GeneralDentalPractice

Stephen J Bonsor

The Use of the Operating Microscope

in General Dental Practice Part 1:
Magnification in General
Abstract: An increasing number of clinicians are using magnification to facilitate their vision when carrying out dental examinations and
treatments. The use of an operating microscope in some dental specialties (such as endodontics) is now commonplace and there is also
a role for this equipment in branches of general dentistry. This paper, the first of two, reviews the many advantages of using an operating
microscope and offers practical advice on how the interested clinician may embark on using such an instrument by discussing the
equipment required. The second paper will focus on the potential uses for the operating microscope in general dental as well as
specialist practice.
Clinical Relevance: The operating microscope enhances the dental surgeon’s vision, potentially improving treatment outcomes not only in
specialist fields, such as endodontics, but also in many of the disciplines that general dental practice encompasses.
Dent Update 2014; 41: 912–919

The benefits of using magnification for Advantages of magnification interventions. Better treatment outcomes
clinical diagnosis and during operative with respect to quality, predictability
There are many advantages
procedures has been recognized for and longevity can therefore result, with
of utilizing magnification in clinical
many years, both in dentistry and in a commensurate increase in job interest
dentistry. First, and most obviously, the
other surgical disciplines.1 Whilst the use and satisfaction for all members of the
clinician enjoys improved vision with
of magnification by dental clinicians has dental team.
respect to clarity (detail) and definition
become more commonplace in the last
of the image as the image is larger and
20 years or so, there is one report in the
therefore easier to see. This reduces
literature on the subject which dates back
operator eye fatigue and so eye strain is Importance of illumination
to 1947,2 illustrating that an appreciation
minimized. Furthermore, as the eyes are To improve the operator’s
of the benefits that enhanced vision
covered they are protected from airborne vision further by complementing this
affords is not a recent development.
foreign bodies and aerosols which may magnification, good illumination is
Magnification aids commonly used
be created during operative procedures. essential. Increased illumination causes
by dentists are loupes or an operating
Secondly, owing to their design, most the iris to constrict which increases the
microscope.
optical aids force the clinician to sit in operator’s depth of vision by up to 33%.
a more comfortable and ergonomic Resolution of detail is also enhanced
position, otherwise the object will be out and so eye fatigue is also reduced. A
of focus. This has the effect of reducing properly angled light source will ensure
Stephen J Bonsor, BDS(Hons), neck and back strain of both the dentist that the clinician is never working in a
MSc, FHEA, Honorary Fellow, and dental nurse due to their improved shadow so that he/she has an optimum
University of Edinburgh, GDP, posture. Thirdly, there is evidence freedom of movement and with it the
The Dental Practice, 21 Rubislaw that magnification gives the clinician correct working posture and position.
Terrace, Aberdeen, UK. the ability to perform more precise Good illumination is especially important
work,3 both in diagnosis and operative when performing highly detailed
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 GeneralDentalPractice

