Continuing Education: Posture-Directed vs. Image-Directed Dentistry - Ergonomic and Economic Advantages Through Dental Microscope Use (June 2006)

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By Gerard M. Cuomo, DDS

Distributed by:

www.sullivanschein.com

Sullivan-Schein Dental is an ADACERP recognized provider.

Posture-Directed vs. Image-Directed

Dentistry: Ergonomic and Economic

Advantages Through Dental Microscope Use

The modern dental practice incorporates office designs that create

an "at-home" atmosphere while using "high-tech" equipment to

promote improved efficiency and increased productivity. The

purpose of this article is to analyze the ergonomic and economic

advantages of the dental microscope over the now obsolete dental

loupes. In order to appreciate the benefits of this 21st-century

equipment, one must understand the distinctions between

posture-directed and image-directed dentistry.

The term "ergonomics" is the applied science of equipment design

for the workplace with the intent of enhancing productivity byreducing operator fatigue and discomfort. An ergonomically

designed product implies that a device must blend smoothly with

a person's body and actions. To understand equipment design,

one should initially recognize the fact that certain risk factors such

as poor body positioning and its related repetitive movements can

alter the ergonomic purpose, thus contributing to pain and injury

over time to various parts of the dental professional’s body.

Musculoskeletal disorders such as herniated discs of the lower back

and rotator cuff impingement are the end products of trying to

work more efficiently while ignoring the proper pathways to

maintain muscle balance. 8,9

Mechanisms related to muscle balance can be explored by first

understanding the differences between posture-directed dentistry

and image-directed dentistry as each relates to the ergonomic

well-being of the dentist. 5

"Image-directed" dentistry is associated with dental procedures

performed by using a "direct line of sight." A good example of

"image-directed" dentistry is the dentist viewing an oral image by

using dental loupes (Figure 1).

Gerard M. Cuomo, DDS, is a graduate of Northwestern

University Dental School, and is a recognized author and

lecturer on the integrated use of chair-mounted micro-

scopes in dentistry. He maintains a private practice in Boca

Raton, Florida, and teaches hands-on dental microscopy

courses for dentists and students throughout the U.S.

Figure 1

06AS4306 June CE Seminar 4/27/06 9:55 AM Page 2



In this instance, the eyes are looking directly at the image through

various lenses aligned with one another attached to a frame. The

head posture of the loupe wearer remains in a constant tilt position

with the chin angled downward. Typically, the dentist’s head

moves toward the image to find and maintain focus at a set focallength.

As the image moves out of focus, it is only natural for one to

refocus by moving their head back inline with the image. As the

need to increase magnification becomes apparent when going from

2.0X to 6.0X, the loupe lens size becomes larger and heavier while

the field of view becomes smaller. Dental loupes add an additional

amount of weight to the front portion of the dentist’s head,

therefore requiring straps to secure the loupes to the back side of

the head to maintain stability. 1-2,5,7 In other words, the image

dictates the movement of the dentist’s head, as shown below

"Posture-directed" dentistry is associated with dental procedures

that are performed by using an "indirect line of sight." 5 The best

way to achieve "posture-directed" dentistry is by viewing an oral

image using a dental microscope (Figure 4).

Here the eyes are looking indirectly at the image through various

lenses and prisms aligned with one another and supported by a

mechanical arm apparatus. It is the use of the microscope’s

inclinable binocular eyepieces that permit the dentist to raise his or

her chin in a more level position. The optics of dental microscope

bend the path of the image to almost 90 º, allowing the dentist to

sit comfortably erect with the head, neck, and back arranged in a

straight line when viewing an object. 3,10

Posture-directed dentistry also includes several techniques for

maintaining focus. The simple method of reclining the patient’s

head backward into a more healthy ergonomic working position

helps to form the foundation of the workplace. Posture-directed

dentists rest their patients in the supine position for maxillary arch

procedures and in a semisupine position for mandibular archprocedures. The dentist’s seating zone is usually in the 11 and 12

o’clock positions (Figure 5).

2

Figures 2 & 3

Figure 4




This ergonomic positioning helps the dentist avoid twisting and

turning movements when using the microscope and receiving hand

instruments. As the image moves out of focus, the dentist relies

more on verbal commands directed toward the patient to move the

image back into focus (Figure 6). 2,3,5

Other focusing methods of posture-directed dentistry include use

of the dental microscope’s fine-focus adjustment when changing

magnification from 2.0X to 20X.6 In addition, the hands, the

forearms, and the shoulders are often well supported by stools with

built-in adjustable arms. In order to achieve posture-directed

benefits, the dentist must first be willing to accept the need for

change and give up old image-directed bad habits.

