Review

Article
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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.

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.
2Professor,

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 binocularoperating 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 wasnt 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

there was an marked increase in DOM use by

endodontists.
DENTAL MICROSCOPE (Fig-2):

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,

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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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
observers 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.
Fig 3: Showing MORA Interface
patient is reclined in to a supine position.
Unfortunately the access opening to the mouth has
a 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 patientscommunication
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

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 conditions
due 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
inaccessible(subgingival) root sections

visually

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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 level
of 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 orthograde
and 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 simultaneously
treated 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 of
patient 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 in
many 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 the
margins of the restoration to be placed on solid

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tooth structure. Several clinicians suggested

that DOM can be used to improve tooth
preparation and final restoration in fixed
prosthodontics.17-23

Advantage of using higher magnification is the

reduction of peripheral visual noise.
Therefore,
properly
trained
auxiliary
personnel are essential.

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.

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 dental operating microscope can be used

for the entire preparation of a tooth, but some
dentists 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 veneer
margin.

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.

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 the
fabrication 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.

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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 worlds 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 patients
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 in
endodontics 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 seen
with 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 they
are 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 make
the 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.

9. Carr GB.Magnification and Illumination in

Endodontics.in: hardin FJ, editor.Clarks clinical
dentistry,vol 4 st.louis,MO:Mosby:1998.p 1-14.

CONFLICT OF INTEREST

10. Sheets CG, Paquette JM. The magic of

magnification.J. Dent today 1998:17(12):60-63.

No potential conflict of interest relevant to this

article was reported.
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