MICROSCOPE IN

ENDODONTICS

Dr. Parthasarathy R

2nd year MDS

INTRODUCTION

Endodontists have frequently boasted they can do much of their work blindfolded
simply because there is “nothing to see.” The truth of the matter is that there is a
great deal to see if only we had the right tools. The only possible way to “see”
inside the root canal system is with the help of radiograph.

THE LIMITS OF HUMAN VISION

Webster defines resolution as the ability of an optical system to make clear and
distinguishable two separate entities. The resolving power of the unaided human
eye is only .2 mm. In other words, most people who view two points closer than .2
mm will see only one point.

The approximate field of view of an individual human eye is 95° away from the
nose, 75° downward, 60° toward the nose, and 60° upward, allowing humans to
have an almost 1800 forward-facing horizontal field of view.

Clinically, most dental practitioners will not be able to see an open margin smaller
than .2 mm. The film thickness of most crown and bridge cements is 25 microns
(0.025 mm) or well beyond the resolving power of the naked eye.

Magnification →precision dentistry

Dentists routinely perform procedures requiring resolution well beyond the 0.2 mm
limit of human sight. Dentists can increase their resolving ability by simply
moving closer to the object of observation.

Dis-Advantages:

Uncomfortable proximity of the practitioner's face to the patient. As the eye-

subject distance decreases, the eyes must converge, creating eyestrain

OPTICAL PRINCIPAL

All clinicians must construct 3-dimensional structures in a patient’s mouth. 3-

dimensional perception is critical to achieving precision dentistry.

Several elements are important for consideration in improving clinical

visualization. Included are factors such as
(1) Stereopsis

(2) Magnification range

(3) Depth of field

(4) Resolving power

(5) Working distance

(6) Spherical and chromatic distortion (i.e., aberration)

(7) Eyestrain

(1) Stereopsis:

Vision where in two separate images from two eyes are successfully combined in
to one image in the brain. Also called as 3-dimensional perception .

(2)Magnification range:

Magnification is ability to produce enlarged images of object. The Maximum

magnification of human eye is .068 cm also called as 1x magnification .

So the image size can be increased by using lenses for magnification. Every
optical system has finite range of magnification , if u magnify beyond that the
result will Empty Magnification.

(3)Depth of field :

It is the range of a depth that a specimen is acceptable in focus. Depth of Field is

basically how much of the object under the microscope can actually be viewed.

(4)Resolving power:

The resolving power of a microscope determines the degree of details that is

visible. The resolving power of normal human eye is 200 micron. Object separated
by less then this distance appears as single Object.

Dentists can increase their resolving ability without using any supplemental device
by simply moving closer to the object of observation.
This movement is accomplished in dentistry by raising the patient up in the dental
chair to be closer to the operator or by the operator bending down to be closer to
the patient. Resolving power can be increased by using lenses for magnification .

Resolving power also enhanced by using the the shorter wavelength Light for
illumination.

(5)Working distance :

The nearest point that the eye can accurately focus on exceeds ideal working
distance. Working distance of Microscope is inversely proportional to the
Magnification.

(6)Spherical and chromatic distortion (i.e., aberration) :

Its type of Distortion in which there is failure of a lens to focus all colors to same
point.

(7)Eyestrain:

One might think that working constantly with the microscope will cause eyestrain
and eye fatigue. Not only is this not true, but what is true is just the opposite.

As a matter of fact, operating microscopes possess the additional benefit of

Galileian Optics, as they focus at infinity and send parallel beams of light to each
eye. With parallel light, the operator’s eyes are at rest, as though looking off into
the distance, permitting performance of time- consuming procedures without
inducing eye fatigue. Eye strain or Eye Fatigue are major problem for microscope
users if they have poor vision and if user don't know the correct position to use it .

Optical aids (loupes, microscopes, surgical headlamps, fiber optic handpiece lights,
etc.) can improve resolution by many orders of magnitude. For example, a
common operating microscope can raise the resolving limit from .2 mm to .006
mm (6 microns).

