Microscope Assisted Precision Dentistry

Microscope Enhanced Dentistry is just starting to become available in India. It will soon
become a standard feature in advanced dental clinics in the future here in India as well
as around the world.Microscope Enhanced Dentistry is a new service which is spreading
across the globe, slowly but surely.
Teeth are normally small structures like the eyes, ear & nose. ENT surgeons,
ophthalmic surgeons & neurosurgeons nowadays routinely use an operating microscope
or magnifying loupes/spectacles to do surgeries of greater precision and accuracy.
Cataract surgery is nowadays routinely done with a microscope nowadays.
It is a stunning treat to watch teeth which are only 1 sq.cm in size magnified to fill a TV
screen 14 or 21 inches cross!! And the joy of seeing a smile is all the more gorgeous to
watch on a large TV screen. A big smile is made much bigger by the magnification
provided by the microscope. And the highly improved quality of the fillings, RCT’s,
crown and bridge preparations and various other procedures which can be done with
the microscope make the patient smile even more! The patient’s confidence in his
dentist is hugely increased as he can see the problems in his teeth very clearly under
brilliant light and magnification. They co-operate better during the treatment as they
are able to see on a TV screen the whole procedure being undertaken on their teeth,
and it also ensures better compliance with advice given.
The dentist who uses the microscope is much more comfortable and avoids un-due
strain on his neck and back. The up-right posture can be maintained during almost all
procedures, which is otherwise impossible. Occupational stress and strain on these 2
areas are very high and there are some incidences in the USA where some senior and
experienced dentists have only been able to continue working after starting to use the
microscope, thus enabling more patients to continue to benefit from their huge
experience. The microscope can be used to magnify almost all the procedures which are
done routinely by dentists. Since the eyes are not seeing the work area directly as
before, a lot of training has to be under-taken to master the use of this new device
effectively
The use of the same operating microscope in the field of dentistry has just started
recently in Western Europe and parts of America. The American Dental Association has
made it mandatory and compulsory for higher post-graduate training in endo-dontics or
the root canal treatment speciality to be trained in the use of the operating microscope.
It is estimated that 75% of the endodontists in the USA now own or use a microscope
at least part of the time. A select few dental colleges have started to introduce
microscopes at under-graduate level. But many general dentists and other dental sub-
specialists like periodontists, oral surgeons and prosthodontists have also pioneered
and mastered the use of the microscope in their practices. This is a revolution in the
dental world – the amount of improvement of care in dentistry done under
magnification with the use of the microscope is very very high.
Since microscopes have been used for endodontic RCT’s , extra canals called MB2’s and
other minute accessory canals have been found and treated effectively which were not
possible before. Thus, the chances of failure of RCT becomes much smaller. Doing
complicated procedures like failed RCT and removal of broken files deep inside the roots
of teeth are challenges which demand the use of a microscope. Teeth will failed RCT’s

can be re-treated with a second RCT and successfully saved, when done very carefully,
and the chances of success are much higher when done under the microscope.
Some teeth have decay which almost require a RCT if done with the naked eye. But
with a microscope and a special caries detector dye, only the decay can be removed
and a RCT avoided. No normal tissue is removed because it is possible to see the
difference much better and clearer under magnification.
Scaling or cleaning of the teeth done under the microscope affords better removal of
tartar and stains and cleaner teeth at the end. Periodontal flap surgery when done
under the microscope, is able to remove much more damaged tissue, with much less
damage to nearby healthy tissue, and hence give a better result. Suturing of wounds
done under the microscope is much finer and delicate, hence better scars, faster
healing, less post-operative pain & discomfort is possible.
Preparation of teeth to fit a metal or ceramic artificial crown is a routine procedure done
in every dental clinic routinely. If a microscope is used for this while preparing the
tooth, the margins of the teeth are much more neater and precise, thus allowing a
much better fit of the artificial crown, better esthetics and longer life with less problems
like leakage and failure. The crown can also be checked before fitting on to the tooth
under the microscope to check for defects in shape, size and irregularities as well. Less
tooth structure is removed as well if possible, because we can see more clearly.
The fitting of crowns and bridges is made very precise and hence the longevity of these
is hugely increased.
Modern surgical practice in most areas of surgery are aimed to deliver a smaller
incision, smaller scar, reduced pain, faster mobilization and a much better quality of
outcome. To achieve this, advances like laparoscopy in general surgery, arthroscopy in
orthopaedic surgery, endoscopy in urology have all played their part. Similarly, the use
of the microscope in neurosurgery, ophthalmic surgery, plastic surgery etc is also
helping in giving such benefits to the patient nowadays. The operating microscope is
used in so many areas of surgery and medicine nowadays, it has almost become
mandatory. The twin benefits of fantastic shadowless illumination and higher
magnification make it un-beatable.
At a meeting held recently in Coimbatore on Microscope Enhanced Dentistry, a well
known plastic and microsurgical reconstructive hand surgeon remarked, “You can only
treat what you can see well. You have to use the microscope to know how good and
useful it is.”

