|Year : 2016 | Volume
| Issue : 2 | Page : 91-100
Magnification-enhanced contemporary dentistry: Getting started
Rashmi Hegde1, Vivek Hegde2
1 Department of Periodontology and Oral Implantology, M.A. Rangoonwala College of Dental Sciences and Research Centre, Pune, Maharashtra, India
2 Department of Conservative Dentistry and Endodontics, M.A. Rangoonwala College of Dental Sciences and Research Centre, Pune, Maharashtra, India
|Date of Web Publication||5-Jan-2017|
Department of Periodontology and Oral Implantology, M.A. Rangoonwala College of Dental Sciences and Research Centre, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Contemporary dental practice is undergoing a sea change; wherein the approach is an interdisciplinary one aimed to impart minimally invasive, painless, and atraumatic treatments to patients. To enhance their vision for both clinical and laboratory procedures, an increasing number of practitioners are opting for magnification systems such as loupes and microscopes in their practice. Due to their benefits such as improved visual acuity due to coaxial lighting, unobstructed vision, illumination, smaller instruments, minimal trauma, and ergonomic benefits, microscope-assisted precision dentistry is becoming the order of the day. Many dental schools are also making the use of these systems mandatory in their teaching curriculi. Even though the use of microscope initially started in ophthalmology, it's benefits in endodontic therapy which can best be performed under magnifications up to ×10-20 remains unparalleled. These benefits also extend to all aspects of dentistry including periodontics, restorative, prosthetic dentistry, and implant dentistry. Barring the disadvantages of steep learning curve, cost, and maneuverability of the equipment, magnifications are definitely becoming an important aspect of modern-day dentistry, owing to their numerous other benefits.
Clinical Relevance To Interdisciplinary Dentistry
Microscope-enhanced dentistry is actually a part of a broader movement of minimally invasive and holistic approach in dentistry, aimed at development of newer techniques, and achieving esthetically superior outcomes , due to improved visual acuity. Magnified vision leads to improvised treatment, thus diagnosis, and management of multiple interdisciplinary problem areas can be achieved with utmost precision by incorporating magnification systems in day to day practice.
Keywords: Ergonomics, loupes, magnification, minimally invasive, surgical microscope
|How to cite this article:|
Hegde R, Hegde V. Magnification-enhanced contemporary dentistry: Getting started. J Interdiscip Dentistry 2016;6:91-100
| Introduction|| |
Contemporary dentistry is spearheaded by a movement in technological advances which help clinicians with adequate training to incorporate the finest skills and equipment in day-to-day practice, thus enhancing their existing skills and knowledge and delivering the most ideal outcomes with utmost precision. The modern-day patients envision and expect treatments delivered to them in the most painless and minimally invasive manner. It is understood that the brain can perceive what the eyes can see; however, there is much more than what the normal eyes can see. What more than magnified vision using magnification tools which improves the accuracy of work by bringing the object as near to the eyes as possible, using finer instruments, smaller incisions, shorter healing time, minimal pain and trauma, superior esthetic outcomes, and higher patient acceptance. Optical magnifications have really broadened the horizons of dentistry.
The concept of magnifications for microsurgery was introduced to medicine during the late 19 th century. ,,,,, Carl Nylen, who is considered the father of microsurgery, first used a binocular microscope for ear surgery in 1921. The pioneers in dentistry were Apotheker and Jako, who first introduced the use of microscope in dental procedures in 1978.  Following this, Carr, in 1992, published an article defining and emphasizing the role of the surgical microscope in endodontic procedures.  In 1994, Shanelec and Tibbetts presented a continuing education course documenting the use of surgical microscope in dentistry and called it "Microscope-Assisted Precision Dentistry." 
Most experienced microscope users comment with amazement about the wonders of working through a microscope. It is well said that a magnified, clear image can speak more for itself than a thousand words put together. Definitely considered as an eye opener to many dental professionals, microsurgery is unfolding to be an interesting concept. In 1979, Daniel defined microsurgery in broad terms as surgery performed under magnification by the microscope.  In 1980, microsurgery was described by Serafin as a methodology - a modification and refinement of existing surgical techniques using magnification to improve visualization, with applications to all specialties.  As a treatment philosophy, microsurgery incorporates three different principles:
- Improvement of motor skills, thereby enhancing surgical ability
- An emphasis on passive wound closure with exact primary apposition of the wound edge
- The application of microsurgical instrumentation and suturing to reduce tissue trauma.