The most common magnification devices that have been introduced in endodontics
are loupes, surgical microscopes

(Pecora 1993; Khayat 1998; Rubinstein 1999; Castellucci 2003)

And more recently, endoscopes

(Bahcall 1999; Bahcall 2000; Von Arx 2002; Bahcall 2003).

Loupes

The most common form of magnification. Magnifying loupes were innovated to

address the problem of proximity, decreased depth of field and eyestrain
occasioned by moving closer to the subject

Two mono-ocular microscopes with lenses mounted side by side and angled
inward (convergent optics) to focus on an object

Loupes are classified by the optical method in which they produce magnification.
There are three types of binocular magnifying loupes:

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

(2) a surgical telescope with a Galileian system configuration (two lens system),

(3) a surgical telescope with a Keplarian system configuration (prism roof design
that folds the path of light).

Diopter system

Relies on a simple magnifying lens

Advantage- the most inexpensive system

Dis-Advantages

The plastic lenses that it uses are not always optically correct

The increased image size depends on being closer to the viewed object, which can
compromise posture

Surgical telescopes

Multiple-lens system. Positioned at a working distance between 28-51 cm

Galilean system:

A magnification range from 2x to 4.5x. Is a small, light and compact system

Keplarian system :

Prism roof design that folds the path of light. The prism loupes (Keplarian system)
use refractive prisms and they are actually telescopes with complicated light paths,
which provide magnifications up to 6x.

Advantages

Superior magnification

Correct spherical and chromatic aberrations

Excellent depth of field are capable of increased focal length (30–45 cm), thereby
reducing eyestrain and head and neck fatigue

Dis-Advantages

The practical maximum magnification is only about 4.5

Loupes with higher magnification are available, but they are heavy and unwieldy
with a limited field of view.

Before advent of operating microscopes, one could “feel” the presence of problems
like a ledge, a perforation, a blockage, a broken instrument, but the clinical
management of that problem was never as predictable as it is now a day’s.

Apotheker H, 1981

HISTORY

Operating Microscope has been used in the medical field for over 50 years.
According to the Zeiss Company, the microscope was first introduced to
otolaryngology around 1950, then to neurosurgery in the 1960s and to endodontics
in the early 1990s.

In 1978, Dr. Apotheker and Dr. Jako introduced the concept of extreme
magnification, in the form of an operating microscope into dentistry.
The first commercially available Dental Operating Microscope (DOM) was
Dentiscope. The first operating microscope was poorly configured and
ergonomically difficult to use.

It did not gain wide acceptance and the manufacturer ceased manufacturing them
shortly thereafter their introduction. Its market failure was more a function of its
very poor ergonomic design rather than its optical properties, which were actually
quite good.

Poorly configured and ergonomically difficult to use. Only one magnification

(8x), positioned on a floor, poorly balanced, had only straight binoculars and had
fixed and long focal length (250 mm). used angled illumination instead of
confocal illumination.

Hence, did not gain wide acceptance.

In 1992, Dr. Gary Carr introduced an ergonomically configured operating

microscope for endodontics, which allowed for easy use.

Howard S Selden [1986] was the first endodontist to publish an article on the use
of the DOM in endodontics. His article discussed its use in the conventional
treatment of a tooth, not in surgical endodontics.

In 1999, Gary Carr, introduced a DOM that had Galilean optics with several
advantages that allowed for easy use of the scope for nearly all endodontic and
restorative procedures. It is now the instrument of choice not only for endodontics
but for periodontics and prosthodontics.

The introduction of the microscope includes numerous ergonomic changes.

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.

The range of working positions is usually from the 9 o’clock to the 12 o’clock
position.
CHOICE OF USE OF MICROSCOPE AMONG ENDODONTIST

Although the operating microscope is now recognized as a powerful adjunct in

endodontics, it has not been adopted universally by all endodontists.

It is seen by many endodontists as simply “another tool” and not as “a way of

practice” that defines how an endodontist works.

Although cost is frequently cited as the major impediment, in truth, it is not cost,
but a failure to understand and implement the positional and ergonomic skills
necessary to effectively use a microscope that has restricted its universal use on all
endodontic cases.