work. For this reason, both loupes and be housed in a bulky mains-powered  Neurosurgery;9
microscopes intended for dental use unit on an adjacent work surface as the  Plastic surgery;10 and
utilize a light source which either comes large amount of heat energy produced  Vascular surgery,11 amongst others.
as an integrated feature or may be added by the bulb had to be dissipated by Their use offers the
to the system as an accessory. However, it means of a cooling fan. The light was advantages of loupes but on a much
is important that the light intensity is not transmitted to the headlight by an larger scale. The ability of the surgeon
too powerful as this can lead to eye strain umbilical fibre-optic cord. Unfortunately, to perform procedures which require
and fatigue and may cause after-images, these cords were readily damaged fine detail is therefore increased.7,12
like a camera flash effect. The hue (colour) during usage. The constant daily use This results in fewer post-operative
of this light may also detrimentally affect of these bulbs caused deterioration of complications with an improved surgical
the actual appearance of tooth structures the output of the halogen bulb with outcome.10 This has been extrapolated
and soft tissues and the clinician should time and their longevity was poor. Light to dentistry13 with the result that the use
be mindful of this possibility. Emitting Diodes (LEDs) are now used in of operating microscopes is becoming
preference and these offer a number of more widespread, both in general dental
advantages: practice and in various dental specialties.
Loupes  They require less power;
The most commonly used  The power source may be derived
Features
magnification aid in dentistry are from a battery or batteries;
The operating microscopes
(binocular) loupes (Figure 1) and these  These cells are housed in a battery
used in dentistry have many features.
instruments are most dentists’ first pack which is clipped on to the belt
Each magnification setting is called
experience of magnification.1,4 It is of the surgeon rendering him/her the
a step. For example, a five-step
important to note that eyesight will not freedom to move around unrestricted;
microscope would have settings at,
be damaged by wearing loupes; they will  The unit is light in weight and so
for example, x3, x5, x8, x13, x20 (Figure 2).
in fact lessen eye strain and reduce eye comfortable for the clinician to wear;
fatigue.  The operating wavelength of the LEDs
Loupes are lenses either can be more precisely controlled so that
inset into (‘through the lens’), or are premature curing of resin composite can
flipped down over, the protective be reduced by moving the operating
spectacles of the operator. These can wavelength away from 470 nm, the
offer a magnification from x2 up to x6.5. optimum curing wavelength for most
The ‘through the lens’ models require light-cured dental materials;
the interpupillary distance and working  They have various intensity settings
distances (dentist’s eye to patient’s for optimum working conditions and
mouth) of the wearer to be measured offer exceptional brightness of daylight
with the result that a customized colour temperature;
instrument is produced. This ensures that  They do not need to be cooled in
the dentist is forced to sit correctly, which the same way as halogen bulbs and
is advantageous as mentioned earlier. The therefore no (bulky) fan is required.
‘flip-up’ models are recommended when It is true to say that, once Figure 1. An example of magnifying loupes
it is important for the operator to switch clinicians become accustomed to using (Orascoptic, Middleton, WI, USA). Note the
(often) between magnification and the magnification, they will find it virtually headlight mounted on the loupes.
naked eye. impossible to revert back to using the
The optical systems most naked eye. This, in many cases, will
commonly utilized in dental loupes are stimulate an interest and curiosity
Keplerian and Galilean. The former allows to increase magnification further as
greater magnification with edge-to-edge they appreciate the many benefits for
clarity, whereas the latter is a telescopic themselves. The next step is to use an
lens arrangement enabling optimum operating microscope.
depth of field and field of vision. The
detail regarding dental loupes is outwith
the scope of this article and so the Operating microscope
reader is referred to other papers and, in Operating microscopes
particular, a review done by Shanelec.5 have been used for some years in many
Many models are compatible branches of surgery. These include: Figure 2. A dial used to select the magnification
with a headlight which may also be  Dermatology;6 required. This product is a five-step microscope
which, in this case, corresponds to magnifications
purchased (Figure 1). The original light  Ophthalmics;7
of x3, x5, x8, x13 and x20.
source was a halogen bulb which had to  Orthopaedics;8
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GeneralDentalPractice

