18 Dr Ramesh Babu.pdf

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Copyright ©2013

Review Article

J Res Adv Dent 2013; 2:3:91-97

Role of Dental Microscope in General Dental Practice

Kiran Kumar Nagubandi1 Vijaya Laxmi2 Ramesh babu Mutthineni3* Sabitha MR4

1Professor, Department of Periodontics, Mamta Dental College, Khammam, Andhra Pradesh, India.2Professor, Department of Periodontics, Farookiya Dental College, Mysore, Karnataka, India.

3Reader, Department of Periodontics, Mamta Dental College, Khammam, Andhra Pradesh, India.4Reader, Consultant Periodontist, Apollo White Dental Studio, Chennai.India.

ABSTRACT

Objective: The Dental microscope is an indispensible tool in dental practice. Dental therapy with high quality

and perfection is the basis for long term function and biological success, ensuring that patients remain free of

pain. State of the art equipment and thorough clinical knowledge however are vitally important to reach this

goal. The purpose of this review article is to explain the use of Dental Operating Microscopes in various branches

of dentistry providing you with new dimensions of knowledge for your every day work.

Material and Methods: A wide variety of dental microscopes which were used in the past and in the new era

were discussed.

Results: With the help of Dental Operating Microscope there is better visualization of the operating field and

hence treatment quality can be improved.

Conclusion: The dental microscope with all its advantages is now absolutely indispensable in any quality and

outcome oriented dental practice philosophy.

Keywords: Dental operating microscope (DOM), Mechanical optical rotating assembly (MORA), General dental

practice.

INTRODUCTION

DOM allows amplification of details, greater

versatility in image magnification, excellent

visualization of the working field, best lighting

possible and a better working posture.

Basically a DOM consists of a light source

and a suspension system.DOM allows the

visualization of textures and details of anatomical

structures, restorative materials and prosthetic

components that would not be visible even with

loupes.

HISTORY

In 1953, the Carl Zeiss Company of West

Germany marketed the first commercial binocular-

operating microscope. The pioneeringwork of Carl

Nylen at the University of Stockholm preceded,Zeiss

by approximately 31 yr with the development of a

monocular microscope for ear surgery in 19221,2 .

From then onwards microsurgery has spread to

literally all the surgical disciplines.

It wasn’t until 1978 that Apotheker, and

Jako, pooled their efforts to produce a DOM(Dental

Operating Microscope)3,4. Their designs were

incorporated in 1981 into the first commercially

available DOM (Dentiscope, Chayes-Virginia Inc.,

Evansville, IN).



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Fig 1: Showing Different parts of microscope

Fig 2: Dental Operating Microscope(DOM)

In March of 1993, 11 yr after the introduction of the

Dentiscope, the first symposium on microscopic

endodontic surgery was held at the University Of

Pennsylvania School Of Dental Medicine. By 1995,

there was an marked increase in DOM use by

endodontists.

DENTAL MICROSCOPE (Fig-2):

Parts of a microscope given in Fig-1.,

Basically a DOM consists of an optical head, a light

source and a suspension system. It has a 180°

tiltable tube with angled optics, the ergonomically

designed grips, and the focusing objective lens

adjustable for left-handed and right-handed

persons. In 1998, Friedman et al. reported that the

microscope is unusable in certain areas of the

mouth, as the 9-10 o’ clock seating positions allow

for securing the smallest distance possible between

the operator and the patients mouth, while allowing

a direct visual access in to the oral cavity when the



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Fig 3: Showing MORA Interface

patient is reclined in to a supine position.

Unfortunately the access opening to the mouth hasa downward inclination towards the chin. This in

turn forces the operator to assume inclined neck

posture with over extension of left arm to hold

mouth mirror for use. This combination of muscle

tension leads to fatigue, pain and musculo skeletal

disorders. To overcome this difficulties MORA

interface was developed

MORA INTERFACE: :(Fig-3)

Definition of the MORA interface

The “MORA interface” is a mechanical

optical rotating assembly that connects at a right

angle the binocular tube to the body of the

operating microscope to make it capable of a limited

independent rotation around the horizontal axis of

the binocular tube.This allow the operator to be

seated in the 12 o’ clock position and allow for

adequate extension of microscope between the

objective lens and the eye pieces which prevents the

operator from bending forward to reach the

eyepieces, which causes strain on the lower back .