Dental school undergraduate curriculums teach image-directed

techniques. Today’s dental students migrate from using no

magnification to using dental loupes during their four years of

undergraduate studies. The combination of using dental loupes

with only limited four-handed dentistry available creates a breeding

ground for the formation of bad habits. Based upon this fact,

image-directed habits are primarily formed in dental schools and

continue to shape the ergonomic foundation of the dentist’s method

of practice.

Postgraduate endodontic curricula currently accept and require

microscope proficiency of graduate students. Even though posture-

directed dentistry has minimal acceptance in dental school

restorative curricula, one can anticipate a change will occur with

the increasing number of practicing dentists transitioning to dental

microscopy. 4

At the time this article was written, pre-dental students attending

Florida Atlantic University participated in their first hands-on

dental microscope course without having any previous dental

microscope experience. Each of the four students was given a molar

to perform a root canal. They were then instructed to restore thesame tooth using current composite modalities.

3

Figure 5

Figure 6

12

9 3

6




These new generations of students are more open to accepting

advances in technology. Following the single-tooth exercise, each

student was asked to prepare teeth on the mannequin’s head

(ergonomically placed) in the dental chair using the various

posture-directed techniques previously discussed in this article.The end result indicated that all four pre-dental students had

achieved an acceptable basic level of proficiency within four hours

by using the dental microscope (Figures 7 and 8).

This exercise clearly supports the "law of primacy" which states,

"Things first learned are best remembered."

Despite the fact that many innovative ideas such as computer

software and hardware, digital X-rays, automated perio-probes, and

image capturing devices have helped to modernize the dental

industry by saving time, none of them have had as much ergonomic

effect on dentists than that of the dental microscope. 10 Use of a

dental microscope improves the dentist’s overall performance.

Connected to flat-screen monitors located in each operatory, thedental microscope visually adds a whole new dimension for

viewing and recording real-time images.

It is this combination of microscope optics and video that have a

tremendous effect on the profitability of the dental business.

Dental assistants and patients now have a front row seat to viewing

the dentistry being performed at several levels of magnification

(Figures 9 and 10).Dentists who use microscopes are able to see more and do more

dentistry. One can detect early crack formation which will

ultimately determine the type of restoration to be placed. 4,11

Dentists are able to find hidden calculus around margins much

more precisely prior to impression taking. They are able to make

more accurate determinations on whether to use sealants, flowables,

or composite resins for conservative dentistry. Final preparation

design can be easily placed without compromise.11,12

Today’s dental microscopes can be mounted via ceiling, wall, or a

more ergonomic space-saving chair-mount. Aside from ergonomic

advantages, the dental microscope user enjoys shadow-free coaxial

lighting and the ability to detach and transport the microscope

head between workstations and office (portability).

In summary, vision in dentistry makes up the very fabric that

determines how successful we become as dentists. It is our choice

4

Figures 7 & 8




5

to practice with either yesterday’s technology, or wake up to the

advances of the 21st century with an exciting new way to practice

dentistry. Current and incoming students are more tech savvy than

previous generations. Not only do they accept new technologies,

but they go out of their way to look for them. Having been

exposed early to eye-hand coordination teaching tools such as Play

Stations and Xboxes, their skills have been honed, and they are

ready to take on advanced magnification methods.

Experienced dentists need not fear this new technology either.

Technology should be embraced as an opportunity rather than an

impediment. With proper instruction, repetition, and a

willingness to learn, the practicing dentist can enjoy all the benefitsof the dental microscope. Posture-directed dentistry is the logical

progression for the industry. Those who make the transition to

microscopy early on, will realize the distinct advantage they have

over those who have not made similar choices.

Acknowledgements

The author acknowledges Gerard J. Cuomo (writing consultant),

Maria Martinez (dental assistant), and Florida Atlantic University

(pre-dental students): Ashley Millstein, Salvatore Colombo, David

Miller, and Justin Grossmayer.

Figure 9 & 10

Dr. Cuomo & students




1. Friedman MJ. Magnification in a Restorative Dental Practice:From Loupes to Microscopes. Compend Cont Educ Dent 2004;

25:48–55.

2. Sheets CG, Paquette JM, Hatate K. The Clinical Microscope in

an Esthetic Practice. J Esthet Restor Dent 2001; 13:187–200.

