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06AS4306 June CE Seminar 4/27/06 9:55 AM Page 2

Posture-Directed vs. Image-Directed

Dentistry: Ergonomic and Economic
Advantages Through Dental Microscope Use
By Gerard M. Cuomo, DDS

Gerard M. Cuomo, DDS, is a graduate of Northwestern

University Dental School, and is a recognized author and
lecturer on the integrated use of chair-mounted micro-
scopes in dentistry. He maintains a private practice in Boca
Raton, Florida, and teaches hands-on dental microscopy
courses for dentists and students throughout the U.S.

The modern dental practice incorporates office designs that create Mechanisms related to muscle balance can be explored by first
an "at-home" atmosphere while using "high-tech" equipment to understanding the differences between posture-directed dentistry
promote improved efficiency and increased productivity. The and image-directed dentistry as each relates to the ergonomic
purpose of this article is to analyze the ergonomic and economic well-being of the dentist. 5
advantages of the dental microscope over the now obsolete dental
"Image-directed" dentistry is associated with dental procedures
loupes. In order to appreciate the benefits of this 21st-century
performed by using a "direct line of sight." A good example of
equipment, one must understand the distinctions between
"image-directed" dentistry is the dentist viewing an oral image by
posture-directed and image-directed dentistry.
using dental loupes (Figure 1).
The term "ergonomics" is the applied science of equipment design
for the workplace with the intent of enhancing productivity by
reducing operator fatigue and discomfort. An ergonomically
designed product implies that a device must blend smoothly with
a person's body and actions. To understand equipment design,
one should initially recognize the fact that certain risk factors such
as poor body positioning and its related repetitive movements can
alter the ergonomic purpose, thus contributing to pain and injury
over time to various parts of the dental professional’s body.
Musculoskeletal disorders such as herniated discs of the lower back
and rotator cuff impingement are the end products of trying to
work more efficiently while ignoring the proper pathways to
maintain muscle balance. 8,9
Figure 1

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06AS4306 June CE Seminar 4/27/06 10:39 AM Page 2

In this instance, the eyes are looking directly at the image through "Posture-directed" dentistry is associated with dental procedures
various lenses aligned with one another attached to a frame. The that are performed by using an "indirect line of sight." 5 The best
head posture of the loupe wearer remains in a constant tilt position way to achieve "posture-directed" dentistry is by viewing an oral
with the chin angled downward. Typically, the dentist’s head image using a dental microscope (Figure 4).
moves toward the image to find and maintain focus at a set focal
As the image moves out of focus, it is only natural for one to
refocus by moving their head back inline with the image. As the
need to increase magnification becomes apparent when going from
2.0X to 6.0X, the loupe lens size becomes larger and heavier while
the field of view becomes smaller. Dental loupes add an additional
amount of weight to the front portion of the dentist’s head,
therefore requiring straps to secure the loupes to the back side of
the head to maintain stability. 1-2,5,7 In other words, the image
dictates the movement of the dentist’s head, as shown below

Figure 4

Here the eyes are looking indirectly at the image through various
lenses and prisms aligned with one another and supported by a
mechanical arm apparatus. It is the use of the microscope’s
inclinable binocular eyepieces that permit the dentist to raise his or
her chin in a more level position. The optics of dental microscope
bend the path of the image to almost 90 º, allowing the dentist to
sit comfortably erect with the head, neck, and back arranged in a
straight line when viewing an object. 3,10
Posture-directed dentistry also includes several techniques for
maintaining focus. The simple method of reclining the patient’s
head backward into a more healthy ergonomic working position
helps to form the foundation of the workplace. Posture-directed
dentists rest their patients in the supine position for maxillary arch
procedures and in a semisupine position for mandibular arch
procedures. The dentist’s seating zone is usually in the 11 and 12
o’clock positions (Figure 5).

Figures 2 & 3

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9 3

Figure 5

This ergonomic positioning helps the dentist avoid twisting and magnification from 2.0X to 20X.6 In addition, the hands, the
turning movements when using the microscope and receiving hand forearms, and the shoulders are often well supported by stools with
instruments. As the image moves out of focus, the dentist relies built-in adjustable arms. In order to achieve posture-directed
more on verbal commands directed toward the patient to move the benefits, the dentist must first be willing to accept the need for
image back into focus (Figure 6). 2,3,5 change and give up old image-directed bad habits.
Other focusing methods of posture-directed dentistry include use Dental school undergraduate curriculums teach image-directed
of the dental microscope’s fine-focus adjustment when changing techniques. Today’s dental students migrate from using no
magnification to using dental loupes during their four years of
undergraduate studies. The combination of using dental loupes
with only limited four-handed dentistry available creates a breeding
ground for the formation of bad habits. Based upon this fact,
image-directed habits are primarily formed in dental schools and
continue to shape the ergonomic foundation of the dentist’s method
of practice.
Postgraduate endodontic curricula currently accept and require
microscope proficiency of graduate students. Even though posture-
directed dentistry has minimal acceptance in dental school
restorative curricula, one can anticipate a change will occur with
the increasing number of practicing dentists transitioning to dental
microscopy. 4
At the time this article was written, pre-dental students attending
Florida Atlantic University participated in their first hands-on
dental microscope course without having any previous dental
microscope experience. Each of the four students was given a molar
to perform a root canal. They were then instructed to restore the
same tooth using current composite modalities.

