The Dental Operating Microscope: Basic Guidelines for Successful ...
The Dental Operating Microscope: Basic Guidelines for Successful ...
The dental operating microscope (DOM) is perhaps one of the most valuable technologies available in dentistry today. In addition to having multiple levels of magnification available at a turn of a dial and superb, shadow-free illumination resulting in increased visualization, increased diagnostic capability, and an increased level of precision when executing various dental procedures, the DOM can also be an invaluable tool when it comes to patient education through its digital documentation capabilities (Figs. 1-4). Perhaps most importantly, the DOM allows the clinician to operate in a comfortable, ergonomically-friendly upright postural position, which reduces strain and fatigue to the eyes and musculoskeletal system.
Having conducted hands-on, live patient-training sessions both privately and at Tufts University's GPR program (possibly the first GPR program in the U.S. providing a DOM for every resident rotating through the dental clinic), I thought this would be a great opportunity to share some practical and hopefully useful information I have learned through training other dentists on how to integrate dental microscopy into a practice.
While the learning curve in operating a DOM can seem challenging and somewhat frustrating at times, formal training can significantly reduce the time needed in successfully integrating them. But for those who desire to start out on their own, following and practicing a few basic guidelines will be helpful in the initial phases of the integration process.
While the integration time varies, once the DOM is fully integrated, the operator will likely wonder how they ever worked without one. The ability to diagnose problems will dramatically improve. Areas of the mouth or a specific tooth that were previously difficult to visualize (even in patients with restricted access) will become very easy to see and operate in. A patient's trust level and acceptance of treatment recommendations will likely skyrocket (especially if the DOM is equipped with digital documentation capabilities). And finally, the clinician will be operating in a very comfortable upright postural position while executing procedures at a level of precision one never imagined possible (Figs. 5-10). Just realize that this does not happen overnight, and that the essential ingredients to integrating any new procedure or technology are patience, practice and persistence.
DOM integration basics
Location
If the DOM is not positioned or mounted in a location of the operatory that does not allow for easy access, it will simply not be used. It is therefore critical that the DOM is located in an area of the operatory that will allow for easy access so that it may be easily maneuvered into the operating position. DOMs can either be mounted on a movable floor stand or permanently mounted to the floor, wall or ceiling. For right-handed operators, it is best to mount the DOM on the ceiling, located to the left side of the dental chair if possible.
Par-focaling
Par-focaling a DOM simply means, tuning the DOM to the individual user's eyesight. It is a simple procedure that is covered in the owner manual that only takes a few minutes to do and should be done periodically. The importance of par-focaling the DOM is basically two-fold. It helps to ensure that the microscope stays in relative focus when changing levels of magnification without having to move the DOM up or down to bring the operating field back into focus. And it helps to ensure that photographs taken with an integrated digital still camera are in focus. When a DOM is not par-focaled correctly to the operator's eyes, an image that is in focus to the operator may be out of focus to the camera.
Position
Unfortunately, learning how to effectively position the DOM so that the operating field or target tooth can be visualized is something that cannot be effectively taught in a short span of time. Some will find formal training helpful, and some will learn it through trial and error.
When I teach beginners how to operate, there are a few basic (yet critical) aspects of the process that if the user is not aware of will make it very difficult to integrate a DOM successfully, no matter how much patience, practice and persistence are applied.
The most important things to be mindful of when learning how to position the DOM is that in addition to the DOM itself, the position of the patient chair, patient's head and mirror also need to be considered when trying to visualize the operating field or a target tooth (Figs. 11-20).
Five helpful implementation tips
1. Keep the patient chair-height low. Actually, in most cases, there is no need to raise it at all! When working with loupes or unassisted vision, most clinicians tend to recline the chair-back and also raise the chair height in order to bring the operating field closer to the operator. When working with a DOM, it is preferable to recline the chair-back and not raise the chair height much, if at all. The reason being that if the chair height is raised too high, the DOM will also need to be positioned higher in order to focus on the operating field. While most DOMs come equipped with inclinable binoculars, I have seen some operators raise the patient chair so high that they are not able to comfortably reach the eyepieces even when the binoculars are fully inclined to its most downward position.