Sun
9
Dec
Microscope assisted precision dentistry
articulatingmicroscope
This article is about the use of microscope assisted precision dentistry, or the use of microscope
in oral health treatment. Although microscopes have been used in medicine as early as 1921, it
wasn’t until the early nineties that microscopes were to be used for dental applications. Shanelec,
Tibbets, Feldman Ruddle, Friedman and others were able to publish a series of papers that
documented the use of microscope n endodontics, termed “microscope assisted precision
dentistry (MAP dentistry). And in 1998 the American Association of Endodontics (AAE)
proposed all postgraduate students should have an experience in operating and handling of a
microscope, in order to qualify for a license in endodontics. In Australia where advancement is
pioneered, dental laboratories have been using microscopes as early as fifteen years ago for
checking filling margins and castings. Some maxillofacial surgeons and other dentist have used
microscopes for apicectomies. With MAP dentistry, it is now possible to remove decayed dental
tissue (caries) to its interface without affecting the normal adjacent tissue. The quality and
precision that MAP dentistry has brought raised the accuracy in removing decayed tissue without
unnecessarily sacrificing normal intact dentin. With this success it prevents the occurrence of
secondary caries.
Dr. Peter Kotschy is a strong advocate of preventive, periodontology as well as minimal invasive
dentistry, as such he has been using microscopes for preventive operations, periodontal and
restorative procedures, endodontic, and prosthodotic work, enabling for a precise removal of
secondary caries which was difficult before microscopes were introduced. What are the
advantages of a microscope, first we have to look at the disadvantages. Conventionally, a
decaying tooth is treated and filled with amalgam. This procedure is without certainty and
complete caries control cannot be assured. It is a fact that a 100% caries control is impossible
and a secondary caries will likely occur. In a secondary caries, it is actually a residual of primary
caries, this are caries which were not completely removed. Although in the field of amalgam
filling advancements have been made on the improvement of the type of amalgam filling, a
tightly sealed amalgam cannot assure a secondary caries will not develop. Thus the article states,
if we were able to completely remove primary caries will then be able to prevent further residual
decay from spreading.
Microscope assisted precision dentistry (MAP dentistry), is one of the field in medicine were an
articulating microscope is needed. Considering that dentistry as the article states, is one of the
medical specialty with the most demanding precision standards. Microscopes have evolved from
fixed type to articulating microscope types. Articulating microscope has the advantage of
mobility. With an articulating arm, the articulating microscope can shift from one position
without moving the entire equipment. Like most microscope in the field of surgery, articulating
microscopes have video attachment capability wherein videos or images can be seen from an

external monitor. The use of microscope assisted precision dentistry (MAP dentistry) is not only
challenging but also time consuming, but considering the breakthrough in oral health surgery; in
caries control, Dr. Peter Kotschy recommends the use for endodontic treatment and all other
dental work in the fight to control caries. Article link
• BLOG
ITS ALL IN THE DETAILS-MICROSCOPE DENTISTRY
DR. GLENN A. VAN AS
HOW YOU VIEW THE PROFESSION
THE D.O.M. AND POST CORONAL SEAL
MONDAY, DECEMBER 3, 2007
One of the findings in endodontic literature is that the Coronal seal (Removing the ability of
contamination of the obturation by saliva and oral bacteria) is a key in the ongoing success of
endodontic treatment. Some studies have shown that exposure of the Gutta Purcha to
bacteria can in as little as 28 days allow for bacteria to travel the entire length of the tooth,
allowing for failure of the treatment to become a possibility.

J Endod. 2002 Nov;28(11):762-4.Click here to read Links
An...
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UNCOVERING MORE ANATOMY
SATURDAY, DECEMBER 1, 2007
In today’s blog we look again at a couple of more cases focussing in on the role of the
microscope in locating Portals Of Entry to the roots of the teeth. The cases below are my own
of varying ages to show the photography possible and the ability if you know where to look to
find canals.
In the first case we see an upper first molar with 4 canals and see where the white line leads
us to uncover the MB2 which as usual is located mesial to the line connecting MB1 and the Pal
canals. The 2nd case is...
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TROUGHING FOR EXTRA PORTALS OF ENTRY (POE)- A LONG REVIEW.
One of the confusing things when you get a microscope is what the heck you are looking at
when you suddenly are getting the gift of actually standing inside the endodontic access ( it
seems like that) and getting this huge magnified and illuminated view of the inside of the
tooth. With time you begin to understand better what you are actually looking at, and
understanding all the visual information that you have never seen before. Once the puzzle of
whitelines, dentin maps, pulp stones, and...
ACCESS WITH THE OPERATING MICROSCOPE- THE ELUSIVE MB2
THURSDAY, NOVEMBER 29, 2007
Many dentists purchase the operating microscope solely to be used in the early stages of
endodontics to locate canals in molars with greater ease. The combination of magnification
and illumination possible with the scope helps incredibly with the visual acuity possible in
endodontic access. The most common tooth to fail after initial endodontic therapy is the
upper first molar and the sobering study by John Stropko published in the JOE in 1999 which
looked at 1732 maxillary molars and found...
ENDO AND THE OPERATING MICROSCOPE - PART 2
TUESDAY, NOVEMBER 27, 2007

