GeneralDentalPractice

Stephen J Bonsor

The Use of the Operating Microscope

in General Dental Practice Part 1:
Magnification in General
Abstract: An increasing number of clinicians are using magnification to facilitate their vision when carrying out dental examinations and
treatments. The use of an operating microscope in some dental specialties (such as endodontics) is now commonplace and there is also
a role for this equipment in branches of general dentistry. This paper, the first of two, reviews the many advantages of using an operating
microscope and offers practical advice on how the interested clinician may embark on using such an instrument by discussing the
equipment required. The second paper will focus on the potential uses for the operating microscope in general dental as well as
specialist practice.
Clinical Relevance: The operating microscope enhances the dental surgeon’s vision, potentially improving treatment outcomes not only in
specialist fields, such as endodontics, but also in many of the disciplines that general dental practice encompasses.
Dent Update 2014; 41: 912–919

The benefits of using magnification for
clinical diagnosis and during operative
procedures has been recognized for
many years, both in dentistry and in
other surgical disciplines.1 Whilst the use
of magnification by dental clinicians has
become more commonplace in the last
20 years or so, there is one report in the
literature on the subject which dates back
to 1947,2 illustrating that an appreciation
of the benefits that enhanced vision
affords is not a recent development.
Magnification aids commonly used
by dentists are loupes or an operating
microscope.
Stephen J Bonsor, BDS(Hons),
MSc, FHEA, Honorary Fellow,
University of Edinburgh, GDP,
The Dental Practice, 21 Rubislaw
Terrace, Aberdeen, UK.
912 DentalUpdate December 2014
Advantages of magnification
There are many advantages
of utilizing magnification in clinical
dentistry. First, and most obviously, the
clinician enjoys improved vision with
respect to clarity (detail) and definition
of the image as the image is larger and
therefore easier to see. This reduces
operator eye fatigue and so eye strain is
minimized. Furthermore, as the eyes are
covered they are protected from airborne
foreign bodies and aerosols which may
be created during operative procedures.
Secondly, owing to their design, most
optical aids force the clinician to sit in
a more comfortable and ergonomic
position, otherwise the object will be out
of focus. This has the effect of reducing
neck and back strain of both the dentist
and dental nurse due to their improved
posture. Thirdly, there is evidence
that magnification gives the clinician
the ability to perform more precise
work,3 both in diagnosis and operative
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interventions. Better treatment outcomes
with respect to quality, predictability
and longevity can therefore result, with
a commensurate increase in job interest
and satisfaction for all members of the
dental team.
Importance of illumination
To improve the operator’s
vision further by complementing this
magnification, good illumination is
essential. Increased illumination causes
the iris to constrict which increases the
operator’s depth of vision by up to 33%.
Resolution of detail is also enhanced
and so eye fatigue is also reduced. A
properly angled light source will ensure
that the clinician is never working in a
shadow so that he/she has an optimum
freedom of movement and with it the
correct working posture and position.
Good illumination is especially important
when performing highly detailed

work. For this reason, both loupes and
microscopes intended for dental use
utilize a light source which either comes
as an integrated feature or may be added
to the system as an accessory. However, it
is important that the light intensity is not
too powerful as this can lead to eye strain
and fatigue and may cause after-images,
like a camera flash effect. The hue (colour)
of this light may also detrimentally affect
the actual appearance of tooth structures
and soft tissues and the clinician should
be mindful of this possibility.
Loupes
The most commonly used
magnification aid in dentistry are
(binocular) loupes (Figure 1) and these
instruments are most dentists’ first
experience of magnification.1,4 It is
important to note that eyesight will not
be damaged by wearing loupes; they will
in fact lessen eye strain and reduce eye
fatigue.
Loupes are lenses either
inset into (‘through the lens’), or are
flipped down over, the protective
spectacles of the operator. These can
offer a magnification from x2 up to x6.5.
The ‘through the lens’ models require
the interpupillary distance and working
distances (dentist’s eye to patient’s
mouth) of the wearer to be measured
with the result that a customized
instrument is produced. This ensures that
the dentist is forced to sit correctly, which
is advantageous as mentioned earlier. The
‘flip-up’ models are recommended when
it is important for the operator to switch
(often) between magnification and the
naked eye.