2. Fully recline the patient chair and once reclined, have the patient scoot up on the chair. When the chair-back is first reclined, the patient's body tends to slouch downward on the chair, positioning their head further away from the operator. So once the chair is reclined, the patient should always be asked to scoot their bodies up on the chair. This will bring the patient's head closer to the operator, which in turn allows for the DOM to be positioned closer to the operator so that the operator does not need to tilt their head excessively forward to reach the oculars. Most DOM manufacturers have an optional attachment called an extender (which I highly recommend), that extends the eyepieces even closer to the operator, further reducing the amount of forward neck-tilt needed to reach the oculars.
3. Use the DOM on every patient. With the exception of removable prothodontics, the DOM should be positioned in place and used on virtually every patient seen. During the initial integration, the most time-consuming aspect is just getting the DOM in the ready position efficiently. Practice significantly decreases the amount of time needed in getting the DOM in the operating position.
4. Move the patient's head around often. When I watch beginners trying to visualize a target tooth, many will tend to move, rotate or tilt the DOM around in positions that are not ergonomically friendly to the operator. Remember that in addition to the DOM, the patient's head can move too! Effectively visualizing all areas of the mouth often requires a combination of tilting and rotating the DOM, the patient's head and mirror. When trying to visualize maxillary posterior teeth for instance, having the patient tilt their heads back (chin-up) will help increase visibility. A slight rotation of both the patient's head and the DOM may also be required at times. For instance, when trying to visualize a posterior tooth in the left arch, a slight rotation of the DOM and patient's head to the left will be helpful, assuming the operator is right-handed and working from an 11-12 o'clock position, which in my experience is the best position to work from when using a DOM.
Once the patient and DOM are positioned, use the DOM through as much of a procedure as possible. If difficulties arise intra-operatively and feelings of frustration arise, it is perfectly fine to push the DOM aside and continue with loupes if needed. Once a preparation is completed, take out the DOM again to inspect the preparation. Chances are the operator will notice areas of a preparation requiring some refinement — refinements that should be done with the microscope.
5. The boDOM line. If the operator patiently and persistently practices getting the patient chair, DOM, patient's head and mirror properly positioned, then soon enough, the amount of time required in accomplishing this task will decrease and become second nature. If the operator makes an effort in starting every procedure with the DOM, in time, more procedures will be executed with the DOM, until the need of pushing it away no longer arises. Once the operator sees first hand what they have been missing, namely, superb visualization of the operating field while working in a comfortable postural position, he or she will wish they had started using the microscope sooner. And don't forget the ease of capturing and sharing images with the patient. Add up all the capabilities and possibilities in using it in your practice, and see how fast you reach a state of DOM nirvana.
The use of the operating microscope in general dental practice part 2
This paper follows on from the first in this two part series which explained how the interested clinician may embark on his/her journey using an operating microscope in dental practice. The use of such an instrument has been shown to enhance quality, longevity and outcome of clinical work in many branches of surgery as well as dentistry. Both the dentist and dental nurse using a microscope have improved posture and work in a more ergonomic manner. At the chairside, close support (four-handed) dentistry is facilitated as the dental nurse is more involved in the procedure owing to improved vision and, as a result, enhanced job satisfaction and interest.
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Dental operating microscopes have many different features which may be useful, depending on the scope of the clinician's practice. Photography and video are often used as an adjunct to the use of the microscope and this has many advantages. Clinical records are enhanced, with clinical images being available to monitor hard or soft tissue lesions or as medico-legal evidence. These images are also invaluable in patient education.
The use of microscopy demands that bespoke microsurgical instruments need to be used in conjunction with the microscope. Both this equipment and the microscope itself must be carefully cared for and maintained as the hardware is expensive.
This paper focuses on the specific uses of an operating microscope in dental practice and how it may be used to facilitate the work of the clinician with the aim of improving the quality of the treatment which the patient receives.
Examination and diagnosis
The operating microscope can greatly facilitate examination and diagnosis of the dental patient. This author has used an operating microscope to examine the oral cavity and its structures for over nine years. Pathologies such as dental caries1 (Figure 1), the presence of enamel infractions, and cracks in tooth structure and soft tissue lesions may all be more easily identified and examined by microscopy. That said, it is inadvisable only to use microscopy when doing an oral examination. This author prefers to examine all of the oral structures initially with the naked eye before proceeding to use the microscope. There are two reasons for this. First, this approach gives the dentist a ‘feel’ for the whole picture and therefore he/she is distracted by minutiae and secondly, suspicious areas or lesions may be noted mentally and then examined more thoroughly at a higher magnification. In practice, this has been well received by patients who are reassured that their mouth is being examined not once but twice during the examination appointment.
