Magnification: The game changer in dentistry

Abstract

During dental examinations and treatments, many dentists are using magnification to improve their vision. The dental operating microscope serves as the most effective tool for this purpose, enhancing the quality, longevity, and outcome of clinical work. This review will explore the latest research and data on the importance of magnification devices in dentistry, including diagnostic methods, treatment options and ergonomics in specialities such as restorative dentistry, endodontics, pedodontics, periodontics, and prosthodontics. This review aims to provide insights into the optimal magnification for different clinical situations, the specific benefits of dental operating microscopes for each dental branch, and their limitations.

Key Words: Magnification; Vision; Endodontics; Dentistry; Dental operating microscope

Core Tip: The primary purpose of using magnification devices in dentistry is to improve visibility and ergonomics. This is particularly crucial when treating obscure microanatomy for a prolonged amount of time. Nonetheless, the use of magnification in dentistry has yet to be widely accepted in general practice due to a variety of reasons in clinical practice.

INTRODUCTION

People have always viewed magnification devices with a lack of confidence, which has sparked fascination and intense discussion. A variety of healthcare professions now commonly use magnification devices due to their significant benefits in identifying and treating certain diseases. Magnification alone can achieve the current goal of preventing as much healthy tooth structure as possible[1]. Nowadays, advanced dentistry strongly encourages the use of dental operating microscopes (Figure 1) and loupes (Figure 2), especially when treating endodontic procedures. Endodontics has created innovative procedures for root canal treatment that improve operative field visibility[2,3]. The small area of the operating field, insufficient lighting, and poor ergonomics encouraged the use of magnification advancements in clinical practice. Nowadays, there has been a rise in the use of magnification devices among practitioners of various specialisations, as well as the success of minimally invasive dental techniques[4].

Figure 1 Working with the dental operating microscope.

Figure 2 Different types of loupes.

A successful dentist must have two qualities: (1) Delicate skills and strong vision. Hard work and consistent training can refine controlled and very precise actions, which are not inherent but learned. The ability to see well is a natural characteristic of all eyes; and (2) Dentists should be aware of their visual abilities, as well as the numerous strategies for compensating for visual deficits[5].

The human eye can distinguish between two separate entities that are at least 0.2 mm away. A dental operating microscope offers a significant advantage: It can distinguish these entities at a distance of only 0.006 mm[6]. In other words, “the resolution of the human eye improves dramatically”.

Dentists frequently perform treatments that need more resolution than a healthy eye can offer. Magnification enables the visualization of minute details in the operating field, enhancing their ability to identify and restore dental abnormalities[7].

HISTORY OF MAGNIFICATION DEVICES

The microsurgical technique began in 1960, Jacobson and Suarez developed the micro-surgical methods by joining tiny vessels using an operating microscope[8]. The literature[9] provides a history of microsurgical procedures in medicine. Following that, micro-surgical techniques underwent significant development and clinical application in many medical and dental specialities around the world. This would not have been possible without the development of the dental operating microscope, precise microinstruments, and microsutures.

Types of magnification devices

Dentists utilize a variety of magnification devices, including loupes and dental operating microscopes: There are several types of loupes available, depending on their optical construction.

Single-lens loupes: Basic and less expensive, but limited in magnification.

Galilean loupes: Typically offer 2.5 × magnification but can reach up to 3.2 ×.

Keplerian loupes: Provide a wider range of magnification, typically between 3.5 × and 4.5 ×, with improved depth of field.

Surgical microscopes: These provide higher magnification (up to 30 ×) and better control over the field of view, making them ideal for complex procedures in both restorative dentistry and endodontics. Modern surgical microscopes also allow for the integration of cameras to capture high-resolution images, aiding patient communication and documentation[33,34].