Figure 6

06AS4306 June CE Seminar 4/27/06 9:55 AM Page 4

Figures 7 & 8

These new generations of students are more open to accepting It is this combination of microscope optics and video that have a
advances in technology. Following the single-tooth exercise, each tremendous effect on the profitability of the dental business.
student was asked to prepare teeth on the mannequin’s head Dental assistants and patients now have a front row seat to viewing
(ergonomically placed) in the dental chair using the various the dentistry being performed at several levels of magnification
posture-directed techniques previously discussed in this article. (Figures 9 and 10).
The end result indicated that all four pre-dental students had
Dentists who use microscopes are able to see more and do more
achieved an acceptable basic level of proficiency within four hours
dentistry. One can detect early crack formation which will
by using the dental microscope (Figures 7 and 8).
ultimately determine the type of restoration to be placed. 4,11
This exercise clearly supports the "law of primacy" which states, Dentists are able to find hidden calculus around margins much
"Things first learned are best remembered." more precisely prior to impression taking. They are able to make
more accurate determinations on whether to use sealants, flowables,
Despite the fact that many innovative ideas such as computer
or composite resins for conservative dentistry. Final preparation
software and hardware, digital X-rays, automated perio-probes, and
design can be easily placed without compromise.11,12
image capturing devices have helped to modernize the dental
industry by saving time, none of them have had as much ergonomic Today’s dental microscopes can be mounted via ceiling, wall, or a
effect on dentists than that of the dental microscope. 10 Use of a more ergonomic space-saving chair-mount. Aside from ergonomic
dental microscope improves the dentist’s overall performance. advantages, the dental microscope user enjoys shadow-free coaxial
lighting and the ability to detach and transport the microscope
Connected to flat-screen monitors located in each operatory, the
head between workstations and office (portability).
dental microscope visually adds a whole new dimension for
viewing and recording real-time images. In summary, vision in dentistry makes up the very fabric that
determines how successful we become as dentists. It is our choice

06AS4306 June CE Seminar 4/27/06 9:55 AM Page 5

Figure 9 & 10

to practice with either yesterday’s technology, or wake up to the

advances of the 21st century with an exciting new way to practice
dentistry. Current and incoming students are more tech savvy than
previous generations. Not only do they accept new technologies,
but they go out of their way to look for them. Having been
exposed early to eye-hand coordination teaching tools such as Play
Stations and Xboxes, their skills have been honed, and they are
ready to take on advanced magnification methods.
Experienced dentists need not fear this new technology either.
Technology should be embraced as an opportunity rather than an
impediment. With proper instruction, repetition, and a
willingness to learn, the practicing dentist can enjoy all the benefits
of the dental microscope. Posture-directed dentistry is the logical
progression for the industry. Those who make the transition to
microscopy early on, will realize the distinct advantage they have Dr. Cuomo & students
over those who have not made similar choices.

The author acknowledges Gerard J. Cuomo (writing consultant),
Maria Martinez (dental assistant), and Florida Atlantic University
(pre-dental students): Ashley Millstein, Salvatore Colombo, David
Miller, and Justin Grossmayer.

06AS4306 June CE Seminar 4/27/06 9:55 AM Page 6


1. Friedman MJ. Magnification in a Restorative Dental Practice:

COURSE SPONSOR From Loupes to Microscopes. Compend Cont Educ Dent 2004;
Sullivan-Schein is course sponsor. Sullivan-Schein’s ADA CERP 25:48–55.
recognition runs from November 2001 to June 2006.

2. Sheets CG, Paquette JM, Hatate K. The Clinical Microscope in

All participants scoring at least 80% on the examination will receive a an Esthetic Practice. J Esthet Restor Dent 2001; 13:187–200.
certificate verifying 2 CEUs. The formal continuing education program of
this sponsor is accepted by the AGD for Fellowship/Mastership credit. 3. Friedman MJ, Landsman HM. Microscope-Assisted Precision
The current term of acceptance extends from December 2001 to June
(MAP) Dentistry – A Challenge for New Knowledge. J Calif Dent
2006. Participants are urged to contact their state dental boards for
continuing education requirements. Assoc 1998; 26:900–905.

