Dental operating

microscope
Department of conservative dentistry and
endodontics
Presented by :
Pranshu Tripathi
CONTENTS :
INTRODUCTION
HISTORY OF MICROSCOPE.
DIFFRENCE BETWEEN LOUPES AND
MICROSCOPE
Types of OM.
Physics behind microscope.
Parts of microscope.
Law of ergonomics.
Operating positions.
Uses in endodontics.

INTRODUCTION
A microscope is a high precision optical
instrument that uses a lens or a
combination of lenses to produce highly
magnified images of small specimens or
objects especially when they are too small
to be seen by the naked (unaided) eye. A
light source is used (either by mirrors or
lamps) to make it easier to see the
subject matter.
Merino endodontic microsurgery
Endodontists have frequently boasted that
they can do much of their work
blindfolded simply because there is
nothing to see. The truth is that there is
a great deal to see with the right tools.

Apotheker H. A microscope for use in dentistry. J
Microsurg 1981;3(1):710)
OMs have been used for decades in other
medical disciplines since 1951:
ophthalmology,
neurosurgery,
reconstructive surgery,
otorhinolaryngology, and
vascular surgery.
Its introduction into dentistry in the last
15 years, particularly in endodontics, has
revolutionized how endodontics is
practiced worldwide.
Endodontic therapy was performed using
tactile sensitivity, and the only way to see
inside the root canal system was to take a
radiograph.
The OM has changed both nonsurgical and
surgical endodontics. In nonsurgical
endodontics, every challenge existing in
the straight portion of the root canal
system, even if located in the most apical
part, can be easily seen and competently
managed under the OM.
THE LIMITS OF HUMAN VISION
Webster defines resolution as the ability
of an optical system to make clear and
distinguishable 2 separate entities.
The resolving power of the unaided
human eye is only 0.2 mm. Most people
who view 2 points closer than 0.2 mm will
see only 1 point.
A dollar bill without magnification. Note that the
lines that make George Washingtons
face cannot be seen in detail.
-The Use of the Operating Microscope in Endodontics :Gary B.
Carr, -Dent Clin N Am 54 (2010) 191214
(A) Magnification 3x.
(B) Magnification 5x. (C) Magnification 8x.
(D)Magnification 10x.
(E) Magnification 18x.
WHY ENHANCED VISION IS
NECESSARY IN DENTISTRY
Restorative dentists, periodontists, and
endodontists routinely perform procedures
requiring resolution well beyond the 0.2- mm
limit of human sight.
Crown margins, scaling procedures, incisions,
root canal location, caries removal, furcation
and perforation repair, postplacement or
removal, and bone- and soft-tissue grafting
procedures are only a few of the procedures
that demand tolerances well beyond the 0.2-
mm limit.


History :
1590 Dutch spectacle makers, Zaccharias Janssen and his
son Hans, experimented with a crude concept of a
microscope that enlarged objects 10x to 30x or so
1609 Galileo (an Italian) improved on the principle of
lenses and
added a focusing device.
1674 Anton van Leeuwenhoek, is considered the father of
microscopes. HE worked in goods store where
magnifying lenses were used to count the threads in
cloth.
He taught himself new methods for grinding and
polishing small lenses which magnified up to 270x.
Anton was the first to see and describe bacteria,
yeast, and life in a drop of water.

1981
Apothekar first used in
dentistry.
1995
AAE recommended
mandatory in the
programme of PG
teachings.
1999
Gary Carr , introduced a DOM that had
Galilean optics and that was
ergonomically configured for dentistry,
with several advantages that allowed
for easy use of the scope for nearly all
endodontic and restorative procedures
Vs
DENTAL LOUPES
MICROSCOPE
LOUPES MICROSCOPE
LENS IS FIXED IN
CONVERGENT BEAM
PATH. CAUSES
EYESTRAIN.FATIGUE
,VISION CHANGES.
LENSES ARE
FOCUSED AT INFINITY
.SEND PARALLEL
BEAMS OF LIGHT TO
EACH EYE.ALOWS
VIEWING IN 3D WITH
DEPTH
MAGNIFICATION FIXED ,UPTO 4x Wide range , 3x to
30x.
INTEGRAL LIGHT NO COAXIAL INTEGRAL
LIGHT
PRESENT PROVIDES
SHADOW FREE
SURGICAL FIELD
DOCUMENTATION CANNOT BE DONE