Magnification's ergonomic and clinical advantages

Magnification devices provide significant ergonomic advantages by encouraging better posture during procedures. Research has demonstrated that using loupes and microscopes helps to reduce musculoskeletal strain and prevent repetitive stress injuries. Improved posture not only enhances clinician comfort, but also prolongs career longevity by reducing the physical toll of dental practice[35].

Limitations of magnification devices

While magnification devices are invaluable tools, they come with certain limitations: (1) Cost: Magnification devices, especially surgical microscopes, can be expensive, making them a significant investment for dental professionals[2,9]; (2) Learning curve: Effective use of higher magnification devices requires training and experience[36]. There may be an initial adjustment period for clinicians learning to work with microscopes or advanced loupes; and (3) Field of view: As magnification increases, the field of view narrows, which can make it challenging to maintain focus during procedures. This necessitates precise handling and a steady hand[37].

Research and clinical outcomes

Several studies have demonstrated the positive impact of magnification devices on clinical outcomes[11]. Research shows that clinicians using microscopes achieve better diagnostic accuracy, especially in detecting minute issues like cracks or cavities. Additionally, endodontic microsurgical procedures, such as osteotomies and retrograde fillings, benefit from the enhanced precision provided by high magnification[38].

Magnification devices, ranging from basic loupes to advanced surgical microscopes, play an essential role in modern restorative dentistry and endodontics. The ability to visualize fine anatomical details improves diagnostic accuracy, procedural precision, and overall clinical outcomes. While there are challenges associated with cost and learning curve, the long-term benefits of magnification for patient care and practitioner ergonomics are undeniable[39]. Dental professionals should be aware of the different magnification options available and select the tools best suited to their clinical needs[40,41]. This version is more structured, ensuring clear sections for different magnification levels, applications in different dental specialties, and the benefits/limitations of each type of device.

Magnification in restorative dentistry and endodontics

Magnification is widely used in Restorative Dentistry and Endodontics. Magnification provides numerous benefits in dentistry, enhancing both diagnosis and treatment. It is important to remember that there is no ideal magnification level. The appropriate level of magnification depends on the type of procedure and its clinical purpose. Various levels of magnification-from low to high-offer different advantages depending on the treatment planning (Figure 3)[10].

Figure 3 Different stages of the procedure require different magnifications.

Levels of magnification in dentistry

Low magnification (3X to 8X): For general examinations, burs orientation, and ultrasonic tip placement, low magnification is ideal. It provides a large field of vision, making it easier to compare nearby anatomical structures. For this level of magnification, dental loupes typically provide sufficient clarity for general procedures and diagnosis.

Medium magnification (8X to 16X): Commonly used for both surgical and non-surgical endodontic procedures, medium magnification offers an adequate field of view and depth of field. Procedures such as perforation repair, instrument retrieval, and complex canal treatments benefit from this level of magnification[2].

High magnification (16X to 30X): High magnification is essential for viewing minute anatomical details, such as calcified canal orifices and small cracks in teeth. While it provides superior visual detail, high magnification comes with a smaller field of view and requires precise control to avoid losing focus with small movements[11-13].

Applications of magnification in restorative dentistry

Magnification improves the precision of various procedures in restorative dentistry, including the following: (1) Identification of demineralized enamel tissue[14]; (2) Conservative removal of old restorations[15,16]; (3) Deep inspection of caries and remaining surrounding tissues[17-19]; (4) Enamel cracks and fissures identification[20]; (5) Assessment of sectional matrix adaptation and liner application[21-23]; (6) Preparation of small class III cavities with minimal invasion[24]; and (7) Evaluation of marginal gaps in restorations[25]. The process involves identifying any gaps or impurities present in the restorations. Clinicians can deliver more precise and conservative removal of pulp stones using magnification, resulting in improved clinical outcomes and long-term dental work durability (Figure 4)[27,28].

Figure 4 Conservative removal of pulp stone under magnification. A: Pulpal floor with embedded pulp stone; B: Pulpal floor after the removal of stone.