USES OF DENTAL MICROSCOPE IN VARIOUS

BRANCHES OF DENTISTRY

Visualization of pathological findings for patients-

communication

DOM helps in visualization of pathological

findings. In addition to visualization, these

recordings can also be used to provide convincing

evidence to insurance companies. These video

recordings also enable dentists to reexamine

complex therapies. Comfortable treatment and

ergonomics due to technological advantages and

improved treatment quality.

Since, with a dental microscope, it is

technically feasible to feed xenon light in to the

observer’s beam path view at an angle of less than 4

degrees, illumination of surgical field is perfect. In

conjunction with motorized zooming every local

detail can be recognized, especially in endodontics.

Microscopic techniques are superior to traditional

treatment concepts, as has been proven by various

studies5-8.

Conservative, adhesive restorations after systemic

caries excavation

If caries is to be excavated close to the pulp,the dental microscope is very useful because, of its

shadow free light in conjunction with rhodium

plated mirrors, it is excellent for distinguishing even

the minutely infected areas. The closer to the pulp

the operator needs to work while removing caries

the more this type of optical vision enables great

care to be exercised.As the DOM gains widespread

acceptance in endodontics, the advantages of its use

in providing precision care will carry over in to

restorative dentistry, and it will eventually become

a universal approach for all phases of dentistry.9-15

Routine dental techniques-tooth extractions with

complications

Many a times a seemingly simple extraction

of a devitalized tooth or the extraction of a partially

retained wisdom tooth may end up in a

complication. When the tooth fractures, individual

fragments can only be removed with difficulty due

to sclerosis of the individual roots with the bone,

and vision is impaired by bleeding. In these cases

the dental microscope provides steady conditionsdue to its excellent illumination and adjustable

magnification. The dentist can zoom down to depth

of the extraction alveolus and thus very precisely

mobilize a stubborn root remnant if the assistant

ensures minimal bleeding with the use of a special

micro aspirator. With microscope assisted tooth

extraction the alveolar bone can also be preserved

with a view to subsequent implantation .

Periodontal therapy in visually

inaccessible(subgingival) root sections



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In closed or open periodontitis therapy,

based on the full mouth therapy concept . One often

has the problem that the deep sub gingival pockets

or interdentally recessions and furcations already

affected by bone destruction are hardly accessible

to the naked eye. Due to the optical benefits

mentioned and the illumination of the surgical field,

we can use dental microscope in these instances

because it is possible to detect any clinging islands

of biofilm and remove them precisely.

Microsurgical techniques in periodontal plastic

surgery and implant surgery

Application of microsurgical principles from

vascular surgery to plastic dental surgery created a

desire to use very fine suture material at a high levelof magnification. Apart from the development of

microsurgical instruments it was the medical loupes

with a magnification of approximately 5x and the

dental microscope with an even higher

magnification that made it possible to see size 7.0 or

8.0 suture materials. Incised sections of papilla

must be adapted as precisely as possible, especially

in the crucial, highly aesthetic, anterior gingival

region. Here, a dental microscope allows excellent

monitoring of suture use and ligature placement.

Microsurgery offers new possibilities to

improve periodontal care in variety of ways.Its

benefits include improved cosmetics, rapid healing

and minimal discomfort and enhanced patient

acceptance. Periodontal microsurgery appears to be

a natural evolution for the specialty of

Periodontics16.

Orthograde and retrograde endodontics-the domain

of the dental microscope

The long term success rate in orthogradeand retrograde endodontics have risen toward

100%, firstly due to the more conservative

preparation philosophies and the thermoplastic

filling technique, and secondly due to the use of

dental microscopes. The shadow free, bright xenon

light enables the straight canal sections to be

examined right down to the constriction.

