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INTRODUCTION

"There is a thin line between excellence and perfection". Since time immemorial, dentistry in general, and endodontics in particular has strived to bridge that thin gap in the quest to achieve perfection. Brilliant developments, pains taking research and landmark break thorough have characterized endodontics relentless march towards the ideal. The development of various aids to arrive at the right diagnosis, the introduction of different armamentarium to achieve good access and thorough cleaning and shaping of canals, the advent of myriad obturating techniques and materials, and advances in surgical endodontics coupled with the explosion in the understanding of anatomy, histology, inflammation healing, host responses, microbiology pathology etc., have in

have been spawned by the constant endeavors to achieve the best

turn made the highly specialized field of endodontics extremely predictable immensely successful. Today endodontics is a highly successful widely practiced branch

of dentistry. !owever it seems to have reached a plateau, the success popularity of endodontics have brought with it numerous complications and exciting new challenges. The focus has now shifted to not "ust achieving

excellence but in achieving perfection. $t is in this scenario that the technological marvel of microscopes has blitzkrieg into endodontics. The microscope according to %merican &nglish dictionary defines it as an'( optical instrument that uses a lens or a combination of lenses to produce magnified images of small ob"ects, especially of ob"ects too small to be seen by the unaided eyes.) *icroscope has been around for a long time. $t may be surprising that the microscope is not a high+tech instrument. $t has been used in medical field for over ,- years. the microscope was first introduced to the otolaryngology around /0,-1s, then to neurosurgery in/02-1s and to endodontics in the early/00-1s. %s in medicine, the incorporation of the microscope in the clinical endodontics has had the profound effects on the way endodontics is done has changed the field fundamentally. 3or this

reason, in /004 %5% accreditation requirement change states that all the accredited 6nited States post+graduate programs must teach the use of microscope in non+surgical surgical endodontics. This was a giant step

forward in the advancement of endodontics. 7ow a days, if we wish to offer an endodontic treatment with all the problems that may be encountered such as locating hidden canals, management of calcified canals, perforation repairs, retrieval of broken

instruments, final examination of the canal preparation etc., the surgical operating microscope is an integral part of the therapy process. The microscope has opened up the hitherto hidden world and helps us visualize what till now escaped undetected. $t has literally become the third eye of the astute clinician. The range of magnification that this instrument produces enables a wide vista of versatility. 3rom the field of dental diagnosis to the intricate art of surgery, the field of restorative dentistry, oral pathology microbiology and the highly precise branch of

endodontics, every specialty is being benefited by the intricate application of this technology. 8perating microscope is the answer to the daily challenges in dentistry. There are no limits to the clinical applications in diagnosis and therapy e.g., for the removal of initial caries with maximum protection of the tooth concerned of for the preparation of gingival margins. The diagnosis with the dental microscope has attained unparalleled heights of precision. 9oming to restorative dentistry, the microscope will permit the optimum cosmetic outcome for a maximum patient satisfaction. $t gives an outstanding contrast, excellent depth orientation, and relaxed stereoscopic vision. The operating microscope can give a successful endodontics as the tooth structure and all the root canals are precisely and clearly visible. The

result: optimum therapy for conventional endodontics to microsurgical apicectomy. Thus, the exacting science of endodontics demands the utility of such high precision instrument. You can treat what you see and you wont what you dont

HISTORY OF MICROSCOPE IN ENDODONTICS


$n 1922, Carl Nylen, did the pioneering work at the university of Stockholm with the development of a monocular microscope for ear surgery. <3rom this beginning, microsurgery has spread to literally all the surgical disciplines=. $n 1953, Carl Zeiss company of west >ermany marketed the first binocular operating microscope, this historical development of operating microscopes provides an instructive perspective. $t wasn?t until 19 !, "#$%&e'ar, DMD, ( )a'$, MD, pooled their efforts to produce a 58* <5ental 8perating *icroscope= or 5entiscope. Their designs were incorporated in /04/ into the first commercially available 58* <5entiscope, 9hayes+@irginia $nc., &vansville, $7=. This two developers, in con"unction with 9hayes+@irginia, offered the first course in the clinical hands+on course for use of 5entiscope at the !arvard 5ental School, Boston, *assachusetts, on September A,th, /04A. $n 19!*, in those early years, interest among endodontists in the 58* seemed to have been spotty at the best. %s a result of disappointing sales, 9hayes+@irginia stopped selling the 5entiscope. $n Mar+& 1993, // years after the introduction of 5entiscope, the first symposium on microscopic endodontic surgery was held at the

university of Bennsylvania school of 5ental *edicine. This heralded the beginning of serious attention to 58*. By 1995, there was an obvious increase in 58* use by the &ndodontists, which was sparked in large measure by the proliferation in the /00-s of numerous commercially available scopes suitable for office use. These new scopes offered the advantage of the choice of multiple steps of magnification, as well as other sophisticated features. This led to a workshop for endodontic program directors, sponsored by the %merican %ssociation of &ndodontists <%%&=, on teaching microscopy. This preceded an anticipated ruling to mandate the scope1s inclusion in program standards by the 9ommission on 5ental %ccreditation <985%= of the %merican 5ental %ssociation. The wheels of change started to move rapidly in /00, as the %%& formally recommended to 985% that microscopy training be included in the new %ccreditation Standards for %dvanced Specialty &ducation Brograms in &ndodontics. %t the 9ommission1s Canuary /002 meeting, the proposal was agreed upon. The new standards, making microscopy training mandatory, became effective in )an,ary 199 . *icroscopy in endodontics has certainly come of age, but its gestation period was surprisingly long. $sn1t it surprising how long sometimes it takes for a new technology to take holdD That 58* is a good example of a technology that experienced a slow acceptance.

HO- OPER"TIN. MICROSCOPE -OR/S


8ne of the most important developments in endodontics has been the introduction of the operating microscope. $nitially conventional surgical telescopes or loupes were used for magnification along with surgical headlamps. They were available with limited magnification, so came the operating microscope which has a capacity of magnification ranging from Ex to E-x and beyond. The lower magnifications <A.,x to 4x= are used for orientation to the operating F surgical field and allow a wide field of view. *id range magnifications </-x to /2x= are used for conventional endodontic and surgical procedures. !igher range of magnifications <A-x to E-x= are used for observing final details. To appreciate what a 58* can do, it is important to understand how it works. The four areas to be discussed are: /. A. E. #. *agnification $llumination 5ocumentation %ccessories.