The skillful use of an operating microscope entails its use for the entire procedure
from start to finish. Working in such a way depends upon refinement of ergonomic
and visual skills to a very high level.

ADVANTAGES

Five basic advantages in using the DOM

1. Increased visualization,

2. Improved Quality and precision of treatment,

3. Enhanced ergonomics,

4. Ease of proper digital documentation and

5. Increased communication ability through integrated video

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.

A DOM can raise the resolving limit from 0.2 -0.006 mm, thus with magnification
the resolution of the human eye improves dramatically .

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 of even the most difficult to access areas of
the oral cavity.

Carr GB, Behle C

Improved Quality and precision of treatment

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

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 (10–20/1000 of a mm) 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.

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. In the latter study, the inclusion of a
microscope resulted in fewer errors than when a set of loupes was used.

Improved & Ideal treatment Ergonomics

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
which allows one to focus completely on the task at hand and able to work
comfortably for extended periods of time.

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.

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.

Mora AF, Van As GA.

Communicate through Integrated Video

Adding video to the microscope have found useful in providing information both
to patients and to auxiliaries, as the microscope, like an intraoral camera, allows
them co-observation of the multiple steps during the procedure in real time but also
become involved in a particular portion of the procedure.

Disadvantages

high initial cost of the equipment and instruments

need for specific training

restricted working field: 11-55 mm

only the tip of the instruments is visible, delicate movements!

learning depth perception and orientation takes time and patience

USES

1. Locating hidden canals that have been obstructed by calcifications and

reduced in size;

2. Removing materials such as obturation materials (silver points and carrier-

based materials), posts or separated instruments;

3. Removing canal obstructions;

4. Assisting in access preparation to avoid unnecessary destruction of

mineralized tissue,

5. Repairing biological and iatrogenic perforations;

 6. Locating cracks and fractures that are neither visible to the naked eye nor
palpable with an endodontic explorer;

7. Facilitating all aspects of endodontic surgery, particularly in root-end

resection and placement of retrofilling material.

USES

1. Examination, diagnosis, and treatment planning.

2. Enhanced visualization enables the clinician to diagnose the problem in very

early stage. High powered magnification allows the clinician to identify colour
alteration, tiny amount of pulp, demineralization around the groove.

3. Diagnosis of cracked teeth

Cracks at elevated enamel margin, craze lines and wear facets exposing dentin can
be viewed more precisely with operating microscope.

Glenn A, Van As (2007)

4. Access cavity preparation

Traditional access preparation of access cavities depends on type of tooth, however

with modern endodontic techniques, a dental operating microscope providing
magnification and better illumination helps in conservative preparation.

Orifice Locating with a Microscope

Maria Cristina

The purpose of this study was to determine whether the use of the dental operating
microscope (DOM) could increase the number of root canal orifices located in
mandibular molars. Ninety-three first and 111 second extracted mandibular molars
were used. With the naked eye, all access cavities were prepared and the number of
canals in each root was recorded. Using a DOM with ×8–×13 magnification, all
teeth had the access cavity preparations again examined. With the naked eye, a
total of 641 canals were seen in all teeth. After the DOM examination, 50 more
canals could be visualized, representing a 7.8% increase in the total number of
located canals. From these canals, 35 were located in the first molars and 15 in the
second molars. The use of the DOM increases the number of root canal orifices
located.

The influence of dental operating microscope in locating the mesiolingual

canal orifice
Lynne A.Baldassari-Cruz

Abstract

Objective. The purpose of this study was to evaluate the influence of using the
dental operating microscope (DOM) for detection of the mesiolingual (ML) canal
orifice in extracted maxillary molars compared with unaided vision (no loupes or
headlamps). Study Design. Using a clinical simulation model system, we mounted
39 maxillary molars in a dentoform and placed them into a mannequin. After
rubber dam placement and preparation of standard access, 2 attempts were made to
locate the ML canal with unaided vision. Then the teeth were examined by using a
DOM. Finally, all teeth were sectioned, stained, and evaluated with the DOM for
actual presence of an ML canal. Results. ML canal orifices were detected in 20 of
the teeth with a sharp explorer and mirror. In the remaining teeth, 12 ML canal
orifice were located by using the DOM. Qualitative nonparametric comparisons
were used. Conclusions. The results of this study indicate that the DOM provides
increased opportunity for the dentist to detect canal orifices.

