THE MICROSCOPE in Practice

:
The simple premise for using the microscope is that
Light + Magnification = Ecellence!
"s some surgeons sa#$ "if you see it, you can protect it." This a%age also applies to
en%o%ontics!
"long &ith an increase in 'rightness$ a correspon%ing increase in magnification is nee%e% for
en%o%ontic ecellence!
En%o%ontic microscop# an% its implication can 'e categori(e% into si areas:
)! *iagnosis!
+! ,onsurgical en%o%ontics!
-! Surgical en%o%ontics!
.! *ocumentation an% patient e%ucation!
/! Mar0eting!
1! Re2itali(ation of #our career
" num'er of fun%amental re3uirements must 'e met 'efore master# of the use of the microscope
can 'e attaine%!
4ision$ 5in%irect 2ision6
"%e3uate illumination$ an%
Patient compliance
*iagnosis:
)! 2isuali(e the root canal s#stem in fine %etail
+! %etect the microfracture 5 fracture line in root 7 cro&n 6
-! %istinguish the floor an% %entin
.! locate small canal orifice
/! eamining %ental caries
1! eamining cro&n margins
8! o'ser2e su' 9 gingi2al %efects
:! o'ser2e comple anatomical situation
,on surgical en%o%ontics:
Access:
; larger 7 coronal more flare%
; eas# to appreciate the color change in the floor of pulp cham'er
; opening of the sclerose% canals 7 location of a'errant canal location
; allo&s more light $ thus enhance% 2ision
Examine the floor,
1 9 for orientation purposes$ use% for ultrasonic tips
)+ 9 to enhance &hat is seen in lo&er magnification
+1 9 to confirm the opening 5 M<
+
6
BMP:
; The root canal s#stem can 'e more thoroughl# 7 efficientl# cleane% 7 shape%
; Smooth glass# &alls of R!C! &alls$ criteria for root canal preparation can 'e easil#
2isuali(e%!
Obturation:
; To assess the %r#ness of the canal 'efore o'turation!
; "ssess uniform %istri'ution of sealers on the &all of the root canal %uring o'turation
; =inal eamination of root canal preparation
Other uses:
; Remo2al of pulp stones in the canal orifice facilitate% '# accurate placement of ultrasonic
tip aroun% it 7 thus pre2enting unnecessar# remo2al of ra%icular %entin!
; =or %iagnosis 7 management of perforation
; Repair '# scaling of the %efect &ith or &ithout a matri
; Locating calcifie% canals
; Retrie2al of 'ro0en %o&n or separate% inst:
Helps to see the instrument &ith in the canal 7 pin point precisel# &here to
trough &ith the ultrasonic instrument!
; management of proce%ural errors
; also helps in post remo2al
Thus increase% li0elihoo% of a successful outcome$ 'ecause it helps in locating etra canals
an% anatom# of tooth is more rea%il# 2isuali(e%!
Surgical En%o%ontics:
)! Osteotom# 5 pr>cise% 7 small 9 /mm6
Earlier
microsurger#
+! Curettage
-! "picectom#
.! Inspection of the resecte% root surface
/! *etect apical perforation
1! "pical preparation
8! Retro filling
:! Eamination of surgical site
?! I%entif# 7 mange isthmus
)@! post 9 operati2e healing 9 use of fine sutures &ith precision
; 3uic0 une2entful healing!
"pical microsurger#:
One of the most important a%2antages of using the operating microscope is in e2aluating the
surgical techni3ue! The pioneers &ho 'egan using the microscope some t&o %eca%es ago
o'ser2e% earl# on that most tra%itional surgical instruments &ere too large to 'e place%
accuratel# in small places$ or that the# &ere too traumatic &hen use% to manage soft an% har%
tissue! This le% to the %e2elopment of a microsurgical armamentarium an% the true practice of
apical microsurger#!
"pical microsurger# can 'e %i2i%e% into +@ stages or sections! These are flap %esign$ flap
reflection$ flap retraction$ osteotom#$ periapical curettage$ 'iops#$ hemostasis$ apical resection$
resecte% ape e2aluation$ apical preparation$ apical preparation e2aluation$ %r#ing the apical
preparation$ selecting retrofilling materials$ miing retrofilling materials$ placing retrofilling
materials$ compacting retrofilling materials$ car2ing retrofilling materials$ finishing retrofilling
materials$ %ocumenting the complete% retrofill$ an% tissue flap closure!
Instruments use%:
" 2ariet# of micro scalpels si(e% );/ use% for precise incision!
Comparison of the small en%s of t&o mini;Molts an% a
stan%ar% Molt +;. curette!
<la%e an% contact surfaces of the Ru'instein Retractors );1!
Impact "ir ./t an% surgical length 'ur in close proimit# to
the mental ner2e!
Mini curettes
Micro apical placement s#stem!
Comparison 'et&een micro an% macro pluggers!
"%2antages of micro surger#:
)! The remo2al of 'one o2erl#ing a root is minimi(e%
+! The periape can 'e eamine% for canal eits$ etrusion of filling materials
Pre2ious retro fills 7 a%%itional roots &ith meth#lene 'lue staining also root fractures can
'e 2isuali(e%
-! "fter resection$ anatomical 2ariation li0e isthmus$ lateral canals &ith shape% canals or fin
can 'e 2isuali(e% 7 retro prepare%!
.! Retro preparation can 'e eecute% precisel# along the longitu%inal ais of canal space 7
eten%e% to proper <ucco 9 Lingual 'oun%ar#
/! Retro filling is more precisel# %one 7 an# ecess retrofilling materials can 'e %etecte%
for remo2al
1! The marginal a%aptation of the retrofilling to the canal &all can 'e chec0e%
CL"SSI=IC"TIO, O= E,*O*O,TIC MICROSARBIC"L PROCE*ARES
5Richar% Ru'enstein an% Cim$ DOE$ +@@+$ +:6
CL"SS " CL"SS < CL"SS C