Magnification, illumination, and instruments (Kim 2001) together form the "Microsurgical Triad." Without these, microsurgery is impossible. Microscope-enhanced practice does not indicate conceptual revolutions in existing techniques, however implies an improved accuracy, better handling, and gentleness and thoroughness in the procedures, with slight modification in the already practiced techniques.
| Types And Principles Of Magnification Systems|| |
Broadly, the concept of magnification-enhanced dentistry incorporates the use of two types of optical magnification systems: (a) loupes and (b) surgical operating microscope.
The most common magnification system used in dentistry is the magnification loupes. Primarily, loupes consist of two monocular microscopes, with side-by-side lenses, angled to focus on an object to form magnified images with stereoscopic properties that are created by the use of convergent lens systems. Wide ranges of magnifications are available in loupes, ranging from × 1.5 to × 10. It is always ideal to adapt to magnified vision by initially using loupes, which enable the operator to adjust to the eye training exercise and changes in hand-eye coordination. Although loupes are widely used, their major disadvantage is that the eyes converge to view an image (Keplerian optics), which can result in eye strain, fatigue, and even vision changes with the prolonged use of poorly fitted loupes.  There are three types of loupes commonly used in practice:
Simple loupes consist of a pair of single, positive, side-by-side meniscus lenses. Each lens has two refracting surfaces, with one occurring as light enters the lens and the other when it leaves. Its main advantage is that it is cost effective. The disadvantages are it is primitive with limited capabilities and are highly subjected to spherical and chromatic aberrations, which distort the image of the object.
Compound loupes or telescopic loupes
Compound loupes or telescopic loupes consist of multiple lenses with intervening air spaces, thus allowing adjustment of magnification, working distance (WD), and depth of field without increase in size or weight.
Prism loupes are optically most advanced containing Pechan or Schmidt prisms that lengthen the light path through a series of mirror reflections within by virtually folding the light so that the barrel of the loupe can be shortened. They produce better magnification, larger fields of view, wider depths of field, and longer WDs. This is a feature that dentists should seek when selecting any magnifying loupe because an achromatic lens consists of two glass pieces, usually bonded together with clear resin. The specific density of each piece counteracts the chromatic aberration of the adjacent piece , [Figure 1].
Surgical operating microscope
In dentistry, operating microscopes are designed on Galilean principles. They incorporate the use of magnifying loupes in combination with a magnification changer and a binocular viewing system so that it employs parallel binoculars for protection against eye strain and fatigue. They also incorporate fully coated optics and achromatic lenses, with high resolution and good contrast stereoscopic vision. Surgical microscopes use coaxial fiber-optic illumination. This type of light produces an adjustable, bright, uniformly illuminated, circular spot of light that is parallel to the optical viewing axis. Due to its shadow-free light, visualization of pathologies, documentation, motion videography, and management of all dental and surgical procedures can be effectively performed under unobstructed vision. Patients can be counseled better as they can directly visualize the magnified image on the screen due to the beam splitter video camera attached to microscope.
| Parts Of Microscope|| |
The surgical microscope is a complicated system of lenses that allows stereoscopic vision at magnification of approximately ×4-40 with an excellent illumination of the working area. Light beam falls parallel into the retina of the observer so that no convergence is necessary and demand on eye muscles, especially the lateral rectus is minimal. Parts of a microscope are broadly divided into: ,,
Magnification changer or Galilean changer consists of one cylinder, in which two Galilean telescope systems with various magnification factors are built. A total of four different magnification levels are available. Power of magnification decided by a magnification factor.
after processing by magnification changer, the image is projected by single objective. This simultaneously projects light from its source twice for deflection by the prisms into the operation area. The most frequently used objective is 250-300 mm in dentistry.
They can be straight or inclined depending on the use. In dentistry, only inclined, swiveling tubes that permit continuously adjustable viewing are used. Furthermore, they improve the feasibility for improving ergonomics as the operator can adjust the tubes without changing his head, neck, or back posture.