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I0 Ma1ni2i+a%i$n:
*agnification is determined by four factors, this includes: /. A. E. #. Bower of the eyepiece, The focal length of the binoculars, The magnification changer factor and The focal length of the ob"ective lens.

i0 P$3er $2 %&e eye#ie+e4 eyepieces are generally available in powers of 2.EG, /-G, /A.,G, /2G, A-G. The viewing side of an eyepiece has a rubber cup, which is turned down if the surgeon wears eyeglasses. &yepieces also have ad"ustable diopter settings. 5iopter settings range from +, to H, and are used to ad"ust for accommodation, which is the ability to focus the lens of the eyes. The ability to accommodate decreases as people age. 5iopter settings also ad"ust for refractive error, which is the degree to which a person needs to wear corrective eyeglasses. ii0 T&e 2,n+%i$n $2 %&e 5in$+,lars is to hold the eyepieces. %s in a typical pair of field binoculars, ad"usting the distance between the two binocular tubes sets the interpupillary distance. 8nce the diopter setting and the interpupillary distance ad"ustment have been made, they should not have to

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be changed until a surgeon with the different optical requirements uses the microscope. Binoculars often come in different focal lengths. $n choosing binocular focal lengths, it is important to remember that the longer the focal length, the greater the magnification and the narrower the field of view. Shorter length binoculars allow the operator to have a wider field of view and to be a little closer to the patient. Binoculars are available with straight, inclined, or inclinable tubes. Straight tube binoculars are oriented so that the tubes are parallel to the head of the microscope. Straight tube binoculars are suggested because they allow the operator to look through the microscope directly at the surgical field. &ar, nose and throat <&7T= surgeons use this system. Similar to endodontists, &7T surgeons use the chair to position the patient so that they can use direct vision while operating. The chair is placed below the operator for maxillary surgery and slightly above the operator for mandibular surgery. This allows the clinician to look down the axial plane of the root in maxillary teeth and up the axial plane of the root in mandibular teeth. Straight tube binoculars have the advantage of allowing the use of direct vision in both the arches. Straight tube binoculars gain even more versatility when a /E,+degree inclined coupler or variable inclined coupler

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is placed between the mounting arm and the microscope. This coupler provides additional axis of rotation and aligns the microscope so that straight tube binoculars provide direct vision whether the patient is sitting up or lying down $nclined binoculars are oriented so that the tubes are offset at #, degrees to the head of the microscope. $nclined binocular tubes could be used for maxillary surgery, but the operator would have to use indirect vision through a mirror or position the patient?s head sharply to the side while performing mandibular surgery. $nclinable tubes are ad"ustable between the straight tube and slightly beyond the inclined tube positions up to and sometimes beyond 0- degrees. $nclinable tube binoculars can often provide the operator with the additional postural disadvantage comfort during long procedures. The only

of inclinable tube binoculars is that they are difficult to

engineer and as such can be quite expensive. 8phthalmologists position the patient in such a fashion that the eye is always facing up. Because it would be physically impossible for them to work directly over the patient, eye surgeons use inclined or inclinable binoculars tubes so that they can approach the patient from the side.

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iii0 Ma1ni2i+a%i$n +&an1ers are available as either three or five+step manual changers or power zoom changers. Some companies also make a manual version of a power zoom changer. *agnification changers are located within the head of the microscope. % power zoom changer is merely a series of lenses that move back and forth on a focusing ring to give a wide range of magnification factors. Bower zoom changers avoid the momentary visual disruption or "ump that occurs with three or five+step manual changers as the clinician rotates the turret and progresses up or down in magnification. *agnification changer functions in power zoom microscopes are controlled by either a foot control or a manual override control knob located on the head of the microscope. The operating microscope is focused similar to a laboratory microscope. The manual focusing control knob is located on the side of the microscope housing and changes the distance between the microscope and the surgical field. %s the control knob is turned, the microscope moves ups and down along a focusing tract, and the sub"ect is brought into focus. Before the microscope can be used, it must be parfocal, meaning that it is in focus throughout the entire of magnification. $n addition, when the microscope is parfocused, accessories such as cameras and auxiliary binoculars are also in focus.

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i60 T&e 2$+al len1%& $2 %&e $57e+%i6e lens determines the operating distance between the lens and the surgical field. Iith the ob"ective lens removed, the microscope focuses at infinity and performs as a pair of field binoculars. % variety of ob"ective lens is available with focal lengths ranging from /-- to #-- mm. % /;,+mm lens focuses at about ; inches, a A--+mm lens focuses at about 4 inches, and a #--+mm lens focuses at about /2 inches. % A--+mm ob"ective is recommended because there is adequate room to place surgical instruments and still be close to the patient. 9harts are available that explain magnification as it relates to eyepiece power, binocular focal lengths, magnification factors, and ob"ective lenses. $n addition, they explain magnification as it relates to the depth of field and field of view. These charts contain valuable information that helps the clinician select the appropriate optical components to satisfy his or her requirements. The information can be summarized as follows: /. %s you increase the focal length of the ob"ective lens, you decrease the magnification and increase the field of view. $n addition, you decrease the illumination because you are the further away from the surgical field. A. %s you increase the focal length of the binoculars, you increase the magnification and decrease the field of view.

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E. %s you increase the magnification factor, you increase the magnification and decrease the field of view. #. %s you increase the power of the eyepiece, you increase the magnification and decrease the field of view. ,. %s you increase the magnification, you decrease the depth of field. %fter considering all the factors "ust described, a typical microscope package could be one with /A.,G eyepieces, /A,+mm straight or inclinable tube binoculars, a power zoom magnification changer, and an ob"ective lens of A-- mm. This package would allow the clinician to operate comfortably about 4 inches from the patient and in the magnification range of about EG to A2G. The power zoom feature would allow a smooth zoom with an 4:/ ratio. The remote foot controls would allow magnification and focus ad"ustments to be made without taking the hands or eyes away from the surgical field.