PARTICIPANT FEEDBACK 4. Garcia A. Dental Magnification: A Clear View of the Present and
If any participant wishes to communicate with the author of this course, a Close-up View of the Future. Compend Cont Educ Dent 2005;
please direct questions to Sullivan-Schein by fax at 1-800-781-6337.
Be sure to provide us with the following information: name, address,
E-mail address, telephone number, and course completed.
5. Cuomo GM. A Fresh Look at the Biomechanics of Advanced
COURSE EVALUATION Magnification. Dent Econ 2004; 94:66–69.
We encourage participant feedback pertaining to all courses. Please be
sure to complete the attached survey included with the answer sheet. 6. Nase JB. Enhanced Vision in the Improvement of Patient Care.
Dental Collab 2005; 2:19–20.
Sullivan-Schein maintains records of your successful completion of any 7. Pace SL. Seeing Through the Eyes of Magnification. Contem
CE Seminars. Please contact our offices at Sullivan-Schein,
Attn.: CEHP, 26600 Haggerty Rd., Farmington Hills, MI 48331,
Dent Assist 2005; 2:14-18.
by mailing a note requesting a copy of your continuing education credits
report. This report, which will list all credits earned to date, will be 8. Valachi B, Valachi K. Mechanisms leading to Musculoskeletal
generated and mailed to you within five business days of receipt.
Disorders in Dentistry: J Am Dent Assoc 2003; 134:1344–1350.
9. Valachi B, Valachi K. Preventing Musculoskeletal Disorders in
The opinions of efficacy or perceived value
of any products or companies mentioned in this course and expressed Clinical Dentistry: J Am Dent Assoc 2003; 134:1604–1612.
herein are those of the author and do not necessarily reflect those of
Sullivan-Schein. Completing a single continuing education course does 10. Kotlow LA. Using a Dental Operating Microscope in a
not provide enough information to make the participant an expert in the
Pediatric Dental Practice: Compend Cont Educ Dent 2004;
field related to the course topic. It is a combination of many educational
courses and clinical experiences that allows the participant to develop 25:482–488.
the skills, broad-based knowledge, and expertise related to the subject
matter. 11. van As GA. The Use of Extreme Magnification in Fixed
Prosthodontics. Dent Today 2003; June:93–99.
The cost for this course is $55.00. Any participant who is not 100%
12. Clark D. Do Traditional Sealants Have a Place in the New,
satisfied with this course can request a full refund by contacting:
Sullivan-Schein Super-Magnified World? Dent Today 2004; Sept:92, 94–98.
Attn: CEHP
26600 Haggerty Road
Farmington Hills, MI 48331

06AS4306 June CE Seminar 4/27/06 9:56 AM Page 7

Continuing Education Test Questions

1. The term "Ergonomics" includes the following except: 7. As the need for increasing magnification becomes apparent,
a. increased productivity dental loupe lenses become larger and heavier, while the
field of view becomes smaller in size.
b. equipment design for the workplace
a. True
c. can not be altered by poor body positioning
b. False
d. reduced body fatigue

8. "Posture-directed" dentistry includes the following except:

2. Which of the following regarding "image-directed"
a. positioning the patient and the dentist into a healthy ergonomic
dentistry is correct? zone
a. "image-directed" dentists use dental microscopes b. dentist’s seating zone is in the 11 and 12 o’clock position
b. "image-directed" dentist’s head posture is in constant tilt c. utilizing verbal commands to move the patient’s head
d. constant movement of the microscope head
c. "image-directed" dentists view oral images using dental loupes
d. b and c
e. all of the above 9. Dental microscopes are mandated in all endodontic
postgraduate curricula. Students must demonstrate
proficiency using the dental microscope before receiving
3. "Image-directed" habits are first learned in dental school their degrees.
undergraduate curricula. a. True
a. True b. False
b. False
10. Dental loupe wearers often refocus an image by moving
4. Which of the following regarding "posture-directed" dentistry their head toward the object.
is correct? a. True
a. "posture-directed" dentists use "direct line of sight" b. False
b. "posture-directed" dentist’s head is in an upright position
c. "posture-directed" dentists use microscopes that only mount to 11. All of the following are correct regarding the pre-dental
the wall hands-on exercise noted in this article except:
d. b a. each of the students explored molar root canals
e. b and c b. each of the students successfully prepared teeth on a
mannequin’s head using posture-directed techniques
5. Dental loupes add weight to the front side of the dentist’s c. each of the students achieved an acceptable basic level of
head and need straps. proficiency using the dental microscope in four hours
a. True d. each of the students performed image-directed dentistry
b. False

6. Which of the following is correct regarding the dental

a. chair-mounted microscopes contain a series of prisms and
lenses that attach to the dentist’s head
b. chair-mounted microscopes demonstrate "indirect line of sight"
c. chair-mounted microscopes have inclinable binocular
d. b and c
e. all of the above

06AS4306 June CE Seminar 4/27/06 9:56 AM Page 8

Posture-Directed vs. Image-Directed Dentistry:

Ergonomic and Economic Advantages Through
Dental Microscope Use By Gerard M. Cuomo, DDS

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