Detection Rate of Root Canal Orifices with a Microscope

Takatomo Yoshioka JOE 2002

The purpose of this study was to compare the detection rate of root canal orifices
by three different methods: naked eye, with surgical loupes, and under a
microscope. Two undergraduate dental students located the orifices of 260 teeth by
using the above-mentioned methods. Then, India ink was injected into the pulp
chamber and all teeth were cleared to determine the actual number of the orifices.
There was a significant difference in the detection rate among the three methods (p
< 0.01, chi-square test); the microscopic method could more accurately detect
orifices than the others could. Surgical loupes were relatively ineffective compared
with the microscopic method for detecting orifices.
During instrumentation

During instrumentation, the improved ability to see specific canals allows

endodontists to maneuver files into canal openings with greater efficiency, to
distinguish between vital and necrotic canals and to detect tiny amounts of
purulence or blood draining through specific canals or see any tiny amounts of
necrotic pulp material that were not removed during canal instrumentation.

So it is possible for an endodontist to determine if all canals are accessed and

instrumented properly when a direct view might be difficult without removing
excessive amounts of coronal tooth structure.

John S, Frank J

Removal of fractured post and instruments

The enhanced vision with magnification and illumination from a microscope

allows endodontist to observe the most coronal aspects of fractured post and
broken instruments and to remove them without any major loss of tooth structure
and perforations, the prognosis for preservation of the tooth is quite good.

Clifford J. Ruddle 1997 , Nimet Gencoglu 2009

Detectability of residual Epiphany and gutta‐percha after root canal

retreatment using a dental operating microscope and radiographs – an ex
vivo study
J. F. Schirrmeister, P. Hermanns

Abstract

Aim To compare the detectability of residual Epiphany and gutta‐percha after root
canal retreatment using a dental operating microscope and radiographic
examination with the residual area measured after rendering the roots transparent.

Conclusion Especially for remaining gutta‐percha, the operating microscopes

provided better detection of residual root filling material in retreated maxillary
incisor teeth.
6. Hidden canals and Removal of calcifications

Complex structures like middle mesial canal in mandibular first molar and c
shaped canal in mandibular second molar can be more readily identified with the
aid operating microscope. Negotiation of calcified canal and removal of
calcification can be done without sacrificing important tooth structure

Identification and removal of Denticles

This specific form of calcification is also encountered very frequently, can block
the canal entrance or even obstruct further instrumentation.

Denticles can be found and negotiate readily with the help of a DOM

Thomas Clauder

Perforation repair

Treatment of iatrogenic problem such as pulpal floor perforation, lateral root

perforation and prognosis chiefly involve visualization of the problem so the
microscope certainly plays a major role in this context

7. Microsurgical apicoectomy

Incorporation of microscope in surgical endodontics by Prof. Kim in the 1990s

along with use of minute retro mirrors made it possible to carefully examine the
apical segment of the root end and better management of tooth and bone.
Microsurgical flap design and soft tissue management is also greatly enhanced by
aid of microscope in surgical endodontics.

Rubinstein RA, Kim S (2002)

Other uses

Other uses such as external cervical invasive resorption repairs, removing

materials such as solid obturation materials (silver points and carrier-based
materials) and other resorptive repairs that also benefit from a microscopic
approach.

Gary B. Carr 2010

DISADVANTAGES

The need for specific training: as a DOM has a restricted working field, 11mm -
55mm . Relatively high initial cost of the equipment and instruments, the need for
retraining of the auxiliary staffs and an adjustment period for the new treatment
paradigms and operator postures.

