use of magnification loupes in periodontics

1. Comparative Evaluation Of Manual Scaling And
Root Planing With Or Without Magnification
Loupes Using Scanning Electron Microscope:
A Pilot Study
Presented by- Dr K. ABHILASHA
Moderated by- Dr HARINI
DEPARTMENT OF PERIODONTICS

2. CONTENTS
O INTRODUCTION
O HISTORY OF MAGNIFICATION
O MAGNIFICATION
O METHODS OF MAGNIFICATION
>Magnification loupes
>Dental Operating Microscope
O APPLICATION IN PERIODONTAL THERAPY
O ARTICLE
O CONCLUSION
O REFERENCES

3. INTRODUCTION
O Currently, the leading theme in periodontal
treatment is the use of magnification system in
treating any kind of periodontal diseases.
O Even though various procedures have
demonstrated potential for treating periodontal
diseases, use of operating microscope and
microsurgical instruments increases the ability of
clinician in controlling the manipulation of tissues
during surgery.

4. O A therapeutic revolution, using magnification in
periodontal therapy has changed the clinical
outcome of both non-surgical and surgical
procedures in practice.
O Nowadays magnification technique is applied to
many of the operations in medical practice to
wide variety of treatment procedures in dental
practice.

5. HISTORY OF MAGNIFICATION
O In 1876, Dr Edwin Saemisch, a German
ophthalmologist, introduced simple binocular loupes
to surgery.
O Soon after, dentists began experimenting with
loupes to assist in the performance of precision
dentistry and this continued to be the practice until
the late 1970s.
O In 1962, Dr Geza Jako, an otolaryngologist, used
the SOM( Surgical Operating Microscope) in oral
surgical procedures.

6. O In 1978, Dr Harvey Apotheker and Dr Jako
began the development of a microscope
specifically designed for dentistry.
O In 1980, Dr Apotheker coined the term
‘microdentistry’
O In 1991, this technique was introduced to the
specialty of periodontics.

7. MAGNIFICATION
O Magnification is a phenomenon of visually
amplifying and availing an enlarged,
exaggerated, intensified view of an object or an
image or a model.
O It is determined by the power of the eyepiece,
the focal length of binoculars, the magnification
changer factor, and the focal length of the
objective lens.

8. O Use of high level magnification improves the
ability of dentist to observe the minute details
at and below the gingival margin that aid in
performance of periodontal therapies which
lead to better treatment outcomes.
O Microscope-aided observation helps in
detecting the microscopic amount of calculus
at the gingival margin and the tactile
perception is also improved at even small
point on the tooth surface sub-gingivally.

9. METHODS OF MAGNIFICATION

10. LOUPES
O Dental loupes are the most common system of
optical magnification used in periodontics.
O Loupes are fundamentally dual monocular
telescopes with side-by-side lenses convergent to
focus on the operative field.
O Mainly classified into 2 types:-
(1) single lens magnifiers (clip‐on, flip‐up, jeweler’s
glasses) and
(2) multi-lens telescopic loupes.

11. Simple Loupes
O Simple loupes consist of a pair of single meniscus
lenses which are primitive magnifiers with limited
capabilities.
O Their magnification can increase only by increasing
lens diameter and thickness. Size and weight
constraints make simple loupes impractical for
magnification beyond ×1.5.
O Another disadvantage of simple loupes is that they
are greatly affected by spherical and chromatic
aberration. This distorts the image shape and colour
of objects being viewed.

12. O Single‐lens magnifiers produce
the described diopter magnification
by adjusting the working distance
to a set length.
O With a set working distance, there is no range and no
opportunity for movement, which makes it difficult to
maintain focus and, therefore, may cause neck and back
strain from poor posture.
(Basset 1983; Diakkow1984; Shugars et al. 1987).

13. TELESCOPIC LOUPES
O Telescopic loupes (compound or prism
loupes), allow good ergonomic posture as
well as significant advancements in
optical performance.
(Shanelec 1992).

14. Compound Loupes
O To gain refracting power, magnification, working
distance, and depth of field, compound loupes
use converging multiple lenses with intervening
air spaces.
O Such lenses can be adjusted to clinical needs
without excessive increase in size or weight.
O Compound lenses can be achromatic.
O The lenses consist of two glass pieces bonded
together with clear resin.

15. O The specific density of each piece counteracts
the chromatic aberration of the adjacent piece,
making such lenses a desired feature by
dentists.
Clinical Periodontolgy and Implant Dentistry, Niklaus p lang & J. Lindhe 6th ed

16. Prism Telescopic Loupes
O The most advanced loupe optical
magnification currently available is the
prism telescopic loupe.
O Prism loupes contain Pechan or Schmidt
prisms that lengthen the light path through
a series of mirror reflections within the
loupes; virtually folding the light so that the
barrel of the loupe can be shortened.

17. Clinical Periodontology and Implant Dentistry, Niklaus p lang & J. Lindhe 6th ed

18. O Prism loupes produce better magnification,
wider depths of field, longer working
distances, and larger fields of view than other
types of loupes.
O Innovations in prism telescopic loupes include
co-axial fiberoptic lighting incorporated in the
lens elements to improve illumination.