Clearly, it is critical that the optics afford for the operator, inclinable binoculars nurse to watch the procedure in real
the clinician excellent vision. Clarity are often provided to minimize neck time (Figure 3). This will enhance a
of view, good contrast and depth and back strain. Some microscopes dental nurse’s interest in his/her work
perception are all therefore important, have a motorized positional mechanism and will improve his/her ability to
as is wide-field stereoscopic vision, all which facilitates the adjustment of assist the dentist. Some operators
for obvious reasons. It is advantageous the microscope during use so that the mount a television screen on to the
for an apochromatic lens system to operator does not need to exit the mouth ceiling above the dental chair so
be used as this eliminates chromatic to adjust the position of the microscope. that the patient may also watch the
aberration. This is the phenomenon of This is more efficient and results in less procedure. The advantage of this is
different colours focusing at different eye strain as the need to accommodate that the patient’s head is kept still as
distances from a lens. Apochromatic the eyes is much reduced. there is no temptation for them to look
lenses are designed to bring three Many microscopes are at the screen intended for the dental
wavelengths (typically red, green and available with a choice of mounting: nurse, so moving the head out of the
blue) into focus in the same plane wall, ceiling or on a moveable stand. operator’s field of view. Any movement
to correct this phenomenon. Other The decision between a wall or ceiling (particularly at a higher magnification) is
optical features may be present on mounting will depend on the dimensions both counterproductive and annoying
some instruments. These include wide of the surgery: how much space is from the operator’s perspective. In the
field, adjustable cup eyepieces with available, the height of the ceiling, or experience of this author, patients react
dioptre settings. These are suitable the distance from the nearest wall. A to the ability to view their treatment
for prescription and discrepancy non- ceiling mount may not be advisable if in usually one of two ways: they either
prescription wearers, so allowing the room above the surgery is populated find the experience very interesting
the operator to wear prescription as vibrations from people walking about or highly disconcerting. It is therefore
spectacles, if necessary, or safety may cause the microscope to move, so advisable to ask patients whether they
glasses if no prescription is required. adversely affecting its use. A high ceiling, wish to watch or not and adjust the
A motorized zoom and autofocus may for example in older buildings, may also television accordingly. The availability of
also be available. Adjustment of focal preclude the use of this mounting type.
lengths (including a range of focal The moveable stand offers the advantage
lengths) is advantageous as it will allow that the microscope is portable and may
the operator to work at his/her ideal be used in more than one surgery in the
working distance. Some products now practice or clinic.
incorporate lens arrangements which Ideally, the microscope should
give an increased depth of field. Most allow the mounting of a (digital) camera
final objectives have a depth of field on the microscope, by means of a lateral
of approximately 30 mm and therefore output port and beam splitter, or have an
any increase results in better posture inbuilt camera. This allows still or video
and obviates the need for continuous photography to be done and allows
repositioning of the microscope for real time viewing for the dentist, dental
gross focusing. nurse and possibly the patient. The many
The importance of good advantages of this are discussed later in Figure 3. A television screen may be mounted in
illumination was discussed earlier and, detail. the direct line of vision of the dental nurse so that
with microscopes, this is provided by It is important to note that she may watch the clinical procedure in real time.
a co-axial radiating light source which not all of the features listed above may
will provide a shadow-free light. If the be available on every instrument, with
bulb is halogen, then a back-up bulb some only being available on the higher
should be available and easy to switch specification models.
to if the one being used fails during the
procedure. Often, xenon sources are
now commonly used which provide The use of photography and
light which is equivalent to ‘daylight’. video
As mentioned earlier, colour filters may A good quality digital camera
be incorporated. An orange filter will is strongly recommended to be used
remove the specific wavelength of light in conjunction with the microscope.
which initiates the setting of light-cured This camera is connected to a monitor Figure 4. A vesicular-bullous lesion on the left
dental materials, whilst green makes a or PC by means of a USB or HDMI or lateral border of the tongue captured using an
operating microscope, allowing more meaningful
surgical site easier to visualize, known as incorporated into the microscope. This
future monitoring by the dentist or a better
‘red free’. will permit a television screen to be
quality referral to another colleague.
To ensure maximum comfort placed in direct eye line for the dental
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a camera also allows the dentist to record medico-legal perspective as evidence of plaque in an area difficult to see and to
material,14 so enhancing the quality of the a particular situation or as justification for demonstrate the appropriate cleaning
clinical records. Whether this is captured a decision. technique. Clinical photographs can
as stills or video footage, it may be used Many colleagues use images also be used to demonstrate a particular
in many ways. The information can be as a patient education tool with the old clinical situation (for example, a heavily
digitally attached to the patient’s clinical adage of a picture painting a thousand restored tooth) and to recommend a
notes with the result that, for example, words being very true. The ability to particular treatment (in this example,
both hard and soft tissue lesions may be show and explain clinical photographs the provision of a crown) (Figure 7).
more easily monitored over a period of to patients can engage them far more Documentation of clinical cases may
time (Figure 4), or sent electronically to in their treatment, so making any future be used by the dentist as a portfolio of
another colleague if the patient is being discussion of treatment options more evidence to be submitted as case reports
referred for further advice or treatment. meaningful and less abstract (Figure 6). for qualifications such as postgraduate
Other information may be captured The critical importance of prevention in degrees. Likewise, the information may
and stored which may not be seen clinical dentistry can never be stressed be used for publication in journals, such
subsequently, such as a fracture line on a enough and clinical photographs are an as case reports or research, as a teaching
cavity floor which has then been restored effective motivational and educational tool to professional colleagues, or as a
(Figure 5). The recording and retention of tool. The obvious example would be library of the dentist’s work to be kept for
such material may also be useful from a to show a patient the presence of his/her own interest.

Instruments
Various instruments are
available which are specifically designed
to be used intra-orally in combination
with the operating microscope. These
instruments are essential to achieve
the full advantages of a less invasive
procedure15 and also to decrease the
potential for other objects (such as the
fingers of the operator) to obstruct the
line of vision. Examples include:
 Very small-headed micro-mirrors;
 Microsurgical scalpel blades;

Figure 5. A hairline crack at the base of a cavity Figure 7. A clinical photograph of a heavily
which has been captured to enhance the clinical restored upper molar tooth. This image may be
notes to show position and extent as it will not shown to the patient and will facilitate discussion
be evident after restoration of the cavity. of the treatment options.