In yesterdays Blog entry, the topic of the microscope in the literature was broached (pun
intended). There is a growing body of evidence in the literature on the role of the microscope
in the discipline of endodontics. Much of the concentration of the literature has been
focussed on the role of the higher levels of magnification for early access into the pulp. The
published material has focussed on ability to discover 4th canals in molars, particularly the
MB2 in maxillary first molars which are...
ENDO AND THE OPERATING MICROSCOPE - SHOW ME THE LIT!
MONDAY, NOVEMBER 26, 2007
Many people have asked during what parts of the endodontic treatment does the operating
microscope help with. I guess the simple answer is all of them, particularly if you look at the
value of the operating microscope for ergonomics, for its ease of documenting in video and
still digital media and finally for the ability to show patients, staff and colleagues any portion
of the entire procedure.
In this first part of looking at the benefit of the microscope for endo, I will attempt to
provide...
PAIR OF CRACKS - A PREDICTOR OF INTERPROXIMAL DECAY
SATURDAY, NOVEMBER 24, 2007
If you have never read Dr. David Clarks article on cracked teeth you owe it to yourself to get
a copy of the article, read it, digest it, read it again. Its that important an article for those of
us who use the operating microscope. I will occasionally cover a single type of cracks that
David talks about in his landmark article. Today is one of those days.David was the founder of
AMED and his enthusiasm and initiative were the driving force for the organization that acts
as the primary annual...
LOOK WHAT I FOUND!
THURSDAY, NOVEMBER 22, 2007

When I started using the operating microscope, it quickly became evident that the
tremendous improvement in visual acuity through both magnification and illumination allowed
for much earlier diagnosis of decay. I still will bring over the diagnodent to help me quantify
an occlusal lesion in terms of size and know whether it is possible to treat it without the
dreaded needle. The “shadows” that the microscope illuminates is impressive. Far earlier
than depending on cavitation and detection of an...
USING THE FULL RANGE OF MAGNIFICATIONS
WEDNESDAY, NOVEMBER 21, 2007
The answer to which magnification I use the most is ALL of them. To be honest when I look at
the range of magnifications that I have, I break the 6 steps down to 3 groups. There is a LOW
magnification range of 2.1 and 3.2X power. These are very useful magnifications for things
like placing rubber dam, providing anesthetic, evaluating line of draw, looking at a smile from
commissure to commissure, looking at a whole quadrant at once, placing orthodontic
brackets, gross reduction of tooth...
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OLD EYES, YOUNG EYES, ANY EYES.
TUESDAY, NOVEMBER 20, 2007
The microscope offers all users regardless of their eyesight tremendous improvements in
visual acuity through the increase in visual information it provides by magnification and
illumination.
Dr. Assad Mora at an early edition of AMED provided us with food for thought by the following
table. The table shows us the tremendous improvement in visual acuity that is possible when
we start to increase magnification compared to the naked eye and low level loupes. This
amount of visual information is...
The Dental Operating Microscope was brought to endodontics by pioneers like Carr,
Arens, Ruddle, Castellucci, and Buchanan. It is now becoming more commonly used

by general dentists to help with treatment outcomes, ergonomics, and improving
communication and documentation for all aspects of daily practice.
Go to archive
j.o. Endod. 2002 Nov;28(11):762-4.Click here to read Links
An assessment of microbial coronal leakage of temporary filling materials in
endodontically treated teeth.
Balto H.
King Saud University, College of Dentistry, Division of Endodontics, Riyadh,
Kingdom of Saudi Arabia.
This in vitro study evaluated the microbial leakage of Cavit, IRM, and Dyract when
used as temporary filling materials after root canal treatment. The degree of coronal
leakage was assessed by using a microbiological marker consisting of Streptococcus
faecalis and Candida albicans. For each of the two organisms, a set of 15 maxillary
premolars were prepared chemomechanically and obturated with thermoplasticized
gutta-percha. A 3.5-mm thick layer of one of the three temporary filling materials
was inserted in the access cavities of the teeth from each group (each group was
compromised of five teeth). The control teeth (four positive and four negative) lacked
any filling material over the gutta-percha, whereas the orifice and the apical foramen
of the negative control were completely sealed with nail polish. Each tooth was
placed in a well of a 24-well tissue culture plate and embedded in trypticase soy