Applications of magnification in endodontics

Magnification devices have made significant advances in endodontics. The enhanced lighting and visual clarity provided by microscopes assist in: (1) Locating and accessing difficult anatomy (e.g., sclerosed canals); and (2) Removing dystrophic calcifications like pulpal stones (Figure 4). Creating strong coronal seals repairing perforations and resorptive defects. Inspecting fractures and assessing microanatomy endodontic surgery, including periradicular and periodontal procedures, commonly employs operating microscopes. Microsurgical techniques allow for more precise tissue handling, resulting in reduced surgical morbidity, less scarring, quicker recovery times, and minimized postoperative pain[29-32].

Use of magnification in periodontology

Several symptoms associated with periodontal disease or gingival treatment necessitate a precise diagnosis. Dental operating microscopes and microsurgical instruments, together with conservative procedures, give the most effective remedies in such instances[42]. Such strategies can improve patient outcomes in terms of treatment relevance, healing time, pain reduction, and postoperative scarring[42,43]. The dental operating microscope makes it easier for the operator to see irritating substances that are still there, like calculus spicules or enamel pearls. This could help explain why epithelial attachment is lost or stays in one place[42].

The dental operating microscope, with its increased magnification and light, is useful in significant areas, such as furcations, and may be necessary to complete the work within. This also helps to provide a practical learning experience in how to use the instruments in the most efficient and least stressful manner feasible. Magnification devices have facilitated the development of various microsurgical procedures in periodontics (Figure 5), aiming to enhance patient satisfaction and improve outcomes[7]. These devices have increased the effectiveness of surgeons[5,6]. Microsurgical concepts have been established to enhance the visual acuity and accuracy of current surgical techniques, and to expand the field of periodontics by merging medical knowledge and technology.

Figure 5 Microsurgical procedures in periodontics.

Microperiodontal surgeries may offer more predictable outcomes, less invasive and more conservative procedures, less patient discomfort, faster healing, improved aesthetics, and more patient compliance[44,45]. Flap reflection and suturing have applied microsurgical principles and procedures, offering an excellent opportunity to accurately control the gingiva without undue tissue damage through stretching, twisting, or tearing[46]. In contrast to macro-surgery, micro-surgery involves training and experience using visual feedback rather than touch feedback[45].

Magnification is a topic of considerable interest and practical application for the advancement and future of periodontics[46]. With proper training, surgical operating microscopes have produced excellent results for periodontists[7]. Magnification offers significant promise for improving oral hygiene, clinical treatment, and dental hygienists' musculoskeletal wellness[47]. Studies have proven that magnification can help reduce the occurrence of musculoskeletal disorders among dental hygienists[14]. Microscope and microsurgical methods are effective approaches to keep our enthusiasm for a more difficult career[47].

Use of magnification in prosthodontics

In prosthodontics practice, using a microscope or magnification device capable of increasing the surgical field by 6X to 8X simplifies several technically challenging tasks[48]. Coaxial lighting and magnification help identify a preliminary arch placement path for detachable partial dentures, minimizing long-term damage to abutment teeth[49]. In fixed prosthodontics, the vertical and horizontal marginal fit of dental prostheses impacts the restoration's outcome, longevity, and appearance (Figure 6). When dentists use a microscope, they can see tiny differences in the heights of marginal ridges or the fixed partial dentures margin above the abutment margin[50]. This allows for incremental improvements in indirect restoration seating[51].

Figure 6 Crown preparations in prosthodontics.

The ideal horizontal marginal separation between dental prostheses and abutments is 0 μm. Dental operating microscopes or loupes, accurate methods in the laboratory, and appropriate training are all easy ways to achieve this. The optimum vertical margin fit is 50 μm. The amount of vertical gap depends on the dental preparation, impression materials, and methods used. Tooth decay-causing bacteria are less than 1 μm in size. However, bacterial aggregations, not a single germ, cause caries. Reducing the marginal gap should lead to a significant reduction in the incidence of marginal caries[52], as well as an increase in patient comfort. Teeth and tongue proprioception detect variations in thickness or roughness of less than 20 μm[53]. Smooth surfaces achieved through proper implantation and polishing of fixed prostheses are critical for the patient's health and comfort[54].

