The experience of surgical microscope application in endodontics

Surgical microscopes are becoming a fixture of a modern dentist’s office. The microscopes are also used in orthopedic and other surgery, periodontics, maxillofacial surgery, and other fields of dentistry. Odontologist Ivan N. Vyuchnov, M.D., Ph. D., talks about using the surgical microscope for better treatment, while protecting the health of the dentist and the assistant doctor.

Please tell us about your work. What exactly do you do?

My primary area is root canal treatment, both conservative and endodontic. Still, sometimes I have patients who need orthopedic preparation and treatment prior to the final tooth rehabilitation when the doctor inserts a retraction cord and takes a contour in wax. It takes knowledge and orthopedic surgery skills, while microscope-enabled visualization facilitates a high-precision preparation for subsequent denture delivery.

How does the surgical microscope affect your day-to-day practice?

I’m considered a «dentist for dentists» since they refer patients to me with conditions that other doctors are unable to treat, sometimes because they lack the necessary instrumentation. Quite often it is a retreatment after an initial unsuccessful treatment that has led to a relapse of the periapical condition. For this reason my job is highly important, just like my professional responsibility: I fix what has been missed during a surgery performed most probably without a microscope.

What is your procedure for using the microscope?

As I work, I directly view the tooth and the surrounding surgical site with the microscope. For instance, with the naked eye it is impossible to see the extra anatomic features of the root canal system located deep in the tooth. So a detailed visualization is an important benefit over the naked eye. It also affects treatment quality.

Another significant aspect is that working without visualization tools forces the doctor to assume inconvenient positions. The surgical approach in dentistry is always limited. We use a system of mirrors, so ergonomic issues are very important since they also affect the doctor’s health. By using a microscope, the doctor takes a more comfortable position from the very beginning; this way, he or she not only sees more anatomic features, but can also spend more time studying them.

What microscope do you use now, and why did you choose it?

A wall- or ceiling-mounted permanently installed microscope is the best choice. Right now I use ZEISS OPMI Pico surgical microscope with a 5-step magnification changer, halogen illumination, a 50/50% light beam divider, and an extra eyepiece for the assistant doctor to observe the procedure and to anticipate my actions at every treatment stage. The assistant’s workstation also has to be convenient and properly designed. The assistant’s workspace layout directly affects the overall treatment quality.

I prefer the ZEISS microscope because, first of all, it is reliable and steady in operation; second, I like its design which has always been a distinctive feature of all ZEISS products. The quality of ZEISS optics goes without saying, their unparalleled performance is well known.

I have used other equipment; I have tried some low-end US-made systems, but the quality has been unsatisfactory. As to other microscopes from Germany, to me their design is not ergonomic enough. For this reason I prefer Carl Zeiss microscopes. With ZEISS lenses and adapters, the image quality is superb. I can also use a regular photo or video camera to record the procedure.

What is the significance of high-definition visualization?

The human hand can be positioned with an accuracy of about one millimeter. The human eye can see objects as small as 0.2 mm. A microscope-assisted visualization minimizes hand tremor, reducing it from 1 mm to several hundredths or even thousandths of a millimeter. So using the microscope cancels out the physiological tremors, making hand movements clear and precise. That is why I can make accurate cuts, and flap removal is less traumatic. We remove only as much as required, and spare the tooth tissue.

What is the biggest benefit of routinely using a surgical microscope for you?

To me, a very important option of my microscope is the extra eyepiece for the assistant to see the same 3D image that the doctor sees, not just a flat image on the screen. This option should be used by assistants in the course of conservative and surgical endodontic treatment. For instance, as we begin filling in a root canal while performing surgical endodontics, the commonly used cofferdam (a rubber screen) cannot be used and saliva may penetrate. The assistant’s work is important since he or she removes blood drops with a blood aspirator as soon as they form. In this way, the canal is kept dry and nothing prevents the filling from curing. Otherwise, the blood inhibits the curing, which leads to relapses.

What can you say about patients' attitudes toward microscope-assisted treatment?

Microscope-assisted treatment may last longer and be more expensive compared to the services of doctors who do not use visualization, so a patient faces a choice. Ultimately, all this is as important as choosing the right treatment and being sure of its quality, which is certainly affected by the use of the microscope. I believe a doctor should use a microscope every time, not occasionally, and not as just an extra light source. A doctor should be responsible towards patients in terms of using a microscope.

What is your personal most significant conclusion about using a microscope?

For me, using a microscope has become a beaten track, a matter of course, and an integral part of my routine practice.