Detailed description of the operating microscope in endodontics, its use and availability in the market. Appropriate review of literature added with case reports.

2. By Dr. Urvashi Tanwar
PG Ist Year

3. Resolution: The
ability of an optical
system to make clear
and distinguishable 2
separate entities.
Limits of the Human Vision

4. A common OM can raise the resolving limit from
0.2 mm to 0.006 mm (6 μm).
At the highest power a restoration margin
opening of only 0.006mm is essentially sealed.

5. WHY ENHANCED VISION IS
NECESSARY IN DENTISTRY?
Few procedures that
demand tolerances well
beyond the 0.2-mm limit.
 Crown margins
 Scaling procedures
 Incisions
 Root canal location
 Caries removal
 Furcation & perforation
repair
 Postplacement or
removal
 Bone- and soft-tissue
grafting

6. Clinical
Visualization
Stereopsis
Depth
of
field
Magnification
range
Resolving
power
Working
distanceCost
Head and
neck
fatigue
Eyestrain
Ergonomics

7. Howard Selden: first endodontist to publish an article on
the use of the OM in endodontics.
In 1999, Gary Carr: introduced an OM that had Galilean
optics and that was ergonomically configured for
dentistry.
1. had a magnification changer that allowed for 5 discrete
magnifications (magnification 􏰁3.5–􏰁30)
2. had a stable mounting on either the wall or ceiling
3. had angled binoculars allowing for sit-down dentistry
4. and was configured with adapters for an assistant’s
scope and video or 35-mm cameras
5. It used a confocal illumination module
How did it all start?
following advantages

8.  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.

13. Working of Microscope
Galilean optics.
Parallel optics
enables the
observer to focus at
infinity, relieving
eyestrain.
Understanding and caring for an operating microscope
C o m m u n i t y E y e H e a l t h J o u r n a l 2 0 1 4 .

14. Illumination
AccessoriesDocumentation
Magnification
The main parts can be divided into 4 groups

15. MAGNIFICATION
Eye pieces which are
available in powers of 6.3X,
10X, 12.5X, 16X, 20X.
It consists of:
1) A viewing side with rubber
cup
2) Adjustable diopter setting
(-5 to +5).
3) Binoculars which is used
to hold eye piece which may
be straight, inclined or
inclinable and again of
shorter or longer focal
length.

16. 1. Straight: The tubes are
parallel to the head of the
microscope.
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.

17. 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. Eyepiece Power (EP)
4. Magnification Factor Of The Changer (MF)
The total magnification can be represented by the following
formula:
TM = (FLB/FLOL) x EP x MF
Total Magnification of Microscope

18. Magnification changer
• A 3-, 5-, 6- step manual
changer or power zoom-
changer.
• Located within the head of
the microscope.
• Permits smooth transition
between magnifications.
Objective lenses whose focal
length (which ranges from 100
mm to 400 mm) determines the
operating distance between
lens and surgical field.

19. Focal length Working distance
175mm 7 inches
200mm 8 inches
400mm 16 inches

20. Optimum Configurations For Endodontic Microsurgery
 12.5x
 200 or 250 mm objective lens
 180° inclinable binoculars
 Five step manual magnification changer
 Creates a working range of 8 inches from patient

21. Magnification State of Surgery
Low
2.5 X to 8 X
Orientation of operating field,
Alignment of surgical tips
Mid Range:
10 X to 16 X
Surgical Procedures: Root-end resections
and root- end preparations
High
16 X to 30 X
To observe and evaluate fine details –
Micro fractures, isthmus etc.
Rahul Kumar et al.: Surgical Operating Microscopes in Endodontics: Enlarged Vision and Possibility

22. ILLUMINATION
Light sources: Xenon bulb/ quartz
halogen bulb
Intensity is controlled by a
rheostat & cooled by a fan.
Path of light: separation of the
light beam: stereoscopic effect
Coaxial illumination-NO shadows

23. Xenon bulb Quartz halogen
Colour temp- 56000 K 32000 K
Brighter ,True colour picture Yellow picture

24. Beam Splitter
 Supplies light to direct the
image to a camera or an
auxillary observation tube.
 To supply light to accessories
 Essential for documentation.

25.  Pistol or bicycle grips
 Liquid crystal display (LCD) and high resolution
monitors which receives video signals from cameras.
 Integrated video camera
 Eye piece with rectile field: used for aligning during
video taping and 35 mm photography.
 Auxiliary monocular or articulating binocular for
dental assistant.
ACCESSORIES

28. Documentation
Documentation is useful for
1. Patient and Student Education
2. Medicolegal Documentation
3. Reports to Referring Dentist
4. Insurance Companies
Photo adapters attach 35mm camera & video
camera to beam splitter.
Dental assistant can act as director while
recording.

29. THE LAWS OF ERGONOMICS
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.
Carr GB. Microscopes in endodontics. J Calif Dent Assoc 1992;20(11):55–61.

31. 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 positioning of the patient
6. Parfocal adjustment
7. Fine focus adjustment
8. Assistant scope adjustment
Carr GB. Microscopes in endodontics. J Calif Dent Assoc 1992;20(11):55–61.