broth and 0.5% Bactoagar. An organism suspension was inoculated in the access
cavity, and microbial penetration was detected as an increase in turbidity of the
broth. At the end of 30 days, the results showed that all positive control teeth
leaked within 1 week, whereas those that served as negative control remained
uncontaminated throughout the test period. With both organisms, IRM started to
leak after 10 days, whereas Cavit and Dyract leaked after 2 weeks.
Others have shown, the temporary restorations have far less ability to provide a
coronal seal than a permanent restorative material on a completed endodontic
procedure.
J Endod. 1999 Mar;25(3):178-80.Links
A comparative study of four coronal obturation materials in endodontic treatment.
Uranga A, Blum JY, Esber S, Parahy E, Prado C.
Faculty of Medicine and Odontology, University of Basque Country, Lejona, Spain.
The aim of this study was to compare, in vitro, the ability of temporary versus
permanent materials to seal the access cavity. Eighty human maxillary single-canal
teeth were prepared biomechanically and obturated with gutta-percha and an
endodontic cement AH Plus, using the warm vertical compaction technique. All access
cavities were sealed with 1 of 4 materials (Cavit, Fermit, Tetric, or Dyract).
Microleakage was assessed by methylene blue dye penetration. The teeth were
submitted to 100 thermocycles, with temperature varying from 0 degree to 55
degrees C. The greatest degree of leakage was observed with the temporary materials
(Cavit and Fermit). There was a significant difference (p < 0.05) in leakage between
all materials except between Dyract and Tetric. This suggests that it may be more
prudent to use a permanent restorative material for provisional restorations to
prevent inadequate canal sealing and the resulting risk of fluid penetration.
PMID: 10321182 [PubMed - indexed for MEDLINE]
It is clear from the literature that the quality of the coronal seal can affect the
longevity of the endodontic therapy. All of us have witnessed a seemingly successful
endodontic case radiographicallly become reinfected and upon access into the tooth,
discovered leakage and bacteria coronally that was responsible for the reinfection of
the canals and for the reoccurrence of the periapical pathology.

In completing an endodontic case the micrsoscope can help with the ability to provide
a nice clean and solid coronal seal. The technique is as follows:
1.Coronal seal is so important to preventing reoccurrence of periapical pathology.
2.Clean up of pulp chamber involves isopropyl alcohol in an Ultradent syringe.
3.Slowspeed round burs, or high speed diamonds to clean up Gutta Percha.
4.Flowable over the GP at the pulpal floors, corebuildup in composite afterwards.
Some like Amalgam for seal
The key in these cases is to see a nice void free interface leading from the endodontic
therapy to the access of the tooth. This should be done at the completion of the
treatment to give the greatest success to long term health for the tooth.
The above procedural guide combined with the microscope which allows for easier
viewing of the access of the tooth and careful placement of restorative materials
provides for a nice radiographic flow of materials from the pulpal floor coronally.
Stay tuned this week for further cases demonstrating the effectiveness of the
microscope for endodontics.
ACCESS AND THE OPERATING MICROSCOPE
UNCOVERING MORE ANATOMY
In today’s blog we look again at a couple of more cases focussing in on the role of the
microscope in locating Portals Of Entry to the roots of the teeth. The cases below are
my own of varying ages to show the photography possible and the ability if you know
where to look to find canals.
In the first case we see an upper first molar with 4 canals and see where the white
line leads us to uncover the MB2 which as usual is located mesial to the line
connecting MB1 and the Pal canals. The 2nd case is an upper 2nd molar and with the
microscope you will soon become uncomfortable only finding one MB canal as well.
There often as John Stropko shows in his study, 4 canals in upper 2nd molars as well.

TROUGHING FOR EXTRA PORTALS OF ENTRY (POE)- A LONG REVIEW.
FRIDAY, NOVEMBER 30, 2007
One of the confusing things when you get a microscope is what the heck you are
looking at when you suddenly are getting the gift of actually standing inside the
endodontic access ( it seems like that) and getting this huge magnified and
illuminated view of the inside of the tooth. With time you begin to understand better
what you are actually looking at, and understanding all the visual information that
you have never seen before. Once the puzzle of whitelines, dentin maps, pulp stones,
and other oddities of the pulp chamber become better understood and more
frequently seen then you know better where to search for the canals.
John Khademi has shown repeatedly cases where extra canals are found. This first
case is John’s taken from Dental Town. If you ever get a chance to see some of what
John has to teach then I highly encourage you to listen to him lecture. He is a very
bright man, with a great ability to teach.

Microscope Assisted Precision Dentistry

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