Jose Roberto Moura

ANATOMY OF DENTAL MICROSCOPE

The operating microscope consists of three primary components:

(1) The supporting structure,

(2) The body of the microscope and

(3) The light source

Schematic diagram of the OM

The Supporting Structure

It is essential that the microscope be stable while in operation, yet remain

maneuverable with ease and precision, particularly when used at high power.

The supporting structure can be mounted on the floor, ceiling or wall.

As the distance between the fixation point and the body of the microscope is
inversely proportional to the stability.

In clinical settings with high ceilings or distant walls, the floor mount is preferable.
Even in that ceiling mount is most preferable.

For establishing perfect balance in any position built-in springs should be tightened
according to the weight of the body this permits precise visualization.

The Body of Microscope

The body of the microscope is the most important component of the instrument and
it contains the lenses and prisms responsible of magnification and stereopsis.
The body of the microscope is made of following components

(1)Eyepieces,

(2)Binoculars,

(3)Magnification changer factor and

(4)The objective lens.

EyePiece

Eyepieces are generally available in powers of 10x, 12.5x, 16x and 20x.

The most commonly used are 10x and 12.5x.

The end of each eyepiece has a rubber cup that can be turned down for clinicians
who wear eyeglasses.

Eyepieces also have adjustable diopter settings.

Diopter settings range from -5 to +5 and are used to adjust for accommodation,
which is the ability to focus the lens of the eyes.

Diopter settings is particularly important when an assistant scope and

documentation equipment are used, so that everything is uniformly in focus

THE BINOCULARS

It contain the eyepieces and allow the adjustment of the interpupillary distance.

They are aligned manually or with a small knob until the two divergent circles of
light combine to effect a single focus.

Once the diopter setting and interpupillary distance adjustments have been made,
they should not have to be changed.

Binoculars are available with 3 different kind of tubes i.e.

(1) Straight: Straight tube binoculars are orientated so that the tubes are parallel to
the head of the microscope. They are generally used in otology and are not well
suited for dentistry.
(2) Inclined: Inclined tubes are fixed at a 45° angle to the line of sight of the
microscope.

(3) Inclinable tubes: The inclinable tubes are adjustable through a range of angles
and allow the clinician to always establish a very comfortable working position.

It is therefore obvious that, even if more expensive, the inclinable binocular is

always to be preferred.

The Magnification Changer Factor :

Magnification changers are available as 3-, 5-, or 6-step manual changers or a

power-zoom changer. They are located within the head of the microscope.

Manual step changers consist of lenses that are mounted on a turret that is
connected to a dial located on the side of the microscope. The magnification is
altered by rotating the dial.

A power zoom changer is a series of lenses that move back and forth on a focusing
ring to give a wide range of magnification factors.

The advantage of the power zoom changers is that they avoid the momentary
visual disruption or jump that occurs with manual step changers as the clinician
rotates the turret and progresses up or down in magnification.

The disadvantages are:

the excursion from the minimum to the maximum magnification is quite slow,
while it is must faster with the manual step changers; the number of lenses is much
higher compared to the manual step changers, and this means a greater absorption
of light; power zoom changer are much more expensive.

The objective lens

The objective lens is the final optical element and its focal length determines the
working distance between the microscope and the surgical field. The range of focal
length varies from 100 mm to 400 mm.

A 200 mm focal length allows approximately 20 cm (8 inches) of working

distance, which is generally adequate for utilisation in endodontics.
Objective lens have several layers of an anti-reflective coating on both surfaces,
which reduces return light loss from normally 2% per lens surface to only 0.5% per
lens surface.

Total Magnification of Microscope

The total magnification (TM) of a microscope depends on the combination of the

four variables:

1) Focal Length of Binocular (FLB);

2) Focal Length of Objective Lens (FLOL);

3) Eye piece Power (EP);

4)Magnification Factor of the changer (MF).

The total magnification can be represented by the following formula:

TM = (FLB/FLOL)xEPxMF

In endodontics we don’t need microscopes that can provide 20x or even more
magnifications since it is almost impossible to work at such high power.

Working at high magnification the illumination could be insufficient and more

importantly it is very difficult to keep the operative field constantly in focus.