They magnify the images generated in the binocular tubes. Varying magnifications can be achieved (×10, ×12.5, and ×20 up to ×40) with the same. Most of the endodontic, periodontic, and restorative procedures can be carried out under ×10 magnification. Certain endodontic procedures such as instrument retrieval or working on the apical foramen, may require magnification up to ×15-20. Majority of the surgical microscopes are equipped with attachments that include integrated video systems, photographic adapters for cameras, units for image storage, color printers, powerful lighting sources, beam splitter cameras, powerful light-emitting diode, and halide lighting systems for unobstructed coaxial illumination.
In surgical microscopes, incandescent, halogen, and fiberoptic are the principal types of illumination. Halogen lamps provide a whiter light than lamps using conventional bulbs due to their higher color temperature. Other options available are the xenon lamps, which function up to 10 times longer than halogen lamp. The light has daylight characteristics with an even whiter color, which delivers exceptionally bright images with sharper contrast.
Ceiling, wall, and floor mounting options are available for surgical microscopes. The surgical microscope must have both maneuverability and stability for practical use in day--to-day practices. Initially, the microscopes were fixed type that were difficult to maneuver. Most modern microscopes are articulating types that feature an articulating arm that allows easy movement of the scope without moving the entire unit [Figure 2]. The ceiling and wall mount have fixed positions, thus cannot be moved; however, they help in space management. The floor mount can be transported easily but may occupy more space. Thus, depending on the space available in the operatory, the mounting system may be selected.
|Figure 2: (a) Parts of a microscope, (b) Determination of Interpupillary distance (IPD)|
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| Steps In Use Of Magnifications|| |
With a steep learning curve associated with the use of magnifications, it is imperative to every desiring clinician to master the steps toward achieving complete harmony in hand and eye movements while using these systems. ,,
It is the distance measured from the eye lens to the object in vision. There is a multitude of back, neck, and eye problems that dentists suffer from, due to a need to attain short WDs for increasing visual acuity. Depending on the individual's height and length of arms, the WD with slightly bended arms using microscope increases and ranges between 30 and 45 cm. At this distance, posture is perfect, ergonomics is greatly improved, and there is decreased eye strain due to less convergence.
Working range (depth of field)
Range within which the object remains in focus. The DOF of normal vision ranges from WD to infinity.
It is the pivotal angle aligning the two oculars, such that they are pointing at the identical distance and angle varies with interpupillary distance (IPD). Defines the position of extraocular muscles that may result in tension of the internal and external rectus muscles, which may be an important source of eye fatigue.
Field of view
Linear size or angular extent of an object when viewed through the telescopic system.
It is the key adjustment for the use of any magnification system. The ideal way to understand your IPD is to focus both the binocular eyepieces to initially see two images or circles and adjust it to the point, wherein they merge and become one circle. That point would be identified as the IPD and used as a permanent reference for the use of magnifications. The IPD varies with each individual and forms an important aspect in the learning curve of use of magnifications.
It is the position of the binocular optics angled in such a way that it enables comfortable working position for the operator. The shallower the angle, the greater the need to tilt the neck to view the object.
| Loupes Versus Operating Microscopes|| |
Advantages of loupes
Less expensive and initially easier to use since they are head mounted, loupes tend to be less cumbersome in the operating field.
Advantages of operating microscope
(a) Greater operator eye comfort because of the parallel viewing optics of the Galilean system as well as the range of variable magnification, excellent coaxial fiber-optic illumination. (b) Countless accessories such as still and video single-lens reflex cameras for case documentation and DVD preparations, co-observer tubes for additional viewing by a third assistant, etc., (c) Magnification allows the surgeon to compare the conventional surgical procedure, which appears as gross crushing and tearing of tissues. (d) Motor coordination is greatly improved using precision grip instruments, thus reducing tremor.