CL"SS * CL"SS E CL"SS =

Classification is 'ase% on assessment root form osseo integrate% implants treatment outcome
E Class " ; "'sence of periapical lesion$ 'ut resolution s#mptoms after non surgical
approaches ha2e 'een ehauste%!
E Class < ; Presence of a small periapical lesion an% no perio%ontal poc0ets!
E Class C ; Presence of a large periapical lesions progressing coronall# 'ut &ithout
perio%ontal poc0et!
E Class * ; Clinical picture similar to Class C &ith a perio%ontal poc0et!
E Class E ; Periapical lesion &ith an en%o%ontic an% perio%ontal communication 'ut no
root fracture!
E Class = 9 Tooth &ith an apical lesion an% complete %enu%ement of the 'uccal plate
=ocuses on preoperati2e presence a a'sence of pulpal pain an% perio%ontal %isease
(Richard Rubenstein and Kim, JOE, 2(6 2!!26
Procedure Traditional Micro surgery
I%entification of ape Sometimes %ifficult Precise
Osteotom# Large 5=F)@ mm6 Small 5= G / mm6
Root surface inspection Imprecise Precise
<e2el angle Large 5./o6 Small 5G )@o6
Isthmus i%entification ,earl# impossi'le Customar#
Retro preparation "pproimate Precise
Root en% filling Imprecise Precise!
Summar#:
Hithout a %ou't$ the greatest re2olution &ith microscopes &as in root;tip resection!
To%a#$ using the trifecta of magnification ; illumination ; instrumentation$ an ecellent$
retrogra%e$ microsurgical root;tip resection$ can 'e carrie% out un%er a surgical microscope &ith
optimal illumination an% '# using ultrasoun%;supporte% retrogra%e treatment an% a special
micro;instrument! The success rate using this metho% &as ?1!: percent &ith a mean healing time
of 8!+ months for the ?. cases o'ser2e% o2er one #ear!
,e& hori(ons &ere$ an% &ill still 'e opene% for surgical microscopes in en%o%ontics! Hithout a
%ou't$ the 3ualit# of the results &ill increase!
The goal of microscopes is to achie2e the highest possi'le precision &hile pro2i%ing maimum
protection to health# tissue! The a%2antage lies in minimal trauma to the treate% tissue an% an
increase% securit# in achie2ing the %esire% result!
=or patients$ this means less pain$ shorter healing times$ greater pro'a'ilit# of reaching the
%esire% result 5e!g! as regar%s aesthetics6 an% 'etter long;term results!
References:
)! S#ngcu0 Cim! Microscopes in En%o%ontics! *C," Iul# )??8$ 2ol .)
+! Richar% Ru'enstein an% Cim$ Dournal of En%o%onticsJ +@@+$ +:5:6$/.);.?!
-! Path&a#s of pulp! Stephen Cohen! :
th
e%ition
.! Magnification an% illumination in apical surger#! Richar% Ru'instein! En%o%ontic Topics
+@@/$ ))$ /1988
/! Cim S$ Pecora B$ Ru'instein R! Color "tlas of Microsurger# in En%o%ontics!
Phila%elphia$ H< Saun%ers$ +@@): +)9++!
1! The %ental operating microscope an% its slo& acceptance! Ho&ar% S Sel%en!Dournal of
En%o%ontics$ +@@+$2ol +: 5-6!
8! Ase of %ental operating microscope in en%o%ontic surger#! Ba'irele Pecora et al! Oral
surg$ Oral Me%$ Oral Pathol )??-$ 8/$ 8/);:!