32. OPERATOR POSITIONING
 The correct operator position :
directly behind the patient, at
the 11- or 12-o’clock position.
 The operator should adjust the
seating position so that the hips
are 90􏰂° to the floor, the knees
are 90°􏰂 to the hips, and the
forearms are 90°􏰂 to the upper
arms.
 The eyepiece is inclined so that
the head and neck are held at an
angle that can be comfortably
sustained.
Carr GB. Microscopes in endodontics. J Calif Dent Assoc 1992;20(11):55–61.

33.  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.
TAKE BACK YOUR BACK!!
Carr GB. Microscopes in endodontics. J Calif Dent Assoc 1992;20(11):55–61.

34. PARFOCALISATION
A. Position the microscope above a flat, stationary surface.
B. Using a pen or pencil, make a dot on a piece of white paper to
serve as a focus target and place it within the illumination field of
the microscope.
C. Set both of the eyepiece diopter settings to “0”.
D. Set the microscope on its highest magnification setting and
focus using the fine-focus control until a sharp image is obtained.
E. Be careful not to physically shift the microscope position,
change the magnification setting to its lowest position. Focus left
and right eyepieces, one at a time, by turning the diopter ring until
the image is clear and sharp.

36. OPERATORY DESIGN PRINCIPLES
The OM ~ standard dental operatories ~ designed in
the conventional way, with outdated ergonomic~-
operatory side cabinets, dual sinks, over-the-patient
delivery systems ~ extremely inefficient because of
the ergonomic constraints.
Clinicians – struggle - use the
OM for all procedures but do
not have appropriate
ergonomic designs to their
operatories - significant
frustrations
Carr GB. Microscopes in endodontics. J Calif Dent Assoc 1992;20(11):55–61.

37. The organizing design principle using the OM in the
dental operatory should revolve around an
ergonomic principle called “Circle Of Influence”.
The principle states that all
instruments and equipment
needed for a procedure are
within reach of either the
clinician or the assistant,
requiring no more than a
class IV motion, and that
most endodontic
procedures are performed
with class I or class II
motions only.

38. (A) Team work development: doctor and assistant working
erect and muscularly relaxed. (B) Adjustable cart allowing
access to all instruments, using only a class III motion.
Carr GB. Microscopes in endodontics. J Calif Dent Assoc 1992;20(11):55–61.

40. THE OM AND CLINICAL PROCEDURES
 In microendodontics, the
use of specialized micro-
mirrors vastly improves
efficiency and capability.
 The use of smaller mirrors
results in the mirror being
placed further away from
its usual location, and even
minor hand movements
can make such use
frustrating for the novice.

41. Clinical Applications
In Conventional Endodontics
1. Cracks And Micro-fracture
2. Visualizing Root Canal System In
Finer Detail
3. Locating The Canal Orifices
4. Managing Calcified Canals
5. Intracanal Medicament
6. Obturation Of Root Canal
7. Retrieval Of Broken Instruments
8. Microscopic Management Of
Endodontic Procedural Errors

42. In Non Surgical
Treatment
• Removal of post
• Perforation errors
• Final examination of the
canal preparation
In Surgical Treatment
• Isthmus identification and
preparation
• Retro preparation
In Conservative Dentistry
• Caries detection
• Coronal preparation
• Impression quality
• Evaluating the restoration under surface
• Restoration delivery and polish
• Bonded restorations

46. Vertical Root Fracture
At 10x magnification

47. • Retro Mirrors, Coaxial Ultrasonic Preparation
• Moderated Bevel Of The Root Resection
• Retrograde Root Canal Filling

49. (A) Intermediary
magnification of
endodontic access
on tooth No. 15
(note there is no
sign of canals). (B)
Dentin smear
resulted from
ultrasonic
instrumentation of
pulp floor. (C)
Groove produced
after ultrasonic
usage. (D)
Mesiobuccal (MB)
and second MB
(MB2) canals
located after
ultrasonic usage.
(E) Files inserted
on MB and MB2
canals.

52. The purpose of this study was
to evaluate the influence of
using the dental operating
microscope (DOM) for
detection of the mesio-lingual
(ML) canal orifice in extracted
maxillary molars compared
with unaided vision (no
loupes or head- lamps).

54. 51%
63%
32 of 39=82%
R
E
S
U
L
T
S

55. 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.

56. Material and methods: A series of 184 consecutively
cases of necrotic teeth with chronic periapical
lesions that met the inclusion criteria, in which the
therapy was performed by postgraduate students
or specialists in Endodontics. All patients were
treated under the same conditions, regarding
materials, techniques and instrumentation.
The outcome of the endodontic treatment was
assessed based on the recommendations made by
the European Society of Endodontics.

57. The clinical and radiographic evaluation after 6 months
was done on a total number of 96 teeth in the control
group and 78 teeth in the study group, due to
complications as vertical root fractures, or the fact that
some patients did not respond to control appointments.
The analysis made between the results of the two
groups has shown a statistical significant difference of
the outcomes in the 6 months control period with
p=0.0151.

