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THE USE OF MAGNIFICATION IN ENDODONTIC THERAPY …

Telescopes or loupes have been readily available ina variety of configurations and magnifications. Withthe aid of a fiberoptic headlamp system, light can beprojected in the line of sight to prevent the creation ofshadows in the surgical field and render optimal visual-ization of the treatment site. However, the magnificationof loupes is limited ( to ) and their optics areconvergent, which creates eye strain and fatigue. In orderto address the limitations present in these devices, clini-cians adopted new techniques and were the first medical specialists to uti-lize the operating microscope in a clinical 1921, Nylen performed a surgical procedure withthe operating Jannetta performed aprocedure called microvascular decompression to treattrigeminal neuralgia, the event became the subject ofcontroversy (to use or not to use the microscope) in theneurosurgical surgical operating micro-scope (SOM) has been recently introduced in dentistry,specifically in endodontics , where increased magnifica-tion and illumination have resulted in improved technicalaccuracy and Surgical Operating MicroscopeThe surgical operating microscope consists of threeprimary components the supporting structure, the bodyof the microscope, and the light Supporting StructureIt is essential that the microscope be stable while in opera-tion, yet remain maneuverable with ease and exceptionalprecision, particularly when used at high power.

The objective lens is the final optical element, and its focal length determines the working distance between the microscope and the surgical field.

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Transcription of THE USE OF MAGNIFICATION IN ENDODONTIC THERAPY …

1 Telescopes or loupes have been readily available ina variety of configurations and magnifications. Withthe aid of a fiberoptic headlamp system, light can beprojected in the line of sight to prevent the creation ofshadows in the surgical field and render optimal visual-ization of the treatment site. However, the magnificationof loupes is limited ( to ) and their optics areconvergent, which creates eye strain and fatigue. In orderto address the limitations present in these devices, clini-cians adopted new techniques and were the first medical specialists to uti-lize the operating microscope in a clinical 1921, Nylen performed a surgical procedure withthe operating Jannetta performed aprocedure called microvascular decompression to treattrigeminal neuralgia, the event became the subject ofcontroversy (to use or not to use the microscope) in theneurosurgical surgical operating micro-scope (SOM) has been recently introduced in dentistry,specifically in endodontics , where increased magnifica-tion and illumination have resulted in improved technicalaccuracy and Surgical Operating MicroscopeThe surgical operating microscope consists of threeprimary components the supporting structure, the bodyof the microscope, and the light Supporting StructureIt is essential that the microscope be stable while in opera-tion, yet remain maneuverable with ease and exceptionalprecision, particularly when used at high power.

2 The sup-porting structure can be mounted on the floor, ceiling, orTHEUSE OFMAGNIFICATIONINENDODONTICTHERAPY:THEOP ERATINGMICROSCOPEB ertrand G. Khayat, DDS, MSD*Pract Periodont Aesthet Dent 1998;10 (1):137-144 Figure 1. Clinical application of the microscope. The operator and assistantare in comfortable positions.* Assistant Professor of endodontics , University of Pennsylvania,Philadelphia, Pennsylvania. Private practice, Paris, G. Khayat, DDS, MSD1, avenue Paul Doumer75116 Paris, FranceTel: (011) 33-1-47-27-41-41 Fax: (011) 33-1-47-27-06-75 Clinicians have recognized that the use of magnificationcan improve the performance of dental procedures. Ofthe various MAGNIFICATION systems available, loupes havebeen the most popular, yet their MAGNIFICATION is article reviews and describes the function and clini-cal application of the surgical operating microscope (SOM),emphasizing its utilization in ENDODONTIC treatment. Severalcases are presented to document the clinical procedureand to illustrate the difference between operative proce-dures performed without MAGNIFICATION and those com-pleted using the SOM with As the distance between the fixation point and thebody of the microscope is decreased, the stability of thesetup is increased.

3 In clinical settings with high ceilingsor distant walls, the floor mount is preferable. Carefulattention should be given to the precise setting of thearms. The built-in springs should be tightened accordingto the weight of the body of the microscope to establishperfect balance in any position. This permits precise visu-alization and renders the fine focus unnecessary in themajority of clinical of the MicroscopeEyepieces are used in the overall MAGNIFICATION . They areavailable in various powers, ranging from to 20 ; thetwo most commonly used are 10 and . The end ofeach eyepiece has a rubber cup that can be lowered forclinicians who wear glasses. Eyepieces also haveadjustable diopter binoculars contain the eyepieces and allow theadjustment of the interpupillary distance; they are alignedmanually or with a small knob until the two divergent cir-cles of light combine to effect a single focus. Binocularsare available with straight, inclined, or inclinable tubes are generally used in otology and are notwell suited for dentistry.

4 Inclined or inclinable tubes arepreferred to allow the clinician to establish a comfortableworking position. Inclined tubes are fixed at a 45 angleto the line of sight of the microscope; inclinable tubes areinfinitely adjustable. The microscope is positioned overthe patient s mouth, and the binoculars are inclined insuch a manner that the head and neck of the operatorcan be held at an angle where comfort can be sustainedthroughout the entire procedure (Figure 1). Indirect visionis a characteristic of clinical diagnosis and treatment thatis specific to dentistry. In conventional endodontics , it isimpossible to examine a root canal with straight lineaccess. With the microscope, use of the mirror is essen-tial and allows multiple angles of vision without movingthe body of the changers are available as 3-, 5-, or6-step manual changers, or a power-zoom changer. Theyconsist of lenses mounted on a turret that is connected toa dial located on the side of the microscope. The mag-nification is altered by rotating the 4.