Examination and diagnosis of dental caries and cracked tooth tissue
Diagnosis of dental caries demands that the teeth are clean and dry to allow proper examination of their surfaces for lesions.2 The appearance of carious lesions changes when the teeth are dry so making them easier to visualize and examine. Small lesions may be treated conservatively (see later) and a better prognosis results with early intervention. Lesions noted without optical aids, which are suspected to be carious, may appear at higher magnification to be dark and shiny. In the absence of plaque, such lesions may be deemed to be inactive3 and should be documented in the clinical records. Such lesions should be kept under observation and reviewed at subsequent examinations. Without magnification the clinician may have been more inclined to intervene operatively.
For a dental examination, this author would recommend that the teeth are examined without microscopy in the first instance (as mentioned earlier) using a dental mirror, air from the 3 in 1 syringe and perhaps a dental probe (explorer) if necessary to remove debris only. This examination is then repeated under magnification using the air from the 3 in 1 syringe to dry the teeth being examined, as well as using it to retract the cheeks and lips to improve access and therefore vision. The operator works from quadrant to quadrant adjusting the position of the microscope as he/she proceeds so that each tooth is in sharp focus. Any suspicious carious lesions or possible defective margins of, or cracks and fractures in, dental restorations identified with the naked eye may then be further examined in more detail using magnification.
Microscopy has facilitated the identification and diagnosis of cracks in the dental hard tissues.4 This is best achieved by using a higher magnification such as a minimum of x13. Teeth may have fracture lines running at the base of the cavity floor (Figure 2) or under a cusp. Once a crack has been identified, a definitive diagnosis can be made and the treatment options may then be shared with the patient.4 Fractures are a leading cause of tooth loss today. The early diagnosis and treatment of cracked teeth and incomplete coronal fracture may prevent early loss of teeth. This treatment may involve the use of cuspal coverage using a bonding technique with either direct resin composite or dental amalgam or the provision of a cast restoration to brace and protect the remaining weakened tooth tissue from occlusal forces, so preventing crack propagation. The successful treatment of symptomatic incompletely fractured teeth is notoriously difficult and, with an uncertain outcome, as the aetiology of the condition is impossible to address, the aim of treatment is to mitigate the situation.
Operative dentistry
Good vision is an advantage when administrating a local anaesthetic, a necessity as a precursor to many dental operative procedures. As the operator is more able to see the bevel on the needle and the mucosa, he/she may introduce it more precisely into the tissues, so reducing intra-injection discomfort. The advantages of this are obvious, particularly with nervous and trypanophobic (needle phobic) patients.
The operating microscope has revolutionized how conservative dentistry may be practised. The modern aim of conserving as much good tooth tissue as possible can only be done with the use of magnification.5 In recent years, there has been a move towards minimally invasive dentistry where a cavity may be prepared as conservatively as possible so preserving precious healthy tooth tissue (Figure 3). The cavity would then be restored with an appropriate dental restorative material such as a flowable resin composite.6 Microscopic techniques will facilitate this as both preparation and restoration are best done under magnification.3,7 The more tooth tissue that can be preserved the better, both in terms of operative dentistry and during endodontic preparation.8
In fixed prosthodontics, magnification provides the opportunity of more precise tooth preparation for an indirect restoration.9 As the operator can see more clearly, better preparation geometry should result. This is especially so in areas which are more difficult to visualize clearly, such as approximal surfaces. The operating microscope can more easily provide an unimpeded view of these areas. Furthermore, the margins of indirect restorations may be placed more precisely in their desired position if the operator can see the area more clearly. This is best illustrated where a core material is present and the dentist wishes to site the crown preparation margin in its ideal position, usually apical to the margin of core material/tooth interface. At the fit appointment and subsequently at follow-up examinations, the margins of the cast may be more accurately assessed using microscopy. High magnification will also facilitate the removal of excess luting cement, resulting in better gingival health as no residual luting cement remains to provoke an inflammatory reaction in the gingival and periodontal tissues.
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The microscope also has a role in the dental laboratory.10 The advantages of magnification may be extrapolated to the (more accurate) construction of dental appliances, especially in fixed prosthodontics. One example is the trimming of dies (Figure 4) which will be done with more precision under magnification, resulting in a better fitting indirect restoration.