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Cal+,la%in1 %$%al 8a1ni2i+a%i$n4 The equation for calculating total magnification is:

*T J ft F fo x *e x *c
Ihere:

*T J Total magnification ft J 3ocal length of the binocular tube fo J 3ocal length of the ob"ective lens *e J *agnification of the eye piece *c J *agnification factor F factor of the magnification changer
II0 Ill,8ina%i$n:
To understand illumination, it is important to understand the path light takes when it travels through the microscope. $t has the light source with a /--+watt xenon halogen bulb. The light intensity is controlled by a rheostat and cooled by a fan. The light is then reflected through a condensing lens to a series of prisms and then through the ob"ective lens to the surgical field. The microscope has a light field width of #, mm. %fter the light reaches the surgical field, it is reflected back through the ob"ective lens, through the magnification changer lenses, and through the binoculars and then exits to the eyes as two separate beams of light. The separation of light beams is what produces the stereoscopic effect that allows the clinician to see depth of field. % beam splitter can be inserted in the path of light as it returns to the

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operator?s eyes. The function of a beam splitter is to supply light to an accessory such as a camera or an auxiliary observation tube. Because the beam splitter divides each path of light separately, up to two accessories can be added. !alf of the light is always available for the operator. $n addition to ,-:,- beam splitters, other configurations are also available. %s the magnification is increased, the effective aperture of the microscope is decreased, and therefore more light is needed. $n addition, optics absorbs more light at higher magnification. Two light sources systems are commonly available: /. The xenon halogen bulb used in a fan+cooled system and A. The quartz halogen bulb. % fan+cooled xenon halogen light system is recommended because fiberoptic cables absorb light and have a tendency to be light deficient. Ihereas the quartz halogen bulb is found in the fiberoptic light system used by ophthalmologists. $n addition, xenon halogen is lighter and warmer than quartz halogen and therefore pro"ects a brighter and warmer light against bone and soft tissues. $llumination with the operating microscope is coaxial with the line of sight. This means that light is focused between the eyepieces in such a fashion that the clinician can look into the surgical site without seeing any

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shadows. This is made possible because the operating microscope uses >alilean optics. >alilean optics focuses at infinity and sends parallel beams of light to each eye. Iith parallel light, the operator?s eyes are at rest as though he or she were looking off into the distance. Because of this, lengthy operations can be performed without eye fatigue.

III0 D$+,8en%a%i$n4
The ability to produce quality slides and videos is proportional to the quality of the magnification and the illumination systems within the microscope. The beam splitter, which provides the illumination for the photographic and video documentation, can be connected to the photo and cine adapters. The function of these adapters is to attach the E,+mm and video cameras to the beam splitter. Bhoto and cine adapters also provide the necessary focal length so that the cameras record an image with the same magnification and field of view as seen by the operator. Because the E,+mm camera gets only half the available light and because of the relative intensity of color photographic film, it is usually necessary to supplement the microscope?s lighting systems by adding a strobe over the ob"ective lens. Several strobes are commercially available and can be adapted to the operating microscope. $n contrast to E,+mm color film, videotape is an extremely sensitive format and does not need supplemental light. *any video cameras are

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commercially available. They are generally capable of capturing about E#lines of resolution. 9ameras with more resolution are available but can be quite expensive. The resolution of the video camera being used should match to the recording capability of the video cassette recorder and the resolution of the monitor. 3or example, an S+@!S format that records more than #-- lines of resolution provides a better match for a E#-+line camera than a standard @!S format, which records only AE- lines. % video monitor that can display #A- line of horizontal resolution is a good match for a E#-+line camera and S+@!S videocassette recorder. Ihen videotaping, a dental assistant can serve as video director and pause the recording if he or she thinks the picture is off center or out of focus. %n addition to the final radiograph, a video print of the complete case can be recorded. @ideo printers can readily be connected to a video cassette recorder or the video camera on the microscope. % microcomputer inside the video printer automatically analyzes the image, and prints are created in ;- seconds by a high+density sublimation dye. The video prints are # inches by 2 inches. $f desired, different images can be digitized during the surgery and later recorded on a single print. @ideo prints can be used for patient education, medicolegal documentation, or reports to referring dentists and insurance companies.

I90 "++ess$ries4

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*any accessories are made for the operating microscope. Bistol grips or bicycle+style handles can be attached to the bottom of the head of the microscope to facilitate movement during surgery. %n eyepiece with a reticule field can be substituted for a conventional eyepiece and can prove an invaluable aid for alignment during videotaping and E,+mm photography. 8bservation ports can be added to the microscope by a beam splitter and can be helpful in teaching situations. %uxiliary monocular or articulating binoculars can also be added and used by a dental assistant. %nother accessory used to facilitate an assistant?s viewing is the K95 <Kiquid 9rystal 5isplay= screen. The K95 screen receives its video signal from the video camera. Ihen viewing the K95 screen, the assistant sees exactly what the surgeon sees without having to take his or her eyes away from the surgical field. This viewing system has an advantage over articulating binoculars because the assistant does not have to move away from the microscope if it is necessary for the surgeon to move the microscope during the surgery.

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MISCONCEPTIONS ":OUT OPER"TIN. MICROSCOPES


Magnification % frequently asked question is how powerful is your ill microscopeD The question addresses the issue of usable power. 6sable power is+ the maximum ob"ect magnification that can be used in a given clinical situation relative to depth of field and field of view. %s the magnification is increased, the depth of field is decreased, and the field of view is narrowed. The question then becomes how usable is the maximum powerD *agnification in excess of E-G, although attainable, is of little value in periapical surgery. Iorking at higher magnification is extremely difficult because slight movements by the patient continually throw the field out of view and out of focus. The surgeon is then constantly recentering and refocusing the in microscope. Illumination There is a limit to the amount of illumination a surgical microscope can provide. %s magnification is increased, the effective aperture of the microscope is decreased, and therefore the amount of light that can reach the surgeon1s eyes is limited. This means that as higher magnifications are selected, the surgical field appears darker. $n addition, if a beam splitter is attached to the microscope, less light is available for the photo adapters and

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auxiliary binoculars. This is important to consider when producing E,+mm photography. Bhotographic color film is not sensitive, and it may be necessary to add a strobe to create quality images. @ideotape is significantly more sensitive than photographic film, and excellent videos can be recorded without supplemental light. epth !erception Before surgery can be performed with an operating microscope, the clinician must feel comfortable receiving an instrument from the assistant and placing it between the microscope and the surgical field. Kearning depth perception and orientation to the microscope takes time and patience. 9oordination and muscle memory are easily forgotten if the microscope is used infrequently. %s a general rule, the clinician should reorient himself or herself to the microscope before beginning each surgery. "ccess The surgical microscope does not improve access to the surgical field. $f access is limited for conventional surgery, it is even more limited when the microscope is placed between the surgeon and the surgical field. 6se of the+microscope, however, creates a much better view of the surgical field. Because vision is enhanced so dramatically, cases can now be treated with a higher degree of confidence.