5 Case 1. Preoperative radiograph tracing a fistula with agutta-percha point. A lateral lesion is 2. The preoperative radiograph does not reveal any complica-tions in the root canal 3. Microscopic view of the pulp chamber reveals 3 distinctorifices in the mesiobuccal root. Palatal orifice and one half ofdistobuccal orifice are not 10, No. 1 Practical Periodontics&AESTHETICDENTISTRYThe objective lens is the final optical element, andits focal length determines the working distance betweenthe microscope and the surgical field. The range of thefocal length varies from 100 mm to 400 mm. A 200-mmfocal length allows approximately 20 cm of working dis-tance, which is generally adequate for utilization in intra-oral total MAGNIFICATION of a microscope4is repre-sented by the following formula:The range in MAGNIFICATION from to 8 is usedfor an intraoral surgical site. For example, the wide-fieldview allows a better evaluation of the root position in sur-gical endodontics . Magnifications in the range of 10 to 16 are used for operating; 90% of the use of themicroscope is at this power.

6 The higher magnifications(20 to 30 ) are used to examine fine typical microscope setup should have the follow-ing features to be properly equipped for application indentistry5: eyepiece power. 125-mm inclined binoculars. 5-step changer, ranging from 4 to 28 . 200-mm objective operating microscopes possess the addi-tional benefit of Galilean Optics. As opposed to loupes,which have convergent optics, Galilean Optics focus atinfinity and send parallel beams of light to each parallel light, the operator s eyes are at rest, asthough looking off into the distance, permitting perfor-mance of time-consuming procedures without inducingeye SourceThe light source is one of the most important features ofan operating microscope. For the first time in dentistry,the illumination is coaxial with the line of sight, whichTM = (FLT/FLOL) EP MVTM:Total :Focal length of :Focal length of objective :Eyepiece : MAGNIFICATION 6. Case 2. View of a surgical site of a maxillary central incisorwithout 5.

7 Microscopic examination reveals a crack that does notextend completely to the margin of the 7. View of the same site at 16 MAGNIFICATION with a micro-mirror. Three portals of exit can be discerned at the the presence of any shadow. The light sourceis generally powered by a 100- to 150-watt halogenlight bulb that is connected to the microscope with a high-efficiency fiberoptic cable. The light passes through acondensing lens, a series of prisms, and then through theobjective lens to the surgical site. The intensity of light iscontrolled by a order to deflect a certain percentage of the light fromthe eyepiece towards the accessories, a beam splittercan be placed between the binoculars and the magnifi-cation changer. The beam is generally split at a 50:50ratio (ie, half of the light is always available to the oper-ator). A photo or video adapter can be connected to thebeam splitter. The video camera is a useful adjunct andserves two additional purposes: it allows the assistantsto follow the procedure precisely and assist efficiently,and it can also be used for documentation using videoprints or of the Surgical Operating Microscopein ENDODONTIC TherapyThe surgical operating microscope was introduced toendodontic THERAPY only a decade ago.

8 At the time, onlya few clinicians in the United States and Europe believedin its utility. The SOM has gained wide acceptanceduring the past 10 years and is now considered to bean important tool in ENDODONTIC practice. Since 1997,microscopic techniques in endodontics have been insti-tuted in the curricula of all graduate dental schools in theUnited States. All graduate students must be proficient inclinical application of the SOM and knowledgeable ofall aspects of its usefulness in ENDODONTIC SOM enables the endodontist to assess the marginalintegrity of restorations and to detect cracks or cracks can be coronal and may be found followingthe removal of a restoration. Once the tooth has beenaccessed, cracks can also be detected on the floor ofthe pulp chamber. For optimal visibility, it is important tocontrol the dryness of the dentin when using the micro-scope. If the dentin is too dry, the texture appears whiteand chalky, and the crack will not be visible; if the dentinis too wet, the reflection of water on the surface will maskthe crack.

9 To precisely adjust the drying of the dentinsurface, the author uses the irrigator (Stropko, EIE Analytic,Orange, CA). It adapts on a 3-way syringe that can beused with any size needle. The average size needle of25 gauge is suitable for most routine applications; a fine30-gauge needle is utilized to dry the inside of root canalswhen using the nonsurgical or surgical SOM is also an efficacious method for detect-ing radicular cracks. While coronal cracks can often betreated by a well-adapted crown, radicular cracks deter-mine the prognosis of the tooth. Undetected root fracturesin large fixed restorations can initiate significant compli-cations. In such cases, the gingiva is carefully retracted,and the root surface is gently dried with the irrigator(Stropko, EIE Analytic, Orange, CA). In numerous in-stances, the width of the crack is merely that of a hairlineFigure 8. The three apical foramina were prepared with ultrasonictips and filled with 9. Case 3. Preoperative radiograph of an unsuccessfulendodontic surgery and inadequately placed amalgam 10, No.

10 1 Practical Periodontics&AESTHETICDENTISTRYand would go unnoticed without the use of the operatingmicroscope. In addition, utilization of the microscopeallows a video print to be recorded and presented to thepatient and the referring EndodonticsAccessing the pulp chamber and locating the canals con-stitute important visual phases of ENDODONTIC at this level will compromise the entire SOM identifies calcified canals and additional canalswith ease. The initial step mandates complete removalof the roof of the pulp chamber. This procedure is accom-plished by using round burs under the microscope in orderto create smooth and regular surfaces on the walls andfloor of the access cavity. The floor of the pulp chambercan then be carefully explored with a DG 16 instruments are used under the microscope tolocalize the canal orifices. The round LN bur (Dentsply/Maillefer, Tulsa, OK ) and ultrasonic tips are used in com-bination in a brush-cutting action to safely eliminate thesecondary dentin overlying the orifices.


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