CAN BE DONE
LOUPES MICROSCOPE

FOCUS MADE BY NECK CAN
CAUSE NECK PAIN
ADJUSTMENTS ARE
MADE BY MOVING THE
MICROSCOPE UP AND
DOWN.FINE FOCUSING
BY A MANUAL KNOB.
MAGNIFICATION
CHANGER
Dental operating microscope
Apotheker introduced the dental OM in
1981.The first OM was poorly configured
and ergonomically difficult to use. It was
capable of only 1 magnification (8x), was
positioned on a floor stand and poorly
balanced, had only straight binoculars,
and had a fixed focal length of 250 mm.
This OM used angled illumination instead
of confocal illumination.

The Dentiscopethe first DOMin use.
In 1999, Gary Carr introduced an OM that had
Galilean optics and that was ergonomically
configured for dentistry, with several advantages
that allowed for easy use of the scope for nearly
all endodontic and restorative procedures. This
OM had a magnification changer that allowed for
5 discrete magnifications (magnification
3.530), had a stable mounting on either the
wall or ceiling, had angled binoculars allowing for
sit-down dentistry, and was configured with
adapters for an assistants scope and video or
35-mm cameras
Parts of a microscope
The head of
the
microscope
has three
main parts
1. Body tube
optics and
two lenses
2. An
eyepiece lens
3. An
objective
lens.

Eye piece is the one through which the
operator views and the objective lens is
towards the patient.
The eyepiece lens and the objective lens are
two convex lenses (lenses are thicker at the
center and narrower at the edges)

Convex lens


Focal length of the objective lens is smaller
than that of the eyepiece lens.

PHYSICS BEHIND MICROSCOPE
A lens has two sides and hence two
centers of curvatures, two radii of
curvature and two principal foci.
Centres of curvature: The centers (C
1
,
C
2
) of the spheres of which the surfaces
of the lens form a part are called centres
of curvature of the lens.
Radii of curvature: Radii (R
1
, R
2
) of the
spheres of which the surfaces of the lens
form a part are called radii of curvature.

Principal axis: It is a straight line
passing through the centre of curvature of
that lens. A line drawn through O that is
perpendicular to the surface of the lens
(C
1
to C
2
).
Optical centre: Point on the principal
axis (O), which is usually the centre of the
lens (through which rays of light can pass
without deviation or lateral displacement).

Principal focus: when rays parallel to
principal axis pass through a lens, they
converge to a point F on the principal
axis.
This point is called principal focus of the
lens.
Focal length: Distance from the
principal focus to the optical centre of the
lens is called focal length of the lens.






parallel beam of light travelling parallel to
the lens axis and passing through the lens
will be converged (or focused) to a spot
on the axis, at a certain distance behind
the lens (known as the focal length).

Reciprocal of focal length of the lens is
called its power (P) measured in
dioptres (D).
P = 1 / F
If the focal length is short,
power will be more.

Image formed by microscope
Object AB to be
examined is
placed at a
distance greater
than the focal
length of the
objective lens.
Image A
1
B
1

formed by the
objective is real,
inverted and
bigger than the
object.

Image formed by microscope
It lies between
eyepiece and its
first focal point F
and acts as an
object for the
eyepiece.
The eyepiece in
turn forms a
magnified,
virtual image of
A
1
B
1
as A
2
B
2

(final image) at
about 25cms
away from the
eyepiece.
EYE PIECES
Together with
the focal length
and
magnification
change factors,
they provide the
desired
magnification of
an object. They
are generally
available in
powers of 6.3 X,
10X, 12.5X, 16X
and 20X
BINOCULARS

The function of the binoculars is to hold
the eyepieces. The binocular projects an
intermediate image into the focal plane of
the eyepieces.

Binoculars come in different focal lengths.
That longer the focal length, greater the
magnification and narrower the field of
view.

Types of binoculars
Straight binoculars

This type of binoculars
allows the operator to
look through the
microscope directly at
the surgical field.
Straight tube binoculars
have the advantage of
allowing the use of direct
vision in both the arches.