Ledges, branches, fractured instruments,

perforations, foreign bodies, and even, isthmus like

branch lines can be localized and simultaneouslytreated with slender ultrasonic tips under optimal,

magnifying vision. The localization of absent canals,

pulp denticles, tooth colored restorations in the

pulp chamber, and the removal of old, insufficient

root canal fillings is much more reliable when using

magnification systems such as dental microscope or

medical loupes.

If, despite a seemingly sound orthograde

root canal filling, apical inflammation does occur in

a few cases-usually where apical ramifications are

inaccessible-a dental microscope is of great help in

apical microsurgery. Again the filigree apical

portion of the root can be removed under optical

illumination and the leakage delta responsible for

the inflammation prepared with ultrasonic tips and

ligated with a suture.A very convincing study

concerning the benefits of microsurgical procedures

was reported by Rubinstein and kim in 19996,7.

Diagnosis of a minute longitudinal fracture is often

only possible at a magnification level exceeding 12x

to 15x. Here too, the dental microscope provides

useful diagnostic reliability

Precise control of prosthetic preparations and

impressions

In order to ensure precise preparation of a hard

tooth structure, especially in the final phase ofpatient rehabilitation performed according to the

treatment plan, it is essential to provide the dental

technician with preparation margins that are as

accurate as possible-irrespective of whether the

restorations are to be made of gold or porcelain.

Finishing of the prepared crown can be done under

dental microscope. As the part of the chain of

precise quality assurance, one can quickly check the

impressions for accuracy under the dental

microscope. With an evolving level of training one

can employ the dental microscope quickly and inmany different ways, without slowing down the

working procedure significantly.

The role of the operating microscope in the

preparation stage of fixed prosthetics

The preparation stage of fixed prosthodontic

case is technically demanding. Many factors

determine the final design of the preparation,

including the required reduction of tooth

structure, detection of marginal caries,

fractures, furcations and the need for themargins of the restoration to be placed on solid



95

tooth structure. Several clinicians suggested

that DOM can be used to improve tooth

preparation and final restoration in fixed

prosthodontics.17-23

In addition, the clinician must consider the

aesthetic, functional, and biologic principles

regarding placement at the margins of the

restoration and the type of margin best suited

for the tooth. While the successful provision of

inlay, onlay, and crown restorations depends

upon a solid understanding of the above,

successful treatment predicted on the ability of

the clinician.

The dental operating microscope can be used

for the entire preparation of a tooth, but somedentists use loupes for gross reduction of tooth

structure before using the microscope to finish

the preparation.

Gross reduction of tooth structure is

accomplished using medium magnification,

and margins are completed using

magnification.

After finishing the margins, the preparation is

examined at a lower magnification to ensure

that no undercuts have been created.

Clinically the use of higher magnification for

preparation of margins appears to reduce the

degree of taper of the preparations.

Close attention must be given to the lines

drawn and parallelism when preparing

multiple abutments for a fixed bridge.

An important benefit of higher magnification is

the ideal placement of the crown or veneermargin.

Cutting at high magnification polishes the

margin, resulting in a smooth and discernible

finish line.

In contrast to high magnification, at medium

magnification the entire visual field is occupied

by one tooth.

At the higher magnification, only part of the

tooth (2 or 3 surfaces) is visible at a time.

Advantage of using higher magnification is the

reduction of peripheral “visual noise”.

Therefore, properly trained auxiliary

personnel are essential.

When first using the microscope for crown and

bridge procedures, the clinician will find that it

takes longer time to prepare teeth for crowns

as compared to conventional technique. It

takes time to develop the motor skills

necessary to work at higher magnification.

The role of the operating microscope during the

insertion stage of fixed prosthesis

Once the impression reaches the lab, it is ideal

if the laboratory uses magnification during thefabrication of the prosthesis. Laboratory

technician can more precisely trim stone dies

with the aid of a microscope. During trial in

and seating appointment, the microscope is

very useful.