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#lap esign and $uturing Leflecting soft tissue flaps and suturing them back in place are not hi magnification procedures. %lthough the microscope could be used at low magnification, little is gained from its use in these applications. The operating microscope is recommended predominately for osteotomy curettage, apicectomy, apical preparation, retrofilling, and documentation

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OPER"TIN. POSITIONS -HEN USIN. OPER"TIN. MICROSCOPE


The most appropriate operating position for a given surgeon is actually a combination on of patient head position, dental chair position, microscope position, surgeon position, assistant position, and assistant observation devices. The dynamics of each of these divisions must be thoroughly understood to arrive at operating positions that are comfortable for the patient, assistant, and surgeon (Fig. No. 8). !atient %ead !osition 7o effort should be spared to insure that the patient will be comfortable during the surgery. $n addition to profound anesthesia, attention must be given to insure that the head and neck muscles are not strained or torqued during surgery. The occlusal plane should be parallel to the floor for mandibular surgery and perpendicular to the floor for maxillary surgery. The head should be comfortably centered or slightly turned toward or +away from the surgeon. ental &hair !osition The dental chair can be maneuvered in a variety of positions. !orizontal and vertical controls position the base of the chair and back supports to regulate the distance from the head of the microscope. $n

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addition vertically positioning the base of the chair can provide room for the surgeon and assistant to position their legs. The ad"ustable headrest should be used to position the head comfortably and maintain the proper plane of occlusion. The dental chair is positioned slightly below the operator for maxillary surgery and slightly above the operator for mandibular surgery. This allows the clinician to look down the axial plane of the root and across the beveled surface in maxillary teeth and up the axial plane of the root and across the beveled surface in mandibular teeth. Microscope !osition *ost endodontists prefer an operating microscope that is mounted to the ceiling. Suspension arms support and position the microscope in horizontal and vertical dimensions. 3riction couplings position the microscope and suspension arms in an infinite number of axes within three+ dimensional space. Koosening and tightening the couplings allows for movement of the arms and flexible "oints. $nserting a /E,+degree inclined coupler between the mounting arm and the head of the microscope provides additional axis of movement and more versatiliy. %s stated earlier, Selection of binoculars is critical in determining correct microscope position. Binoculars are available as straight tubes, inclined tubes, and inclinable tubes. The surgeon should select a binocular that allows him or

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her to look down the axial plane of the root and across the beveled surface in maxillary surgery and up the plane of the root and across the beveled surface in mandibular surgery. The combination of microscope position and dental chair position places the microscope in three+dimensional space, which can be accessed by the surgeon. The microscope must be positioned to provide the necessary visual access to perform the surgery while allowing for postural comfort for the surgeon and assistant. $urgeon !osition The surgeon should use an ad"ustable operator stool. The surgeon?s thighs should beM parallel to the floor so that the large muscle groups are at rest. The surgeon?s arms should be relaxed and comfortable at his or her side. Specially designed stools are available with arm supports that can be used to provide additional comfort and minimize fatigue. The surgeon should be facing the side of the patient. This may or may not mean that the surgeon is seated on the affected side. 8ften the surgeon can accomplish the same result by having the patient turn slightly toward or away from him or her. $t has been suggested that a right handed surgeon positions himself or herself on the right side of the dental chair in all situations except during mandibular left surgeries, when the surgeon

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should move to the left side of the dental chair. 3or a right+handed surgeon. the monitor should be placed to the right and in front of the dental chair.

"ssistant position'
% well+designed microsurgery may use three dental assistants. The first assistant is primarily responsible for suctioning and is usually seated, although he or she may prefer to stand in some situations. $f seated, an ad"ustable assistant1s stool is suggested, which ensures postural comfort. The second assistant passes instruments and usually stands. This assistant is positioned next to the surgeon1s dominant side to facilitate instrument passing. $f a front delivery system is used, the second assistant can be positioned across from the surgeon and may pass instruments from the tray over the patient. The third assistant functions as a charge nurse and can leave the operatory to obtain additional instruments or materials if necessary. The third assistant is also in charge of video and photographic functions. The positions of the assistants may vary depending on their visual access and which observation devices are being used. >ood communication is essential between the surgeon and the assistants. The first or suctioning assistant must let the surgeon know if he or she does not have good visual access to the surgical field. Bositional ad"ustments may be necessary for both the surgeon and the assistants at times during the surgery depending on the location of the tooth being treated.

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"ssistant (bser)ation e)ices $n most clinical situations, the assistant has a choice of three observation on devices: articulating assistant binoculars, K95 screens, and high resolution monitors. %lthough +they provide the first or suctioning assistant with the ability to see depth of field and have the same visual acuity of the surgeon, articulating assistant binoculars have the disadvantage of being quite costly. &ach surgeon must weigh the cost benefit and ask if it is necessary for the assistant to see a stereoptic view of the surgical field. %nother disadvantage is that every time the patient moves his or her head, it is necessary for both the surgeon and the assistant momentarily to break their concentration and reposition the microscope. This canFbecome fatiguing and wasteful of time. K95 screens can be placed in line with the video camera on the microscope and mounted on a swivel arm so that it can be positioned in front of the first assistant. Similar to the articulating assistant binoculars, the K95 screen has the advantage of orienting the assistant toward the surgical field. %mong the disadvantages are the cost and the inability to see depth of field. $t has been suggested to use of high resolution monitors because of their affordability and practically. %ll three assistant have visual access to the surgery. The only disadvantage is that the first assistant must momentarily take his or her eyes away from the surgical field to view the

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monitor. 3or convenience, the monitor can be placed a mobile cart with the video printer and video cassette recorder. $n addition, a Cazy Susan can be placed under the monitor so that it can easily be turned toward the assistant. The mobile cart is usually placed at the foot of the dental chair and angled toward the center of the operatory.