Inclined binoculars:-

Inclined binoculars are
orientated so that tubes are
offset at 45
0
to head of the
microscope .These could be
used for maxillary surgery ,
But the operator would
have to use indirect vision
through a mirror or position
the patients head sharply
to the side while performing
mandibular surgery .

Inclinable binoculars:-

Inclinable binoculars
allow the binoculars to
be adjusted for added
flexibility and also with
additional operator
comfort (postural
comfort during long
procedure).
The only disadvantage is
that they are difficult to
engineer and can be
quite costly.

OBJECTIVE LENS
The focal length of the objective
lens determines the operating
distance between the lens and
the surgical field.
Objective lenses are available
with focal lengths ranging from
100 to 400 mm.
A 200-mm objective lens is
recommended because there is
adequate room to place the
surgical instruments and
constitutes a comfortable
working distance.

MAGNIFICATION CHANGERS:

Magnification changers
are located in the head
of the microscope and
are available as either
three or five step
manual changers or
power zoom changers.

Illumination:
2 light source systems are commonly
available:

100-watt Xenon halogen bulb which is
used in a fan-cooled system.

Quartz halogen bulb, which is found in the
fibre optic light system.
The fan cooled xenon halogen light
system is recommended because
fiberoptic cables absorb light and have a
tendency to be light deficient.

In addition xenon halogen is brighter and
warmer than quartz halogen and
therefore projects a brighter and warmer
light against bone and soft tissues.

UNOBSTRUCTED
COAXIAL ILLUMINATION (UCI)
It means illumination without shadows.
Dentists are all familiar with the shadows
cast by various parts of our bodies and
even hand instruments while using an
overhead lamp. The reason why this
occurs is because of the different paths of
the operators vision in respect to the path
of illumination.
UNOBSTRUCTED
COAXIAL ILLUMINATION
The light source from a microscope,
however, is totally unobstructed because
the light is emitted directly through the
objective lens itself. This means that the
operators visual path is traveling in the
same exact direction as the path of
illumination.

Mechanism of functioning:



1. Eye piece lens

2.Prisms


3. Magnification
changer

4.Objective lens


The light intensity is controlled by the rheostat and
cooled by a fan.

The light is then reflected through a condensing lens
to a series of prisms

objective lens



Surgical field.

After the light reaches the surgical field, it is reflected
back through the magnification changer lens 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 the depth of field.

A beam splitter can be inserted
in the optical pathway of the
microscope.

The function of the beam
splitter is to supply light that
directs the images to a camera
or an auxiliary observation
tube.

Because the beam splitter
divides each beam path
separately, up to two
accessories can be added.

The beam splitter is essential
for documentation.

BEAM SPLITTER
Assistant observation devices
Auxiliary monocular / binoculars can
be added.

Another accessory used to
facilitate an assistants
viewing is the liquid
crystal display (LCD)
screen.

The LCD screen receives its
video signal form the video
camera.

When viewing the LCD
screen the assistant sees
exactly what the surgeon
sees without having to
take his or her eyes away
form the surgical field
USE OF AN OM IN ENDODONTICS
Although the OM is now recognized as a
powerful adjunct in endodontics, it has
not been adopted universally by all
endodontists.
The skillful use of an OM entails its use for
the entire procedure from start to finish.
Working in such a way depends on
refinement of ergonomic and visual skills
to a high level.
THE LAWS OF ERGONOMICS
Ergonomic motion is divided into 4
classes of motion:
Class I motion: moving only the fingers

(A) Fingers waiting for the file. (B) File placed in between
fingers. (C) Fingers capturing file.

THE LAWS OF ERGONOMICS
Class II motion: moving only the fingers
and wrists
(A) Hand waiting for the instrument. (B) Fingers
and wrist movement receiving the instrument. (C)
Fingers movement receiving the instrument.
THE LAWS OF ERGONOMICS
Class III motion: movement originating
from the elbow

(A) Elbow rested at the stool support. (B)
Supported elbow rotation and instrument
apprehension. (C) Supported elbow rotation to
working position.
THE LAWS OF ERGONOMICS
Class IV motion: movement originating
from the shoulder
(A) Professional at the neutral position. (B)
Shoulders, arms, elbows, and hands moving to
reach the OM. (C) OM moved to the ideal position
without rotational movement of the waist.
note the improved posture allowed with increasing
levels of magnication; the longer working
distance provides a more neutral and balanced
posture
OPERATING POSITIONS :
Maxillary left position
Surgeon positioned to the right and to the
rear of the patient
Occlusal plane perpendicular to the floor.
Patient looking slightly to the left
Microscope angled down the axial plane of
the roots
Dental chair position low.
Surgeon position high.