Figure 9. Diagrams to illustrate the difference

Figure 8. Examples of bespoke intra-oral between a front surface and conventional (second
Figure 6. A radicular fracture of an upper incisor instruments which are used in combination surface) mirror. The upper diagram shows the image
tooth which previously supported a post crown with the operating dental microscope. From being reflected from the surface unaltered, whereas
restoration. The presence of the fracture may be left to right: micro-mirror, endodontic file in the lower the image reflects from the surface and
shown to the patient so facilitating a less abstract holders, microsurgical scalpel blade handle and internally within the front glass so ‘ghosting’ (a faint
discussion of the clinical problem. microsurgical suturing forceps and needle holders. reflection from the first layer) occurs.

December 2014 DentalUpdate 917

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 GeneralDentalPractice

 Suturing instruments; Operating position move his/her head from side-to-side

 Longer-shanked burs; and When dentists work on a or by tilting the head up and down.
 Endodontic file holders (Figure 8). patient with an operating microscope, Should the operator find that he/she
Front surface dental mirrors they require extra chairside help from has to crane the neck to look into the
are recommended as they produce a the dental nurse. The dentist and dental eyepieces then the dental chair may be
clearer single image, unlike conventional nurse should sit as they would when lowered to facilitate vision and reduce
mirrors. A front surface mirror is a mirror ‘close support (four-handed)’ dentistry16,17 neck strain. Clearly, those patients who
with the reflective surface being above a is being practised (Figure 10). Both the are unable to be placed in the supine
backing, as opposed to the conventional dentist and dental nurse should be seated position, for whatever reason, would
mirror with the reflective surface behind with their backs straight and their knees not be candidates for those procedures
a transparent substrate such as glass. The bent at a 110° angle with their feet flat which require an operating microscope.
‘silvering’ on a dental front surface mirror on the floor. Furthermore, their legs are The proximity of the dentist
is usually aluminium. No ‘ghosting’ effect is intertwined, so permitting them both to and dental nurse facilitates their
seen with the front surface mirror, unlike sit closer to the head of the patient. It is ability to see and to pass instruments
the conventional mirror (Figure 9). recommended that the dentist’s stool is between them. This is particularly
Ultrasonic instruments are supplied with arm rests to reduce fatigue. important when the microscope is
commonly used in conjunction with This may also reduce any tremulous being used. To avoid eye fatigue by
the operating microscope as their use movement as the arms are more able constant accommodation between
permits much more precise usage than to relax, particularly during a long near and further away objects, the
conventional rotary instrumentation. procedure. operator should only look down the
A more conservative preparation can The patient is placed in eyepieces. The help of the dental nurse
therefore be achieved both of tooth tissue the normal supine operating position is invaluable to guide instruments into
during a dental procedure and bone (Figure 10). The dental team’s vision may the hand of the operator and then
removal during a surgical procedure. be improved by asking the patient to into the patient’s mouth and thus into
view (Figure 11). Clearly, this is most
important when sharp instruments are
being handled, such as dental probes
(explorers), needles or scalpel blades.
The role of the dental nurse in the
retraction of the oral soft tissues to
improve access and vision is also critical.
This may be done by the dental nurse
holding the aspirator in one hand and
the 3 in 1 syringe in the other. Both
these instruments may be used to
retract the soft tissues, with the 3 in 1
syringe being used to blow air on to the
Figure 10. The dentist and dental nurse sitting dental mirror to prevent fogging (Figure
in the normal operating (close support) position. 12).
Note the supine position of the patient. Figure 12. The dental nurse may retract the oral
soft tissues using an aspirator and a 3 in 1 syringe
which is also used to blow air on to the dental
mirror to prevent it from fogging.
Maintenance and care
Just like any other piece
of dental equipment which is used
frequently, it is wise to have the
microscope serviced annually. Fixing
bolts and screws can work loose from
regular movement during usage and
other problems, such as the microscope
‘drifting’ or rubber eyepieces perishing,
can occur over time. Regular servicing
Figure 11. The dental nurse guiding a sharp will minimize problems, which can be
instrument into the mouth to avoid inadvertent highly inconvenient should a problem
injury to the patient as the operator is unable to occur unexpectedly. It is sensible
see this region when looking down the eyepieces Figure 13. A cover should be placed over the to ensure that, when purchasing a
of the microscope. microscope when not in use to protect it. microscope, that the vendor company

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 GeneralDentalPractice

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December 2014 DentalUpdate 919
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