O#era%in1 P$si%i$ns F$r " Ri1&%;Han<e< S,r1e$n Usin1 Fr$n% Deli6ery Sys%e8
/. *axillary left position. a. Surgeon positioned to the right and to the rear of the patient. b. 8cclusal plane perpendicular to the floor. c. Batient looking slightly to the right. d. *icroscope angled down the axial plane of the roots. e. 5ental chair position low. f. Surgeon position high. A. *axillary anterior position. a. Surgeon positioned to the right and to the rear of the patient. b. 8cclusal plane perpendicular to the floor. c. Batient looking straight ahead. d. *icroscope angled down the axial plane of the roots. e. 5ental chair position low. f. Surgeon position high. E. *axillary right position. a. Surgeon positioned to the right and to the rear of the patient.

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b. 8cclusal plane perpendicular to the floor. c. Batient looking slightly to the left. d. *icroscope angled down the axial plane of the roots. e. 5ental chair position tow. f. Surgeon position high. #. *andibular left position. a. Surgeon positioned to the left and to the side of the patient. b. 8cclusal plane parallel to the floor. c. Batient looking straight ahead or slightly to the right. d. *icroscope angled up the axial plane of the roots. e. 5ental chair position high. f. Surgeon position low. g. 3irst assistant stands or sits depending on comfort. h. $nstruments on a bracket tray behind the patient. ,. *andibular anterior position. a. Surgeon positioned to the right and toward the front of the patient. b. 8cclusal plane parallel to the floor. c. Surgeon looking straight ahead. d. *icroscope angled up the axial plane of the roots. e. 5ental chair position high. f. Surgeon position low. g. Second assistant moves to the left side of the chair to make room for the surgeon. h. Surgeon rests right arm on the operating stool armrest.

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2. *andibular right position. a. Surgeon positioned to the right and to the side of the patient. b. 8cclusal plane parallel to the floor. c. Batient looking straight ahead or slightly to the left. d. *icroscope angled up the axial plane of the roots. e. 5ental chair position high. f. Surgeon position low.

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PRERE=UISITES FOR THE USE OF THE MICROSCOPE IN NONSUR.IC"> ENDODONTICS


*ubber dam placement The placement of a rubber dam prior to any endodontic procedure is an absolute requirement for sterility purposes. This technique is being taught at all dental schools. $n endodontics. !owever, the purpose is greater. !ere, the rubber dam placement is necessary because direct viewing through the canal with the microscope is difficult, if not impossible. % mirror is needed to reflect the canal view that is illuminated by the focused light and magnified by the lens of the microscope. $f the mirror were used for this purpose without a rubber dam, then the mirror would fog immediately from the exhalation of the patient. Thus, the powerful microscope magnification and illumination would be rendered totally useless for the necessary visualization of the chamber floor and the canal anatomy. To absorb reflected bright light and to accentuate the tooth structure, it is recommended to use blue or green rubber dams. Indirect )iew and patient head position %s mentioned previously, it is nearly impossible to view the pulp chamber directly under the microscope. $nstead the view seen through the microscope lens is a view reflected by way of a mirror. To maximize the

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access and quality of the view by this indirect means the position of the patient <especially the head position= is important. The optimum angle between the microscope and the mirror is #,N and the clinician should be able to obtain this angle without requiring the patient to assume an uncomfortable position. The maxillary arch is rather easy for indirect viewing. Basically, the patient?s head is ad"usted to create a 0-N angle between the maxillary arch and the binocular. $n this position the mirror placement will be close to #,N for best viewing. Mouth mirror placement $t is always a good idea to use the best mirror for this purpose. $f a rubber dam has been placed, then the mirror must be placed away from the tooth within the confines of the rubber dam. $f the mirror is placed close to the tooth, then it will be difficult to use other endodontic instruments. Lead"usting the mirror will necessitate refocusing of the microscope making the entire operation time+consuming and, at times, frustrating. This is especially true during a lengthy perforation repair with practice, however, the Ocorrect' placement of the mirror will become automatic. $ome +ey instruments The ability to locate hidden canals is the most important and significant benefit gained from using the microscope. To do this effectively and efficiently, clinicians must use specially designed microinstruments.

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%n explorer can pick the entrance of a canal under the microscope, but negotiating the canal with a file can + be challenging because there is only a tiny space between mirror and the tooth for a finger with a file to move around. 3iles specially designed by *aileffer called micro+openers have with different sized tips and can be extremely useful. These hand+held files allow the clinician to initially negotiate the canal verifying that the )catch) is truly a canal. %fter the canal is located in this manner, clinicians can instrument the canal normally without the microscope. The use of >ates+ >lidden burs to enlarge the canal entrance prior to full instrumentation, however, can be easily achieved under the microscope, facilitating the subsequent steps of canal instrumentation.

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"PP>IC"TIONS OF OPER"TIN. MICROSCOPE


,. -ses in con)entional .ndodontics' a. Breserving tooth substance during access preparation and visualization of the canal entrances. b. Kocalization and visualization of accessory canals and locating calcified canals c. 3inal examination of the canal preparation: d. Lemoval of fractured instruments e. 8bturation with warm gutta+percha f. Lecognition and location of fractures g. Berforation repair /. -ses in surgical endodontics' a. Soft tissue management b. Loot end procedures <apicectomy with retrograde filling= c. $ntentional Leplantation

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9is,ali?a%i$n $2 %&e +anal en%ran+es: Before commencing the trepanation of a tooth, the dental practitioner should plan his treatment strategy so that as little tooth substance as possible, but as much as necessary, is removed. The preservation of a healthy tooth substance is of decisive importance for a favorable long+term prognosis. The classic access cavities still found in many of today?s textbooks must be slightly modified to take into account our current status of knowledge in this field. The trepanation opening on the maxillary / st and And molars, for example, is no longer triangular, but must be quadrangular due to fourth canal, marked as *BA, which is also frequently found. 8nly with the use of operating microscope it is possible to recognize and remove the structures that cover the fourth canal. %s the substance is ablated under direct visual control and with the appropriate magnification, it is possible to preserve the healthy tooth substance not concealing the canal entrances. %t the end of the visualization of the access cavity, the canal entrances should form the corners of the cavity. >$+ali?a%i$n an< 6is,ali?a%i$n $2 a++ess$ry +anals 4 %s it is now known that the upper /st molars have four canals in most of the cases, the search for the *BA should not be concluded until this fourth canal has been found. !owever, every endodontist must ask himself

