of orascopy for visualization in

conventional and surgical endodontic treatment.

Þ The difference between an endoscope and an orascope is that: an

orascope is made of FIBER-optics and an endoscope is made up of
glass rods.

Þ Both an orascope and an endoscope works in conjunction with a

camera, light source and a monitor.

Þ The option of a printer or a digital recorder can be added to the system

for the documentation procedure.
 Þ The image quality from fiber optic usage has a direct correlation to the
number of fibers and the size of the lens used in an orascope.

Þ The orascope has a 10,000 parallel visual fibers. Each visual fiber is
in between 3.7 to 5µ in diameter. A ring of much larger light transmitting
fibers surrounds the visual fibers for illumination of treatment field.
Þ 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

Fiber optics are made up of glass or plastic. The advantages of fiber optics
in endodontics are significant. They are:

1. Small

2. Lightweight

3. Very flexible

Orascopic Visualization Technique For Conventional Endodontic

Treatment

Þ The 0.8-mm orascope is used to visualize within the canal system.

Þ The small fiber-optic size enables the orascope to actually go down

into a canal.

Þ Prior to the placement of the 0.8-mm fiber-optic scope, the canal must
be prepared to a size No. 90 file in the coronal 15 mm of the canal.

Þ If the canal is not instrumented to this diameter, a wedging of the probe

may occur, damaging some of the fibers within the scope.

Þ Appropriate preparation also allows the full 15 mm of the orascope to

penetrate within the canal.

Þ If a canal is curved, the orascope may not be able to visualize around

the curve because of limited flexibility.
 Þ It is important to note that the canal must be dried prior to usage of the
0.8-mm scope.

Þ The focus and depth of field of an orascope is zero mm to infinity.

Þ This allows the orascope to provide imaging of the apical third of the
root without actually having to be positioned within this region of the
canal.

ENDODONTIC VISUALIZATION SYSTEM

Þ The recently introduced Endodontic Visualization System (EVS)

(JEDMED Instrument Company, St Louis, MO, USA) incorporates both
endoscopy and orascopy into one unit.

Þ The EVS system allows for two methods of documentation. The

camera head used in the EVS system is an S-video camera and, as
such, documentation is usually accomplished by recording streaming
video onto tape or digitized to DVD.

Þ Now days the EVS II System is introduced.

Þ It also combines the fiber optic orascope and a rigid endoscope.

Þ It is said to provide optimal illumination and magnification for

visualization during endodontic procedures.

Þ The system is designed to provide comfort and high quality images,

and using it is said to require the same hand-eye coordination and
patient positioning for ordinary procedures.

Þ The quick-connect camera handpieces can be efficiently switched to

meet the needs of the procedure being performed

ZEISS OPMI PROERGO

— It has a feature of motorized/foot-controlled adjustment of focal length.

— This causes the least disturbance and optimal ergonomic work even
when treatment continues for several hours.
MECHANICAL OPTICAL ROTATING ASSEMBLY INTERFACE (MORA
INTERFACE)

— It is a mechanical optical rotating assembly that connects the binocular

tube at a right angle to the body of the operating microscope making it
capable of a limited independent rotation around the horizontal axis of
the binocular tube.

— This was devised to overcome the drawbacks of conventional

microscopes which were designed to allow the clinician to sit at the 9–
10 o’clock position.

— This led to an inclined neck position toward the right shoulder, leading
to overextension of the left arm, muscle tension, fatigue, and disability.

— This technology enables the operator to be seated at 12 o’clock

position, providing a horizontal WD that is compatible with the distance
between the head and the mouth of the patient.

PERIODONTAL ENDOSCOPE

— It is a new procedure using a miniature dental endoscope which allows

subgingival visualization of the root surface at magnifications of ×24 to
×48.

— This is accompanied by a 99 mm fiber-optic bundle that is a

combination of 10,000 pixel capture bundle surrounded by multiple
illumination fibers.

— This fiber is delivered to the subgingival margin coupled into an

instrument called explorer.

— The magnified images are immediately displayed on a chairside video

screen, following which any residual islands of calculus or biofilms can
be effectively debrided.
VARIOSCOPE

— Referred to as Augmented Reality, it is a lightweight miniature

head-mounted operating microscope for surgical navigation; it features
display of additional computer-generated sceneries.
 — It has an integrated camera for documentation.

— One of the greatest advantages of the varioscope is mobility of the

operator head, which is contrary to the surgical microscopes which lack
maneuverability due to cumbersome equipment.

— The infrared 800, flow 800, and blue 400 fluorescence tools allow
surgeons to see vascular circulation at the surgical site and determine
the sequence and direction of blood flow.

CONCLUSION
Þ The use of magnification has quietly become the standard of care, as
it keeps showing a frank superior result in all restorative techniques,
with consequent increase in the longevity of restorations.

Þ The introduction of the magnification devices in dentistry, particularly

in endodontics, has been a significant addition to the profession’s
armamentarium.

Þ The increased magnification and illumination have enhanced the

treatment possibilities in surgical and nonsurgical procedures.
Treatment modalities that were not possible in the past have become
reliable and predictable

Þ The use of magnification has quietly become the standard of care, as

it keeps showing a frank superior result in all restorative techniques,
with consequent increase in the longevity of restorations.

Þ The introduction of the magnification devices in dentistry, particularly

in endodontics, has been a significant addition to the profession’s
armamentarium.

Þ The increased magnification and illumination have enhanced the

treatment possibilities in surgical and nonsurgical procedures.
Treatment modalities that were not possible in the past have become
reliable and predictable