58. After 18 months the evaluation was made on 87 and 73
respectively, due to endo-periodontal lesions, coronal
sub-gingival fractures or refusal to come to scheduled
control visit (Table 3). At this control period the
statistical analysis is more significant with p=0.0078.

59. Labomed Prima Mu Microscope
Rs. 2,61,400
Microscopes in the Market

60. Carl Zeiss Microscopes
3 available OP MIs:
1. OPMI PROergo
2. EXTARO 300
3. OPMI pico
Approx. 10,00,000

61. Dental Microscope led
light 3 Step
Magnification With HD
Camera Attachment
US $2400 / ₹1,67,892
3 Step Magnifications
(5x, 10x & 20x)
45 degree Inclined
Binocular Tubes
12.5x Wide Field Eye
Pieces
F=200mm Objective
Lens

62. 1. Keep the microscope in a dry, cool and well-
ventilated place to prevent fungus growth on the
optics (lenses).
2. Every week, clean the optics.
3. To protect it from dust when not in use, drape a
cover over the microscope.
4. Wipe down the external surfaces with a damp
cloth soaked in hot, soapy water.
Caring For The Operating Microscope

63. 5. Cover the foot pedal with a clear plastic bag to prevent
surgical and cleaning fluids from entering and damaging
the electronics.
6. Before using, test the controls of the foot pedal (the x,y
movement, zoom, focus, light on and off).
7. Avoid kinking or bending the fibre optic cables.
8. When replacing the bulbs, avoid touching them with your
fingers. The oil left as fingerprints on the bulb can shorten
its life.
9. Do not move the microscope while the bulb is still hot
because strong vibrations may damage the filament.
10. Every six months, clean and oil the wheels and the brakes.
Remove any surplus oil when done.

64. Disadvantages
1. Need for specific training: as a DOM has a
restricted working field, 11mm -55mm.
2. An operator using a DOM can see only the tip of
the instruments, and they are used in delicate
movements of small amplitude.
3. Relatively high initial cost of the equipment and
instruments
4. The need for retraining of the auxiliary staffs.
5. Adjustment period for the new treatment
paradigms and operator postures.

65. 5. May increase treatment costs and reduce initial
productivity, besides the need for rescheduling.
6. Its size which is difficult to fit in a small
operatories.
7. It takes the operator some time to get used to
the equipment.
8. Adaptation to indirect vision.
9. Narrower field.
10. Movement of the patient.

67. Conclusion
 The dental operating microscope has become an integral
part of endodontic practice.
 For both nonsurgical and surgical endodontic therapy it is
indispensable for excellency.
 Besides the obvious benefits for clinical practice, evidence
has become available that demonstrates better outcomes
compared to treatment without vision enhancement or
magnifying eyewear.
 Treatment rendered using the dental operating microscope
results in superior care for patients, and modern
endodontic therapy is more effective because of its use.

68. 1. Apotheker H. A microscope for use in dentistry. J Microsurg 1981;3(1):7–10.
2. Friedman S, Lustmann J, Shahardany V. Treatment results of apical surgery in premolar and molar teeth.
J Endod 1991;17(1):30–3.
3. Weller N, Niemczyk S, Kim S. The incidence and position of the canal isthmus: part 1. The mesiobuccal
root of the maxillary first molar. J Endod 1995;21(7): 380–3.
4. Carr GB. Magnification and illumination in endodontics. In: Hardin FJ, editor.
5. Clark’s clinical dentistry, vol. 4. St Louis, MO: Mosby; 1998. p. 1–14.
6. Selden HS. The role of a dental operating microscope in improved nonsurgical treatment of ‘‘calcified’’
canals. Oral Surg Oral Med Oral Pathol 1989;68(1):93–8.
7. Carr GB. Common errors in periradicular surgery. Endod Rep 1993;8(1):12–8.
8. Carr GB. Microscopes in endodontics. J Calif Dent Assoc 1992;20(11):55–61.
9. Selden HS. The dental-operating microscope and its slow acceptance. J Endod 2002;28(3):206–7.
10. Michaelides PL. Use of the operating microscope in dentistry. J Calif Dent Assoc 1996;24(6):45–50.
11. Sheets CG, Paquette JM. The magic of magnification. Dent Today 1998;17(12): 60–3, 65–7.
12. Worschech CC, Murgel CAF. Micro-odontologia: visa ̃o e precisa ̃o em tempo real.
13. Londrina: Dental Press International; 2008. p. 31–81.
14. Carr GB. Endodontics at the crossroads. J Calif Dent Assoc 1996;24(12):20–6.
15. Carr GB. Ultrasonic root end preparation. Dent Clin North Am 1997;41(3):541–54.
16. Castellucci A. Magnification in endodontics: the use of the operating microscope.
17. Pract Proced Aesthet Dent 2003;15(5):377–84.
18. Murgel CAF, Gondim E Jr, Souza Filho FJ. Microsco􏰂pio Ciru􏰂rgico: a busca da exceleˆncia na Cl􏰂ınica
Odontolo􏰂gica [Surgical Microscope: the search for excel- lence on clinical dentistry]. Rev da Assoc Paul
Cir Dent 1997;51:31–5 [in Portuguese].
REFERENCES