The optical systems most
commonly utilized in dental loupes are
Keplerian and Galilean. The former allows
greater magnification with edge-to-edge
clarity, whereas the latter is a telescopic
lens arrangement enabling optimum
depth of field and field of vision. The
detail regarding dental loupes is outwith
the scope of this article and so the
reader is referred to other papers and, in
particular, a review done by Shanelec.5
Many models are compatible
with a headlight which may also be
purchased (Figure 1). The original light
source was a halogen bulb which had to
December 2014 DentalUpdate 913
GeneralDentalPractice
be housed in a bulky mains-powered  Neurosurgery;9
unit on an adjacent work surface as the  Plastic surgery;10 and
large amount of heat energy produced  Vascular surgery,11 amongst others.
by the bulb had to be dissipated by Their use offers the
means of a cooling fan. The light was advantages of loupes but on a much
transmitted to the headlight by an larger scale. The ability of the surgeon
umbilical fibre-optic cord. Unfortunately, to perform procedures which require
these cords were readily damaged fine detail is therefore increased.7,12
during usage. The constant daily use This results in fewer post-operative
of these bulbs caused deterioration of complications with an improved surgical
the output of the halogen bulb with outcome.10 This has been extrapolated
time and their longevity was poor. Light to dentistry13 with the result that the use
Emitting Diodes (LEDs) are now used in of operating microscopes is becoming
preference and these offer a number of more widespread, both in general dental
advantages: practice and in various dental specialties.
 They require less power;
 The power source may be derived
Features
from a battery or batteries;
The operating microscopes
 These cells are housed in a battery
used in dentistry have many features.
pack which is clipped on to the belt
Each magnification setting is called
of the surgeon rendering him/her the
a step. For example, a five-step
freedom to move around unrestricted;
microscope would have settings at,
 The unit is light in weight and so
for example, x3, x5, x8, x13, x20 (Figure 2).
comfortable for the clinician to wear;
 The operating wavelength of the LEDs
can be more precisely controlled so that
premature curing of resin composite can
be reduced by moving the operating
wavelength away from 470 nm, the
optimum curing wavelength for most
light-cured dental materials;
 They have various intensity settings
for optimum working conditions and
offer exceptional brightness of daylight
colour temperature;
 They do not need to be cooled in
the same way as halogen bulbs and
therefore no (bulky) fan is required.
It is true to say that, once Figure 1. An example of magnifying loupes
clinicians become accustomed to using (Orascoptic, Middleton, WI, USA). Note the
magnification, they will find it virtually headlight mounted on the loupes.
impossible to revert back to using the
naked eye. This, in many cases, will
stimulate an interest and curiosity
to increase magnification further as
they appreciate the many benefits for
themselves. The next step is to use an
operating microscope.
Operating microscope
Operating microscopes
have been used for some years in many
branches of surgery. These include: Figure 2. A dial used to select the magnification
 Dermatology;6 required. This product is a five-step microscope
which, in this case, corresponds to magnifications
 Ophthalmics;7
of x3, x5, x8, x13 and x20.
 Orthopaedics;8
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GeneralDentalPractice
Clearly, it is critical that the optics afford
the clinician excellent vision. Clarity
of view, good contrast and depth
perception are all therefore important,
as is wide-field stereoscopic vision, all
for obvious reasons. It is advantageous
for an apochromatic lens system to
be used as this eliminates chromatic
aberration. This is the phenomenon of
different colours focusing at different
distances from a lens. Apochromatic
lenses are designed to bring three
wavelengths (typically red, green and
blue) into focus in the same plane
to correct this phenomenon. Other
optical features may be present on
some instruments. These include wide
field, adjustable cup eyepieces with
dioptre settings. These are suitable
for prescription and discrepancy non-
prescription wearers, so allowing
the operator to wear prescription
spectacles, if necessary, or safety
glasses if no prescription is required.
A motorized zoom and autofocus may
also be available. Adjustment of focal
lengths (including a range of focal
lengths) is advantageous as it will allow
the operator to work at his/her ideal
working distance. Some products now
incorporate lens arrangements which
give an increased depth of field. Most
final objectives have a depth of field
of approximately 30 mm and therefore
any increase results in better posture
and obviates the need for continuous
repositioning of the microscope for
gross focusing.