3. Friedman MJ, Landsman HM. Microscope-Assisted Precision

(MAP) Dentistry – A Challenge for New Knowledge. J Calif Dent

Assoc 1998; 26:900–905.

4. Garcia A. Dental Magnification: A Clear View of the Present and

a Close-up View of the Future. Compend Cont Educ Dent 2005;

26:459–463.

5. Cuomo GM. A Fresh Look at the Biomechanics of Advanced

Magnification. Dent Econ 2004; 94:66–69.

6. Nase JB. Enhanced Vision in the Improvement of Patient Care.

Dental Collab 2005; 2:19–20.

7. Pace SL. Seeing Through the Eyes of Magnification. Contem

Dent Assist 2005; 2:14-18.

8. Valachi B, Valachi K. Mechanisms leading to Musculoskeletal

Disorders in Dentistry: J Am Dent Assoc 2003; 134:1344–1350.

9. Valachi B, Valachi K. Preventing Musculoskeletal Disorders in

Clinical Dentistry: J Am Dent Assoc 2003; 134:1604–1612.

10. Kotlow LA. Using a Dental Operating Microscope in a

Pediatric Dental Practice: Compend Cont Educ Dent 2004;

25:482–488.

11. van As GA. The Use of Extreme Magnification in Fixed

Prosthodontics. Dent Today 2003; June:93–99.

12. Clark D. Do Traditional Sealants Have a Place in the New,

Super-Magnified World? Dent Today 2004; Sept:92, 94–98.

6

COURSE SPONSOR

Sullivan-Schein is course sponsor. Sullivan-Schein’s ADA CERP

recognition runs from November 2001 to June 2006.

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All participants scoring at least 80% on the examination will receive a

certificate verifying 2 CEUs. The formal continuing education program of

this sponsor is accepted by the AGD for Fellowship/Mastership credit.

The current term of acceptance extends from December 2001 to June

2006. Participants are urged to contact their state dental boards for

continuing education requirements.

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herein are those of the author and do not necessarily reflect those of

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References




Continuing Education Test Questions

1. The term "Ergonomics" includes the following except:

a. increased productivity

b. equipment design for the workplacec. can not be altered by poor body positioning

d. reduced body fatigue

2. Which of the following regarding "image-directed"dentistry is correct?

a. "image-directed" dentists use dental microscopes

b. "image-directed" dentist’s head posture is in constant tiltposition

c. "image-directed" dentists view oral images using dental loupes

d. b and c

e. all of the above

3. "Image-directed" habits are first learned in dental schoolundergraduate curricula.

a. True

b. False

4. Which of the following regarding "posture-directed" dentistryis correct?

a. "posture-directed" dentists use "direct line of sight"

b. "posture-directed" dentist’s head is in an upright position

c. "posture-directed" dentists use microscopes that only mount tothe wall

d. b

e. b and c

5. Dental loupes add weight to the front side of the dentist’shead and need straps.

a. True

b. False

6. Which of the following is correct regarding the dentalmicroscope?

a. chair-mounted microscopes contain a series of prisms andlenses that attach to the dentist’s head

b. chair-mounted microscopes demonstrate "indirect line of sight"

c. chair-mounted microscopes have inclinable binoculareyepieces

d. b and c

e. all of the above

7. As the need for increasing magnification becomes apparent,dental loupe lenses become larger and heavier, while thefield of view becomes smaller in size.

a. True

b. False

8. "Posture-directed" dentistry includes the following except:

a. positioning the patient and the dentist into a healthy ergonomiczone

b. dentist’s seating zone is in the 11 and 12 o’clock position

c. utilizing verbal commands to move the patient’s head

d. constant movement of the microscope head

9. Dental microscopes are mandated in all endodonticpostgraduate curricula. Students must demonstrateproficiency using the dental microscope before receivingtheir degrees.

a. True

b. False

10. Dental loupe wearers often refocus an image by movingtheir head toward the object.

a. True

b. False

11. All of the following are correct regarding the pre-dentalhands-on exercise noted in this article except:

a. each of the students explored molar root canals

b. each of the students successfully prepared teeth on amannequin’s head using posture-directed techniques

c. each of the students achieved an acceptable basic level ofproficiency using the dental microscope in four hours

d. each of the students performed image-directed dentistry

7

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Posture-Directed vs. Image-Directed Dentistry:

Ergonomic and Economic Advantages Through

Dental Microscope Use By Gerard M. Cuomo, DDS

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Continuing Education: Posture-Directed vs. Image-Directed Dentistry - Ergonomic and Economic Advantages Through Dental Microscope Use (June 2006)