19. Prism loupes, sealed to avoid
leakage of moisture, front
frame mounted and fully
adjustable (Prism principle)
Sterilizable guards against
contact for a safe rotation of
the loupe during the
treatment procedures.
Clinical Periodontology and Implant Dentistry, Niklaus p lang & J. Lindhe 6th ed

20. Clinical Periodontology and Implant Dentistry, Niklaus p lang & J. Lindhe 6th ed

22. For use in Periodontal Therapy, an adjustable, sealed
prism loupe with high‐quality, coated lenses offering a
magnification between 4× and 4.5×, either headband‐ or
front frame‐mounted, with a suitable working distance
and a large field of view, seems to be the instrument of
choice.

23. DENTAL OPERATING
MICROSCOPE
O The dental operating microscope is a complicated
system of lenses that allows stereoscopic vision
with excellent illumination of the working area.
O Most microscopes can be configured to
magnifications up to × 40 and beyond but
limitations in depth of field and field of view make
it impractical.
O The lower-range magnifications (× 2.5–× 8) are
used for orientation to the surgical field and allow
for a wide field of view.
O Mid-range magnifications (× 10 –× 16) are used
for operating.

24. System Components Of Dental Operating Microscope
Clinical Periodontology and Implant Dentistry, Niklaus p lang & J. Lindhe 6th ed

25. JEDMED V-Series SOM with
assistant
binoculars, a three-chip video
camera, and counter balanced arms.
Global G-6 SOM (Global Surgicalt
Corporation, St Louis, MO, USA) with
an
enhanced metal halide illumination
system.

26. Zeiss OPMI PROergo (Carl Zeiss Surgical Inc., Thornwood, NY, USA) with
magnetic clutches, power zoom, and power focus on the handgrips

27. APPLICATIONS IN
PERIODONTAL THERAPY
O Non-surgical periodontal therapy
O
OA magnified view improved calculus removal ability and lead
to better periodontal disease treatment outcomes in dentistry.
John Mamoun et al. Use of high-magnification loupes or
surgical operating microscope when performing prophylaxes,
scaling or root planing procedures

28. O Management of periodontal flaps –
Using a surgical microscope and microsurgical instruments offers
definite advantages in terms of improved visual acuity, superior
approximation of wounds, rapid wound healing, decreased post-
operative morbidity, and increased acceptance by the patients.
Hegde R et al., Microscope-Enhanced Periodontal
Therapy:A Review and Report of Four Cases

29. O Mucogingival surgery –
.
Francetti L et al., Microsurgical treatment of gingival
recession: a controlled clinical study.
The application of magnification in mucogingival surgery
accomplished better results in terms of success and predictability
compared to conventional techniques and might help achieve
excellent esthetic outcomes
Microsurgical approach substantially improved the
vascularization of the grafts and the percentages of root
coverage compared with applying a conventional macroscopic
approach.
Burkhardt R et al., Coverage of localized gingival recessions:
comparison of micro and macrosurgical techniques

30. O Regenerative therapy
Both therapeutic modalities used for the treatment of intrabony
defects achieve successful outcomes in terms of periodontal
health
The use a microsurgical approach resulted in clinically
important amounts of CAL gains and minimal recessions.
Ribeiro FV et al., Clinical and patient-centered outcomes
after minimally invasive non-surgical or surgical
approaches for the treatment of intrabony defects: a
randomized clinical trial
Cortellini P et al., Microsurgical approach to periodontal
regeneration. Initial evaluation in a case cohort.

31. O Implant therapy
Hend Mahmoud Abou El Nasr. The use of Dental
Operating Microscope for Retrieval of different types of
Fractured Implant Abutment Screws: Case Reports
Demonstrated the use of the surgical operating microscope and
endodontic instruments for the retrieval of 2 different types of
broken abutment screws.

32. ARTICLE

33. AIM OFTHE STUDY
O The aim of the present study is to
compare the amount of remaining
calculus, loss of tooth substance, and
roughness of root surface after scaling
and root planing with or without
magnification loupes using scanning
electron microscope.

34. INTRODUCTION

38. MATERIALSAND METHODS
O The study included 30 extracted teeth
from the patients within the age group of
25–70 years.
O Ethical clearance was taken from
Institutional Ethics and Review Board.
O Patients were explained about the
procedure to be performed and an
informed consent was taken.
O Detailed medical and dental history of all
the patients was taken.

39. INCLUSION CRITERIA
O Patients with good general health
suffering from periodontitis.
O Caries-free teeth, and single-rooted teeth
scheduled for extraction having ≥5 mm of
clinical attachment loss having only
Miller’s Grade I and Grade II mobility

40. EXCLUSION CRITERIA
O Medically compromised patients.
O Patients with endodontically involved
teeth.
O Pregnant/lactating women.
O Patients who had undergone any
periodontal therapy in the past 6 months

41. O A randomized control clinical study was
done.
O The study design comprised three groups,
namely, test Group I, test Group II, and
control Group III.
O All the teeth were equally and randomly
assigned into these three groups, so each
group was comprised 10 teeth.