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the question whether he has found and been able to prepare the fourth canal on every upper /st molar with or without the use of a microscope. 7eedless to say, apart from the regular anatomy in the maxillary molars, there are also irregular root anatomies. Therefore it is always good to inspect the prepared canals prior to filling in order to discover any concealed canal entrances. 3inally at this point, it can be said that the operating microscope alone cannot offer all the benefits required for success. 9anal localization or the visualization of the canal entrances is only possible with the use of ultrasonic. 8nly with its assistance it is possible to ablate material under visual control and with the appropriate magnification. >$+a%in1 Cal+i2ie< Canals The microscope has proven to be indispensable for the localization of coronally obstructed canals. There is no longer any need for guesswork when searching for calcified canals or canals occluded by restorative materials. The microscope can bring the practitioner right onto the pulp chamber floor, with high+intensity light revealing in intimate detail an area that was once under+illuminated and which required guesswork and great caution. Bractitioners can proceed with confidence and skill because they can see. Subtle and minute differences in color and calcification patterns become immediately obvious, serving as a road map in removing the

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obstructions. 3or example, fourth canals of upper molars can be localized and instrumented in minutes, using an ultrasonic retrotip and high magnification. $n most cases, the shape and orientation of the canals, and sometimes even the portals of exit, can be visualized, as well as some accessory portals of exit. The ability to sub"ect the canal space to such critical visual scrutiny is especially helpful when there are root dilacerations, mid root bifurcation or trifurcation, or sharp demarcations

or curvatures. *ore importantly, the clinician can examine and evaluate his or her own shaping skills and make rapid improvements in technique simply by observing the end result of instrumentation activities. The process of mental imaging, so necessary in developing sophisticated endodontic skills, is greatly assisted by observing, at close quarters, the final result of one?s work. Final e@a8ina%i$n $2 %&e +anal #re#ara%i$n4 $t takes a simple step to see whether the canal is completely cleaned. 6nder the microscope, a small amount of sodium hypochlorite, a popular irrigation solution, is deposited into the canal and observed carefully at high magnification. $f there are bubbles coming from the prepared canal, then there are still remnants of pulp tissue in the canal. $n short the canal needs more cleaning.

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Re8$6in1 Fra+%,re< Ins%r,8en%s Separation of an instrument inside the confines of the canal is one of the most common problems in endodontics. $atrogenic accidents of this sort sub"ect the patient and treating doctor to harmful stress level, provide the legal profession with cases and frequently lead to further damage in attempting to remove or bypass the obstruction. Traditionally, fractured instrument cases are handled by attempting to bypass the instrument with other instruments, thereby running the risk of perforation or the separation of additional instruments. 8ther methods rely on trephine burs or extractors using cyanoacrylic glue or pinch+pressure devices to remove the offending instrument. These methods are ingenious, but unfortunately the scale of these devices is often too large for the task and frequently results in perforations or gross destruction of root structure. 6sing the operating microscope and a specially designed ultrasonic unit and tips, most instruments can now be easily removed. The instrument is visualized using high magnification. Then a specialized ultrasonic tip is energized, creating a trough around the coronal Amm of the instrument. The doctor has commanding visual control at all times during this procedure, resulting in minimal loss of root dentin. %fter the troughing procedure, the instrument is vibrated with the side of the tip. $t will begin to spin and move coronally because of its

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tapered shape. $t can then be removed using microsurgical forceps that can be manipulated in the pulp chamber because of their small size. $nstruments large and small can be removed in this manner whether they are in the coronal, middle or apical third of a straight root. $nstruments separated apical to severe curvatures are not good candidates for this procedure. The important reason for the use of the operating microscope is to maximize the preservation of tooth substance. %fter all, there is little point in successfully removing the instrument if, at the same time, the root is weakened or even perforated to such an extent that its length of stay in the patient?s mouth is severely limited. O5%,ra%i$n 3i%& 3ar8 1,%%a;#er+&a: 3illing prepared root canals with warm gutta+percha only makes sense if the preparations can be made under visual control. The root filling is condensed into the apical third of the root canals using special pluggers. The microscope helps the clinicians to perform these work stages in a controlled manner at any time. Re+$1ni%i$n an< l$+a%i$n $2 2ra+%,res : The operating microscope is often very beneficial in the diagnosis of pain symptoms. $f inexplicable pain continues and cannot be eradicated by

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replacing the filling and abrasive measures, the tooth should be inspected using the highest magnification. 8ften a fracture can only be recognized by staining the tooth with methylene blue. 3or the patient the diagnosis means that the tooth has to be extracted, but it also spares him further unnecessary treatments which could not have had a successful outcome in any case, would have caused much pain and cost a considerable amount of money. Per2$ra%i$n re#air : $f a dental operating microscope is not used, perforations with serious consequences are often the result, especially when pins are being inserted. $n the past, the prognosis for these teeth was so bad that the extraction was preferred. Today, with the availability of such new materials as Bro Loot from the firm 5entsply and the possibility of using these materials more precisely under the operating microscope, we have an opportunity to save many more teeth. Ihat is important here is not only the precise application of the filling material, but also the removal of the posts, the cleaning of the tooth substance without losing even more hard tissue, and the handling of the vital tissue in the transition area. $n combination with micro+ instruments and ultrasonic attachments, the operating microscope provides with the most reliable possibility of saving the tooth.

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Mi+r$s+$#es in S,r1i+al En<$<$n%i+s


*agnification, illumination and instrumentation constitutes a microsurgical triad. The microscope and new microinstruments specific to the means of endodontic microsurgery have made the microsurgical approach reality. %pical surgery can now be performed with accuracy and predictability eliminating the guess factor inherent in conventional endodontic surgery. The introduction of the operating microscope and ultrasonic instruments has taken endodontic surgery to another level of sophistication: the microsurgical approach. *agnification, illumination, and micro+ instruments constitute a microsurgery triad. 8f all the areas in endodontics, surgical endodontics has perhaps benefited most by the introduction of the operating microscope. %lthough a comprehensive discussion of its role in surgical endodontics is beyond the scope, we can gain some appreciation of the tremendous advance this instrument has provided by considering the following uses. Surgical endodontics demands an entirely different set of skills than conventional endodontics. The clinician must have a comprehensive knowledge and understanding of the multiple parameters involved in the management of both hard and soft tissue, as well as an appreciation for the many factors involved in surgical wound healing. The operating