Ergonomics is one of the most beneficial aspects of using magnifications, especially the surgical microscope.  It is the study of people's efficiency in their working environment. It is also the applied science of equipment design for the workplace with the intent of enhancing productivity by reducing operator fatigue and discomfort. Musculoskeletal problems such as herniated discs, spondylosis, rotator cuff impingement, and neck, back, and shoulder problems are on the rise in the dental fraternity due to various postural variations, working at very close field, bending, or inappropriately standing. Mechanisms related to muscle balance and problems associated with the same can be explored by understanding the differences between "posture-directed dentistry" and "image-directed dentistry." "Image-directed dentistry" is associated with dental procedures performed using a direct vision. "Posture-directed dentistry" is associated with dental procedures that are performed using an indirect line of sight such as microscope. This position is directed toward ergonomical well-being of the operator. The optics of a surgical microscope bend the path to almost 90° allowing the dentist to sit comfortably erect with the head, neck, and back arranged in a straight line when viewing an object. During microsurgery, the dentists' seating zone is usually recommended for 11 o'clock and 12 o'clock positions. This prevents twisting and turning movements during procedures, and verbal communication plays a greater role [Figure 3].
| Instruments|| |
Microsurgical instruments, especially designed to inflict minimal trauma, are generally lightweight. They are circular in cross section, as they are manipulated between the thumb, index finger, and middle finger. They should provide tactile perception for controlled rotating movements. Approximately, 18 cm long only finger tips should move while using these instruments. They are held between the pad of the thumb and index finger, allowing precision controlled movements of only finger tips. They are designed with colored coating surfaces or dull finish, to avoid reflection of light under the scope and minimize glare. Weight should not exceed 15-20 g. Precise working lock on needle holder with locking force 50 g. Basic set comprises needle holder, microscissors, micro scalpel holder, anatomic and surgical forceps, and various elevators. Fine chisels, raspatories, elevators, hooks, and suction. Micromirrors (furcation and interdental), endodontic pluggers, root-end preparation tips, and ultrasonics. An important characteristic of microsurgical instruments is their ability to create clean butt joint incisions that prepare wounds for healing by primary intention. Several types of ophthalmic knives such as the crescent, lamellar, blade breaker, sclera, and spoon knife can also be used. Ophthalmic knives offer the dual advantages of extreme sharpness and minimal size. This helps limit tissue trauma and promotes faster healing [Figure 4] - microinstruments]. ,,
Approximately, 6-0-10-0 resorbable or nonresorbable sutures are used in microsurgery. Layered technique for suturing butt joint incisions is preferred. Dark blue or violet tinted sutures preferred as colorless sutures can be invisible under the microscope. A 3/8 reverse cutting needle preferably 5-13 mm in length, for papillary sutures, needle lengths 1-15 mm are required. For anterior areas 10-12 mm and buccal-releasing incisions 5-8 mm. ,
| Microsurgical Indications In Periodontal Surgery|| |
Improved root visualization
The critical determinant of the success of periodontal therapy is the thoroughness of debridement of the root surface (Lindhe et al. 1984). Accessibility and visibility in deep subgingival pockets, furcation areas, and interdental areas can remarkably be improved using magnifications. It is clear that magnification around ×4-10 greatly improves the surgeon's ability to create a clean, smooth root surface. It can help to detect islands of biofilm, calculus, or material alba clinging to the root surface and facilitate removal from areas which were normally not visible to the naked eyes [Figure 5]. ,,,,,
|Figure 5: Scaling and Root Planing. (a) Pre-operative view, (b) Scaling at 8x magnification, (c) Root planing with Gracey Curette 8 x magnification, (d) Post-operative view|
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Applications in mucogingival surgery
All mucogingival surgical procedures are technique and operator sensitive and therefore tend to have varying therapeutic results. Periodontal plastic microsurgery has remarkably improved the predictability of root coverage procedures, frenectomy, vestibuloplasty, etc., with less operative trauma and discomfort, excellent postoperative esthetics, and significantly faster healing. For connective tissue and free gingival grafts, initial graft survival depends on early plasmatic diffusion. A minimally traumatic approach ensures more precise recipient and donor site preparation with minimal tissue and vessel injury, more rapid and complete anastomosis of capillary buds, and faster healing. ,,,,,, This fact was emphasized by several authors in their studies. Highly sensitive techniques such as papilla reconstruction can also be performed with higher predictability using a microscope [Figure 6] - free gingival graft and comparison].