The importance of good
illumination was discussed earlier and,
with microscopes, this is provided by
a co-axial radiating light source which
will provide a shadow-free light. If the
bulb is halogen, then a back-up bulb
should be available and easy to switch
to if the one being used fails during the
procedure. Often, xenon sources are
now commonly used which provide
light which is equivalent to ‘daylight’.
As mentioned earlier, colour filters may
be incorporated. An orange filter will
remove the specific wavelength of light
which initiates the setting of light-cured
dental materials, whilst green makes a
surgical site easier to visualize, known as
‘red free’.
To ensure maximum comfort
914 DentalUpdate December 2014
for the operator, inclinable binoculars nurse to watch the procedure in real
are often provided to minimize neck time (Figure 3). This will enhance a
and back strain. Some microscopes dental nurse’s interest in his/her work
have a motorized positional mechanism and will improve his/her ability to
which facilitates the adjustment of assist the dentist. Some operators
the microscope during use so that the mount a television screen on to the
operator does not need to exit the mouth ceiling above the dental chair so
to adjust the position of the microscope. that the patient may also watch the
This is more efficient and results in less procedure. The advantage of this is
eye strain as the need to accommodate that the patient’s head is kept still as
the eyes is much reduced. there is no temptation for them to look
Many microscopes are at the screen intended for the dental
available with a choice of mounting: nurse, so moving the head out of the
wall, ceiling or on a moveable stand. operator’s field of view. Any movement
The decision between a wall or ceiling (particularly at a higher magnification) is
mounting will depend on the dimensions both counterproductive and annoying
of the surgery: how much space is from the operator’s perspective. In the
available, the height of the ceiling, or experience of this author, patients react
the distance from the nearest wall. A to the ability to view their treatment
ceiling mount may not be advisable if in usually one of two ways: they either
the room above the surgery is populated find the experience very interesting
as vibrations from people walking about or highly disconcerting. It is therefore
may cause the microscope to move, so advisable to ask patients whether they
adversely affecting its use. A high ceiling, wish to watch or not and adjust the
for example in older buildings, may also television accordingly. The availability of
preclude the use of this mounting type.
The moveable stand offers the advantage
that the microscope is portable and may
be used in more than one surgery in the
practice or clinic.
Ideally, the microscope should
allow the mounting of a (digital) camera
on the microscope, by means of a lateral
output port and beam splitter, or have an
inbuilt camera. This allows still or video
photography to be done and allows
real time viewing for the dentist, dental
nurse and possibly the patient. The many
advantages of this are discussed later in Figure 3. A television screen may be mounted in
detail. the direct line of vision of the dental nurse so that
It is important to note that she may watch the clinical procedure in real time.
not all of the features listed above may
be available on every instrument, with
some only being available on the higher
specification models.
The use of photography and
video
A good quality digital camera
is strongly recommended to be used
in conjunction with the microscope.
This camera is connected to a monitor Figure 4. A vesicular-bullous lesion on the left
or PC by means of a USB or HDMI or lateral border of the tongue captured using an
operating microscope, allowing more meaningful
incorporated into the microscope. This
future monitoring by the dentist or a better
will permit a television screen to be
quality referral to another colleague.
placed in direct eye line for the dental
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a camera also allows the dentist to record
material,14 so enhancing the quality of the
clinical records. Whether this is captured
as stills or video footage, it may be used
in many ways. The information can be
digitally attached to the patient’s clinical
notes with the result that, for example,
both hard and soft tissue lesions may be
more easily monitored over a period of
time (Figure 4), or sent electronically to
another colleague if the patient is being
referred for further advice or treatment.
Other information may be captured
and stored which may not be seen
subsequently, such as a fracture line on a
cavity floor which has then been restored
(Figure 5). The recording and retention of
such material may also be useful from a
Figure 5. A hairline crack at the base of a cavity
which has been captured to enhance the clinical
notes to show position and extent as it will not
be evident after restoration of the cavity.
Figure 6. A radicular fracture of an upper incisor
tooth which previously supported a post crown
restoration. The presence of the fracture may be
shown to the patient so facilitating a less abstract
discussion of the clinical problem.
December 2014 DentalUpdate 917
medico-legal perspective as evidence of
a particular situation or as justification for
a decision.