A little movement of the patient or sometimes just his/her breathing can be enough
to be completely out of focus.

The Light Source

The light source is one of the most important features of an operating microscope.
Besides optics, the light source is responsible for operating in operative fields that
are small and deep like the root canal.

Two light source systems are commonly available: (1)halogen light and (2)xenon
light.

The halogen light frequently does not provide enough illumination for quality
documentation especially at higher powers.
The xenon light is much more powerful and provides a brighter light at about
5,000° Kelvin approximating day light. In both cases the light intensity is
controlled by a rheostat and cooled by a fan.

After the light reaches the surgical field, it is reflected back through the objective
lens, through the magnification changer lenses and through the binoculars and then
exits to the eyes as two separate beams of light.

The separation of the light beams is what produces the stereoscopic effect that
allows the clinician to see depth of field

Accessories

Some microscopes are built with fixed components and don’t allow the insertion
any accessories. Some others can be personalized with accessories like the
assistant scope and documentation tools, like a 35-mm and a video camera.

The video camera can be connected to a monitor, a videotape recorder, and a video
printer. The monitor can be used not only to motivate the patient, but mainly to the
second surgical assistant, who can follow the surgical procedure and give to the
operator the right instruments at the right moment.

Other important accessories are the eyepiece with the reticle and the assistant
scope.

An eyepiece with a reticle field can be substituted for a conventional eyepiece and
can prove an invaluable aid for alignment during videotaping and 35 mm
photography.

Very useful is the assistant scope which allows the assistant to “assist” the operator
during the entire procedure.

The Law OF Ergonomics

An understanding of efficient workflow using an OM entails knowledge of the

basics of ergonomic motion. Ergonomic motion is divided into 5 classes of motion:

Class I motion: moving only the fingers

Class II motion: moving only the fingers and wrists

Class III motion: movement originating from the elbow

Class IV motion: movement originating from the shoulder

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

Positioning the Microscope

The introduction of the OM in a dental office requires significant forethought,

planning and an understanding of the required ergonomic skills necessary to use
the OM efficiently.

Most problems in using an OM in a clinical setting are related to either positioning

errors or lack of ergonomic skills in the clinician. If proper ergonomic guidelines
are followed, it is possible to work with the OM in complete comfort with little or
no muscle tension.

In chronologic order, the preparation of the OM involves the following maneuvers:

(1)Operator positioning

(2)Rough positioning of the patient

(3) Positioning of the OM and focusing

(4)Adjustment of the interpupillary distance

(5)Fine Focus positioning

(6)Parfocal adjustment

(7)Fine focus adjustment

(8)Assistant scope adjustment.

The Operator Position

The correct operator position for nearly all endodontic procedures is directly
behind the patient, at the 11- or 12-o’clock position.
Positions other than the 11- or 12- o’clock position (eg, 9-o’clock position) may
seem more comfortable when first learning to use an OM, but as greater skills are
acquired, changing to other positions rarely serves any purpose.

Clinicians who constantly change their positions around the scope are extremely
inefficient in their procedures.

The operator should adjust the seating position so that the hips are 90 O to the floor,
the knees are 90 degree to the hips and the forearms are 900 degree to the upper
arms.

The operator’s forearms should lie comfortably on the armrest of the operator’s
chair and feet should be placed flat on the floor.

The back should be in a neutral position, erect and perpendicular to the floor.

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

The patient is moved to accommodate this position. After the patient has been
positioned correctly, the armrests of the doctor’s and assistant’s chairs are adjusted
so that the hands can be comfortably placed at the level of the patient’s mouth.

The trapezius, sternocleidomastoid and erector spinae muscles of the neck and
back are completely at rest in this position.

Once the ideal position is established, the operator places the OM on one of the
lower magnifications to locate the working area in its proper angle of orientation.
The image is focused and stepped up to higher magnifications if desired.

Positioning of Microscope and Focusing

After turning on the light of the microscope, the microscope should be maneuvered
so that the circle of light shines on the working area.