Maxillary Anterior position
Surgeon positioned to the left and to the
rear of the patient.
Occlusal plane perpendicular to the floor.
Patient looking straight ahead.
Microscope angled down the axial plane of
the roots.
Dental chair position low
Surgeon position high.

Mandibular Left position:
Surgeon positioned to the right and to the
side of the patient
Occlusal plane perpendicular to the floor.
Patient looking straight ahead or slightly to
the left.
Microscope angled up the axial plane of the
roots.
Dental chair position high.
Surgeon position low.

Mandibular Anterior position:
Surgeon positioned to the left and towards
the front of the patient
Occlusal plane parallel to the floor.
Patient looking straight ahead
Microscope angled up the axial plane of the
roots.
Dental chair position high.
Surgeon position low.
Second assistant moves to the right side of
the chair to make room for the surgeon.
Surgeon rests left arm on the operating stool
arm rest.

ADVANTAGES
1. Increased diagnostic power .
2. Reduced trauma.
3. Marketing benefits to the surgeons
professional practice.
4. Broader therapy treatment spectrum
Perforations , mesiopalatal canals of
maxillary molars,removal of broken
instruments.
DISADVANTAGES
LEARNING CURVE : Its duration is around
9 months.,, while of loupes is 1-4 weeks.
Workplace arrangement takes a lot of
place.
Skills acquisition.
Assistants learning curve.
Longer sessions.
Expensive armamentarium.
USES OF MICROSCOPES IN
ENDODONTICS

DIAGNOSIS
MANAGEMENT OF PROCEDURAL ERRORS
PERFORATIONS
SEPERATED INSTRUMENTS
SURGICAL ENDODONTICS
DOCUMENTATION

DIAGNOSIS-


In case of crack or micro fracture or
vertically fractured tooth, periodontal probing,
X-ray examination and use of tooth sloth can
help in diagnosis but there are cases that cannot
always be seen by naked eyes or by
magnification loupes and also to identify the
extent of the crack or how far a fracture line
extends along a canal wall.

In these cases, microscope is an excellent
instrument and of tremendous help to visualize
the extension of these lines and also where they
stop.


Micro fracture
same tooth after extraction
A persistently sensitive or painful tooth
after or during a root canal therapy may
be due to an untreated missed canal
(especially MB
2
of maxillary molar).


Clinical diagnosis of prosthetic margins. (A) Low
magnification of crown on tooth (B) Intermediary
magnification of crown margin. (C) High
magnification of crown margin.
Clinical diagnosis of caries. (A) Intermediary
magnification of occlusal surface on tooth . (B)
Higher magnification showing gross microleakage
and an open margin on cervical area
Locating canals is perhaps the most
obvious use of the OM in endodontics.
Calcified canals , missed canals ,
dilacerated canals, and canals blocked by
restorative materials are all addressed
easily by the skillful use of an OM.
(A) Preoperative radiograph of teeth Nos. 15, 16 and 17 showing
inadequate previous root canal treatment . (B) Intermediary
magnification of 06 file at MB2. (C) Higher magnification
showing MB and MB2, cleaned and shaped. (D) Immediately
postoperation. (E, F) Long-term recall.
CONCLUSION
Endodontics has evolved over the period
of time. Gadgets like loupes & microscope
helped us to achieve better results as
compared to the past few years.
Magnification is essentiality in modern
endodontics .
REFRENCES

Endodontic microsurgery : enrique M. merino

The Use of the Operating Microscope in Endodontics
:Gary B. Carr, -Dent Clin N Am 54 (2010) 191214

Dental Operating Microscope in Endodontics-A Review
-IOSR Journal of Dental and Medical Sciences (IOSR-
JDMS)

Apotheker H. A microscope for use in dentistry. J
Microsurg 1981;3(1):710)

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