Many colleagues use images
as a patient education tool with the old
adage of a picture painting a thousand
words being very true. The ability to
show and explain clinical photographs
to patients can engage them far more
in their treatment, so making any future
discussion of treatment options more
meaningful and less abstract (Figure 6).
The critical importance of prevention in
clinical dentistry can never be stressed
enough and clinical photographs are an
effective motivational and educational
tool. The obvious example would be
to show a patient the presence of
Figure 7. A clinical photograph of a heavily
restored upper molar tooth. This image may be
shown to the patient and will facilitate discussion
of the treatment options.
Figure 8. Examples of bespoke intra-oral
instruments which are used in combination
with the operating dental microscope. From
left to right: micro-mirror, endodontic file
holders, microsurgical scalpel blade handle and
microsurgical suturing forceps and needle holders.
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GeneralDentalPractice
plaque in an area difficult to see and to
demonstrate the appropriate cleaning
technique. Clinical photographs can
also be used to demonstrate a particular
clinical situation (for example, a heavily
restored tooth) and to recommend a
particular treatment (in this example,
the provision of a crown) (Figure 7).
Documentation of clinical cases may
be used by the dentist as a portfolio of
evidence to be submitted as case reports
for qualifications such as postgraduate
degrees. Likewise, the information may
be used for publication in journals, such
as case reports or research, as a teaching
tool to professional colleagues, or as a
library of the dentist’s work to be kept for
his/her own interest.
Instruments
Various instruments are
available which are specifically designed
to be used intra-orally in combination
with the operating microscope. These
instruments are essential to achieve
the full advantages of a less invasive
procedure15 and also to decrease the
potential for other objects (such as the
fingers of the operator) to obstruct the
line of vision. Examples include:
 Very small-headed micro-mirrors;
 Microsurgical scalpel blades;
Figure 9. Diagrams to illustrate the difference
between a front surface and conventional (second
surface) mirror. The upper diagram shows the image
being reflected from the surface unaltered, whereas
in the lower the image reflects from the surface and
internally within the front glass so ‘ghosting’ (a faint
reflection from the first layer) occurs.
 GeneralDentalPractice
 Suturing instruments;
 Longer-shanked burs; and
 Endodontic file holders (Figure 8).
Front surface dental mirrors
are recommended as they produce a
clearer single image, unlike conventional
mirrors. A front surface mirror is a mirror
with the reflective surface being above a
backing, as opposed to the conventional
mirror with the reflective surface behind
a transparent substrate such as glass. The
‘silvering’ on a dental front surface mirror
is usually aluminium. No ‘ghosting’ effect is
seen with the front surface mirror, unlike
the conventional mirror (Figure 9).
Ultrasonic instruments are
commonly used in conjunction with
the operating microscope as their use
permits much more precise usage than
conventional rotary instrumentation.
A more conservative preparation can
therefore be achieved both of tooth tissue
during a dental procedure and bone
removal during a surgical procedure.
Figure 10. The dentist and dental nurse sitting
in the normal operating (close support) position.
Note the supine position of the patient.
Figure 11. The dental nurse guiding a sharp
instrument into the mouth to avoid inadvertent
injury to the patient as the operator is unable to
see this region when looking down the eyepieces
of the microscope.
918 DentalUpdate December 2014
Operating position
When dentists work on a
patient with an operating microscope,
they require extra chairside help from
the dental nurse. The dentist and dental
nurse should sit as they would when
‘close support (four-handed)’ dentistry16,17
is being practised (Figure 10). Both the
dentist and dental nurse should be seated
with their backs straight and their knees
bent at a 110° angle with their feet flat
on the floor. Furthermore, their legs are
intertwined, so permitting them both to
sit closer to the head of the patient. It is
recommended that the dentist’s stool is
supplied with arm rests to reduce fatigue.
This may also reduce any tremulous
movement as the arms are more able
to relax, particularly during a long
procedure.
The patient is placed in
the normal supine operating position
(Figure 10). The dental team’s vision may
be improved by asking the patient to
Figure 12. The dental nurse may retract the oral
soft tissues using an aspirator and a 3 in 1 syringe
which is also used to blow air on to the dental
mirror to prevent it from fogging.
Figure 13. A cover should be placed over the
microscope when not in use to protect it.