Conventional endodontics
Endodontists have embraced and benefited most from the increased magnification and illumination which an operating microscope provides.11,12,13,14,15 Most endodontists, or those dentists with a special interest in endodontics, use some method of magnification.16,17 In endodontics, the improved vision and illumination can facilitate:
The examination of the tooth and the diagnosis of cracks have already been discussed and are significant in endodontics as these may be the cause of bacterial microleakage, leading to irreversible pulpitis, or may compromise the coronal seal, leading to failure of the endodontic treatment.28,29 Generally speaking, a higher magnification is used when performing endodontics than operative dentistry as the structures being managed are smaller.
Surgical endodontics and periodontics
The operating microscope is already used by many clinicians during periradicular30,31 and periodontal surgery.32 Setzer and co-workers have shown, in a meta-analysis of the literature, that outcomes of endodontic surgery are improved with the use of an operating microscope.33,34 The equipment allows microsurgical techniques to be employed. These techniques allow the soft tissues to be handled and replaced more accurately, which is associated with reduced surgical morbidity,16 as the tissues are more readily able to heal. Inaccurate apposition of the edges of the surgical flap, such as overlapping or invagination, will result in scarring. Increased magnification can at best eliminate and at worst reduce this as the surgeon may more accurately handle and control the final position of the tissues and suture the wound by passive primary closure. Consequently, as well as less scarring, less post-operative pain and more rapid healing will result. Microsurgical knots differ from conventional surgical knots as they have a ‘lumen’ which gives them the ability to compensate for any tightening of the tissues which is seen during initial healing due to oedema. Surgeons must learn these precision tailoring techniques at postgraduate courses and, once learned, it is advisable that they regularly practice knot tying to maintain their skills. This may be done by suturing a cut made in a piece of rubber dam.
The use of magnification allows a more conservative approach and the surgical site to be more easily controlled.30,31 This is particularly so in implant placement surgery as the fixture may be placed through a relatively small gingival incision, thereby minimizing tissue trauma and significantly reducing the post-operative pain. Healing and osseo-integration are both expedited and post-operative aesthetics improved.35 Other procedures associated with the placement of implants may also be facilitated with the use of an operating microscope, such as sinus lifts.
Minor oral surgery
It could be argued that the operating microscope has a more limited role in oral surgery. For example, exodontia would not be facilitated by the detail provided by a microscope. That said, this author has certainly used the operating microscope to examine sockets for the presence of retained roots or for the presence of oro-antral communications intra-operatively. The role of the operating microscope in periradicular and periodontal surgery has already been discussed and therefore the advantages of its use may be extrapolated to minor oral surgical procedures. Microscopy is already used for major oral and maxillofacial surgical procedures, such as the microsurgical connection of blood vessels and nerves in grafts after tumour resection.
Technique learning and development
When clinicians first begin to use an operating microscope they will find that the speed at which they work will be slower. There is a learning curve as they have to develop finer motor control and new ways of working.36 New techniques which are not possible without high magnification, such as microsurgical work and advanced endodontic techniques, will have to be learned and, to this end, attendance at postgraduate courses is to be highly recommended. However, with practice, most clinicians quickly become accustomed to working with the microscope.
The operating microscope is not useful in all branches of dentistry. Some subjects, such as orthodontics and removable prosthodontics, which are more concerned with ‘macroprocedures’, do not require such fine detail and so would not benefit from the use of a microscope.
Specialist society
In order for colleagues already using an operating microscope to interact professionally and to promote the advantages of its use, the European Society of Microscope Dentistry was founded in The Netherlands in . This is an international association which encompasses all branches of microdentistry with its aims being:
The Society's website can be found at http://www.esmd.info
Conclusion
Once practitioners start to use magnification in their daily work, they find it impossible to return to operating without the help of optical aids. This is very much more the case with an operating microscope. The practice of clinical dentistry can be challenging but being able to see more clearly and being more comfortable at the chairside will make life much easier for the operator. Any dentist who has introduced an operating microscope into their clinical practice will surely testify that they are less fatigued at the end of the working day and the work they have produced is better. This has obvious benefits for the patient and increased job satisfaction for the clinician. Large teeth are easier to work on than small teeth and the use of the operating microscope will prove again and again that if you can see it, you can treat it!
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