After the final margins have been completed,

another benefit of the operating microscope is

improved tissue management. The provisional

restoration can be trimmed under the

microscope, ensuring that the restoration is

well adapted and will allow for the healing of

the tissues during the provisional stage.

The role of operating microscope in orthodontics

After orthodontic brackets debonding,

there is a residual layer of composite left on the

enamel surface that should be removed. These

composite remnants on the enamel are potential

plaque traps. Dental microscope can be used to

examine carefully remnants of composites and

finishing of tooth surface can be done precisely.Stereomicroscope offers great possibilities of

enamel surface investigation, providing high quality

images with good sharpness23-25.

The used microscope was a binocular light

stereo microscope -Olympus SZx ZB 12 with a

WHS 30X-H ocular, a DFP LAP07 X PF lens and

3100 light system for photo micrography.

The camera was placed on the microscope and

connected to a computer and a frame grabber

of the same manufacturer.



96

After cleaning the enamel surface, each surface

was examined in the following two

magnification modes:

-50x for the entire buccal tooth surface.

-For the four quadrants of the same surface.

RESULTS

Today the world’s leading dental

practioners are largely in agreement that DOM has

pushed the limits of treatment potential a long way

toward enhancing long term patient outcomes. In

particular, the digital visualization technology in

combination with the dental microscope can be

used as a powerful documentation tool for patient’s

records, legal documentation as well as the

education of the dental profession. With the help of

DOM there is better visualization of the operating

field and hence treatment quality can be improved.

DISCUSSION

The eventual dramatic change from casual

interest in microscopes to fevered involvement

heralded a new era in endodontics. Undoubtedly the

current wide-employment of DOMs in endodontics

speaks to, their obvious advantages. Microscopy inendodontics has certainly come of age, but its

gestation period was surprisingly long. With a

microscope, dental procedures can be performed

more accurately and more reliably using variable

and adjustable magnifications and shadow free light

due to a coaxial radiating light source.

In general, magnification can be set to 4x

and 24x, thereby expanding the diagnostic options

due to better lighting and sight. For example, most

fissure caries and micro fractures cannot be seenwith the naked eye. With the aid of a microscope it

is even possible to view down to the apex of a

straight root canal.

Additionally clinicians will experience an

increase in job satisfaction. Many procedures are

simplified and accelerated greatly, as much better

visibility is provided with the

microscope.Treatment results become more

predictable. For example, the outline preparation

and assessment for a crown preparation becomes

much simpler. Making a cast impression is also no

longer problematic. Moreover, working with a

dental microscope improves ergonomics.

Furthermore, the patients can be better

counseled and educated. With a video camera

attached to the dental microscope, the images can

be recorded directly. This greatly simplifies the

counseling of patients because, as we all agree,

sometimes an image talks more than a thousand

words.

Although operating microscopes can

greatly enhance dental practice there are some

disadvantages especially at the initial stages.

Sometimes specific training may be necessary. An

operator using DOM cannot see his hands or fingers,

only the tip of the instruments can be seen, and theyare used in delicate movements of small amplitude.

High initial cost of the equipment and instruments,

the need for retraining of the auxiliary staffand an

adjustment for the new treatment paradigms and

operator postures are other disadvantages.

The dental microscope has many benefits,

and when integrated with documentation devices it

offers an unparalleled opportunity to document

patient care in an efficient manner and unique

perspective .Future clinical advancements will makethe microscope an essential part of daily patient

care.

CONCLUSION

The dental microscope, in conjunction with

further technological developments and an increase

in experience, is bound to lead to specialization that

will continue to enjoy a high degree of protection

against emulation in the competitive world of

dentistry.

One advantage of the dental microscope

that should not be under estimated, especially in the

physically and psychologically highly strenuous

dental profession, is a healthy, namely upright,

working posture. Due to its superior technological

features the convenience to use microscope can

provide the dentist with considerable quality of life

and good health. To put it crudely, the microscope

can “hump up” for us as we sit in a highly

ergonomic, upright position keeping the spine

relaxed.



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The popularity of the dental operating

microscope will likely increase in the future for

prosthodontic procedures also.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this

article was reported.

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