|Figure 6: Microsurgical Free Gingival Graft. (a) Pre-operative view: Miller's Class II Recession, (b) Microsurgical Free gingival Graft sutured with 6-0 sutures, (c) Superior healing at 1 week, (d) Healing at 1 month, (e) Comparison with Macrosurgical FGG with 3-0 sutures|
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Minimally invasive surgical technique
The minimally invasive surgical technique (MIST, Cortellini and Tonetti, 2007) is a concept that was designed, especially for isolated intrabony defects for periodontal regeneration. It is based on minimal reflection of very short buccal and lingual flaps with minimal mesiodistal and coronoapical extensions, the aim being to expose the coronal edge of the residual bone crest that include the defect-associated interdental papilla. In narrow interdental spaces, a diagonal incision is given closer to the lingual side (simplified papilla preservation flap), whereas a horizontal butt joint incision is performed at the base of papilla in wide interdental spaces, modified papilla preservation technique (MPPT), incorporating the whole papilla into the palatal or lingual flaps. Scaling and root planin is performed by means of mini-curettes and sonic/ultrasonic instruments. Modified minimally invasive surgical technique (M-MIST) has been proposed by Cortellini and Tonetti, 2009, for use in combination with enamel matrix derivatives (amelogenins). The overall idea of the M-MIST is to provide a very small interdental access to the defect only from the buccal side, following which the supracrestal interdental tissue is dissected from the granulation tissue by means of a mini-blade, and regenerative material of choice applied. Passive closure by internal mattress sutures is preferred." ,,,,
The clinical benefits of microsurgical approach for periodontal regenerative surgery have further been confirmed by various authors through case reports (de Campos et al., 2006) and case-cohort studies (Cortellini and Tonetti 1999, 2007 and Francetti et al. 2004). All studies confirmed the beneficial effects of microsurgical approach in terms of Clinical Attachment Level (CAL) gains, reduction in pocket depth, regenerative outcomes, etc., ,,,,, [Figure 7] - flap for regeneration].
|Figure 7: Microsurgical flap for Periodontal Regeneration. (a) Pre-operative Raidiograph, (b) Microsurgical flap with bone graft placement for Gr II furcation involvement, (c) Microsurgical 6-0 sutures|
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Microsurgery in implant therapy
All stages of implants may be performed with higher precision using a microscope. The microscope may be a valuable tool in visualizing the last threads of the implant for subcrestal placement, implant recovery with minimal trauma to adjacent tissues, management of peri-implantitis, visualization of the sinus membrane during sinus lift procedures, and minimizing the risk of perforations or tears ,, [Figure 8]a-d - implant exposure].
|Figure 8: Microsurgical implant exposure. (a) Pre-operative with Opthalmic blade at 8x magnificatio, (b) Minimal crestal incision, (c) Minimal flap reflection at 8x magnification, (d) Exposed implant with healing abutment and 6-0 sutures|
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Bonded dentistry ideal restorative margins form the key of successful restorations with longevity. Caries close to the pulp can be excavated by distinguishing even the minutest infected dentin areas due to the shadow-free light. This can help spare-affected dentin and minimize pulp exposures. Margin preparation and outline for a crown or veneer preparation can also be perfected with thorough precision under the scope [Figure 9] - restorative margins, [[Figure 10] - veneer preparation, [Figure 11] - bonding brush].
The use of microscope has redefined the concept of visualization in endodontics, to the extent that it can be considered as an integral part of the armamentarium for all endodontic procedures. The ability to inspect the root canal both orthograde and retrograde have established newer standards for outcomes of root canal therapy. Diagnosis of fissure caries, microfractures, straight line access to the apex of the canal, complete exposure of the pulp chamber, removal of pulpal roof (deroofing), location of canal orifices, especially MB2 in the maxillary first molars, dentinal map, bent, split, oval canals, pulp stones/calcifications, obturation techniques, perforation repairs using mineral trioxide aggregate, fractures, instrument retrieval, apical ramifications, retreatment, especially gutta-percha removal, and defects or kinks in rotary files, can be traced earlier, thus preventing instrument fractures ,, [Figure 12] - access cavity with dentinal map, [Figure 13] - obturation, [Figure 14] - instrument fracture n retrieval, [Figure 15] - laser root canal sterilization, [Figure 16] - root fracture, [Figure 17] - root end preparation, [Figure 18] - periapical surgery].