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microscope enhances surgical skill in both soft and hard tissue management. Kight and visibility are critical for any surgical procedure. the operating microscope provides levels of illumination and magnification that are appropriate for endodontic surgery. Surgical correction of failing endodontic treatment has a checkered history. Lecent articles place the success rate for apicoectomy at #- to 2percent. The reasons for such a low success rate are unknown and are the sub"ect of much debate and speculation within the profession. There are undoubtedly a multitude of reasons for surgical failure. 9ertainly one of the main causes of periapical breakdown following surgery is the failure to seal hermetically all portals of exit. This failure can be the result of inadequate lighting, visibility and technique. The following is a brief review of some of the errors commonly made in apical surgery and how the operating microscope can help to avoid such mistakes and raise the level of care. S$2% %iss,e 8ana1e8en%4 The most frequent error in flap management in endodontic surgery is unnecessary trauma during incision, reflection, retraction and suturing. Ihen sulcular incisions are made, frequently the sulcular epithelium is removed or crushed during the incision or elevation procedure. Breserving this tissue is probably the single most important factor in ensuring rapid wound healing. *icrosurgical scalpel blades, curved to confirm to the

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cervical contour of the tooth, enable the surgeon to make a sulcular incision without damaging the epithelial lining of the sulcus. Ihen performed under the microscope, sharp dissection and completely atraumatic elevation of the papilla and interdental col area is accomplished. Specially designed curettes allow for an undermining elevation of the flap. By elevating a full thickness flap, maximum healing and reattachment potential are preserved. Ihen the flap is handled under the microscope, the physical trauma is lessened and gentle manipulation is assured. *icrosurgical suturing techniques take advantage of smaller gauge tapered+point needles and smaller suture sizes. Sutures sizes of ,+- and 2+- are handled with ease. sutures are placed much more accurately then with the naked eye. $f one follows an atraumatic microsurgical flap management technique, sutures can be removed in A# to #4 hours, with startling healing rates evident. R$$% en< #r$+e<,res A a#i+e+%$8y 3i%& re%r$1ra<e 2illin1 B4 %lthough the introduction of the operating microscope to endodontics is new, the surgical procedures that endodontist perform have always been true microsurgical procedures. Kike other areas of endodontics, surgical endodontics is extremely technique sensitive, with only a small margin for error. Traditionally, these procedures have been done without the lighting and magnification needed to perform them properly. &valuation, preparation and filling of the root apex are a true microsurgical procedure, and simply can1t be done predictably without

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magnification. Lecently introduced optical grade micro mirrors allow the clinician to exam the beveled root apex in minute detail. The ability to observe the beveled edge of the root at high magnification brings a whole new world of detail into focus. Boorly condensed gutta+percha, leakage around the sealer voids, eccentric and irregular canal shapes,

uninstrumented isthmus areas, accessory canals and canal fins and circumferential resorption of prior retrofilling materials, all become very obvious, helping the practioner1s design and implement a corrective design to his retropreparation. Based on a large number of microsurgical inspections of failed apicoectomies, one of the most significant problems in apical surgery responsible for such a high failure rate is poor design and preparation of the retropreparation itself. Because instruments were not available to allow preparation down the long axis of the root, almost all retropreparation were placed obliquely into the root. This has the unfortunate consequence of having to rely on the axial wall of the preparation to do the sealing, when ideally it is the pulpal floor of the preparation, which should do the sealing, with the axial walls only used for retention. Because most roots sustain an exaggerated bevel at the time of their resection, the needed preparation must become broad bucco+lingually. This is exceedingly difficult to accomplish with conventional or microhandpiece preparations as one move further lingually in the crypt.

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3ortunately, the recent introduction of specialized ultrasonic tips solves this problem. 7ow retorpreparations can be placed down the longitudinal axis of the pulpal space and the preparations can be extended to the correct bucco+lingual dimension with ease. 6sing the operating microscope and retromirrors, we can now modify the bevel and section roots more perpendicularly to the long axis of the root. Ie also have the ability to inspect, prepare and seal the isthmus area between confluent canal systems. This techniques decrease the probability of lingual root perforations when the retropreparation must be extended lingually. 6ltrasonic preparations are >.@.Black+type slot preparations with parallel walls, which confirm to the anatomic reality of the root canal system. The ability to cut perpendicular to the long axis is especially helpful in cases where there is a post placed deep into the canal and where a standard bevel would expose the post and compromise the retrofilling procedure. In%en%i$nal re#lan%a%i$n4 The intentional replantation of teeth has been a part of the dental armamentarium for many years, not always with the high success rate, but rather considered as a procedure of last resort. The advent of operating microscope and its uses during replantation with the current techniques for performing intentional replantation has increased the success rate to approximately 4,P, making intentional replantation viable treatment modality. Iith the use of operating microscope during replantation one can

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be much more comfortable working in areas close to the vital anatomic landmarks because they can be seen under great illumination and magnification and therefore control their movements. Trea%8en% 3i%& an O#era%in1 Mi+r$s+$#e s%ill Cle1e ar%isDE To sum up, the use of the 8* must still be seen as )lege artis) therapy. 8r the question should be asked whether root treatment or apicectomy without the use of the microscope can still be termed as lege artis. This question is, of course, a very provocative one. !owever, a decision must be made for the benefit of patients. The top priority must be to provide them with the best possible therapy. !owever, it must not be stressed that intensive training is required for the correct use of these innovations. 9ourses are available to learn and apply these techniques. Ie should use this opportunity F technology for the sake of our patientsMQ 6ses of magnification in stages of endodontic microsurgery

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"D9"NT".ES "ND DIS"D9"NT".ES OF OPER"TIN. MICROSCOPE


"<6an%a1es4 >reater visual acuity with the operating microscope, wide range of magnifications and bright illumination allows for a higher success rate, because vision is enhanced so dramatically, cases can be treated with a higher degree of confidence and accuracyQ &arlier surgical telescopes and surgical headlamps have benefited from increased magnification and illumination, but efficient use of these aids require a steady head and only incremental movements, a difficult habit to acquire. The operating microscope, in contrast, is much easier to use, especially with a low to mid range magnification <GERG/2=Q. The important features of an endodontic operating microscope are 8ptics, *aneuverability, Stability and *odularity. 5ocumentation by means of a video camera attached to the microscope is valuable for communicating with referring dentists and for teaching patients etc,QQQ %n assistant observation scope attached to the main scope reduces the maneuverability of the operating microscope and the effectiveness of the assistant.