The operator moves the body of the microscope approximately to the working
distance and then, looking through the eyepiece, moves the microscope up and
down until the working area comes into focus.
The inclinable eyepiece is now adjusted so that the operator’s head and spine can
maintain a comfortable position with the working area in focus.

Adjustment of Interpupillray distance

The interpupillary distance should be now adjusted by taking the two halves of the
binocular head of the microscope and moving them apart and then together, until
the two circles are combined and only one illuminated circle is seen.

Those who wear glasses should have the cups in the lowered position and those
who work without glasses should work with the cups in the raised position.

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.

These are the steps to follow for the parfocal adjustment: 1) Position the
microscope above a flat, stationary surface. 2) Using a pen or pencil, make an “X”
on a piece of white paper to serve as a focus target and place it within the
illumination field of the microscope.

3) Set both the eyepiece diopter settings to “0”.

Fine Focus Adjustment

Installing an operating microscope should also be considered a new ergonomic

organisation in the dental office.

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

In fact, the fine focus and even more, changing the focused area from one plane to
another dipper inside the root canal, is made lifting just a few millimetres the entire
back of the dental chair with the operator’s knee .
This way, working inside a root canal, the area in focus can be changed from the
orifice level to the deepest point of the canal itself without using the hands and
without moving the hands from the working area.

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 .

Prerequisites for the use of the microscope in nonsurgical endodontics

Rubber dam placement

Indirect view and patient head position

Mouth mirror placement

Some key instruments

Rubber dam & mirror placement

Specially designed micro instruments

micro mirror, explorer / micro opener, plugger

For what procedures is the microscope really essential?

1. Locating hidden canals that have been obstructed by calcifications and

reduced in size;

2. Removing materials such as obturation materials (silver points and carrier-

based materials), posts or separated instruments;

3. Removing canal obstructions;

4. Assisting in access preparation to avoid unnecessary destruction of

mineralized tissue,

5. Repairing biological and iatrogenic perforations;

 6. Locating cracks and fractures that are neither visible to the naked eye nor
palpable with an endodontic explorer;

7. Facilitating all aspects of endodontic surgery, particularly in root-end

resection and placement of retrofilling material.

THE IMPACT OF OPERATING MICROSCOPE ON THE OUTCOME OF

ENDODONTIC TREATMENT PERFORMED BY POSTGRADUATE
STUDENTS
Monica Monea ESJ 2015

Abstract

Aim of our study. To assess the impact of the operating microscope on the success
rate of primary endodontic treatments performed by postgraduate students, during
their training program in Endodontics. As null hypotheses we considered that the
use of a dental operating microscope in cleaning and shaping the root canals has no
statistically significant influence on the treatment outcome in non-surgical
treatment of apical periodontitis.

Results. The outcome of the endodontic treatment was assessed based on the
recommendations made by the European Society of Endodontics. At 6 months
there was a statistical significant difference of the outcomes between study groups
(p=0.0151) which became more evident after 18 months (p=0.0078).

Conclusions. High-quality endodontic therapy is the basis for long-term clinical

and radiological success in endodontic treatment of necrotic teeth. State of the art
equipment and thorough knowledge are very important in reaching this goal.

The Future

The next stage in microscopic endodontics will involve the use of even finer
microscopic instruments and the development of even more sophisticated
techniques.

Eventually, endodontists will be able to re-vascularize the pulp and grow dentin.
These procedures will most certainly be microscopic in nature and will be quickly
embraced by a specialty already well trained in microscopic procedures.
CONCLUSION

If you can see it better you can treat it better. The operating microscope has
revolutionised the specialty of endodontics. The increased magnification and the
coaxial illumination have enhanced the treatment possibilities in non-surgical and
surgical endodontics. Treatment modalities that were not possible in the past have
become reliable and predictable with help of OM. As today we cannot imagine a
dental office without the X-ray machine, in the same way we can state that the day
is not far away when dentistry will be entirely and diffusely performed under the
operating microscope.

The only limitation that exist for the operating microscope is the Imagination.
Clinical practice with operating microscopes… not a fancy, but a necessity!

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