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move his/her head from side-to-side
or by tilting the head up and down.
Should the operator find that he/she
has to crane the neck to look into the
eyepieces then the dental chair may be
lowered to facilitate vision and reduce
neck strain. Clearly, those patients who
are unable to be placed in the supine
position, for whatever reason, would
not be candidates for those procedures
which require an operating microscope.
The proximity of the dentist
and dental nurse facilitates their
ability to see and to pass instruments
between them. This is particularly
important when the microscope is
being used. To avoid eye fatigue by
constant accommodation between
near and further away objects, the
operator should only look down the
eyepieces. The help of the dental nurse
is invaluable to guide instruments into
the hand of the operator and then
into the patient’s mouth and thus into
view (Figure 11). Clearly, this is most
important when sharp instruments are
being handled, such as dental probes
(explorers), needles or scalpel blades.
The role of the dental nurse in the
retraction of the oral soft tissues to
improve access and vision is also critical.
This may be done by the dental nurse
holding the aspirator in one hand and
the 3 in 1 syringe in the other. Both
these instruments may be used to
retract the soft tissues, with the 3 in 1
syringe being used to blow air on to the
dental mirror to prevent fogging (Figure
12).
Maintenance and care
Just like any other piece
of dental equipment which is used
frequently, it is wise to have the
microscope serviced annually. Fixing
bolts and screws can work loose from
regular movement during usage and
other problems, such as the microscope
‘drifting’ or rubber eyepieces perishing,
can occur over time. Regular servicing
will minimize problems, which can be
highly inconvenient should a problem
occur unexpectedly. It is sensible
to ensure that, when purchasing a
microscope, that the vendor company

is willing to provide such a service or
can recommend another which can. The
unwillingness or reticence of a vendor
to provide this service may influence
the decision of the dentist to buy from a
given company. Sadly, some companies
are very keen for the sale then let
themselves down with their after sales
service. Customers should therefore be
wary and satisfy themselves that back-up
is in place with respect to maintenance
and breakdown.
The optics of the microscope
should be looked after carefully.
Cleaning of the various lenses and
glasses should only be done using
products recommended for such use,
otherwise scratches may result which will
compromise the optics. These products
may be purchased at opticians’ shops.
When not in use, the microscope should
be kept covered to reduce any dust from
the atmosphere falling on to the glasses
(Figure 13).
Costs and finance
As would be expected, an
operating microscope is an expensive
item. The initial outlay (purchase price)
can start from approximately £5000, rising
steeply for top of the range models. Many
companies (both microscope vendor
companies and specialist dental finance
houses) offer finance to allow the practice
to pay for the equipment over a period of
months or years, so spreading the cost of
the initial outlay. This should be viewed as
an investment with a return being realized
over a period of years. This is not only
in financial terms, but also clinically and
personally. This is because a microscope
will facilitate an increased satisfaction in
one’s work, as well as providing a tool
which will make clinical dentistry easier
and reduce back, neck and eye strain.
Inevitably, there are some
associated ongoing running costs.
Periodic servicing has already been
discussed, but other costs may not be
so apparent, such as the replacement
of halogen bulbs. These will fail from
time-to-time and will need to be
replaced. When considering purchasing
a microscope, the dentist should enquire
how often this may occur and the cost of
replacement bulbs.
December 2014 DentalUpdate 919
Clearly, such an investment
in a business will require to be recouped.
Generally speaking, two approaches
are used by colleagues in private
practice to that end. Some practitioners
charge the patient a fee for each case
requiring the use of the microscope,
whilst others prefer to include the cost
into the general running expenses of
the practice and charge indirectly by
increasing their hourly charge-out rate.
Clearly, those dentists working solely
in NHS general dental services are not
able to use the latter method and so
will have to make it clear to the patient
at the outset that an extra (private)
charge will be levied or, alternatively,
absorb the extra cost themselves.
That said, notwithstanding the costs,
the satisfaction of using an operating
microscope with its other many
advantages will pay for the instrument
in non-monetary ways in the long term.
Conclusion
The incorporation of an
operating microscope system into
dental practice offers many advantages
to the dental team and offers great
potential for improving the clinical care
which the patient receives. The second
paper in this series will discuss the
specific potential uses of the operating
microscope in general dental and
specialist practice.
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