42.  Manual scaling
and root planing was
performed without any
visual aid (unaided) on
the randomly selected
interproximal tooth
surface in a single
session with a set of
Gracey curettes.
 The scaling was
done until the test
surface appeared
smooth and clear by
visual and tactile
judgment.
 Manual scaling
and root planing
was
accomplished
with Gracey
curettes by
means of
Magnification
loupes of
magnification
(×2.5).
 NO scaling and
root planing was
done
TEST GROUP I
TEST GROUP II CONTROL
GROUP III

43. Description of the procedure
Followed by extraction of particular tooth under local anesthesia with forceps
placed above the circumferential groove.
Scaling and root planing was then performed in the groups
The groove provided a landmark for future microscopic reference for evaluation of
the subgingival root surface for all the groups
A circumferential groove was marked on the selected tooth surface at the level of
free gingival margin with a no. 2 round bur in using a high-speed handpiece with
copious water irrigation

44. Then, tooth was stored in 0.9% normal saline till the further procedure
is carried out
The teeth were rinsed thoroughly under cold tap water and were
brushed lightly with a soft toothbrush for about 1 min to remove any
blood or food debris
During the extraction process, care was taken that root surface
remains unaltered

45. Preparation of tooth specimen for scanning
electron microscope study
All the 30 teeth were sagittally sectioned using
micromotor handpiece and disk bur.
From circumferential groove, a marking point of 4 mm ×
5 mm surface area was marked with a bur.
Both test group and control group tooth specimens were
then placed in 2.5% glutaraldehyde in 0.1 M phosphate
buffer (pH 7.4) for 24 h.
The specimens were then washed and dehydrated
through ascending grades of ethyl alcohol (30%, 50%,
70%, and 100%) followed by air drying for 48 h.
After dehydrating, the teeth specimens were fixed and
sent for scanning electron microscope (SEM)
examination.

46. O The specimens were examined for the amount
of remaining calculus, surface roughness, and
loss of tooth substance using the following
indices:
1. Remaining calculus index (RCI) given by
Meyer and Lie in 1977
2. Loss of tooth substance index (LTSI) given
by Meyer and Lie in 1977
3. Roughness loss of tooth substance index
(RLTSI) given by Lie and Leknes in 1985
4. Presence or absence of smear layer

47. RESULTS
O All of the samples after treating were prepared for
SEM evaluation.
O Standardized photomicrographs of the selected
sites were obtained at magnification of ×50 and
×100 for each tooth specimen.
O Results are depicted as number, percentage, and
mean ± standard deviation along with the
intergroup comparisons
O RCI, LTSI, and RLTSI mean score was calculated
using descriptive analysis and one-way ANOVA
test.
O Multiple intergroup comparisons were done using
Tukey’s honestly significant difference study.
O P = 0.05 or less was set for statistical significance.

54. DISCUSSION

57. CONCLUSION
O From the present study, it concludes that the use of
magnification along with manual scaling appreciably
increases the effectiveness of supra-.and
sub-gingival scaling and root planing as there is
less loss of tooth surface and less roughness is on
the tooth surface after the procedure.
O Furthermore, there is a need for the comprehensive
understanding of the consequences that may occur
on topography of root surface during
instrumentation.
O Closed root planing using magnification loupes
could produce the positive results clinically and
histologically.

58. REFERENCES
O Textbook of Periodontology, Carranza 11th Ed
O Clinical Periodontology and Implant Dentistry, Niklaus p
lang & J. Lindhe 6th ed
O Mohan Kumar. P, Jaswitha. V, Gautami SP, Ramesh KSV,
Applications of microscope in periodontal therapy- Role in
magnification really matters!. Int J Periodontol Implantol
2019;4(1):1-5.
O Manuel García Calderón et al. The application of
microscopicsurgery in dentistry. Med Oral Patol Oral Cir
Bucal 2007;12:E311-6.
O Tibbetts LS, Shanelec D. Principles and practice of
periodontal microsurgery. Int J Microdent. 2009 Aug
1;1(1):2-12.
O MURAT S, DURMAZ S, GURBUZ A. In-Vitro Assessment of
Surface Characteristics and Bacterial Adhesion of
Hypoallergenic Prosthesis Base Materials.

59. O Ribeiro FV, Casarin RC, Palma MA, Júnior FH, Sallum
EA, Casati MZ. Clinical and patient‐centered outcomes
after minimally invasive non‐surgical or surgical
approaches for the treatment of intrabony defects: A
randomized clinical trial. Journal of periodontology.
2011 Sep;82(9):1256-66.
O Mamoun J. Use of high-magnification loupes or
surgical operating microscope when performing
prophylaxes, scaling or root planing procedures. New
York State Dental Journal. 2013 Aug 1;79(5):48.
O Hegde R, Sumanth S, Padhye A. Microscope-
enhanced periodontal therapy: a review and report of
four cases. J Contemp Dent Pract [Internet]. 2009.