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The operating microscope can provide important benefits in clinical practice in the following ways: The surgical field can be inspected at the high magnification so that minute details of the anatomical structure can be identified and managed. Surgical techniques can be evaluated. 3ewer or no radiographs may be needed during endodontic surgery because the surgeon can inspect the apex or apices directly and can record the procedures. @ideo recording of the procedure can be used for patient teaching, video libraries can be made for teaching programs, video recording of different surgical procedures and techniques can be effective teaching tools. 9ommunication with the referring dentists and insurance company or companies can be improved. 8ccupational stress can be reduced, use of 8.* requires erect posture, also, the clinical environment is less stressful when clinicians can see what they are doing rather than guessing.

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/. The minimum requirements for an endodontic microsurgery are five step magnifications, a light source carried by a fiber optic cable, and a /4-+degree inclinable binocular. A. % basic surgical microscope for dentistry should have the following configuration: E. /A., G eyepieces with reticule #. /4-+degree inclinable binocular ,. 3ive step manual magnification changer or power zoom

magnification changer. 2. 3iber optic illumination system ;. %udiovisual accessories <e.g.. video camera= 4. The loupes provide magnification in the range of <GARG2=, but with operating microscope the overall magnification range is GERGE-. The low magnification <GERG4= produces a wider field of view and high focal depth. this keeps the field in focus despite moderate movements, this range therefore is useful for orientation within the surgical field and for alignment of instrument tips.

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The midrange magnifications <G/-RG/2= provides moderate focal depth. $n endodontic these are the working magnifications. they provide reasonably large magnifications. Disa<6an%a1es4 /. $t is costly A. $ts integration into the practice requires many changes in instrumentation and procedures, operating room etc Q E. The surgeon F clinician and the staff must learn the new handling and assisting requirements. #. %t the higher magnifications, the slightest movement by the patient, sometimes even simple breathing, throws the field out of view and out of focus. The surgeon must repeatedly recenter and refocus the microscope, wasting time and creating unnecessary eye fatigue and not really adding to the visibility of the surgical site.

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SUMM"RY "ND CONC>USION


The simple premise for using the microscope is that light plus magnification, equals to excellence. $t certainly makes sense that if the clinician can see something more clearly and magnified, he or she can better evaluate and treat that ob"ect. %s some surgeons say, Oif you see it, you can protect it'. This adage also applies to endodontics. *any of the clinicians who perform endodontic procedures and do not use dental microscope are still evaluating the benefits of its use. Bracticality is the key concern. !ow does one recoup the cost of the capital expenditure and the time associated with trainingD %re the clinical benefits worth the expenditure of time and moneyD To address this critical cost and efficiency issue. Ie as a clinician should take an intensive training course at the very beginning to make us more comfortable with handling the microscope and work underneath it and also become totally committed to using the microscope in each treatment cases, not "ust selected ones. Thus practice is the fastest route towards proficiency, and the best way to maximize the return on investment. $n addition to clinical benefits associated with the use of the microscope in endodontics, after the initial learning curve, endodontics procedures can be done in less time because of the greater visibility of the root canal anatomy. Brocedural errors can be greatly reduced, if not eliminated and complicated cases becomes less under the microscope.

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$n endodontics, the microscope is indispensable. 9linicians are discovering that every facet of endodontics is better, safer, and easier. The learning curve can be fairly steep, but it is one worth climbing. 3uture controlled studies should document an improvement of endodontic outcomes. This is becoming truer as dentistry becomes more extensive and expensive, and needs to last longer and longer. The days of )easy cases) are much fewer, even for the general practitioner. Kastly, there is a groundswell conversation, at least in the endodontic community, that the benefits of the microscope are beyond biology. 9linicians experience a greater sense of personal and professional fulfillment because they are not achieving what is )good enough,) but aspiring to )what is possible.) The microscope has opened up the hitherto hidden world and helps us visualize what till now escaped undetected. $t has literally become the third eye of the astute clinician. The range of magnification that this instrument produces enables a wide vista of versatility, from the field of dental diagnosis to the intricate art of surgery, the field of restorative dentistry, oral pathology and microbiology and the most important the highly precise branch of dentistry i.e. endodontics, every specialty is being benefited by the intricate application of this technology. Microscopic endodontics is a new technology that emphasi0es )isual information1 rather than tactile information.

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/. :,rley >) a% el0 &ffect of magnification on locating the *B+A canal in maxillary molars. Journal of Endodontics A--A. A4<#=: EA#+;. A. .$r<,ys,s MO, .$r<,ys,s M, Frie<8an S&i8$n0 8perating microscope improves negotiation of second mesiobuccal canals in maxillary molars. Journal of Endodontics A--/. A;: 24E+2. E. /i8 Syn1+,'0 9olor %tlas of *icrosurgery in &ndodontics. Bhiladelphia: IB Saunders 9o. A--/: #,+,-. #. /i8 Syn1+,'0 *icroscope in &ndodontics. Dent Clin North Am /00;. #/: E0/+2A;. ,. /i8 Syn1+,'0 The microscope in endodontics. Dent Clin North Am. A--#. #4: //+/4. 2. /in$8$%$ Y$&i2,8i, e% al0 8ptimal positioning for a dental operating microscope during 7on+surgical endodontics. Journal of Endodontics A--#. E-</A=: 42-+A. ;. Ra8#a<$ ME, e% al0 The benefit of the operating microscope for access cavity preparation by the undergraduates students. Journal of Endodontics A--#. E-: 42E+;. 4. Sel<en HS0 The dental+operating microscope and its slow acceptance. Journal of Endodontics A--A. A4<E=: A-2+;. 0. Sla%$n CC, >$,s&ine R), S3eller RN, e% al0 $dentification of

resected root+end dentinal cracks: a comparative study of visual magnification. Journal of Endodontics A--E. A0<4=: ,/0+AA.

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/-. -al8ann )D, e% al0 Smear layer removal with and without the 5ental 8perating *icroscope. Journal of Endodontics A--,. E/<E=: AEA. //. Y$s&i$'a T, /$5ayas&i C, S,<a H0 5etection rate of the root canal orifices with a microscope. Journal of Endodontics A--A. A4<2=: #,A+,E. /A. Zeiss Carl 4 www.zeiss.deFdentistry

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