|Figure 12: Endodontic Access cavity 10x magnification showing dentinal map|
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|Figure 13: Post-Obturation. (a) Post-obturation at 16x magnification, (b) Post-obturation showing MB2 canal at 16x magnification|
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|Figure 15: Root Canal sterilization. (a) Laser & Microscope -assisted Root Canal Sterilization, (b) Removal of pulp tissue|
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|Figure 16: Vertical root fracture detected at 10x magnification with dye|
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| Errors In The Use Of Microscope|| |
Wrong power of magnification
Wrong power of magnification using too high magnification can lead to narrower field of vision and smaller DOF, too low magnification may not serve the purpose. Ideal magnification should be that which allows the surgeon to operate with ease without losing focus at all times. In periodontal surgery, magnifications of up to ×5 for loupes and ×10-20 for microscopes appear to be ideal. ×10-15 for papilla preservation, ×12-15 for single-tooth root coverage, or guided tissue regeneration for intrabony defect interdentally, ×6-8 for clinical inspection/diagnosis, or flap surgery for quadrant, and ×15-25 for endodontics appear to be the ideal range for magnifications. 
Inadequate coordination between surgeon and assistant can lead to disruption of optimal workflow. In microendodontics, there is straight line vision, minimum movement of the object, and change of position in the operating persons; however, during surgery, there may be a wider field, constant movement, thus a second assistant for arranging instruments may be required, and co-observer tubes for the assistant are of added benefit.
Improper training or lack of practice
Improper training or lack of practice may lead to inadequate coordination between surgeon's eyes and hands, and reduction of tremor, achieving ergonomically beneficial positions may get difficult to achieve. A learning curve of minimum 6 months may be needed.
| Recent Advances In Microscopes|| |
Zeiss OPMI PROErgo
It has a feature of motorized/foot-controlled adjustment of focal length. This causes the least disturbance and optimal ergonomic work even when treatment continues for several hours. 
Mechanical optical rotating assembly interface (MORA Interface)
It is a mechanical optical rotating assembly that connects the binocular tube at a right angle to the body of the operating microscope making it capable of a limited independent rotation around the horizontal axis of the binocular tube. This was devised to overcome the drawbacks of conventional microscopes which were designed to allow the clinician to sit at the 9-10 o'clock position. This led to an inclined neck position toward the right shoulder, leading to overextension of the left arm, muscle tension, fatigue, and disability. This technology enables the operator to be seated at 12 o'clock position, providing a horizontal WD that is compatible with the distance between the head and the mouth of the patient. 
It is a new procedure using a miniature dental endoscope which allows subgingival visualization of the root surface at magnifications of ×24 to ×48. This is accompanied by a 99 mm fiber-optic bundle that is a combination of 10,000 pixel capture bundle surrounded by multiple illumination fibers. This fiber is delivered to the subgingival margin coupled into an instrument called explorer. The magnified images are immediately displayed on a chairside video screen, following which any residual islands of calculus or biofilms can be effectively debrided. 
Referred to as Augmented Reality, it is a lightweight miniature head-mounted operating microscope for surgical navigation; it features display of additional computer-generated sceneries. It has an integrated camera for documentation. One of the greatest advantages of the varioscope is mobility of the operator head, which is contrary to the surgical microscopes which lack maneuverability due to cumbersome equipment. 
The infrared 800, flow 800, and blue 400 fluorescence tools allow surgeons to see vascular circulation at the surgical site and determine the sequence and direction of blood flow.
| Conclusion|| |
The use of magnifications, though associated with a steep learning curve and added cost factor attached to them, have proven beneficial as seen through a cursory review of various therapeutic aspects of dentistry. The opponents of microsurgery may mention the adverse effects of prolonged duration of procedures carried out under microscope; however, it is compensated by the minimally invasive nature of the technique ultimately leading to superior outcomes. Some areas in the mouth may be difficult to access using the microscope; in such areas, loupes may be preferred. With the advent of newer systems such as varioscope, procedure scopes, these limitations may further be overcome. Above all the microscope can be a valuable patient education, practice enhancement, and self-appraisal tool, for improving the overall quality of work in day-to-day practice. In the above-mentioned clinical scenario, there appear to be no obvious contraindications for the use of magnification systems in dentistry, rather they could become an integral aspect of the future of clinical dentistry.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18]