Use of magnification in maxillofacial surgery

Magnification, laparoscopic, and endoscopic technologies reduce surgical morbidity by avoiding major incisions. Following the principles of microsurgery (Figure 7) significantly reduces the difficulties associated with fracture repair by creating micro incisions that only expose a limited amount of soft tissue[55]. Furthermore, minimally invasive approaches have progressed with the introduction of dental operating microscopes, which, are built with digital cameras, and aid in image acquisition during maxillofacial surgery procedures.

Figure 7 Micro-surgery under the dental operating microscope.

An endoscope, a valuable tool in this field, typically performs surgical operations on the maxillary sinus, salivary glands, or temporomandibular joint[56]. The microscope plays a crucial role in anastomosing blood vessels and nerve tissues after tumour removal.

Oral surgeons use the dental operating microscope to extract teeth. During surgery, surgeons successfully used it to inspect sockets for residual roots or oro-antral connections[57].

Use of magnification in orthodontics

So far, the magnification has seen minimal use in this speciality, necessitating further research. However, studies have shown that using a magnification system significantly increases bonding and cleaning procedures. The magnification of the finest features is very crucial to consider during the debonding technique to save as much enamel tissue as possible during adhesive removal[58].

Selection of magnification devices

Incorrectly adjusted magnification devices can lead to poor ergonomics, putting the operator at risk for muscular and skeletal issues[11]. “The working distance, depth of field, and optical declination angle of the selected system must all meet the clinician's musculoskeletal needs”[35,59]. Galilean loupes of 2.6 × or 3.25 × are commonly used, which provide a perfect blend of working distance, field of view, depth of focus, affordability, and comfort[15]. A clinician research assessment of over 1600 dentists, of whom more than 90% used loupes, showed that the majority of dentists advocated a longer working distance, with 18 inches being the most prevalent[60]. To avoid tiredness and headaches, the two eyepieces must have the same angle of convergence. It will help reduce eye strain, preventing double vision. Improper selection can lead to a shorter attention span throughout the clinical job. Dental specialists observed a high prevalence of coaxial misalignment among surgical loupes[61]. Prosthetics, orthodontics, and shade selection are just a few examples where magnification will provide little or no aid[62].

CONCLUSION

Magnification in dentistry offers numerous benefits and is poised to become a standard of care across all specialties. Clinical procedures, regardless of speciality, are inherently challenging, and enhanced vision through magnification can significantly improve both precision and comfort for the clinician. Loupes are currently the most commonly used magnification tool, and beyond just improved vision, they offer substantial ergonomic benefits that promote the long-term health of the practitioner. Clinicians using loupes often experience reduced musculoskeletal strain, leading to a higher quality of life and greater career longevity. While simple diopter lenses provide some magnification, compound and prismatic telescopic lenses offer superior clarity, depth of field, and a wider field of vision, making them more effective for complex dental procedures. Though magnification tools may have an initial learning curve, the long-term benefits far outweigh the drawbacks, including enhanced procedural accuracy and improved practitioner well-being. Dental institutions worldwide must incorporate the use of magnification, particularly loupes, into their curricula. Early exposure to magnification technology will help future dentists develop ergonomically sound practices and improve their clinical precision. Newly graduated clinicians, in particular, should start with low-magnification loupes to ease into their use, gradually building their skill set while reducing musculoskeletal stress over time. This version: Clarifies the benefits of magnification in terms of clinical outcomes and ergonomics. The text offers more precise comparisons between various types of lenses. It facilitates better transitions between ideas, such as moving from the benefits of magnification to the necessity of institutional adoption. The advice is tailored more clearly for different audiences, such as students and graduated clinicians.