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1. THE MICROSCOPE in Practice:
The simple premise for using the microscope is that
Light + Magnification = Excellence.
As some surgeons say, "if you see it, you can protect it." This adage also applies to
endodontics.
Along with an increase in brightness, a corresponding increase in magnification is needed for
endodontic excellence.
Endodontic microscopy and its implication can be categorized into six areas:
1. Diagnosis.
2. Nonsurgical endodontics.
3. Surgical endodontics.
4. Documentation and patient education.
5. Marketing.
6. Revitalization of your career
A number of fundamental requirements must be met before mastery of the use of the microscope
can be attained.
Vision, (indirect vision)
Adequate illumination, and
Patient compliance
Diagnosis:
1. visualize the root canal system in fine detail
2. detect the microfracture ( fracture line in root & crown )
3. distinguish the floor and dentin
4. locate small canal orifice

2. 5. examining dental caries
6. examining crown margins
7. observe sub – gingival defects
8. observe complex anatomical situation
Non surgical endodontics:
Access:
- larger & coronal more flared
- easy to appreciate the color change in the floor of pulp chamber
- opening of the sclerosed canals & location of aberrant canal location
- allows more light , thus enhanced vision
Examine the floor,
6 x – for orientation purposes, used for ultrasonic tips
12 x – to enhance what is seen in lower magnification
26 x – to confirm the opening ( MB2)
BMP:
- The root canal system can be more thoroughly & efficiently cleaned & shaped
- Smooth glassy walls of R.C. walls, criteria for root canal preparation can be easily
visualized.
Obturation:
- To assess the dryness of the canal before obturation.
- Assess uniform distribution of sealers on the wall of the root canal during obturation
- Final examination of root canal preparation
Other uses:
- Removal of pulp stones in the canal orifice facilitated by accurate placement of ultrasonic
tip around it & thus preventing unnecessary removal of radicular dentin.
- For diagnosis & management of perforation

3. - Repair by scaling of the defect with or without a matrix
- Locating calcified canals
- Retrieval of broken down or separated inst:
Helps to see the instrument with in the canal & pin point precisely where to
trough with the ultrasonic instrument.
- management of procedural errors
- also helps in post removal
Thus increased likelihood of a successful outcome, because it helps in locating extra canals
and anatomy of tooth is more readily visualized.
Surgical Endodontics:
1. Osteotomy ( précised & small – 5mm)
Earlier
microsurgery
2. Curettage
3. Apicectomy
4. Inspection of the resected root surface
5. Detect apical perforation
6. Apical preparation

4. 7. Retro filling
8. Examination of surgical site
9. Identify & mange isthmus
10. post – operative healing – use of fine sutures with precision
- quick uneventful healing.
Apical microsurgery:
One of the most important advantages of using the operating microscope is in evaluating the
surgical technique. The pioneers who began using the microscope some two decades ago
observed early on that most traditional surgical instruments were too large to be placed
accurately in small places, or that they were too traumatic when used to manage soft and hard
tissue. This led to the development of a microsurgical armamentarium and the true practice of
apical microsurgery.
Apical microsurgery can be divided into 20 stages or sections. These are flap design, flap
reflection, flap retraction, osteotomy, periapical curettage, biopsy, hemostasis, apical resection,
resected apex evaluation, apical preparation, apical preparation evaluation, drying the apical
preparation, selecting retrofilling materials, mixing retrofilling materials, placing retrofilling
materials, compacting retrofilling materials, carving retrofilling materials, finishing retrofilling
materials, documenting the completed retrofill, and tissue flap closure.
Instruments used:
A variety of micro scalpels sized 1-5 used for precise incision.

5. Comparison of the small ends of two mini-Molts and a
standard Molt 2-4 curette.
Blade and contact surfaces of the Rubinstein Retractors 1-6.
Impact Air 45t and surgical length bur in close proximity to
the mental nerve.
Mini curettes

6. Micro apical placement system.
Comparison between micro and macro pluggers.
Advantages of micro surgery:
1. The removal of bone overlying a root is minimized
2. The periapex can be examined for canal exits, extrusion of filling materials
Previous retro fills & additional roots with methylene blue staining also root fractures can
be visualized
3. After resection, anatomical variation like isthmus, lateral canals with shaped canals or fin
can be visualized & retro prepared.
4. Retro preparation can be executed precisely along the longitudinal axis of canal space &
extended to proper Bucco – Lingual boundary
5. Retro filling is more precisely done & any excess retrofilling materials can be detected
for removal
6. The marginal adaptation of the retrofilling to the canal wall can be checked

7. CLASSIFICATION OF ENDODONTIC MICROSURGICAL PROCEDURES
(Richard Rubenstein and Kim, JOE, 2002, 28)
CLASS A CLASS B CLASS C
CLASS D CLASS E CLASS F
Classification is based on assessment root form osseo integrated implants treatment outcome
• Class A - Absence of periapical lesion, but resolution symptoms after non surgical
approaches have been exhausted.
• Class B - Presence of a small periapical lesion and no periodontal pockets.

8. • Class C - Presence of a large periapical lesions progressing coronally but without
periodontal pocket.
• Class D - Clinical picture similar to Class C with a periodontal pocket.
• Class E - Periapical lesion with an endodontic and periodontal communication but no
root fracture.
• Class F – Tooth with an apical lesion and complete denudement of the buccal plate
Focuses on preoperative presence a absence of pulpal pain and periodontal disease
(Richard Rubenstein and Kim, JOE, 28(8) 2002)
Procedure Traditional Micro surgery
Identification of apex Sometimes difficult Precise
Osteotomy Large (=>10 mm) Small (= < 5 mm)
Root surface inspection Imprecise Precise
Bevel angle Large (45o) Small (< 10o)
Isthmus identification Nearly impossible Customary
Retro preparation Approximate Precise
Root end filling Imprecise Precise.

9. Summary:
Without a doubt, the greatest revolution with microscopes was in root-tip resection.
Today, using the trifecta of magnification - illumination - instrumentation, an excellent,
retrograde, microsurgical root-tip resection, can be carried out under a surgical microscope with
optimal illumination and by using ultrasound-supported retrograde treatment and a special
micro-instrument. The success rate using this method was 96.8 percent with a mean healing time
of 7.2 months for the 94 cases observed over one year.
New horizons were, and will still be opened for surgical microscopes in endodontics. Without a
doubt, the quality of the results will increase.
The goal of microscopes is to achieve the highest possible precision while providing maximum
protection to healthy tissue. The advantage lies in minimal trauma to the treated tissue and an
increased security in achieving the desired result.
For patients, this means less pain, shorter healing times, greater probability of reaching the
desired result (e.g. as regards aesthetics) and better long-term results.
References:
1. Syngcuk Kim. Microscopes in Endodontics. DCNA july 1997, vol 41
2. Richard Rubenstein and Kim, Journal of Endodontics; 2002, 28(8),541-49.
3. Pathways of pulp. Stephen Cohen. 8th
edition
4. Magnification and illumination in apical surgery. Richard Rubinstein. Endodontic Topics
2005, 11, 56–77
5. Kim S, Pecora G, Rubinstein R. Color Atlas of Microsurgery in Endodontics.
Philadelphia, WB Saunders, 2001: 21–22.
6. The dental operating microscope and its slow acceptance. Howard S Selden.Journal of
Endodontics, 2002,vol 28 (3).
7. Use of dental operating microscope in endodontic surgery. Gabirele Pecora et al. Oral
surg, Oral Med, Oral Pathol 1993, 75, 751-8.